Systematic literature review: treatment of postural orthostatic tachycardia syndrome (POTS)

TL;DR

This paper reviews current treatments for POTS, a condition causing abnormal heart rate increases when standing, focusing on non-drug and drug therapies, especially in children and those with chronic fatigue syndrome.

Contribution

The study systematically reviews evidence for POTS treatments, highlighting gaps in research and potential non-pharmacological and pharmacological options.

Findings

Non-pharmacological treatments like compression garments and physical training may be practical first-line options for POTS.

Pharmaceuticals such as ivabradine and beta-blockers show some effectiveness in managing POTS symptoms.

More large randomized controlled trials are needed to establish effective therapies for POTS.

Abstract

Postural orthostatic tachycardia syndrome (POTS) is a condition defined by symptoms of orthostatic intolerance and a sustained heart rate (HR) increment of ≥ 30 beats per minute (bpm) upon postural change to the upright position in the absence of orthostatic hypotension, defined as a sustained decrease in systolic blood pressure (SBP) of ≥ 20 mmHg or a decrease in diastolic blood pressure (DBP) of ≥ 10 mmHg within 3 min of standing. In children, a sustained HR increment of at least 40 bpm is required for diagnosis of POTS. POTS is a common condition in adults and children suffering from myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). In daily clinical practice, therapeutic recommendations are rare and evidence is missing. The objective of this review is to present the current knowledge on non-pharmacological and pharmacological approaches in POTS with a special focus on POTS therapy in children and people with ME/CFS. Of 3853 studies, 45 studies were included in the systematic review. Evidence on therapy in POTS is rare and large randomized controlled trials (RCT) on single interventions are needed. Non-pharmacological approaches such as the use of compression garments, physical training, salt supplementation and transdermal vagal nerve stimulation could be possible treatment options in POTS because they are easy to implement as first-line therapeutic measures in clinical practice. For pharmaceuticals, several studies showed significant effects following therapy with ivabradine and β-adrenergic blocking agents. There are single studies which imply that midodrine (hydrochloride) and pyridostigmine seem to have a beneficial effect on hemodynamics in POTS.

The online version contains supplementary material available at 10.1007/s10286-025-01172-2.

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