What Actually Causes POTS? A Mechanistic Reading of Postural Orthostatic Tachycardia Syndrome — What this means for treatment

A treatment approach anchored in the four-pathway stratification looks different from standard POTS care. Symptomatic management runs throughout, because the symptomatic relief is real and the patient deserves to feel better while the upstream work proceeds. The added work depends on the dominant pathway. For Pathway 1, the sequence is roughly: assess the post-viral context, restore the NAD+ pool, address any persistent infection or immune dysregulation, support the autonomic ganglion bioenergetic recovery with mitochondrial cofactor work, add reconditioning carefully once the bioenergetic state can sustain it. For Pathway 2, the sequence is roughly: address the gut driver per the Host Capacity Model approach to gut dysfunction , work the vagal tone directly through breath work, cold exposure, and other autonomic interventions, address any concurrent MCAS through pattern stratification. For Pathway 3, the sequence is roughly: confirm the hEDS or hypermobility substrate, optimize the structural management (compression, joint protection, pelvic floor work in many cases), support the connective tissue nutritionally, address the concurrent MCAS and gut features as their patterns indicate. For Pathway 4, the sequence is roughly: structured graduated reconditioning per the Levine protocol or equivalent, plasma volume expansion, beta blockade as needed for symptom control, careful att