Do you prefer ivabradine over a beta-blocker as first-line heart rate control in a patient with hyperadrenergic postural orthostatic tachycardia syndrome?

To quote Voltaire, "If you are going to speak with me, you must first define your terms."

Hyperadrenergic POTS, so-called, is an ill-defined entity for which there are no agreed-upon criteria. There are four generally accepted markers of excessive sympathetic tone, however:

• Standing norepinephrine ...

I prefer it, but most of our insurance companies do not. :)

In all seriousness, we prescribe the beta-blocker to document "failure of a first-line option," then attempt ivabradine PA. More often, we must also document failure of a non-dihydropyridine CCB before we sniff coverage for ivabradine.