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Dixit K, Frishman WH. Postural Tachycardia Syndrome and COVID-19: Focus on Ivabradine Therapy. Cardiol Rev 2024; 32:279-284. [PMID: 36729924 DOI: 10.1097/crd.0000000000000503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In this article we discuss the association of postural orthostatic tachycardia syndrome (POTS) with coronavirus-19 (COVID-19), ivabradine's unique mechanism of action, and its use in POTS patients. We highlight the pathophysiology and common etiologies of POTS, including preceding viral infections, vaccines, trauma, surgeries, and other stressors. COVID-19, a viral illness, has been associated with POTS through a variety of mechanisms that are not yet well understood. The initial management strategy for POTS is largely nonpharmacological, focusing on increasing venous return to the heart through physical therapy or other exercise activities. Ivabradine is a selective inhibitor of the funny sodium channels within the sinoatrial node. This unique mechanism of action allows for the reduction of heart rate without any effect on the heart's ionotropic activity. With an increase in the number of POTS cases, especially during the COVID pandemic, the importance of utilizing new medications and management strategies for POTS becomes imperative. Though ivabradine is currently only approved for the management of patients with coronary artery disease and heart failure by the Food and Drug Administration (FDA), it has also proven to be effective at reducing symptoms among patients with refractory POTS, and thus, should be considered for the management of patients who do not respond to initial treatment strategies.
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Affiliation(s)
- Keshav Dixit
- From the Department of Medicine, ISMMS Mount Sinai Morningside-West, New York, New York
| | - William H Frishman
- Departments of Medicine and Cardiology, New York Medical College and Westchester Medical Center, Valhalla, NY
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2
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Peebles KC, Jacobs C, Makaroff L, Pacey V. The use and effectiveness of exercise for managing postural orthostatic tachycardia syndrome in young adults with joint hypermobility and related conditions: A scoping review. Auton Neurosci 2024; 252:103156. [PMID: 38401460 DOI: 10.1016/j.autneu.2024.103156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 02/06/2024] [Accepted: 02/10/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE Postural Orthostatic Tachycardia Syndrome (POTS) is a form of dysautonomia. It may occur in isolation, but frequently co-exists in individuals with hypermobile variants of Ehlers-Danlos Syndrome (EDS) and related conditions (chronic fatigue syndrome [CFS] and fibromyalgia). Exercise is recommended for non-pharmacological POTS management but needs to be individualised. This scoping review explores the current literature on use and effectiveness of exercise-based management for POTS, with specific focus on individuals with joint hypermobility and related conditions who experience hypermobility, and/or pain, and/or fatigue. METHODS A systematic search, to January 2023, of Medline, EMBASE, AMED, CINAHL and the Cochrane library was conducted. Studies that reported on adolescents and adults who had been diagnosed with POTS using standard criteria and underwent an exercise-based training intervention were included. RESULTS Following full-text screening, 10 articles were identified (2 randomised control trials, 4 comparative studies and 4 case reports). One comparative study reported a small subset of participants with EDS and one case report included an individual diagnosed with CFS; the remainder investigated a wider POTS population. Overall, 3 months of endurance followed by resistance exercise, graduating from the horizontal-to-upright position reduced POTS symptoms and improved quality-of-life. CONCLUSION The findings highlight a paucity of higher-level studies documenting exercise for POTS management in people with joint hypermobility and related conditions. Results from the wider POTS population demonstrate exercise is safe and effective. Large, well-designed clinical studies exploring exercise for POTS management adapting to meet the complex musculoskeletal and non-musculoskeletal features of symptomatic joint hypermobility are needed.
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Affiliation(s)
- Karen C Peebles
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.
| | - Charl Jacobs
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Logan Makaroff
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Verity Pacey
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
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3
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Minhas R, Bharadwaj AS. COVID-19-Induced Postural Orthostatic Tachycardia Syndrome and Dysautonomia. Cureus 2023; 15:e40235. [PMID: 37435242 PMCID: PMC10332885 DOI: 10.7759/cureus.40235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2023] [Indexed: 07/13/2023] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a disorder characterized by orthostatic intolerance and, by definition, includes clinical symptoms of lightheadedness, palpitations, and tremulousness among others. It is considered a relatively rare condition that affects approximately 0.2% of the general population, and it is estimated that between 500,000 to 1,000,000 individuals in the United States have the condition and recently has been linked to post-infectious (viral) etiologies. We present a case of a 53-year-old woman who was diagnosed with POTS following extensive autoimmune workup, who was also status post-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The post-coronavirus disease 2019 (COVID-19) cardiovascular autonomic dysfunction can affect global circulatory control, which describes increased heart rate even at resting states, and local circulatory disorders, such as coronary microvascular disease leading to vasospasm, as described by the patient's chest pain, and venous retention leading to pooling and reduced venous return after standing. Along with tachycardia with orthostatic intolerance, other symptoms can also accompany the syndrome. In the majority of patients, intravascular volume is reduced, leading to decreased venous return to the heart and causing reflex tachycardia and orthostatic intolerance. Management varies from lifestyle modifications to pharmacologic therapy, to which patients generally show a good response. POTS should be a differential on the cards, especially in patients post-COVID-19 infection, as these symptoms can be misdiagnosed as having psychological etiologies.
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Affiliation(s)
- Resnah Minhas
- Medicine, American University of Antigua, St. Johns, ATG
| | - Adithya Sateesh Bharadwaj
- Medicine, University of Maryland Midtown Campus, Baltimore, USA
- Medicine, American University of Antigua, St. Johns, ATG
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de Oliveira MDCS, Távora-Mehta MZP, Mehta N, Magajevski AS, Concato L, Ortiz MR, Doubrawa E, Lofrano-Alves MS. Distinct Hemodynamic Responses That Culminate With Postural Orthostatic Tachycardia Syndrome. Am J Cardiol 2023; 197:3-12. [PMID: 37104891 DOI: 10.1016/j.amjcard.2023.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/08/2023] [Accepted: 03/26/2023] [Indexed: 04/29/2023]
Abstract
It is of paramount importance to characterize the individual hemodynamic response of patients with postural orthostatic tachycardia syndrome (POTS) to select the best therapeutic intervention. Our aim in this study was to describe the hemodynamic changes in 40 patients with POTS during the head-up tilt test and compare them with 48 healthy patients. Hemodynamic parameters were obtained by cardiac bioimpedance. Patients were compared in supine position and after 5, 10, 15, and 20 minutes of orthostatic position. Patients with POTS demonstrated higher heart rate (74 beats per minute [64 to 80] vs 67 [62 to 72], p <0.001) and lower stroke volume (SV) (83.0 ml [72 to 94] vs 90 [79 to 112], p <0.001) at supine position. The response to orthostatic challenge was characterized by a decrease in SV index (SVI) in both groups (ΔSVI in ml/m2: -16 [-25 to -7.] vs -11 [-17 to -6.1], p = NS). Peripheral vascular resistance (PVR) was reduced only in POTS (ΔPVR in dyne.seg/cm5:-52 [-279 to 163] vs 326 [58 to 535], p <0.001). According to the best cut-off points obtained using the receiver operating characteristic analysis for the variation of SVI (-15.5%) and PVR index (PVRI) (-5.5%), we observed 4 distinct groups of POTS: 10% presented an increase in both SVI and PVRI after the orthostatic challenge, 35% presented a PVRI decrease with SVI maintenance or increase, 37.5% presented an SVI decrease with PVRI maintenance or elevation, and 17.5% presented a reduction in both variables. Body mass index, ΔSVI, and ΔPVRI were strongly correlated with POTS (area under the curve = 0.86 [95% confidence interval 0.77 to 0.92], p <0.0001). In conclusion, the use of appropriate cut-off points for hemodynamic parameters using bioimpedance cardiography during the head-up tilt test could be a useful strategy to identify the main mechanism involved and to select the best individual therapeutic strategy in POTS.
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Affiliation(s)
| | - Maria Zildany P Távora-Mehta
- Postgraduate Program in Internal Medicine, Internal Medicine Department, Federal University of Parana, Curitiba, Parana, Brazil
| | - Niraj Mehta
- Postgraduate Program in Internal Medicine, Internal Medicine Department, Federal University of Parana, Curitiba, Parana, Brazil
| | - Adriano Senter Magajevski
- Postgraduate Program in Internal Medicine, Internal Medicine Department, Federal University of Parana, Curitiba, Parana, Brazil
| | - Leticia Concato
- Postgraduate Program in Internal Medicine, Internal Medicine Department, Federal University of Parana, Curitiba, Parana, Brazil
| | - Marcio Rogerio Ortiz
- Postgraduate Program in Internal Medicine, Internal Medicine Department, Federal University of Parana, Curitiba, Parana, Brazil
| | - Eduardo Doubrawa
- Postgraduate Program in Internal Medicine, Internal Medicine Department, Federal University of Parana, Curitiba, Parana, Brazil
| | - Marco Stephan Lofrano-Alves
- Postgraduate Program in Internal Medicine, Internal Medicine Department, Federal University of Parana, Curitiba, Parana, Brazil.
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COVID-19 Induced Postural Orthostatic Tachycardia Syndrome (POTS): A Review. Cureus 2023; 15:e36955. [PMID: 37009342 PMCID: PMC10065129 DOI: 10.7759/cureus.36955] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2023] [Indexed: 04/03/2023] Open
Abstract
POTS (Postural Orthostatic Tachycardia Syndrome) is a multisystem disorder characterized by the abnormal autonomic response to an upright posture, causing orthostatic intolerance and excessive tachycardia without hypotension. Recent reports suggest that a significant percentage of COVID-19 survivors develop POTS within 6 to 8 months of infection. Prominent symptoms of POTS include fatigue, orthostatic intolerance, tachycardia, and cognitive impairment. The exact mechanisms of post-COVID-19 POTS are unclear. Still, different hypotheses have been given, including autoantibody production against autonomic nerve fibers, direct toxic effects of SARS-CoV-2, or sympathetic nervous system stimulation secondary to infection. Physicians should have a high suspicion of POTS in COVID-19 survival when presented with symptoms of autonomic dysfunction and should conduct diagnostic tests like the Tilt table and others to confirm it. The management of COVID-19-related POTS requires a comprehensive approach. Most patients respond to initial non-pharmacological options, but when the symptoms become more severe and they do not respond to the non-pharmacological approach, pharmacological options are considered. We have limited understanding and knowledge of post-COVID-19 POTS, and further research is warranted to improve our understanding and formulate a better management plan.
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Ormiston CK, Świątkiewicz I, Taub PR. Postural orthostatic tachycardia syndrome as a sequela of COVID-19. Heart Rhythm 2022; 19:1880-1889. [PMID: 35853576 PMCID: PMC9287587 DOI: 10.1016/j.hrthm.2022.07.014] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 07/08/2022] [Accepted: 07/12/2022] [Indexed: 12/19/2022]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a complex multisystem disorder characterized by orthostatic intolerance and tachycardia and may be triggered by viral infection. Recent reports indicate that 2%-14% of coronavirus disease 2019 (COVID-19) survivors develop POTS and 9%-61% experience POTS-like symptoms, such as tachycardia, orthostatic intolerance, fatigue, and cognitive impairment within 6-8 months of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Pathophysiological mechanisms of post-COVID-19 POTS are not well understood. Current hypotheses include autoimmunity related to SARS-CoV-2 infection, autonomic dysfunction, direct toxic injury by SARS-CoV-2 to the autonomic nervous system, and invasion of the central nervous system by SARS-CoV-2. Practitioners should actively assess POTS in patients with post-acute COVID-19 syndrome symptoms. Given that the symptoms of post-COVID-19 POTS are predominantly chronic orthostatic tachycardia, lifestyle modifications in combination with the use of heart rate-lowering medications along with other pharmacotherapies should be considered. For example, ivabradine or β-blockers in combination with compression stockings and increasing salt and fluid intake has shown potential. Treatment teams should be multidisciplinary, including physicians of various specialties, nurses, psychologists, and physiotherapists. Additionally, more resources to adequately care for this patient population are urgently needed given the increased demand for autonomic specialists and clinics since the start of the COVID-19 pandemic. Considering our limited understanding of post-COVID-19 POTS, further research on topics such as its natural history, pathophysiological mechanisms, and ideal treatment is warranted. This review evaluates the current literature available on the associations between COVID-19 and POTS, possible mechanisms, patient assessment, treatments, and future directions to improving our understanding of post-COVID-19 POTS.
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Affiliation(s)
- Cameron K Ormiston
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, San Diego, California; Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland
| | - Iwona Świątkiewicz
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, San Diego, California; Department of Cardiology and Internal Medicine, Nicolaus Copernicus University Torun, Collegium Medicum in Bydgoszcz, Bydgoszcz, Poland
| | - Pam R Taub
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, San Diego, California.
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Mayuga KA, Fedorowski A, Ricci F, Gopinathannair R, Dukes JW, Gibbons C, Hanna P, Sorajja D, Chung M, Benditt D, Sheldon R, Ayache MB, AbouAssi H, Shivkumar K, Grubb BP, Hamdan MH, Stavrakis S, Singh T, Goldberger JJ, Muldowney JAS, Belham M, Kem DC, Akin C, Bruce BK, Zahka NE, Fu Q, Van Iterson EH, Raj SR, Fouad-Tarazi F, Goldstein DS, Stewart J, Olshansky B. Sinus Tachycardia: a Multidisciplinary Expert Focused Review. Circ Arrhythm Electrophysiol 2022; 15:e007960. [PMID: 36074973 PMCID: PMC9523592 DOI: 10.1161/circep.121.007960] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sinus tachycardia (ST) is ubiquitous, but its presence outside of normal physiological triggers in otherwise healthy individuals remains a commonly encountered phenomenon in medical practice. In many cases, ST can be readily explained by a current medical condition that precipitates an increase in the sinus rate, but ST at rest without physiological triggers may also represent a spectrum of normal. In other cases, ST may not have an easily explainable cause but may represent serious underlying pathology and can be associated with intolerable symptoms. The classification of ST, consideration of possible etiologies, as well as the decisions of when and how to intervene can be difficult. ST can be classified as secondary to a specific, usually treatable, medical condition (eg, pulmonary embolism, anemia, infection, or hyperthyroidism) or be related to several incompletely defined conditions (eg, inappropriate ST, postural tachycardia syndrome, mast cell disorder, or post-COVID syndrome). While cardiologists and cardiac electrophysiologists often evaluate patients with symptoms associated with persistent or paroxysmal ST, an optimal approach remains uncertain. Due to the many possible conditions associated with ST, and an overlap in medical specialists who see these patients, the inclusion of experts in different fields is essential for a more comprehensive understanding. This article is unique in that it was composed by international experts in Neurology, Psychology, Autonomic Medicine, Allergy and Immunology, Exercise Physiology, Pulmonology and Critical Care Medicine, Endocrinology, Cardiology, and Cardiac Electrophysiology in the hope that it will facilitate a more complete understanding and thereby result in the better care of patients with ST.
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Affiliation(s)
- Kenneth A. Mayuga
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Artur Fedorowski
- Karolinska Institutet & Karolinska University Hospital, Stockholm, Sweden
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, “G.d’Annunzio” University of Chieti-Pescara, Chieti Scalo, Italy
| | | | | | | | | | | | - Mina Chung
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Phoenix, AZ
| | - David Benditt
- University of Minnesota Medical School, Minneapolis, MN
| | | | - Mirna B. Ayache
- MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Hiba AbouAssi
- Division of Endocrinology, Metabolism, and Nutrition, Duke University Medical Center, Durham, NC
| | | | | | | | | | - Tamanna Singh
- Department of Cardiovascular Medicine, Cleveland Clinic, OH
| | | | - James A. S. Muldowney
- Vanderbilt University Medical Center &Tennessee Valley Healthcare System, Nashville Campus, Department of Veterans Affairs, Nashville, TN
| | - Mark Belham
- Cambridge University Hospitals NHS FT, Cambridge, UK
| | - David C. Kem
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Cem Akin
- University of Michigan, Ann Arbor, MI
| | | | - Nicole E. Zahka
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Qi Fu
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas & University of Texas Southwestern Medical Center, Dallas, TX
| | - Erik H. Van Iterson
- Section of Preventive Cardiology & Rehabilitation, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic Cleveland, OH
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Wafa SEI, Chahal CAA, Sawatari H, Khanji MY, Khan H, Asatryan B, Ahmed R, Deshpande S, Providencia R, Deshmukh A, Owens AT, Somers VK, Padmanabhan D, Connolly H. Frequency of Arrhythmias and Postural Orthostatic Tachycardia Syndrome in Patients With Marfan Syndrome: A Nationwide Inpatient Study. J Am Heart Assoc 2022; 11:e024939. [PMID: 36000435 PMCID: PMC9496423 DOI: 10.1161/jaha.121.024939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Marfan syndrome (MFS) is an autosomal dominant connective tissue disorder affecting multiple systems, particularly the cardiovascular system. The leading causes of death in MFS are aortopathies and valvular disease. We wanted to identify the frequency of arrhythmia and postural orthostatic tachycardia syndrome, length of hospital stay, health care-associated costs (HAC), and in-hospital mortality in patients with MFS. Methods and Results The National Inpatient Sample database from 2005 to 2014 was queried using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for MFS and arrhythmias. Patients were classified into subgroups: supraventricular tachycardia, ventricular tachycardia (VT), atrial fibrillation, atrial flutter, and without any type of arrhythmia. Data about length of stay, HAC, and in-hospital mortality were also abstracted from National Inpatient Sample database. Adjusted HAC was calculated as multiplying HAC and cost-to-charge ratio; 12 079 MFS hospitalizations were identified; 1893 patients (15.7%) had an arrhythmia; and 4.9% of the patients had postural orthostatic tachycardia syndrome. Median values of length of stay and adjusted HAC in VT group were the highest among the groups (VT: 6 days, $18 975.8; supraventricular tachycardia: 4 days, $11 906.6; atrial flutter: 4 days, $11 274.5; atrial fibrillation: 5 days, $10431.4; without any type of arrhythmia: 4 days, $8336.6; both P=0.0001). VT group had highest in-patient mortality (VT: 5.3%, atrial fibrillation: 4.1%, without any type of arrhythmia: 2.1%, atrial flutter: 1.7%, supraventricular tachycardia: 0%; P<0.0001) even after adjustment for potential confounders (without any type of arrhythmia versus VT; odds ratio [95% CI]: 3.18 [1.62-6.24], P=0.001). Conclusions Arrhythmias and postural orthostatic tachycardia syndrome in MFS were high and associated with increased length of stay, HAC, and in-hospital mortality especially in patients with VT.
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Affiliation(s)
- Syed Emir Irfan Wafa
- Department of Cardiology Northampton General Hospital Northampton United Kingdom
| | - C Anwar A Chahal
- Division of Cardiology, Department of Medicine University of Pennsylvania Philadelphia PA.,Department of Cardiovascular Diseases Mayo Clinic Rochester MN.,Department of Cardiology, Barts Heart Centre Barts Health NHS Trust London United Kingdom
| | - Hiroyuki Sawatari
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN.,Department of Perioperative and Critical Care Management Hiroshima University Hiroshima Japan
| | - Mohammed Y Khanji
- NIHR Barts Cardiovascular Biomedical Research Centre, Barts and The London School of Medicine and Dentistry Queen Mary University of London London United Kingdom.,Department of Cardiology St. Bartholomew's Hospital London United Kingdom.,Department of Cardiology Newham University Hospital, Barts Health NHS Trust London United Kingdom
| | - Hassan Khan
- Leon H. Charney Division of Cardiology New York University Langone Health New York NY
| | - Babken Asatryan
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Raheel Ahmed
- Department of Cardiology Royal Brompton Hospital London United Kingdom
| | - Saurabh Deshpande
- Sri Jayadeva Institute of Cardiovascular Sciences and Research Bangalore Karnataka
| | - Rui Providencia
- Department of Cardiology, Barts Heart Centre Barts Health NHS Trust London United Kingdom
| | | | - Anjali Tiku Owens
- Division of Cardiology, Department of Medicine University of Pennsylvania Philadelphia PA
| | - Virend K Somers
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | - Deepak Padmanabhan
- Division of Cardiology, Department of Medicine University of Pennsylvania Philadelphia PA.,Department of Cardiovascular Diseases Mayo Clinic Rochester MN.,Sri Jayadeva Institute of Cardiovascular Sciences and Research Bangalore Karnataka
| | - Heidi Connolly
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
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Benito KG, Ramanathan A, Lobato D, Jandasek B, Mamaril E, McBride H, Feit LR. Symptoms, impairment and treatment needs among youth with orthostatic intolerance in a secondary care setting. CHILDRENS HEALTH CARE 2022. [DOI: 10.1080/02739615.2022.2047049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Kristen G. Benito
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Pediatric Heart Center, Hasbro Children’s Hospital, Providence, RI, USA
| | - Amrita Ramanathan
- Pediatric Heart Center, Hasbro Children’s Hospital, Providence, RI, USA
| | - Debra Lobato
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Barbara Jandasek
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Pediatric Heart Center, Hasbro Children’s Hospital, Providence, RI, USA
| | - Erin Mamaril
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Haley McBride
- Pediatric Heart Center, Hasbro Children’s Hospital, Providence, RI, USA
| | - Lloyd R. Feit
- Pediatric Heart Center, Hasbro Children’s Hospital, Providence, RI, USA
- Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Long-COVID Syndrome and the Cardiovascular System: A Review of Neurocardiologic Effects on Multiple Systems. Curr Cardiol Rep 2022; 24:1711-1726. [PMID: 36178611 PMCID: PMC9524329 DOI: 10.1007/s11886-022-01786-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Long-COVID syndrome is a multi-organ disorder that persists beyond 12 weeks post-acute SARS-CoV-2 infection (COVID-19). Here, we provide a definition for this syndrome and discuss neuro-cardiology involvement due to the effects of (1) angiotensin-converting enzyme 2 receptors (the entry points for the virus), (2) inflammation, and (3) oxidative stress (the resultant effects of the virus). RECENT FINDINGS These effects may produce a spectrum of cardio-neuro effects (e.g., myocardial injury, primary arrhythmia, and cardiac symptoms due to autonomic dysfunction) which may affect all systems of the body. We discuss the symptoms and suggest therapies that target the underlying autonomic dysfunction to relieve the symptoms rather than merely treating symptoms. In addition to treating the autonomic dysfunction, the therapy also treats chronic inflammation and oxidative stress. Together with a full noninvasive cardiac workup, a full assessment of the autonomic nervous system, specifying parasympathetic and sympathetic (P&S) activity, both at rest and in response to challenges, is recommended. Cardiac symptoms must be treated directly. Cardiac treatment is often facilitated by treating the P&S dysfunction. Cardiac symptoms of dyspnea, chest pain, and palpitations, for example, need to be assessed objectively to differentiate cardiac from neural (autonomic) etiology. Long-term myocardial injury commonly involves P&S dysfunction. P&S assessment usually connects symptoms of Long-COVID to the documented autonomic dysfunction(s).
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11
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Yanagimoto Y. Transition of adult patients with pediatric orthostatic intolerance from child-centered care to adult-centered care. Front Pediatr 2022; 10:946306. [PMID: 36389345 PMCID: PMC9650207 DOI: 10.3389/fped.2022.946306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yoshitoki Yanagimoto
- Department of Pediatrics, Kansai Medical University, Hirakata, Japan.,Department of Pediatrics, Kansai Medical University Medical Center, Moriguchi, Japan
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12
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van der Ster BJP, Kim YS, Westerhof BE, van Lieshout JJ. Central Hypovolemia Detection During Environmental Stress-A Role for Artificial Intelligence? Front Physiol 2021; 12:784413. [PMID: 34975538 PMCID: PMC8715014 DOI: 10.3389/fphys.2021.784413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/18/2021] [Indexed: 11/19/2022] Open
Abstract
The first step to exercise is preceded by the required assumption of the upright body position, which itself involves physical activity. The gravitational displacement of blood from the chest to the lower parts of the body elicits a fall in central blood volume (CBV), which corresponds to the fraction of thoracic blood volume directly available to the left ventricle. The reduction in CBV and stroke volume (SV) in response to postural stress, post-exercise, or to blood loss results in reduced left ventricular filling, which may manifest as orthostatic intolerance. When termination of exercise removes the leg muscle pump function, CBV is no longer maintained. The resulting imbalance between a reduced cardiac output (CO) and a still enhanced peripheral vascular conductance may provoke post-exercise hypotension (PEH). Instruments that quantify CBV are not readily available and to express which magnitude of the CBV in a healthy subject should remains difficult. In the physiological laboratory, the CBV can be modified by making use of postural stressors, such as lower body "negative" or sub-atmospheric pressure (LBNP) or passive head-up tilt (HUT), while quantifying relevant biomedical parameters of blood flow and oxygenation. Several approaches, such as wearable sensors and advanced machine-learning techniques, have been followed in an attempt to improve methodologies for better prediction of outcomes and to guide treatment in civil patients and on the battlefield. In the recent decade, efforts have been made to develop algorithms and apply artificial intelligence (AI) in the field of hemodynamic monitoring. Advances in quantifying and monitoring CBV during environmental stress from exercise to hemorrhage and understanding the analogy between postural stress and central hypovolemia during anesthesia offer great relevance for healthy subjects and clinical populations.
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Affiliation(s)
- Björn J. P. van der Ster
- Department of Internal Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Anesthesiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Laboratory for Clinical Cardiovascular Physiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Yu-Sok Kim
- Laboratory for Clinical Cardiovascular Physiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Internal Medicine, Medisch Centrum Leeuwarden, Leeuwarden, Netherlands
| | - Berend E. Westerhof
- Laboratory for Clinical Cardiovascular Physiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Pulmonary Medicine, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Johannes J. van Lieshout
- Department of Internal Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Laboratory for Clinical Cardiovascular Physiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Medical Research Council Versus Arthritis Centre for Musculoskeletal Ageing Research, Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, The Medical School, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, United Kingdom
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13
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Chronic Fatigue Syndrome and Cardiovascular Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 78:1056-1067. [PMID: 34474739 DOI: 10.1016/j.jacc.2021.06.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/21/2021] [Indexed: 11/22/2022]
Abstract
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a medically unexplained illness characterized by severe fatigue limiting normal daily activities for at least 6 months accompanied by problems with unrefreshing sleep, exacerbation of symptoms following physical or mental efforts (postexertional malaise [PEM]), and either cognitive reports or physiological evidence of orthostatic intolerance in the form of either orthostatic tachycardia and/or hypocapnia. Although rarely considered to have cardiac dysfunction, ME/CFS patients frequently have reduced stroke volume with a significant inverse relation between cardiac output and PEM severity. Magnetic resonance imaging of ME/CFS patients compared with normal control subjects found significantly reduced stroke, end-systolic, and end-diastolic volumes together with reduced end-diastolic wall mass. Another cardiovascular abnormality is reduced nocturnal blood pressure assessed by 24-hour monitoring. Autonomic dysfunction is also frequently observed with postural orthostatic tachycardia and/or hypocapnia. Two consecutive cardiopulmonary stress tests may provide metabolic data substantiating PEM.
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14
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Koudelka M, Sovová E. COVID-19 Causing Hypotension in Frail Geriatric Hypertensive Patients? ACTA ACUST UNITED AC 2021; 57:medicina57060633. [PMID: 34207161 PMCID: PMC8235779 DOI: 10.3390/medicina57060633] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/10/2021] [Accepted: 06/15/2021] [Indexed: 01/16/2023]
Abstract
Background: The association of coronavirus disease 2019 (COVID-19) with hypertension has been one of the frequently discussed topics in current studies since hypertension was identified as a risk factor for coronavirus disease. However, no studies seem to be focused on the BP (blood pressure) in patients with hypertension after COVID-19. Report: This report presents the cases of five frail geriatric patients (avg. age 78.3 (±6.4) years) with sarcopenia and controlled hypertension (office BP < 140 mmHg) who were diagnosed with SARS-CoV-2. Findings: Control ABPM performed after COVID-19 showed that these hypertensive patients were hypotensive and that the previously well-established therapy was suddenly too intensive for them. Conclusions: These findings suggest that BP control after COVID-19 is needed and that ABPM is, particularly in frail geriatric patients, by no means a luxury but a necessity.
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Affiliation(s)
- Marek Koudelka
- Department of Exercise Medicine and Cardiovascular Rehabilitation, Palacký University Olomouc and University Hospital Olomouc, 77520 Olomouc, Czech Republic;
- Department of Internal Medicine, FRANZISKUS SPITAL GmbH, Landstraßer Hauptstraße 4a, 1030 Vienna, Austria
- Correspondence: ; Tel.: +43-1-71126; Fax: +43-1-711269968
| | - Eliška Sovová
- Department of Exercise Medicine and Cardiovascular Rehabilitation, Palacký University Olomouc and University Hospital Olomouc, 77520 Olomouc, Czech Republic;
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15
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van Campen CLMC, Rowe PC, Visser FC. Deconditioning does not explain orthostatic intolerance in ME/CFS (myalgic encephalomyelitis/chronic fatigue syndrome). J Transl Med 2021; 19:193. [PMID: 33947430 PMCID: PMC8097965 DOI: 10.1186/s12967-021-02819-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/08/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Orthostatic intolerance (OI) is a frequent finding in individuals with myalgic encephalomyelitis /chronic fatigue syndrome (ME/CFS). Published studies have proposed that deconditioning is an important pathophysiological mechanism in various forms of OI, including postural orthostatic tachycardia syndrome (POTS), however conflicting opinions exist. Deconditioning can be classified objectively using the predicted peak oxygen consumption (VO2) values from cardiopulmonary exercise testing (CPET). Therefore, if deconditioning is an important contributor to OI symptomatology, one would expect a relation between the degree of reduction in peak VO2during CPET and the degree of reduction in CBF during head-up tilt testing (HUT). METHODS AND RESULTS In 22 healthy controls and 199 ME/CFS patients were included. Deconditioning was classified by the CPET response as follows: %peak VO2 ≥ 85% = no deconditioning, %peak VO2 65-85% = mild deconditioning, and %peak VO2 < 65% = severe deconditioning. HC had higher oxygen consumption at the ventilatory threshold and at peak exercise as compared to ME/CFS patients (p ranging between 0.001 and < 0.0001). Although ME/CFS patients had significantly greater CBF reduction than HC (p < 0.0001), there were no differences in CBF reduction among ME/CFS patients with no, mild, or severe deconditioning. We classified the hemodynamic response to HUT into three categories: those with a normal heart rate and blood pressure response, postural orthostatic tachycardia syndrome, or orthostatic hypotension. No difference in the degree of CBF reduction was shown in those three groups. CONCLUSION This study shows that in ME/CFS patients orthostatic intolerance is not caused by deconditioning as defined on cardiopulmonary exercise testing. An abnormal high decline in cerebral blood flow during orthostatic stress was present in all ME/CFS patients regardless of their %peak VO2 results on cardiopulmonary exercise testing.
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Affiliation(s)
| | - Peter C Rowe
- Department of Paediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Frans C Visser
- Stichting CardioZorg, Planetenweg 5, 2132 HN, Hoofddorp, Netherlands
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16
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Dixit NM, Churchill A, Nsair A, Hsu JJ. Post-Acute COVID-19 Syndrome and the cardiovascular system: What is known? AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2021; 5:100025. [PMID: 34192289 PMCID: PMC8223036 DOI: 10.1016/j.ahjo.2021.100025] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/08/2021] [Accepted: 06/10/2021] [Indexed: 02/06/2023]
Abstract
Post-Acute COVID-19 Syndrome (PACS) is defined by persistent symptoms >3-4 weeks after onset of COVID-19. The mechanism of these persistent symptoms is distinct from acute COVID-19 although not completely understood despite the high incidence of PACS. Cardiovascular symptoms such as chest pain and palpitations commonly occur in PACS, but the underlying cause of symptoms is infrequently known. While autopsy studies have shown that the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) rarely causes direct myocardial injury, several syndromes such as myocarditis, pericarditis, and Postural Orthostatic Tachycardia Syndrome have been implicated in PACS. Additionally, patients hospitalized with acute COVID-19 who display biomarker evidence of myocardial injury may have underlying coronary artery disease revealed by the physiological stress of SARS-CoV-2 infection and may benefit from medical optimization. We review what is known about PACS and the cardiovascular system and propose a framework for evaluation and management of related symptoms.
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Key Words
- ACE2, angiotensin converting enzyme-2
- AF/AFL, atrial fibrillation or flutter
- CBT, cognitive behavioral therapy
- CFS, Chronic Fatigue Syndrome
- CMR, cardiac magnetic resonance imaging
- CRP, C-reactive protein
- CV, cardiovascular
- Cardiology
- Coronavirus Disease 2019
- ECG, electrocardiography
- ECV, extracellular volume
- LGE, late gadolinium enhancement
- Long COVID
- Long-Haul COVID
- MCAS, Mast Cell Activation Syndrome
- MERS, Middle East Respiratory Syndrome
- POTS, Post-Acute COVID-19 Syndrome
- SARS-COV-1, Severe Acute Respiratory Syndrome Coronavirus-1
- SARS-CoV-2
- T1MI, type 1 myocardial infarction
- T2MI, type 2 myocardial infarction
- TTT, tilt table testing
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Affiliation(s)
- Neal M. Dixit
- Department of Medicine, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Austin Churchill
- School of Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA 90095, USA
| | - Ali Nsair
- Department of Medicine, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA 90095, USA,Division of Cardiology, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Jeffrey J. Hsu
- Department of Medicine, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA 90095, USA,Division of Cardiology, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA 90095, USA,Veterans Affairs Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA 90073, USA,Corresponding author at: UCLA Center for Health Sciences, A2-237, 650 Charles E. Young Dr. South, Los Angeles, CA 90095-1679, USA
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17
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Barbic F, Minonzio M, Cairo B, Shiffer D, Zamuner AR, Cavalieri S, Dipaola F, Magnavita N, Porta A, Furlan R. Work Ability Assessment and Its Relationship with Cardiovascular Autonomic Profile in Postural Orthostatic Tachycardia Syndrome. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17217836. [PMID: 33114659 PMCID: PMC7662324 DOI: 10.3390/ijerph17217836] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/21/2020] [Accepted: 10/21/2020] [Indexed: 12/28/2022]
Abstract
Postural orthostatic tachycardia syndrome (POTS) negatively impacts quality of life. The excessive increase in cardiac sympathetic modulation during standing, which characterizes POTS patients, leads to many symptoms and signs of orthostatic intolerance. Little is known about the consequences of the disease on work performance and its relationship with individual autonomic profiles. Twenty-two POTS patients regularly engaged in working activity (20 females, age 36 ± 12 years) and 18 gender- and age-matched controls underwent a clinical evaluation and filled out the Work Ability Index (WAI) questionnaire. POTS patients completed the Composite Autonomic Symptom Score (COMPASS31) questionnaire, underwent continuous electrocardiogram, blood pressure and respiratory activity recordings while supine and during a 75° head-up tilt (HUT). A power spectrum analysis provided the index of cardiac sympatho-vagal balance (LF/HF). WAI scores were significantly reduced in POTS patients (29.84 ± 1.40) compared to controls (45.63 ± 0.53, p < 0.01). A significant inverse correlation was found between individual WAI and COMPASS31 scores (r = −0.46; p = 0.03), HUT increase in heart rate (r = −0.57; p = 0.01) and LF/HF (r = −0.55; p = 0.01). In POTS patients, the WAI scores were inversely correlated to the intensity of autonomic symptoms and to the excessive cardiac sympathetic activation induced by the gravitational stimulus.
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Affiliation(s)
- Franca Barbic
- Internal Medicine, Humanitas Clinical and Research Center—IRCCS, Via Manzoni 56, 20089 Rozzano-Milan, Italy; (M.M.); (D.S.); (F.D.); (R.F.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele-Milan, Italy
- Correspondence:
| | - Maura Minonzio
- Internal Medicine, Humanitas Clinical and Research Center—IRCCS, Via Manzoni 56, 20089 Rozzano-Milan, Italy; (M.M.); (D.S.); (F.D.); (R.F.)
| | - Beatrice Cairo
- Department of Biomedical Sciences for Health, University of Milan, 20122 Milan, Italy; (B.C.); (A.P.)
| | - Dana Shiffer
- Internal Medicine, Humanitas Clinical and Research Center—IRCCS, Via Manzoni 56, 20089 Rozzano-Milan, Italy; (M.M.); (D.S.); (F.D.); (R.F.)
| | | | - Silvia Cavalieri
- Department of Life Sciences & Public Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (S.C.); (N.M.)
| | - Franca Dipaola
- Internal Medicine, Humanitas Clinical and Research Center—IRCCS, Via Manzoni 56, 20089 Rozzano-Milan, Italy; (M.M.); (D.S.); (F.D.); (R.F.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele-Milan, Italy
| | - Nicola Magnavita
- Department of Life Sciences & Public Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (S.C.); (N.M.)
- Department of Woman, Children & Public Health, Fondazione Policlinico A. Gemelli—IRCCS, 00168 Rome, Italy
| | - Alberto Porta
- Department of Biomedical Sciences for Health, University of Milan, 20122 Milan, Italy; (B.C.); (A.P.)
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Raffaello Furlan
- Internal Medicine, Humanitas Clinical and Research Center—IRCCS, Via Manzoni 56, 20089 Rozzano-Milan, Italy; (M.M.); (D.S.); (F.D.); (R.F.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele-Milan, Italy
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18
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Treatment Updates in Postural Tachycardia Syndrome. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00643-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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19
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Time Course of Autonomic Symptoms in Postural Orthostatic Tachycardia Syndrome (POTS) Patients: Two-Year Follow-Up Results. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17165872. [PMID: 32823577 PMCID: PMC7460485 DOI: 10.3390/ijerph17165872] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 11/16/2022]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a multifactorial condition capable of chronically reducing the quality of life and the work ability of patients. The study aim was to assess the burden of autonomic symptoms in a cohort of POTS patients over 2 years. Patients’ clinical profiles were assessed by the 31-item Composite Autonomic Symptom Score questionnaire (COMPASS 31) and a visual analog scale (VAS). One-way ANOVA for repeated measures followed by Dunnett’s post-hoc test were used to compare symptoms at baseline and at 1 and 2 years. Out of 42 enrolled patients, 25 had a 1-year follow-up and 12 had a 2-year follow-up. At baseline, the reported burden of autonomic symptoms was high (overall COMPASS 31 = 49.9 ± 14.3 /100). Main complaints were related to orthostatic intolerance according to both COMPASS 31 and VAS. Fourteen patients were rendered inactive because of symptoms. At 1-year follow-up, a statistically significant improvement in pupillomotor function and overall score was detected by the COMPASS 31. These findings were confirmed at 2 years, together with a significant reduction in quality of life impairment, assessed by VAS. However, these improvements did not change patients’ occupational status. Awareness of POTS diagnosis, patient monitoring, and tailored therapies can help to improve patients’ condition.
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20
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Medic Spahic J, Ricci F, Aung N, Hallengren E, Axelsson J, Hamrefors V, Melander O, Sutton R, Fedorowski A. Proteomic analysis reveals sex-specific biomarker signature in postural orthostatic tachycardia syndrome. BMC Cardiovasc Disord 2020; 20:190. [PMID: 32321428 PMCID: PMC7178975 DOI: 10.1186/s12872-020-01465-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 04/05/2020] [Indexed: 12/12/2022] Open
Abstract
Background Postural orthostatic tachycardia syndrome (POTS) is a variant of cardiovascular (CV) autonomic disorder of unknown etiology characterized by an excessive heart rate increase on standing and orthostatic intolerance. In this study we sought to identify novel CV biomarkers potentially implicated in POTS pathophysiology. Methods We conducted a nested case-control study within the Syncope Study of Unselected Population in Malmö (SYSTEMA) cohort including 396 patients (age range, 15–50 years) with either POTS (n = 113) or normal hemodynamic response during passive head-up-tilt test (n = 283). We used a targeted approach to explore changes in cardiovascular proteomics associated with POTS through a sequential two-stage process including supervised principal component analysis and univariate ANOVA with Bonferroni correction. Results POTS patients were younger (26 vs. 31 years; p < 0.001) and had lower BMI than controls. The discovery algorithm identified growth hormone (GH) and myoglobin (MB) as the most specific biomarker fingerprint for POTS. Plasma level of GH was higher (9.37 vs 8.37 of normalised protein expression units (NPX); p = 0.002), whereas MB was lower (4.86 vs 5.14 NPX; p = 0.002) in POTS compared with controls. In multivariate regression analysis, adjusted for age and BMI, and stratified by sex, lower MB level in men and higher GH level in women remained independently associated with POTS. Conclusions Cardiovascular proteomics analysis revealed sex-specific biomarker signature in POTS featured by higher plasma level of GH in women and lower plasma level of MB in men. These findings point to sex-specific immune-neuroendocrine dysregulation and deconditioning as potentially key pathophysiological traits underlying POTS.
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Affiliation(s)
- Jasmina Medic Spahic
- Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Clinical Research Center, 214 28, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, 214 28, Malmö, Sweden
| | - Fabrizio Ricci
- Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Clinical Research Center, 214 28, Malmö, Sweden.,Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, 66100, Chieti, Italy.,Casa di Cura Villa Serena, Città Sant'Angelo, 65013, Pescara, Italy
| | - Nay Aung
- William Harvey Research Institute, NIHR Cardiovascular Biomedical Research Unit at Barts, Queen Mary University of London, London, UK
| | - Erik Hallengren
- Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Clinical Research Center, 214 28, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, 214 28, Malmö, Sweden
| | - Jonas Axelsson
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Clinical Research Center, 214 28, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, 214 28, Malmö, Sweden
| | - Olle Melander
- Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Clinical Research Center, 214 28, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, 214 28, Malmö, Sweden
| | - Richard Sutton
- National Heart and Lung Institute, Imperial College, Hammersmith Hospital Campus, Ducane Road, W12 0NN, London, UK
| | - Artur Fedorowski
- Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Clinical Research Center, 214 28, Malmö, Sweden. .,Department of Cardiology, Skåne University Hospital, Carl-Bertil Laurells gata 9, 214 28, Malmö, Sweden.
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21
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Abstract
Postural orthostatic tachycardia syndrome (POTS) is a clinically heterogeneous disorder with multiple contributing pathophysiologic mechanisms manifesting as symptoms of orthostatic intolerance in the setting of orthostatic tachycardia (increase in heart rate by at least 30 beats per minute upon assuming an upright position) without orthostatic hypotension. The three major pathophysiologic mechanisms include partial autonomic neuropathy, hypovolemia, and hyperadrenergic state. Patients often will exhibit overlapping characteristics from more than one of these mechanisms. The approach to the treatment of POTS centers on treating the underlying pathophysiologic mechanism. Stockings, abdominal binders, and vasoconstrictors are used to enhance venous return in partial neuropathic POTS. Exercise and volume expansion are the main treatment strategies for hypo-volemic POTS. For hyperadrenergic POTS, beta-blockers and avoidance of norepinephrine reuptake inhibitors is important. Attempts should be made to discern which pathophysiologic mechanism(s) may be afflicting patients so that treatment regimens can be individualized.
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Affiliation(s)
- Philip L. Mar
- Division of Cardiology, Department of Medicine, St. Louis University School of Medicine, St. Louis, Missouri 63110, USA
| | - Satish R. Raj
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta T2N 4Z6, Canada
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
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22
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Jacob G, Diedrich L, Sato K, Brychta RJ, Raj SR, Robertson D, Biaggioni I, Diedrich A. Vagal and Sympathetic Function in Neuropathic Postural Tachycardia Syndrome. Hypertension 2019; 73:1087-1096. [PMID: 30879357 DOI: 10.1161/hypertensionaha.118.11803] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The diagnosis of neuropathic postural tachycardia syndrome (POTS) requires research techniques not available clinically. We hypothesized that these patients will have impaired vagal and sympathetic cardiovascular control that can be characterized with clinical autonomic tests. We included 12 POTS patients with possible neuropathic subtype because of normal plasma norepinephrine and no increase in upright blood pressure. We compared them to 10 healthy subjects. We assessed hemodynamics, heart rate and blood pressure variability, baroreflex sensitivity, raw and integrated muscle sympathetic nerve activity, and blood volume. To understand the vagal/sympathetic control, we dissected the phase 2 of Valsalva maneuver (VM) into early (VM2e) and late (VM2l). POTS' upright heart rate increased 43±3 bpm. Patients had normal plasma volume but reduced red blood cell volume (1.29 L versus predicted normal values 1.58 L; P=0.02). Vagal indices of heart rate variability, HFRRI (430±130 versus 1680±900; P=0.04), PNN50, and root mean squared of successive differences were lower in POTS. Patients showed a decrease in vagal baroreflex sensitivity (VM2e; P=0.04). In POTS, integrated muscle sympathetic nerve activity was lower at rest (12±1.5 versus 20±2 burst/min; P=0.004) and raw muscle sympathetic nerve activity spike analysis showed blunted responses during VM2e, despite a greater drop in systolic blood pressure (34±5 in POTS and 14±6 mm Hg in controls; P=0.01). This cohort of POTS patients enriched for possible neuropathic subtype had lower resting muscle sympathetic nerve activity, impaired vagal cardiac control, and exaggerated drop in blood pressure in response to VM and a delay in the sympathetic cardiovascular responsiveness during hypotensive challenge.
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Affiliation(s)
- Giris Jacob
- From the Department of Medicine F & J. Recanati Autonomic Dysfunction Center, Tel Aviv "Sourasky" Medical Center and Sackler Faculty of Medicine, University of Tel Aviv, Israel (G.J.)
| | - Laura Diedrich
- US Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville (L.D.)
| | - Kyoko Sato
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center (K.S., S.R.R., D.R., I.B., A.D.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine, Tokyo Women's Medical University, Medical Center East, Japan (K.S.)
| | - Robert J Brychta
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD (R.J.B.)
| | - Satish R Raj
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center (K.S., S.R.R., D.R., I.B., A.D.), Vanderbilt University School of Medicine, Nashville, TN
| | - David Robertson
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center (K.S., S.R.R., D.R., I.B., A.D.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Neurology (D.R.), Vanderbilt University School of Medicine, Nashville, TN
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center (K.S., S.R.R., D.R., I.B., A.D.), Vanderbilt University School of Medicine, Nashville, TN
| | - André Diedrich
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center (K.S., S.R.R., D.R., I.B., A.D.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Biomedical Engineering (A.D.), Vanderbilt University School of Medicine, Nashville, TN
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23
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Normal versus abnormal: What normative data tells us about the utility of heart rate in postural tachycardia. Auton Neurosci 2019; 221:102578. [DOI: 10.1016/j.autneu.2019.102578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 04/05/2019] [Accepted: 08/02/2019] [Indexed: 11/24/2022]
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24
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Junghans-Rutelonis AN, Postier A, Warmuth A, Schwantes S, Weiss KE. Pain Management In Pediatric Patients With Postural Orthostatic Tachycardia Syndrome: Current Insights. J Pain Res 2019; 12:2969-2980. [PMID: 31802934 PMCID: PMC6827519 DOI: 10.2147/jpr.s194391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 09/21/2019] [Indexed: 11/23/2022] Open
Abstract
Pediatric patients with postural orthostatic tachycardia syndrome (POTS) often present with co-occurring struggles with chronic pain (POTS+pain) that may limit daily activities. POTS is a clinical syndrome characterized by orthostatic symptoms and excessive postural tachycardia without orthostatic hypotension. Active research from the medical and scientific community has led to controversy over POTS diagnosis and treatment, yet patients continue to present with symptoms associated with POTS+pain, making treatment recommendations critical. This topical review examines the literature on diagnosing and treating pediatric POTS+pain and the challenges clinicians face. Most importantly, clinicians must employ an interdisciplinary team approach to determine the ideal combination of pharmacologic (e.g., fludrocortisone), non-pharmacologic (e.g., physical therapy, integrative medicine), and psychological (e.g., cognitive behavioral therapy, psychoeducation) treatment approaches that acknowledge the complexity of the child's condition, while simultaneously tailoring these approaches to the child's personal needs. We provide recommendations for treatment for youth with POTS+pain based on the current literature.
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Affiliation(s)
- Ashley N Junghans-Rutelonis
- Department of Pain Medicine, Palliative Care, and Integrative Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | - Andrea Postier
- Department of Pain Medicine, Palliative Care, and Integrative Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA.,Children's Minnesota Research Institute, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | - Andrew Warmuth
- Department of Pain Medicine, Palliative Care, and Integrative Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA.,Department of Physical Medicine and Rehabilitation, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | - Scott Schwantes
- Department of Pain Medicine, Palliative Care, and Integrative Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | - Karen E Weiss
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine & Seattle Children's Hospital, Seattle, DC, USA
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Bryarly M, Phillips LT, Fu Q, Vernino S, Levine BD. Postural Orthostatic Tachycardia Syndrome. J Am Coll Cardiol 2019; 73:1207-1228. [DOI: 10.1016/j.jacc.2018.11.059] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 11/01/2018] [Accepted: 11/05/2018] [Indexed: 12/26/2022]
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MEHDIRAD ALI, FEIGOFSKY SUSAN, LEI LUCY, SHEIKH NASIA, RAJ SATISH, KANJWAL KHALIL, CANNOM DAVID. Water Ingestion in Postural Orthostatic Tachycardia Syndrome: A Feasible Treatment Option? J Innov Card Rhythm Manag 2019; 10:3545-3551. [PMID: 32494413 PMCID: PMC7252859 DOI: 10.19102/icrm.2019.100207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Fu Q, Levine BD. Exercise and non-pharmacological treatment of POTS. Auton Neurosci 2018; 215:20-27. [PMID: 30001836 DOI: 10.1016/j.autneu.2018.07.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/29/2018] [Accepted: 07/01/2018] [Indexed: 12/11/2022]
Abstract
Recent research has demonstrated that cardiovascular deconditioning (i.e., cardiac atrophy and hypovolemia) contributes significantly to the Postural Orthostatic Tachycardia Syndrome (POTS) and its functional disability. Therefore, physical reconditioning with exercise training and volume expansion via increased salt and fluid intake should be initiated early in the course of treatment for patients with POTS if possible. The use of horizontal exercise (e.g., rowing, swimming, recumbent bike, etc.) at the beginning is a critical strategy, allowing patients to exercise while avoiding the upright posture that elicits their POTS symptoms. As patients become increasingly fit, the duration and intensity of exercise should be progressively increased, and upright exercise can be gradually added as tolerated. Supervised training is preferable to maximize functional capacity. Other non-pharmacological interventions, which include: 1) chronic volume expansion via sleeping in the head-up position; 2) reduction in venous pooling during orthostasis by lower body compression garments extending at least to the xiphoid or with an abdominal binder; and 3) physical countermeasure maneuvers, such as squeezing a rubber ball, leg crossing, muscle pumping, squatting, negative-pressure breathing, etc., may also be effective in preventing orthostatic intolerance and managing acute clinical symptoms in POTS patients. However, randomized clinical trials are needed to evaluate the efficacies of these non-pharmacological treatments of POTS.
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Affiliation(s)
- Qi Fu
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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Astudillo L, Laure A, Fabry V, Pugnet G, Maury P, Labrunée M, Sailler L, Pavy-Le Traon A. [Postural tachycardia syndrome (PoTS): An up-to-date]. Rev Med Interne 2018; 39:627-634. [PMID: 29909001 DOI: 10.1016/j.revmed.2018.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 03/13/2018] [Accepted: 04/17/2018] [Indexed: 11/16/2022]
Abstract
Postural tachycardia syndrome (PoTS) is a multifactorial syndrome defined by an increase in heart rate ≥30bpm, within 10minutes of standing (or during a head up tilt test to at least 60°), in absence of orthostatic hypotension. It is associated with symptoms of cerebral hypoperfusion that are worse when upright and improve in supine position. Patients have an intense fatigue with a high incidence on quality of life. This syndrome can be explained by many pathophysiological mechanisms. It can be associated with Ehlers-Danlos disease and some autoimmune disorders. The treatment is based on nonpharmacological measures and treatment with propranolol, fludrocortisone or midodrine.
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Affiliation(s)
- L Astudillo
- Service de médecine interne, CHU Purpan, Toulouse, France; Institut national de la santé et de la recherche médicale (Inserm), UMR1037, France; Société de médecine, chirurgie et pharmacie de Toulouse, France
| | - A Laure
- Société de médecine, chirurgie et pharmacie de Toulouse, France
| | - V Fabry
- Service de neurologie, France
| | - G Pugnet
- Service de médecine interne, CHU Purpan, Toulouse, France; Institut national de la santé et de la recherche médicale (Inserm), UMR1027, France
| | - P Maury
- Service de cardiologie, France
| | - M Labrunée
- Service de médecine physique et réadaptation, France
| | - L Sailler
- Service de médecine interne, CHU Purpan, Toulouse, France; Institut national de la santé et de la recherche médicale (Inserm), UMR1027, France
| | - A Pavy-Le Traon
- Service de neurologie, France; Institut National de la santé et de la recherche médicale (Inserm), UMR1048, France
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Zadourian A, Doherty TA, Swiatkiewicz I, Taub PR. Postural Orthostatic Tachycardia Syndrome: Prevalence, Pathophysiology, and Management. Drugs 2018; 78:983-994. [DOI: 10.1007/s40265-018-0931-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Graf N, Fernandes Santos AM, Ulrich CT, Fung C, Raabe A, Beck J, Z’Graggen WJ. Clinical symptoms and results of autonomic function testing overlap in spontaneous intracranial hypotension and postural tachycardia syndrome. CEPHALALGIA REPORTS 2018. [DOI: 10.1177/2515816318773774] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and purpose: Orthostatic headache is a hallmark of patients with spontaneous intracranial hypotension (SIH) but may also occur in patients with postural tachycardia syndrome (POTS). Our aim was to compare the clinical symptoms and findings of autonomic function testing in patients with SIH and POTS. Methods: This was a retrospective analysis of the clinical symptoms and findings of autonomic function testing, including sympathetic vasoconstrictor and parasympathetic cardiac function as well as head-up tilt in patients with SIH and POTS. Results: Nine patients with confirmed SIH and 48 with POTS (neuropathic N = 35, hyperadrenergic N = 5, deconditioned N = 8) were included. SIH patients experienced on average a shorter disease duration than patients with POTS. Orthostatic headache was present in all patients with SIH and 27% of patients with POTS. There was a broad overlap of other clinical symptoms of orthostatic intolerance. Screening autonomic function testing revealed normal sympathetic and parasympathetic function in all patients. All patients with SIH showed an excessive clinically symptomatic heart rate increase during standing, fulfilling the diagnostic criteria for POTS. Conclusion: Clinical symptoms and results of autonomic function testing overlap in SIH and POTS. Hence, patients with prominent orthostatic headache fulfilling the diagnostic criteria for POTS should also be evaluated for further testing of a spinal cerebrospinal fluid leak, in the absence of a history of lumbar puncture.
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Affiliation(s)
- Nina Graf
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | | | - Christian T Ulrich
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Christian Fung
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Werner J Z’Graggen
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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Mehr SE, Barbul A, Shibao CA. Gastrointestinal symptoms in postural tachycardia syndrome: a systematic review. Clin Auton Res 2018; 28:411-421. [PMID: 29549458 DOI: 10.1007/s10286-018-0519-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 03/05/2018] [Indexed: 01/06/2023]
Abstract
Gastrointestinal symptoms are among the most common complaints in patients with postural tachycardia syndrome (POTS). In some cases, they dominate the clinical presentation and cause substantial disabilities, including significant weight loss and malnutrition, that require the use of invasive treatment to support caloric intake. Multiple cross-sectional studies have reported a high prevalence of gastrointestinal symptoms in POTS patients with connective tissue diseases, such as Ehlers-Danlos, hypermobile type, and in patients with evidence of autonomic neuropathy. Previous studies that evaluated gastric motility in these patients reported a wide range of abnormalities, particularly delayed gastric emptying. The pathophysiology of gastrointestinal symptoms in POTS is likely multifactorial and probably depends on the co-morbid conditions. In patients with POTS and Ehlers-Danlos syndromes, structural and functional abnormalities in the gastrointestinal connective tissue may play a significant role, whereas in neuropathic POTS, the gastrointestinal tract motility and gut hormonal secretion may be directly impaired due to localized autonomic denervation. In patients with normal gastrointestinal motility but persistent gastrointestinal symptoms, gastrointestinal functional disorders should be considered. We performed a systematic review of the literature related to POTS and gastrointestinal symptoms have proposed possible mechanisms and discussed diagnosis and treatment approaches for delayed gastric emptying, the most common gastrointestinal abnormality reported in patients with POTS.
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Affiliation(s)
- Shahram E Mehr
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, 506 RRB, 2222 Pierce Ave, Nashville, TN, 37232, USA
| | - Adrian Barbul
- Department of Surgery, Vanderbilt University Medical Center, Nashville, USA
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, 506 RRB, 2222 Pierce Ave, Nashville, TN, 37232, USA.
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Stewart JM, Boris JR, Chelimsky G, Fischer PR, Fortunato JE, Grubb BP, Heyer GL, Jarjour IT, Medow MS, Numan MT, Pianosi PT, Singer W, Tarbell S, Chelimsky TC. Pediatric Disorders of Orthostatic Intolerance. Pediatrics 2018; 141:peds.2017-1673. [PMID: 29222399 PMCID: PMC5744271 DOI: 10.1542/peds.2017-1673] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2017] [Indexed: 01/18/2023] Open
Abstract
Orthostatic intolerance (OI), having difficulty tolerating an upright posture because of symptoms or signs that abate when returned to supine, is common in pediatrics. For example, ∼40% of people faint during their lives, half of whom faint during adolescence, and the peak age for first faint is 15 years. Because of this, we describe the most common forms of OI in pediatrics and distinguish between chronic and acute OI. These common forms of OI include initial orthostatic hypotension (which is a frequently seen benign condition in youngsters), true orthostatic hypotension (both neurogenic and nonneurogenic), vasovagal syncope, and postural tachycardia syndrome. We also describe the influences of chronic bed rest and rapid weight loss as aggravating factors and causes of OI. Presenting signs and symptoms are discussed as well as patient evaluation and testing modalities. Putative causes of OI, such as gravitational and exercise deconditioning, immune-mediated disease, mast cell activation, and central hypovolemia, are described as well as frequent comorbidities, such as joint hypermobility, anxiety, and gastrointestinal issues. The medical management of OI is considered, which includes both nonpharmacologic and pharmacologic approaches. Finally, we discuss the prognosis and long-term implications of OI and indicate future directions for research and patient management.
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Affiliation(s)
| | | | | | | | - John E. Fortunato
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
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Abstract
Postural tachycardia syndrome (POTS) represents a common form of orthostatic intolerance that disproportionately affects young women from puberty through adulthood. Patients with POTS have day-to-day orthostatic symptoms with the hallmark feature of an excessive, sustained, and symptomatic rise in heart rate during orthostatic testing. Although considerable overlap exists, three subtypes of POTS have been described: neuropathic, hyperadrenergic, and hypovolemic forms. The wide spectrum of symptoms and comorbidities can make treatment particularly challenging. Volume expansion with fluid and salt, exercise, and education constitute a reasonable initial therapy for most patients. Several medicines are also available to treat orthostatic intolerance and the associated comorbidities. Defining the POTS subtypes clinically in each patient may help to guide medicine choices. A multidisciplinary approach to overall management of the patient with POTS is advised. This review highlights several aspects of POTS with a specific focus on adolescent and young adult patients. [Pediatr Ann. 2017;46(4):e145-e154.].
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Orthostatic Intolerance and Postural Orthostatic Tachycardia Syndrome in Joint Hypermobility Syndrome/Ehlers-Danlos Syndrome, Hypermobility Type: Neurovegetative Dysregulation or Autonomic Failure? BIOMED RESEARCH INTERNATIONAL 2017; 2017:9161865. [PMID: 28286774 PMCID: PMC5329674 DOI: 10.1155/2017/9161865] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/16/2017] [Accepted: 01/19/2017] [Indexed: 12/21/2022]
Abstract
Background. Joint hypermobility syndrome/Ehlers-Danlos syndrome, hypermobility type (JHS/EDS-HT), is a hereditary connective tissue disorder mainly characterized by generalized joint hypermobility, skin texture abnormalities, and visceral and vascular dysfunctions, also comprising symptoms of autonomic dysfunction. This study aims to further evaluate cardiovascular autonomic involvement in JHS/EDS-HT by a battery of functional tests. Methods. The response to cardiovascular reflex tests comprising deep breathing, Valsalva maneuver, 30/15 ratio, handgrip test, and head-up tilt test was studied in 35 JHS/EDS-HT adults. Heart rate and blood pressure variability was also investigated by spectral analysis in comparison to age and sex healthy matched group. Results. Valsalva ratio was normal in all patients, but 37.2% of them were not able to finish the test. At tilt, 48.6% patients showed postural orthostatic tachycardia, 31.4% orthostatic intolerance, 20% normal results. Only one patient had orthostatic hypotension. Spectral analysis showed significant higher baroreflex sensitivity values at rest compared to controls. Conclusions. This study confirms the abnormal cardiovascular autonomic profile in adults with JHS/EDS-HT and found the higher baroreflex sensitivity as a potential disease marker and clue for future research.
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De Wandele I, Rombaut L, De Backer T, Peersman W, Da Silva H, De Mits S, De Paepe A, Calders P, Malfait F. Orthostatic intolerance and fatigue in the hypermobility type of Ehlers-Danlos Syndrome. Rheumatology (Oxford) 2016; 55:1412-20. [DOI: 10.1093/rheumatology/kew032] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Indexed: 01/26/2023] Open
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George SA, Bivens TB, Howden EJ, Saleem Y, Galbreath MM, Hendrickson D, Fu Q, Levine BD. The international POTS registry: Evaluating the efficacy of an exercise training intervention in a community setting. Heart Rhythm 2016; 13:943-50. [DOI: 10.1016/j.hrthm.2015.12.012] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Indexed: 01/22/2023]
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Huang H, Deb A, Culbertson C, Morgenshtern K, DePold Hohler A. Dermatological Manifestations of Postural Tachycardia Syndrome Are Common and Diverse. J Clin Neurol 2015; 12:75-8. [PMID: 26610893 PMCID: PMC4712289 DOI: 10.3988/jcn.2016.12.1.75] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 06/20/2015] [Accepted: 06/22/2015] [Indexed: 01/21/2023] Open
Abstract
Background and Purpose Postural tachycardia syndrome (POTS) is a syndrome of orthostatic intolerance in the setting of excessive tachycardia with orthostatic challenge, and these symptoms are relieved when recumbent. Apart from symptoms of orthostatic intolerance, there are many other comorbid conditions such as chronic headache, fibromyalgia, gastrointestinal disorders, and sleep disturbances. Dermatological manifestations of POTS are also common and range widely from livedo reticularis to Raynaud's phenomenon. Methods Questionnaires were distributed to 26 patients with POTS who presented to the neurology clinic. They were asked to report on various characteristics of dermatological symptoms, with their answers recorded on a Likert rating scale. Symptoms were considered positive if patients answered with "strongly agree" or "agree", and negative if they answered with "neutral", "strongly disagree", or "disagree". Results The most commonly reported symptom was rash (77%). Raynaud's phenomenon was reported by over half of the patients, and about a quarter of patients reported livedo reticularis. The rash was most commonly found on the arms, legs, and trunk. Some patients reported that the rash could spread, and was likely to be pruritic or painful. Very few reported worsening of symptoms on standing. Conclusions The results suggest that dermatological manifestations in POTS vary but are highly prevalent, and are therefore of important diagnostic and therapeutic significance for physicians and patients alike to gain a better understanding thereof. Further research exploring the underlying pathophysiology, incidence, and treatment strategies is necessary.
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Affiliation(s)
- Hao Huang
- Boston University School of Medicine, Boston, MA, USA.
| | - Anindita Deb
- Department of Neurology, Boston University Medical Center, Boston, MA, USA
| | | | | | - Anna DePold Hohler
- Department of Neurology, Boston University Medical Center, Boston, MA, USA.,Boston University School of Medicine, Boston, MA, USA
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Huang H, Hohler AD. The Dermatological Manifestations of Postural Tachycardia Syndrome: A Review with Illustrated Cases. Am J Clin Dermatol 2015; 16:425-30. [PMID: 26242228 DOI: 10.1007/s40257-015-0144-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Postural tachycardia syndrome (POTS) is a syndrome of excessive tachycardia with orthostatic challenge, and relief of such symptoms with recumbence. There are several proposed subtypes of the syndrome, each with unique pathophysiology. Numerous symptoms such as excessive tachycardia, lightheadedness, blurry vision, weakness, fatigue, palpitations, chest pain, and tremulousness are associated with orthostatic intolerance. Other co-morbid conditions associated with POTS are not clearly attributable to orthostatic intolerance. These include chronic headache, fibromyalgia, functional gastrointestinal or bladder disorders, cognitive impairment, and sleep disturbances. Dermatological manifestations of POTS are also common and wide ranging, from livedo reticularis to Raynaud's phenomenon, from cutaneous flushing to erythromelalgia. Here, we provide three illustrative cases of POTS with dermatological manifestations. We discuss the potential pathophysiology underlying such dermatological manifestations, and how such mechanisms could in turn help guide development of management.
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Affiliation(s)
- Hao Huang
- Department of Neurology, Boston University Medical Campus, 72 East Concord St, A-302, Boston, MA, 02118, USA.
| | - Anna DePold Hohler
- Department of Neurology, Boston University Medical Campus, 72 East Concord St, A-302, Boston, MA, 02118, USA
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39
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Baker J, Kimpinski K. A prospective 1-year study of postural tachycardia and the relationship to non-postural versus orthostatic symptoms. Physiol Behav 2015; 147:227-32. [PMID: 25936824 DOI: 10.1016/j.physbeh.2015.04.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 03/23/2015] [Accepted: 04/27/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Healthy subjects with asymptomatic postural tachycardia at baseline were evaluated over a one year period to determine whether they developed non-postural versus orthostatic symptoms that could predispose them to develop Postural Tachycardia Syndrome (POTS). METHODS Participants (n=30) were recruited for a 1-year follow-up (FUP) study if at baseline they demonstrated a heart rate increment of ≥30bpm on head-up tilt (HUT). At FUP, HUT was repeated and four self-report questionnaires were used to assess symptoms. RESULTS Heart rate (HR) increment was reduced in 19 subjects (-11.8±7.4bpm) and increased in 11 subjects (8.3±6.1bpm) at FUP versus baseline. Heart rate increment at FUP demonstrated no correlation to general fatigue (r=0.006), body vigilance (r=0.195), or the component scores for physical (r=-0.087) and mental (r=-0.137) health of the SF-36. Similarly, there was no correlation between HR increment at FUP and orthostatic scores (r=0.04). However, orthostatic scores did show a significant positive correlation with general fatigue and body vigilance scores (r=0.374, r=0.392, respectively; p<0.05). CONCLUSIONS Despite meeting the heart rate criteria for POTS, these findings further support that the majority of young individuals express benign orthostatic tachycardia. In addition, after one year this patient population showed no predisposition to develop non-postural or postural symptoms that could lead to the full syndrome of POTS. These data further argue for the re-evaluation of the heart rate criteria for diagnosing POTS in young populations.
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Affiliation(s)
- Jacquie Baker
- Department of Clinical Neurological Sciences, University Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Kurt Kimpinski
- Department of Clinical Neurological Sciences, University Hospital, London Health Sciences Centre, London, Ontario, Canada; Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.
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40
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Eccles JA, Owens AP, Mathias CJ, Umeda S, Critchley HD. Neurovisceral phenotypes in the expression of psychiatric symptoms. Front Neurosci 2015; 9:4. [PMID: 25713509 PMCID: PMC4322642 DOI: 10.3389/fnins.2015.00004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 01/05/2015] [Indexed: 12/01/2022] Open
Abstract
This review explores the proposal that vulnerability to psychological symptoms, particularly anxiety, originates in constitutional differences in the control of bodily state, exemplified by a set of conditions that include Joint Hypermobility, Postural Tachycardia Syndrome and Vasovagal Syncope. Research is revealing how brain-body mechanisms underlie individual differences in psychophysiological reactivity that can be important for predicting, stratifying and treating individuals with anxiety disorders and related conditions. One common constitutional difference is Joint Hypermobility, in which there is an increased range of joint movement as a result of a variant of collagen. Joint hypermobility is over-represented in people with anxiety, mood and neurodevelopmental disorders. It is also linked to stress-sensitive medical conditions such as irritable bowel syndrome, chronic fatigue syndrome and fibromyalgia. Structural differences in “emotional” brain regions are reported in hypermobile individuals, and many people with joint hypermobility manifest autonomic abnormalities, typically Postural Tachycardia Syndrome. Enhanced heart rate reactivity during postural change and as recently recognized factors causing vasodilatation (as noted post-prandially, post-exertion and with heat) is characteristic of Postural Tachycardia Syndrome, and there is a phenomenological overlap with anxiety disorders, which may be partially accounted for by exaggerated neural reactivity within ventromedial prefrontal cortex. People who experience Vasovagal Syncope, a heritable tendency to fainting induced by emotional challenges (and needle/blood phobia), are also more vulnerable to anxiety disorders. Neuroimaging implicates brainstem differences in vulnerability to faints, yet the structural integrity of the caudate nucleus appears important for the control of fainting frequency in relation to parasympathetic tone and anxiety. Together there is clinical and neuroanatomical evidence to show that common constitutional differences affecting autonomic responsivity are linked to psychiatric symptoms, notably anxiety.
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Affiliation(s)
- Jessica A Eccles
- Psychiatry, Brighton and Sussex Medical School Brighton, UK ; Sussex Partnership National Health Service Foundation Trust Brighton, UK
| | - Andrew P Owens
- National Hospital Neurology and Neurosurgery, UCL National Health Service Trust London, UK ; Institute of Neurology, University College London London, UK
| | - Christopher J Mathias
- National Hospital Neurology and Neurosurgery, UCL National Health Service Trust London, UK ; Institute of Neurology, University College London London, UK
| | - Satoshi Umeda
- National Hospital Neurology and Neurosurgery, UCL National Health Service Trust London, UK ; Department of Psychology, Keio University Tokyo, Japan
| | - Hugo D Critchley
- Psychiatry, Brighton and Sussex Medical School Brighton, UK ; Sussex Partnership National Health Service Foundation Trust Brighton, UK ; Sackler Centre for Consciousness Science, University of Sussex Falmer, UK
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41
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Fu Q, Levine BD. Exercise in the postural orthostatic tachycardia syndrome. Auton Neurosci 2014; 188:86-9. [PMID: 25487551 DOI: 10.1016/j.autneu.2014.11.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 10/06/2014] [Accepted: 11/15/2014] [Indexed: 01/05/2023]
Abstract
Patients with the Postural Orthostatic Tachycardia Syndrome (POTS) have orthostatic intolerance, as well as exercise intolerance. Peak oxygen uptake (VO2peak) is generally lower in these patients compared with healthy sedentary individuals, suggesting a lower physical fitness level. During acute exercise, POTS patients have an excessive increase in heart rate and reduced stroke volume for each level of absolute workload; however, when expressed at relative workload (%VO2peak), there is no difference in the heart rate response between patients and healthy individuals. The relationship between cardiac output and VO2 is similar between POTS patients and healthy individuals. Short-term (i.e., 3 months) exercise training increases cardiac size and mass, blood volume, and VO2peak in POTS patients. Exercise performance is improved after training. Specifically, stroke volume is greater and heart rate is lower at any given VO2 during exercise after training versus before training. Peak heart rate is the same but peak stroke volume and cardiac output are greater after training. Heart rate recovery from peak exercise is significantly faster after training, indicating an improvement in autonomic circulatory control. These results suggest that patients with POTS have no intrinsic abnormality of heart rate regulation during exercise. The tachycardia in POTS is due to a reduced stroke volume. Cardiac remodeling and blood volume expansion associated with exercise training increase physical fitness and improve exercise performance in these patients.
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Affiliation(s)
- Qi Fu
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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42
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Pianosi PT, Goodloe AH, Soma D, Parker KO, Brands CK, Fischer PR. High flow variant postural orthostatic tachycardia syndrome amplifies the cardiac output response to exercise in adolescents. Physiol Rep 2014; 2:2/8/e12122. [PMID: 25168872 PMCID: PMC4246579 DOI: 10.14814/phy2.12122] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) is characterized by chronic fatigue and dizziness and affected individuals by definition have orthostatic intolerance and tachycardia. There is considerable overlap of symptoms in patients with POTS and chronic fatigue syndrome (CFS), prompting speculation that POTS is akin to a deconditioned state. We previously showed that adolescents with postural orthostatic tachycardia syndrome (POTS) have excessive heart rate (HR) during, and slower HR recovery after, exercise – hallmarks of deconditioning. We also noted exaggerated cardiac output during exercise which led us to hypothesize that tachycardia could be a manifestation of a high output state rather than a consequence of deconditioning. We audited records of adolescents presenting with long‐standing history of any mix of fatigue, dizziness, nausea, who underwent both head‐up tilt table test and maximal exercise testing with measurement of cardiac output at rest plus 2–3 levels of exercise, and determined the cardiac output ( ) versus oxygen uptake ( ) relationship. Subjects with chronic fatigue were diagnosed with POTS if their HR rose ≥40 beat·min−1 with head‐up tilt. Among 107 POTS patients the distribution of slopes for the , relationship was skewed toward higher slopes but showed two peaks with a split at ~7.0 L·min−1 per L·min−1, designated as normal (5.08 ± 1.17, N = 66) and hyperkinetic (8.99 ± 1.31, N = 41) subgroups. In contrast, cardiac output rose appropriately with in 141 patients with chronic fatigue but without POTS, exhibiting a normal distribution and an average slope of 6.10 ± 2.09 L·min−1 per L·min−1 . Mean arterial blood pressure and pulse pressure from rest to exercise rose similarly in both groups. We conclude that 40% of POTS adolescents demonstrate a hyperkinetic circulation during exercise. We attribute this to failure of normal regional vasoconstriction during exercise, such that patients must increase flow through an inappropriately vasodilated systemic circulation to maintain perfusion pressure. e12122 Forty percent of postural orthostatic tachycardia syndrome (POTS) adolescents who, by definition have abnormal sympathetic control of HR and BP, demonstrate a hyperkinetic circulation during exercise. We attribute this to failure of normal regional vasoconstriction during exercise, such that patients must increase flow through an inappropriately vasodilated systemic circulation to maintain perfusion pressure.
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Affiliation(s)
- Paolo T Pianosi
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Adele H Goodloe
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota Department of Pediatrics, Vanderbilt University, Nashville, Tennessee
| | - David Soma
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ken O Parker
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Chad K Brands
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota Department of Pediatrics, All Children's Hospital, St. Petersburg, Florida and Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
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Figueroa RA, Arnold AC, Nwazue VC, Okamoto LE, Paranjape SY, Black BK, Diedrich A, Robertson D, Biaggioni I, Raj SR, Gamboa A. Acute volume loading and exercise capacity in postural tachycardia syndrome. J Appl Physiol (1985) 2014; 117:663-8. [PMID: 25059240 DOI: 10.1152/japplphysiol.00367.2014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Postural tachycardia syndrome (POTS) is associated with exercise intolerance, hypovolemia, and cardiac atrophy, which may contribute to reduced stroke volume and compensatory exaggerated heart rate (HR) increases. Acute volume loading with intravenous (iv) saline reduces HR and improves orthostatic tolerance and symptoms in POTS, but its effect on exercise capacity is unknown. In this study, we determined the effect of iv saline infusion on peak exercise capacity (VO2peak) in POTS. Nineteen patients with POTS participated in a sequential study. VO2peak was measured on two separate study days, following administration of placebo or 1 liter of i.v. saline (NaCl 0.9%). Patients exercised on a semirecumbent bicycle with resistance increased by 25 W every 2 min until maximal effort was achieved. Patients exhibited blood volume deficits (-13.4 ± 1.4% ideal volume), consistent with mild to moderate hypovolemia. At baseline, saline significantly increased stroke volume (saline 80 ± 8 ml vs. placebo 64 ± 4 ml; P = 0.010), increased cardiac output (saline 6.9 ± 0.5 liter/min vs. placebo 5.7 ± 0.2 liter/min; P = 0.021), and reduced systemic vascular resistance (saline 992.6 ± 70.0 dyn-s/cm(5) vs. placebo 1,184.0 ± 50.8 dyn-s/cm(5); P = 0.011), with no effect on HR or blood pressure. During exercise, saline did not produce differences in VO2peak (saline 26.3 ± 1.2 mg·kg(-1)·min(-1) vs. placebo 27.7 ± 1.8 mg·kg(-1)·min(-1); P = 0.615), peak HR [saline 174 ± 4 beats per minute (bpm) vs. placebo 175 ± 3 bpm; P = 0.672] or other cardiovascular parameters. These findings suggest that acute volume loading with saline does not improve VO2peak or cardiovascular responses to exercise in POTS, despite improvements in resting hemodynamic function.
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Affiliation(s)
- Rocío A Figueroa
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University, Nashville, Tennessee; and
| | - Amy C Arnold
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University, Nashville, Tennessee; and
| | - Victor C Nwazue
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University, Nashville, Tennessee; and
| | - Luis E Okamoto
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University, Nashville, Tennessee; and
| | - Sachin Y Paranjape
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University, Nashville, Tennessee; and
| | - Bonnie K Black
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University, Nashville, Tennessee; and
| | - Andre Diedrich
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University, Nashville, Tennessee; and
| | - David Robertson
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University, Nashville, Tennessee; and Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Pharmacology, Vanderbilt University, Nashville, Tennessee
| | - Italo Biaggioni
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University, Nashville, Tennessee; and Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Pharmacology, Vanderbilt University, Nashville, Tennessee
| | - Satish R Raj
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University, Nashville, Tennessee; and Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Pharmacology, Vanderbilt University, Nashville, Tennessee
| | - Alfredo Gamboa
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University, Nashville, Tennessee; and
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Wallman D, Weinberg J, Hohler AD. Ehlers–Danlos Syndrome and Postural Tachycardia Syndrome: A relationship study. J Neurol Sci 2014; 340:99-102. [DOI: 10.1016/j.jns.2014.03.002] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 02/05/2014] [Accepted: 03/02/2014] [Indexed: 10/25/2022]
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Kizilbash SJ, Ahrens SP, Bruce BK, Chelimsky G, Driscoll SW, Harbeck-Weber C, Lloyd RM, Mack KJ, Nelson DE, Ninis N, Pianosi PT, Stewart JM, Weiss KE, Fischer PR. Adolescent fatigue, POTS, and recovery: a guide for clinicians. Curr Probl Pediatr Adolesc Health Care 2014; 44:108-33. [PMID: 24819031 PMCID: PMC5819886 DOI: 10.1016/j.cppeds.2013.12.014] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 10/22/2013] [Accepted: 12/13/2013] [Indexed: 12/15/2022]
Abstract
Many teenagers who struggle with chronic fatigue have symptoms suggestive of autonomic dysfunction that may include lightheadedness, headaches, palpitations, nausea, and abdominal pain. Inadequate sleep habits and psychological conditions can contribute to fatigue, as can concurrent medical conditions. One type of autonomic dysfunction, postural orthostatic tachycardia syndrome, is increasingly being identified in adolescents with its constellation of fatigue, orthostatic intolerance, and excessive postural tachycardia (more than 40 beats/min). A family-based approach to care with support from a multidisciplinary team can diagnose, treat, educate, and encourage patients. Full recovery is possible with multi-faceted treatment. The daily treatment plan should consist of increased fluid and salt intake, aerobic exercise, and regular sleep and meal schedules; some medications can be helpful. Psychological support is critical and often includes biobehavioral strategies and cognitive-behavioral therapy to help with symptom management. More intensive recovery plans can be implemented when necessary.
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Affiliation(s)
- Sarah J Kizilbash
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Shelley P Ahrens
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Barbara K Bruce
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Gisela Chelimsky
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | | | | | - Robin M Lloyd
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Kenneth J Mack
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Dawn E Nelson
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Nelly Ninis
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Paolo T Pianosi
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Julian M Stewart
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Karen E Weiss
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
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What is brain fog? An evaluation of the symptom in postural tachycardia syndrome. Clin Auton Res 2013; 23:305-11. [PMID: 23999934 DOI: 10.1007/s10286-013-0212-z] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 08/12/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Adolescents with postural tachycardia syndrome (POTS) often experience ill-defined cognitive impairment referred to by patients as "brain fog." The objective of this study was to evaluate the symptom of brain fog as a means of gaining further insight into its etiology and potential palliative interventions. METHODS Eligible subjects who reported having been diagnosed with POTS were recruited from social media web sites. Subjects were asked to complete a 38-item questionnaire designed for this study, and the Wood mental fatigue inventory (WMFI). RESULTS Responses were received from 138 subjects with POTS (88 % female), ranging in age from 14 to 29 years; 132 subjects reported brain fog. WMFI scores correlated with brain fog frequency and severity (P < 0.001). The top ranked descriptors of brain fog were "forgetful," "cloudy," and "difficulty focusing, thinking and communicating." The most frequently reported brain fog triggers were fatigue (91 %), lack of sleep (90 %), prolonged standing (87 %), dehydration (86 %), and feeling faint (85 %). Although aggravated by upright posture, brain fog was reported to persist after assuming a recumbent posture. The most frequently reported interventions for the treatment of brain fog were intravenous saline (77 %), stimulant medications (67 %), salt tablets (54 %), intra-muscular vitamin B-12 injections (48 %), and midodrine (45 %). CONCLUSIONS Descriptors for "brain fog" are most consistent with it being a cognitive complaint. Factors other than upright posture may play a role in the persistence of this symptom. Subjects reported a number of therapeutic interventions for brain fog not typically used in the treatment of POTS that may warrant further investigation.
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A 46-year-old woman with postural orthostatic tachycardia syndrome. JAAPA 2013; 26:30, 32, 34. [DOI: 10.1097/01720610-201305000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Arnold AC, Okamoto LE, Diedrich A, Paranjape SY, Raj SR, Biaggioni I, Gamboa A. Low-dose propranolol and exercise capacity in postural tachycardia syndrome: a randomized study. Neurology 2013; 80:1927-33. [PMID: 23616163 DOI: 10.1212/wnl.0b013e318293e310] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the effect of low-dose propranolol on maximal exercise capacity in patients with postural tachycardia syndrome (POTS). METHODS We compared the effect of placebo vs a single low dose of propranolol (20 mg) on peak oxygen consumption (VO2max), an established measure of exercise capacity, in 11 patients with POTS and 7 healthy subjects in a randomized, double-blind study. Subjects exercised on a semirecumbent bicycle, with increasing intervals of resistance to maximal effort. RESULTS Maximal exercise capacity was similar between groups following placebo. Low-dose propranolol improved VO2max in patients with POTS (24.5 ± 0.7 placebo vs 27.6 ± 1.0 mL/min/kg propranolol; p = 0.024), but not healthy subjects. The increase in VO2max in POTS was associated with attenuated peak heart rate responses (142 ± 8 propranolol vs 165 ± 4 bpm placebo; p = 0.005) and improved stroke volume (81 ± 4 propranolol vs 67 ± 3 mL placebo; p = 0.013). In a separate cohort of POTS patients, neither high-dose propranolol (80 mg) nor metoprolol (100 mg) improved VO2max, despite similar lowering of heart rate. CONCLUSIONS These findings suggest that nonselective β-blockade with propranolol, when used at the low doses frequently used for treatment of POTS, may provide a modest beneficial effect to improve heart rate control and exercise capacity. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that a single low dose of propranolol (20 mg) as compared with placebo is useful in increasing maximum exercise capacity measured 1 hour after medication.
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Affiliation(s)
- Amy C Arnold
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University, Nashville, TN, USA
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Fu Q, Levine BD. Exercise and the autonomic nervous system. HANDBOOK OF CLINICAL NEUROLOGY 2013; 117:147-60. [DOI: 10.1016/b978-0-444-53491-0.00013-4] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Benarroch EE. Postural tachycardia syndrome: a heterogeneous and multifactorial disorder. Mayo Clin Proc 2012; 87:1214-25. [PMID: 23122672 PMCID: PMC3547546 DOI: 10.1016/j.mayocp.2012.08.013] [Citation(s) in RCA: 238] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 08/28/2012] [Accepted: 08/28/2012] [Indexed: 02/07/2023]
Abstract
Postural tachycardia syndrome (POTS) is defined by a heart rate increment of 30 beats/min or more within 10 minutes of standing or head-up tilt in the absence of orthostatic hypotension; the standing heart rate is often 120 beats/min or higher. POTS manifests with symptoms of cerebral hypoperfusion and excessive sympathoexcitation. The pathophysiology of POTS is heterogeneous and includes impaired sympathetically mediated vasoconstriction, excessive sympathetic drive, volume dysregulation, and deconditioning. POTS is frequently included in the differential diagnosis of chronic unexplained symptoms, such as inappropriate sinus tachycardia, chronic fatigue, chronic dizziness, or unexplained spells in otherwise healthy young individuals. Many patients with POTS also report symptoms not attributable to orthostatic intolerance, including those of functional gastrointestinal or bladder disorders, chronic headache, fibromyalgia, and sleep disturbances. In many of these cases, cognitive and behavioral factors, somatic hypervigilance associated with anxiety, depression, and behavioral amplification contribute to symptom chronicity. The aims of evaluation in patients with POTS are to exclude cardiac causes of inappropriate tachycardia; elucidate, if possible, the most likely pathophysiologic basis of postural intolerance; assess for the presence of treatable autonomic neuropathies; exclude endocrine causes of a hyperadrenergic state; evaluate for cardiovascular deconditioning; and determine the contribution of emotional and behavioral factors to the patient's symptoms. Management of POTS includes avoidance of precipitating factors, volume expansion, physical countermaneuvers, exercise training, pharmacotherapy (fludrocortisone, midodrine, β-blockers, and/or pyridostigmine), and behavioral-cognitive therapy. A literature search of PubMed for articles published from January 1, 1990, to June 15, 2012, was performed using the following terms (or combination of terms): POTS; postural tachycardia syndrome, orthostatic; orthostatic; syncope; sympathetic; baroreceptors; vestibulosympathetic; hypovolemia; visceral pain; chronic fatigue; deconditioning; headache; Chiari malformation; Ehlers-Danlos; emotion; amygdala; insula; anterior cingulate; periaqueductal gray; fludrocortisone; midodrine; propranolol; β-adrenergic; and pyridostigmine. Studies were limited to those published in English. Other articles were identified from bibliographies of the retrieved articles.
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