Which options fit what matters to me?

Start without medicine

Scores 3 for measures guidelines list first, 0 for medicines.

• Fluids and salt: 3. A dietary measure that guidelines list first (HRS 2015, Class IIb).
• Compression: 3. A garment with no drug involved, named first-line in the 2026 JAMA review.
• Exercise: 3. A behavioral therapy that HRS 2015 rates Class IIa and the 2026 JAMA review calls first line.
• Propranolol: 0. A medicine, used off-label.
• Pyridostigmine: 0. A medicine, used off-label.
• Midodrine: 0. A medicine, used off-label.
• Fludrocortisone: 0. A medicine, used off-label.
• Ivabradine: 0. A medicine, used off-label.

Strongest trial evidence

Scores by the type and size of the trials and the guideline class, from 0 (no randomized trial) to 3.

• Fluids and salt: 2. A randomized crossover with a controlled diet (14 with POTS), but reviews call the evidence of benefit relatively weak.
• Compression: 3. A randomized crossover in 30 adults showed heart rate on tilt fell as coverage grew (Bourne 2021).
• Exercise: 3. Class IIa in HRS 2015 and heart rate improved in all 7 reviewed studies, though bias risk was moderate to high.
• Propranolol: 2. Randomized placebo-controlled crossovers (54 and 18 people), with hours-long endpoints.
• Pyridostigmine: 1. One randomized single-dose trial in 17 people plus an uncontrolled chart review.
• Midodrine: 1. A 2-week randomized crossover in 20 people and a meta-analysis of mostly small or observational studies.
• Fludrocortisone: 0. No randomized trial specific to POTS. Evidence is a small, old, uncontrolled report of 11 women.
• Ivabradine: 2. A randomized double-blind crossover in 22 people plus meta-analyses that rate the evidence low quality.

Works within hours

Scores by whether a trial measured an effect within hours of a dose or while worn, from 0 (months) to 3.

• Fluids and salt: 2. Oral rehydration raised standing tolerance within an hour in 10 teens (Medow 2019). The sodium diet trial ran 6 days.
• Compression: 3. Effects appeared during a single session and reversed when the garment came off (Bourne 2021, 2026).
• Exercise: 0. Trials trained for 3 months, so benefits build over weeks to months.
• Propranolol: 3. A 20 mg dose lowered standing heart rate and improved symptoms at 2 hours (Raj 2009).
• Pyridostigmine: 3. A 30 mg dose lowered standing heart rate and improved symptoms at 2 hours (Raj 2005).
• Midodrine: 1. Trials covered 2 weeks or longer, so no hours-scale result is listed.
• Fludrocortisone: 0. The only report was open-label before and after, with no timing data.
• Ivabradine: 1. The randomized crossover ran 1 month per arm.

Slows a racing heart directly

Scores by whether the option acts on heart rate itself and by the heart rate drop a trial reported, from 0 to 3.

• Fluids and salt: 1. A high-sodium diet lowered the rise on standing, but it stayed 46 bpm against 19 in controls (Garland 2021).
• Compression: 1. Heart rate on tilt fell from 109 to 92 bpm with full coverage, by reducing blood pooling (Bourne 2021).
• Exercise: 1. Training lowered standing heart rate in small studies (Fu 2011, George 2016).
• Propranolol: 3. It slows the heart rate, and 20 mg lowered standing heart rate in a randomized trial.
• Pyridostigmine: 2. It lowered standing heart rate from 111 to 100 bpm versus placebo (Raj 2005).
• Midodrine: 0. It tightens blood vessels and does not act on heart rate directly.
• Fludrocortisone: 0. It expands blood volume and does not act on heart rate directly.
• Ivabradine: 3. It slows the sinus node directly, and standing heart rate fell 18.5 bpm on average across 9 studies (Kumar 2026).

Cautions and Ask-first flags

• My blood pressure runs low, Propranolol: Can worsen low blood pressure and fatigue.
• My blood pressure runs high, Fluids and salt: Salt adds sodium, which matters with high blood pressure.
• My blood pressure runs high, Midodrine: Raises blood pressure when lying down, with a boxed warning for supine high blood pressure.
• My blood pressure runs high, Fludrocortisone: Can raise blood pressure and lower potassium.
• I have asthma, Propranolol: Can worsen asthma.
• I may become pregnant, Ivabradine: Not for use in pregnancy, and it needs contraception counseling.
• I have kidney disease or heart failure, Fluids and salt: Salt adds sodium, which matters with kidney disease or heart failure.