Treatment of Postural Orthostatic Tachycardia Syndrome (POTS)

Non-Pharmacologic Foundation

The American College of Cardiology recommends increasing dietary sodium to 5-10 grams daily through liberalized salt in food for POTS patients 1
Patients with POTS should consume 3 liters of water or electrolyte-balanced fluid daily to expand plasma volume 1
Wearing waist-high compression stockings is recommended to maintain central blood volume and reduce venous pooling in POTS patients 1
Elevating the head of the bed 4-6 inches during sleep can help with chronic volume expansion in POTS patients 1
Recumbent exercise, such as rowing, swimming, or recumbent bike, should be started to avoid upright posture that triggers symptoms, then gradually progress to upright exercise as tolerated 1

Propranolol is the initial pharmacologic choice for excessive sympathetic activity and tachycardia in POTS patients, according to the American College of Cardiology 1
Ivabradine 5 mg twice daily can be used as a second-line treatment after propranolol failure, particularly when beta-blocker fatigue is problematic 1
Ivabradine selectively inhibits the If channel in the sinoatrial node, reducing heart rate without affecting contractility or worsening fatigue in POTS patients 1
Evidence from 22 POTS patients showed improvement in heart rate and quality of life after one month of ivabradine treatment 1
Fludrocortisone up to 0.2 mg at night can be used for mineralocorticoid-mediated volume expansion in POTS patients, working synergistically with salt loading 1
Midodrine 2.5-10 mg provides direct alpha-1 agonist peripheral vasoconstriction, particularly effective for neuropathic POTS phenotype with impaired vasoconstriction 1

The American College of Cardiology and American Heart Association acknowledge POTS as excessive sinus tachycardia in response to upright posture, but note that syncope in POTS is relatively infrequent and there is little evidence that syncope is directly caused by POTS itself 2, 3
The 2017 ACC/AHA/HRS Syncope Guidelines defer to the Heart Rhythm Society consensus statement for detailed POTS management rather than providing specific treatment algorithms 2, 3

The American College of Cardiology recommends combining ivabradine with beta-blockers, such as propranolol, for a synergistic effect on different mechanisms in patients with hyperadrenergic/mixed POTS, with a strength of evidence level of moderate 4, 5
The American Heart Association suggests that beta-blockers, such as propranolol, can be used to address excessive sympathetic activity and hyperadrenergic features in POTS patients, with a strength of evidence level of high 4, 5

The American College of Cardiology warns of the risk of excessive bradycardia when combining ivabradine with beta-blockers, and recommends careful monitoring of heart rate in patients with hyperadrenergic/mixed POTS, with a strength of evidence level of moderate 4, 5
The Heart Rhythm Society notes that phosphenes, or visual brightness, are a potential side effect of ivabradine, reported in 3% of patients, and recommends monitoring for this symptom in patients with hyperadrenergic/mixed POTS, with a strength of evidence level of low 4, 5

The American College of Cardiology, American Heart Association, and Heart Rhythm Society explicitly recommend referral to a specialist for patients with drug resistance or intolerance, complex autonomic dysfunction, or those desiring optimization beyond single-agent therapy, with a strength of evidence level of high 6, 7, 8
The American Autonomic Society suggests that an autonomic specialist can perform formal autonomic function testing, titrate combination therapy safely, and consider advanced interventions if standard therapy fails, with a strength of evidence level of moderate 4, 5

The American College of Cardiology advises against adding AV nodal blocking agents without specialist guidance, as these may worsen hypotension in patients with hyperadrenergic/mixed POTS, with a strength of evidence level of moderate 9, 10