From "evidence is scarce" to trial-ready care pathways in POTS: an audit-ready roadmap prompted by Schiweck et al.

Postural orthostatic tachycardia syndrome (POTS) represents a growing clinical and public health challenge, particularly in the context of post-infectious and post-COVID-19 syndromes. Recent systematic synthesis highlights that, despite widespread clinical use of pharmacologic and non-pharmacologic interventions, high-certainty randomized evidence remains scarce and heterogeneous. In this correspondence, prompted by contemporary treatment reviews, we argue that the primary limitation is no longer the absence of therapies but the absence of decision-grade trial architecture. We propose an audit-ready, globally scalable framework that integrates phenotype-stratified pragmatic trials, platform-based comparative effectiveness designs, and a minimum core outcome set anchored to minimally clinically important differences. Emphasis is placed on patient-relevant functional recovery, interpretability across health systems, and equitable implementation beyond tertiary autonomic centers.