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Fedorowski A, Fanciulli A, Raj SR, Sheldon R, Shibao CA, Sutton R. Cardiovascular autonomic dysfunction in post-COVID-19 syndrome: a major health-care burden. Nat Rev Cardiol 2024; 21:379-395. [PMID: 38163814 DOI: 10.1038/s41569-023-00962-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 01/03/2024]
Abstract
Cardiovascular autonomic dysfunction (CVAD) is a malfunction of the cardiovascular system caused by deranged autonomic control of circulatory homeostasis. CVAD is an important component of post-COVID-19 syndrome, also termed long COVID, and might affect one-third of highly symptomatic patients with COVID-19. The effects of CVAD can be seen at both the whole-body level, with impairment of heart rate and blood pressure control, and in specific body regions, typically manifesting as microvascular dysfunction. Many severely affected patients with long COVID meet the diagnostic criteria for two common presentations of CVAD: postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia. CVAD can also manifest as disorders associated with hypotension, such as orthostatic or postprandial hypotension, and recurrent reflex syncope. Advances in research, accelerated by the COVID-19 pandemic, have identified new potential pathophysiological mechanisms, diagnostic methods and therapeutic targets in CVAD. For clinicians who daily see patients with CVAD, knowledge of its symptomatology, detection and appropriate management is more important than ever. In this Review, we define CVAD and its major forms that are encountered in post-COVID-19 syndrome, describe possible CVAD aetiologies, and discuss how CVAD, as a component of post-COVID-19 syndrome, can be diagnosed and managed. Moreover, we outline directions for future research to discover more efficient ways to cope with this prevalent and long-lasting condition.
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Affiliation(s)
- Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
- Department of Medicine, Karolinska Institute, Stockholm, Sweden.
- Department of Clinical Sciences, Lund University, Malmö, Sweden.
| | | | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cyndya A Shibao
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Hammersmith Hospital, National Heart & Lung Institute, Imperial College, London, UK
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2
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Pena C, Moustafa A, Mohamed AR, Grubb B. Autoimmunity in Syndromes of Orthostatic Intolerance: An Updated Review. J Pers Med 2024; 14:435. [PMID: 38673062 PMCID: PMC11051445 DOI: 10.3390/jpm14040435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
Orthostatic intolerance is a broad term that represents a spectrum of dysautonomic disorders, including postural orthostatic tachycardia syndrome (POTS) and orthostatic hypotension (OH), as manifestations of severe autonomic failure. While the etiology of orthostatic intolerance has not yet fully been uncovered, it has been associated with multiple underlying pathological processes, including peripheral neuropathy, altered renin-aldosterone levels, hypovolemia, and autoimmune processes. Studies have implicated adrenergic, cholinergic, and angiotensin II type I autoantibodies in the pathogenesis of orthostatic intolerance. Several case series have demonstrated that immunomodulation therapy resulted in favorable outcomes, improving autonomic symptoms in POTS and OH. In this review, we highlight the contemporary literature detailing the association of autoimmunity with POTS and OH.
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Affiliation(s)
- Clarissa Pena
- Department of Internal Medicine, University of Toledo, Toledo, OH 43614, USA;
| | - Abdelmoniem Moustafa
- Division of Cardiovascular Medicine, University of Toledo, Toledo, OH 43614, USA; (A.M.); (B.G.)
| | - Abdel-Rhman Mohamed
- Department of Internal Medicine, University of Toledo, Toledo, OH 43614, USA;
| | - Blair Grubb
- Division of Cardiovascular Medicine, University of Toledo, Toledo, OH 43614, USA; (A.M.); (B.G.)
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3
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Laurin JKH, Oyewunmi OA, Garland EM, Gamboa A, Nwazue VC, Paranjape SY, Black BK, Okamoto LE, Shibao CA, Biaggioni I, Robertson D, Diedrich A, Dupont WD, Sheldon RS, Raj SR. Adrenal gland response to adrenocorticotropic hormone is intact in patients with postural orthostatic tachycardia syndrome. Auton Neurosci 2023; 248:103105. [PMID: 37393658 DOI: 10.1016/j.autneu.2023.103105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 05/18/2023] [Accepted: 06/20/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Many patients with postural orthostatic tachycardia syndrome (POTS) are hypovolemic with plasma volume deficits of 10-30 %. Some also have low levels of aldosterone and diminished aldosterone-renin ratios despite elevations in angiotensin II, pointing to potential adrenal dysfunction. To assess adrenal gland responsiveness in POTS, we measured circulating levels of aldosterone and cortisol following adrenocorticotropin hormone (ACTH) stimulation. METHODS While on a low Na+ diet (∼10 mEq/day), 8 female patients with POTS and 5 female healthy controls (HC) received a low dose (1 μg) ACTH bolus following a baseline blood sample. After 60 min, a high dose (249 μg) infusion of ACTH was administered to ensure maximal adrenal response. Venous aldosterone and cortisol levels were sampled every 30 min for 2 h. RESULTS Aldosterone increased in both groups in response to ACTH but was not different between POTS vs. HC at 60 min (53.5 ng/dL [37.8-61.8 ng/dL] vs. 46.1 ng/dL [36.7-84.9 ng/dL]; P = 1.000) or maximally (56.4 ng/dL [49.2-67.1 ng/dL] vs. 49.5 ng/dL [39.1-82.8 ng/dL]; P = 0.524). Cortisol increased in both groups in response to ACTH but was not different in patients with POTS vs. HC at 60 min (39.9 μg/dL [36.1-47.7 μg/dL] vs. 39.3 μg/dL [35.4-46.6 μg/dL]; P = 0.724) or maximally (39.9 μg/dL [33.9-45.4 μg/dL] vs. 42.0 μg/dL [37.6-49.7 μg/dL]; P = 0.354). CONCLUSIONS ACTH appropriately increased the aldosterone and cortisol levels in patients with POTS. These findings suggest that the response of the adrenal cortex to hormonal stimulation is intact in patients with POTS.
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Affiliation(s)
- Jill K H Laurin
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Oyebimbola A Oyewunmi
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Emily M Garland
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alfredo Gamboa
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Victor C Nwazue
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sachin Y Paranjape
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bonnie K Black
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Luis E Okamoto
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cyndya A Shibao
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Italo Biaggioni
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David Robertson
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - André Diedrich
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Engineering, School of Engineering, Vanderbilt University, Nashville, TN, USA
| | - William D Dupont
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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4
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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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Rodriguez B, Hochstrasser A, Eugster PJ, Grouzmann E, Müri RM, Z’Graggen WJ. Brain fog in neuropathic postural tachycardia syndrome may be associated with autonomic hyperarousal and improves after water drinking. Front Neurosci 2022; 16:968725. [PMID: 35992935 PMCID: PMC9388780 DOI: 10.3389/fnins.2022.968725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/19/2022] [Indexed: 11/18/2022] Open
Abstract
Background Brain fog is a common and highly disturbing symptom for patients with neuropathic postural tachycardia syndrome (POTS). Cognitive deficits have been measured exclusively in the upright body position and mainly comprised impairments of higher cognitive functions. The cause of brain fog is still unclear today. This study aimed to investigate whether increased autonomic activation might be an underlying mechanism for the occurrence of brain fog in neuropathic POTS. We therefore investigated cognitive function in patients with neuropathic POTS and a healthy control group depending on body position and in relation to catecholamine release as a sensitive indicator of acute stress. The second aim was to test the effect of water intake on cardiovascular regulation, orthostatic symptoms, cognitive function and catecholamine release. Methods Thirteen patients with neuropathic POTS and 15 healthy control subjects were included. All participants completed a total of four rounds of cognitive testing: two before and two after the intake of 500 ml still water, each first in the supine position and then during head-up tilt. At the end of each cognitive test, a blood sample was collected for determination of plasma catecholamines. After each head-up tilt phase participants were asked to rate their current symptoms on a visual analogue scale. Results Working memory performance in the upright body position was impaired in patients, which was associated with self-reported symptom severity. Patients had elevated plasma norepinephrine independent of body position and water intake that increased excessively in the upright body position. The excessive increase of plasma norepinephrine was related to heart rate and symptom severity. Water intake in patients decreased norepinephrine concentrations and heart rate, and improved symptoms as well as cognitive performance. Conclusion Brain fog and symptom severity in neuropathic POTS are paralleled by an excessive norepinephrine secretion. Bolus water drinking down-regulates norepinephrine secretion and improves general symptom severity including brain fog.
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Affiliation(s)
- Belén Rodriguez
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annie Hochstrasser
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Philippe J. Eugster
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Eric Grouzmann
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - René M. Müri
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Gerontechnology and Rehabilitation Group, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Werner J. Z’Graggen
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- *Correspondence: Werner J. Z’Graggen,
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6
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Snapper H, Cheshire WP. Oral and intravenous hydration in the treatment of orthostatic hypotension and postural tachycardia syndrome. Auton Neurosci 2022; 238:102951. [PMID: 35123367 DOI: 10.1016/j.autneu.2022.102951] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 12/07/2021] [Accepted: 01/25/2022] [Indexed: 01/21/2023]
Abstract
Hydration with water and salt is the mainstay of treatment for autonomic nervous system disorders that impair orthostatic tolerance. The goal is to expand intravascular volume to compensate for the downward displacement of blood volume that occurs when standing and thereby sustain cerebral perfusion and restore quality of life. Despite strong consensus recommendations for salt supplementation as standard treatment of these disorders, published evidence of benefit is relatively weak, and no randomized clinical trials have occurred. This review summarizes the physiological rationale for hydration and evaluates the literature on oral and intravenous hydration in the treatment of neurogenic orthostatic hypotension, postural tachycardia syndrome, and recurrent vasovagal syncope. We conclude that oral salt replacement is indicated for treatment of neurogenic orthostatic hypotension because these patients have excessive renal sodium excretion, and for treatment of chronic orthostatic intolerance because these patients are often hypovolemic. As not all patients are able to tolerate sufficient oral hydration, there is also a role for intravenous volume-loading in severe cases of postural tachycardia syndrome. We offer guidance, based on review of the literature and the clinical judgment of a cardiologist and neurologist with experience treating autonomic disorders, regarding the option of ongoing intravenous hydration for treatment of severe, refractory cases of postural tachycardia syndrome.
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Affiliation(s)
- Howard Snapper
- Department of Cardiology, Wellstar Healthcare System, Marietta, GA 30060, USA.
| | - William P Cheshire
- Division of Autonomic Disorders, Department of Neurology, Mayo Clinic, Jacksonville, FL 32224, USA
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Wheeler C, Pacheco JM, Kim AC, Camacho-Santiago M, Kalafut MA, Ahern T, White AA, Patay B, Criado JR. Cardiovascular Autonomic Regulation, ETCO 2 and the Heart Rate Response to the Tilt Table Test in Patients with Orthostatic Intolerance. Appl Psychophysiol Biofeedback 2022; 47:107-119. [PMID: 35171410 DOI: 10.1007/s10484-022-09536-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 11/27/2022]
Abstract
Chronic orthostatic intolerance (COI) is defined by changes in heart rate (HR), blood pressure (BP), respiration, symptoms of cerebral hypoperfusion and sympathetic overactivation. Postural tachycardia syndrome (POTS) is the most common form of COI in young adults and is defined by an orthostatic increase in heart rate (HR) of ≥ 30 bpm in the absence of orthostatic hypotension. However, some patients referred for evaluation of COI symptoms do not meet the orthostatic HR response criterion of POTS despite debilitating symptoms. Such patients are ill defined, posing diagnostic and therapeutic challenges. This study explored the relationship among cardiovascular autonomic control, the orthostatic HR response, EtCO2 and the severity of orthostatic symptoms and fatigue in patients referred for evaluation of COI. Patients (N = 108) performed standardized testing protocol of the Autonomic Reflex Screen and completed the Composite Autonomic Symptom Score (COMPASS-31) and the Fatigue Severity Scale (FSS). Greater severity of COI was associated with younger age, larger phase IV amplitude in the Valsalva maneuver and lower adrenal baroreflex sensitivity. Greater fatigue severity was associated with a larger reduction in ETCO2 during 10 min of head-up tilt (HUT) and reduced low-frequency (LF) power of heart rate variability. This study suggests that hemodynamic changes associated with the baroreflex response and changes in EtCO2 show a stronger association with the severity of orthostatic symptoms and fatigue than the overall orthostatic HR response in patients with COI.
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Affiliation(s)
- Carmen Wheeler
- Division of Cardiology Clinical Research, Scripps Clinic, La Jolla, CA, 92037, USA
| | - Jannay M Pacheco
- Department of Applied and Integrated Neurosciences, Pontifical Catholic University of Puerto Rico, Ponce, PR, 00717, USA
| | - Anna C Kim
- Vascular Laboratory, Scripps Clinic, La Jolla, CA, 92037, USA
| | | | - Mary A Kalafut
- Division of Neurology, Autonomic Neuro Lab, Scripps Clinic, 9898 Genesee Ave., La Jolla, CA, 92037, USA
| | - Thomas Ahern
- Division of Cardiology, Scripps Clinic, La Jolla, CA, 92037, USA
| | - Andrew A White
- Division of Allergy/Immunology, Scripps Clinic, La Jolla, CA, 92037, USA
| | - Bradley Patay
- Division of Internal Medicine, Scripps Clinic, La Jolla, CA, 92037, USA
| | - José R Criado
- Division of Neurology, Autonomic Neuro Lab, Scripps Clinic, 9898 Genesee Ave., La Jolla, CA, 92037, USA.
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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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9
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Williams EL, Raj SR, Schondorf R, Shen WK, Wieling W, Claydon VE. Salt supplementation in the management of orthostatic intolerance: Vasovagal syncope and postural orthostatic tachycardia syndrome. Auton Neurosci 2021; 237:102906. [PMID: 34823150 DOI: 10.1016/j.autneu.2021.102906] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/23/2021] [Accepted: 11/06/2021] [Indexed: 02/07/2023]
Abstract
Salt supplementation is a common non-pharmacological approach to the management of recurrent orthostatic syncope or presyncope, particularly for patients with vasovagal syncope (VVS) or postural orthostatic tachycardia syndrome (POTS), although there is limited consensus on the optimal dosage, formulation and duration of treatment. Accordingly, we reviewed the evidence for the use of salt supplementation to reduce susceptibility to syncope or presyncope in patients with VVS and POTS. We found that short-term (~3 months) salt supplementation improves susceptibility to VVS and associated symptoms, with little effect on supine blood pressure. In patients with VVS, salt supplementation is associated with increases in plasma volume, and an increase in the time taken to provoke a syncopal event during orthostatic tolerance testing, with smaller orthostatic heart rate increases, enhanced peripheral vascular responses to orthostatic stress, and improved cerebral autoregulation. Responses were most pronounced in those with a baseline sodium excretion <170 mmol/day. Salt supplementation also improved symptoms, plasma volume, and orthostatic responses in patients with POTS. Salt supplementation should be considered for individuals with recurrent and troublesome episodes of VVS or POTS without cardiovascular comorbidities, particularly if their typical urinary sodium excretion is low, and their supine blood pressure is not elevated. The efficacy of the response, in terms of the improvement in subjective and objective markers of orthostatic intolerance, and any potential deleterious effect on supine blood pressure, should be routinely monitored in individuals on high salt regimes.
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Affiliation(s)
- E L Williams
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - S R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - R Schondorf
- Department of Neurology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - W K Shen
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - W Wieling
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - V E Claydon
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada.
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10
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Vernino S, Bourne KM, Stiles LE, Grubb BP, Fedorowski A, Stewart JM, Arnold AC, Pace LA, Axelsson J, Boris JR, Moak JP, Goodman BP, Chémali KR, Chung TH, Goldstein DS, Diedrich A, Miglis MG, Cortez MM, Miller AJ, Freeman R, Biaggioni I, Rowe PC, Sheldon RS, Shibao CA, Systrom DM, Cook GA, Doherty TA, Abdallah HI, Darbari A, Raj SR. Postural orthostatic tachycardia syndrome (POTS): State of the science and clinical care from a 2019 National Institutes of Health Expert Consensus Meeting - Part 1. Auton Neurosci 2021; 235:102828. [PMID: 34144933 DOI: 10.1016/j.autneu.2021.102828] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/10/2021] [Accepted: 05/30/2021] [Indexed: 12/13/2022]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a chronic and often disabling disorder characterized by orthostatic intolerance with excessive heart rate increase without hypotension during upright posture. Patients often experience a constellation of other typical symptoms including fatigue, exercise intolerance and gastrointestinal distress. A typical patient with POTS is a female of child-bearing age, who often first displays symptoms in adolescence. The onset of POTS may be precipitated by immunological stressors such as a viral infection. A variety of pathophysiologies are involved in the abnormal postural tachycardia response; however, the pathophysiology of the syndrome is incompletely understood and undoubtedly multifaceted. Clinicians and researchers focused on POTS convened at the National Institutes of Health in July 2019 to discuss the current state of understanding of the pathophysiology of POTS and to identify priorities for POTS research. This article, the first of two articles summarizing the information discussed at this meeting, summarizes the current understanding of this disorder and best practices for clinical care. The evaluation of a patient with suspected POTS should seek to establish the diagnosis, identify co-morbid conditions, and exclude conditions that could cause or mimic the syndrome. Once diagnosed, management typically begins with patient education and non-pharmacologic treatment options. Various medications are often used to address specific symptoms, but there are currently no FDA-approved medications for the treatment of POTS, and evidence for many of the medications used to treat POTS is not robust.
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Affiliation(s)
- Steven Vernino
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kate M Bourne
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lauren E Stiles
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA; Dysautonomia International, East Moriches, NY, USA
| | - Blair P Grubb
- Division of Cardiology, Department of Medicine, The University of Toledo Medical Center, USA
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Julian M Stewart
- Center for Hypotension, Departments of Pediatrics and Physiology, New York Medical College, Valhalla, NY, USA
| | - Amy C Arnold
- Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laura A Pace
- Center for Genomic Medicine and Department of Pediatrics, Division of Medical Genetics and Genomics, University of Utah, Salt Lake City, UT, USA
| | - Jonas Axelsson
- Department of Clinical Immunology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Jeffrey P Moak
- Department of Pediatrics, George Washington Univeristy School of Medicine and Health Sciences, Washington, DC, USA
| | - Brent P Goodman
- Neuromuscular Division, Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA
| | - Kamal R Chémali
- Department of Neurology, Eastern Virginia Medical School, Division of Neurology, Neuromuscular and Autonomic Center, Sentara Healthcare, Norfolk, VA, USA
| | - Tae H Chung
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David S Goldstein
- Autonomic Medicine Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Andre Diedrich
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine and Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mitchell G Miglis
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Melissa M Cortez
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Amanda J Miller
- Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, Boston, MA, USA; Center for Autonomic and Peripheral Nerve Disorders, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Italo Biaggioni
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Departments of Medicine and Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Cyndya A Shibao
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Departments of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David M Systrom
- Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Glen A Cook
- Department of Neurology, Uniformed Services University, Bethesda, MD, USA
| | - Taylor A Doherty
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of California at San Diego, La Jolla, CA, USA
| | | | - Anil Darbari
- Pediatric Gastroenterology, Children's National Hospital, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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11
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Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C, Calkins H, Corrado D, Deftereos SG, Diller GP, Gomez-Doblas JJ, Gorenek B, Grace A, Ho SY, Kaski JC, Kuck KH, Lambiase PD, Sacher F, Sarquella-Brugada G, Suwalski P, Zaza A. 2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J 2021; 41:655-720. [PMID: 31504425 DOI: 10.1093/eurheartj/ehz467] [Citation(s) in RCA: 497] [Impact Index Per Article: 165.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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12
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Garland EM, Gamboa A, Nwazue VC, Celedonio JE, Paranjape SY, Black BK, Okamoto LE, Shibao CA, Biaggioni I, Robertson D, Diedrich A, Dupont WD, Raj SR. Effect of High Dietary Sodium Intake in Patients With Postural Tachycardia Syndrome. J Am Coll Cardiol 2021; 77:2174-2184. [PMID: 33926653 DOI: 10.1016/j.jacc.2021.03.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND High sodium intake is recommended for the treatment of postural tachycardia syndrome (POTS) to counteract the hypovolemia and elevated plasma norepinephrine that contribute to excessive orthostatic tachycardia, but evidence of its efficacy is not available. OBJECTIVES This study tested whether a high sodium (HS) diet reduces orthostatic tachycardia (Δ heart rate) and upright heart rate compared with a low sodium (LS) diet in POTS patients, and secondarily its effect on plasma volume (PV) and plasma norepinephrine. METHODS A total of 14 POTS patients and 13 healthy control subjects (HC), age 23 to 49 years, were enrolled in a crossover study with 6 days of LS (10 mEq sodium/day) or HS (300 mEq sodium/day) diet. Supine and standing heart rate, blood pressure, serum aldosterone, plasma renin activity, blood volume, and plasma norepinephrine and epinephrine were measured. RESULTS In POTS, the HS diet reduced upright heart rate and Δ heart rate compared with the LS diet. Total blood volume and PV increased, and standing norepinephrine decreased with the HS compared with the LS diet. However, upright heart rate, Δ heart rate, and upright norepinephrine remained higher in POTS than in HC on the HS diet (median 117 beats/min [interquartile range: 98 to 121 beats/min], 46 beats/min [interquartile range: 32 to 55 beats/min], and 753 pg/ml [interquartile range: 498 to 919 pg/ml] in POTS vs. 85 beats/min [interquartile range: 77 to 95 beats/min], 19 beats/min [interquartile range: 11 to 32 beats/min], and 387 pg/ml [interquartile range: 312 to 433 pg/ml] in HC, respectively), despite no difference in the measured PV. CONCLUSIONS In POTS patients, high dietary sodium intake compared with low dietary sodium intake increases plasma volume, lowers standing plasma norepinephrine, and decreases Δ heart rate. (Dietary Salt in Postural Tachycardia Syndrome; NCT01547117).
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Affiliation(s)
- Emily M Garland
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alfredo Gamboa
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Victor C Nwazue
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jorge E Celedonio
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sachin Y Paranjape
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bonnie K Black
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Luis E Okamoto
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cyndya A Shibao
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Italo Biaggioni
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David Robertson
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - André Diedrich
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Biomedical Engineering, School of Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - William D Dupont
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Satish R Raj
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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13
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Eftekhari H, Maddock H, Pearce G, Raza S, Kavi L, Lim PB, Osman F, Hayat SA. Understanding the future research needs in Postural Orthostatic Tachycardia Syndrome (POTS): Evidence mapping the POTS adult literature. Auton Neurosci 2021; 233:102808. [PMID: 33901811 DOI: 10.1016/j.autneu.2021.102808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 03/15/2021] [Accepted: 03/27/2021] [Indexed: 01/01/2023]
Abstract
POTS is under diagnosed with an estimated prevalence of 0.2%. North American and Australian researchers, as well as patient groups have called for more research into POTS. However, there has been no comprehensive appraisal of the current POTS evidence base. AIM To map the POTS evidence base. METHODS Two reviewers systematically searched 12 databases until July 1st 2019 using the search term "Postural Tachycardia Syndrome" (n = 7280) and categorised the literature. Inclusion criteria included all adult published literature with no language restrictions. 779 papers are analysed and mapped. RESULTS Seven themes were identified: symptomology and quality of life 16.8% (n = 132), biomedical topics 16.5% (n = 130), co-morbidities 10.3% (n = 81), non-pharmacological management 9.8% (n = 77), aetiologies 6.9% (n = 53), pharmacological management 6.7% (n = 53), and clinical management 6.6% (n = 52). There 45 subthemes. Quality appraisal of the research studies (n = 233) evaluated design, sample size, outcome measures, data analysis and research biases. 74.8% (n = 175) were observational designs and 25.2% (n = 59) were experimental designs (16 using a randomised controlled design, 11 of which had a sample size greater than 21). 47.4% (n = 111) of studies only measured duration of effect for <1 day. 11.5% (n = 27) of studies reported outcomes using an unvalidated subjective measurement tool. CONCLUSION The volume of adult POTS literature is small and the validity and reliability of the research lacks rigour. The evidence map methodology provides POTS researchers with a benchmark for research thus far. This paper adds an in-depth research appraisal to the broad calls for action, highlighting the pressing need for multicentre, good quality research in POTS, to support guidelines and consensus development in the future.
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Affiliation(s)
- H Eftekhari
- University Hospitals Coventry & Warwickshire NHS Trust, United Kingdom of Great Britain and Northern Ireland.
| | - H Maddock
- Faculty of Health and Life Sciences, Coventry University, United Kingdom of Great Britain and Northern Ireland.
| | - G Pearce
- Faculty of Health and Life Sciences, Coventry University, United Kingdom of Great Britain and Northern Ireland.
| | - S Raza
- Biomedical Sciences, Coventry University, United Kingdom of Great Britain and Northern Ireland.
| | - L Kavi
- PoTS UK, United Kingdom of Great Britain and Northern Ireland.
| | - P B Lim
- Imperial College NHS Healthcare Trust, United Kingdom of Great Britain and Northern Ireland.
| | - F Osman
- University Hospitals Coventry & Warwickshire NHS Trust, United Kingdom of Great Britain and Northern Ireland; Warwick Medical School, University of Warwick, Coventry, United Kingdom of Great Britain and Northern Ireland.
| | - S A Hayat
- Heart Hospital, Hamad Medical Corporation, Doha, Qatar.
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14
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Prevention and Management of Supine Hypertension in Patients With Orthostatic Hypotension. Am J Ther 2021; 28:e228-e231. [PMID: 31524637 DOI: 10.1097/mjt.0000000000001054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Orthostatic hypotension (OH) is a potentially debilitating condition caused by dysfunction of the autonomic nervous system, which is essential for the physiologic response to orthostatic posture. In addition to OH, autonomic dysfunction may also be associated with the development of concurrent supine hypertension (SH). AREAS OF UNCERTAINTY This paradoxical effect speaks to the complexity of the pathogenesis of autonomic disease and greatly complicates management of these patients. Clinicians are faced with a dilemma because aggressive treatment of orthostatic intolerance can worsen supine hypertension and attempts to control supine hypertension can worsen orthostatic intolerance. DATA SOURCES Systematic review of the published literature. PREVENTION OF SUPINE HYPERTENSION Patients should aim to avoid known stressors, perform physical maneuvers (eg, slowly getting up from bed, sleeping with head of bed elevated), manage underlying related conditions (eg, diabetes mellitus), and exercise. MANAGEMENT OF SUPINE HYPERTENSION With failure of conservative management, patients may advance to pharmacologic therapy. It is important to understand the underlying suspected etiology of the syndrome of supine hypertension and OH (SH-OH) to select promising pharmacologic agents. This article reviews medical treatment options to work toward achieving a better quality of life for patients afflicted with this disease. Although clonidine and beta-blockers can be used to treat hypertension without causing significant hypotension, midodrine, pyridostigmine, and droxidopa may be helpful in preventing OH. CONCLUSION The etiology and severity of autonomic dysfunction vary widely between patients, suggesting a need for an individualized treatment approach. Achieving perfect blood pressure control is not a realistic goal. Rather, treatment should be aimed at improving the patient's quality of life and decreasing their risk of injury and organ damage.
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15
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Loughlin EA, Judge CS, Gorey SE, Costello MM, Murphy RP, Waters RF, Hughes DS, Kenny RA, O'Donnell MJ, Canavan MD. Increased Salt Intake for Orthostatic Intolerance Syndromes: A Systematic Review and Meta-Analysis. Am J Med 2020; 133:1471-1478.e4. [PMID: 32603788 DOI: 10.1016/j.amjmed.2020.05.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 05/04/2020] [Accepted: 05/04/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Guidelines recommend increased salt intake as a first-line recommendation in the management of symptomatic orthostatic hypotension and recurrent syncope. There have been no systematic reviews of this intervention. We sought to summarize the evidence for increased salt intake in patients with orthostatic intolerance syndromes. METHODS We conducted a systematic review and meta-analysis of studies in PubMed, EMBASE, and CINAHL. Interventional studies that increased salt intake in individuals with orthostatic intolerance syndromes were included. Primary outcome measures included incidence of falls and injuries, and rates of syncope and presyncope. Secondary outcome measures included other orthostatic intolerance symptoms, blood pressure, and heart rate. RESULTS A total of 14 studies were eligible, including participants with orthostatic hypotension, syncope, postural orthostatic tachycardia syndrome, and idiopathic orthostatic tachycardia (n = 391). Mean age was 35.6 (± 15) years. All studies were small and short-term (<60 mins-90 days). No study reported on the effect of increased salt intake on falls or injuries. Meta-analysis demonstrated that during head-up tilt, mean time to presyncope with salt intake increased by 1.57 minutes (95% confidence interval [CI], 1.26-1.88), mean systolic blood pressure increased by 12.27 mm Hg (95% CI, 10.86-13.68), and mean heart rate decreased by -3.97 beats per minute (95% CI, -4.08 to -3.86), compared with control. Increased salt increased supine blood pressure by 1.03 mm Hg (95% CI, 0.81 to 1.25). Increased salt intake resulted in an improvement or resolution of symptoms in 62.3% (95% CI, 51.6 to 72.6) of participants in short-term follow-up studies (mean follow-up of 44.3 days, 6 studies; n=91). Methodological quality of studies were low with high statistical heterogeneity in all meta-analyses. CONCLUSIONS Our meta-analysis provides low-quality evidence of a short-term improvement in orthostatic intolerance with increased salt intake. There were no clinical trials demonstrating the efficacy and safety of increased salt intake on long-term clinical outcomes. Overall, there is a paucity of clinical trial evidence to support a cornerstone recommendation in the management of orthostatic intolerance syndromes.
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Affiliation(s)
- Elaine A Loughlin
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Galway University Hospital, Newcastle Road, Galway, Ireland.
| | - Conor S Judge
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Galway University Hospital, Newcastle Road, Galway, Ireland; Wellcome Trust - HRB, Irish Clinical Academic Training, Dublin, Ireland
| | - Sarah E Gorey
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Galway University Hospital, Newcastle Road, Galway, Ireland
| | - Maria M Costello
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Galway University Hospital, Newcastle Road, Galway, Ireland
| | - Robert P Murphy
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Galway University Hospital, Newcastle Road, Galway, Ireland
| | - Ruairi F Waters
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Galway University Hospital, Newcastle Road, Galway, Ireland
| | - Diarmaid S Hughes
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Galway University Hospital, Newcastle Road, Galway, Ireland
| | - Rose Ann Kenny
- Mercer's Institute for Successful Ageing, St. James's Hospital, Dubline, Ireland
| | - Martin J O'Donnell
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Galway University Hospital, Newcastle Road, Galway, Ireland
| | - Michelle D Canavan
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Galway University Hospital, Newcastle Road, Galway, Ireland
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Y Lei L, S Chew D, K Sandhu R, S Sheldon R, R Raj S. Non-Pharmacological and Pharmacological Management of Cardiac Dysautonomia Syndromes. J Atr Fibrillation 2020; 13:2395. [PMID: 33024496 DOI: 10.4022/jafib.2395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/10/2020] [Accepted: 03/16/2020] [Indexed: 11/10/2022]
Abstract
Vasovagal syncope, postural orthostatic tachycardia syndrome, and inappropriate sinus tachycardia comprise a heterogenous group of common autonomic disorders that are associated with significant symptoms that impair quality of life. Clinical management of these disorders should prioritize conservative non-pharmacological therapies and consider incorporating pharmacological agents for recurrences. The selection and titration of medications may be complicated by the occurrence of potentially overlapping pathophysiological variants, differences in specific clinical presentations, and commonly associated comorbidities. However, with appropriate long-term management and specialist input, most patients note both symptomatic improvement and functional restoration over time.
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Affiliation(s)
- Lucy Y Lei
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Derek S Chew
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.,Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.,Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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17
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Abstract
Syncope and palpitations are common complaints for patients presenting to their primary care provider. They represent symptoms that most often have a benign etiology but rarely can be the first warning sign of a serious condition, such as arrhythmias, structural heart disease, or noncardiac disease. The history, physical examination, and noninvasive testing can, in most cases, distinguish benign from pathologic causes. This article introduces syncope and palpitations, with emphasis on the differential diagnoses, initial presentation, diagnostic strategy, and various management strategies.
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Affiliation(s)
- Johannes C von Alvensleben
- Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, B100, Aurora, CO 80045, USA.
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18
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Kanjwal K, Jamal SM, McComb DW, Mughal M, Kichloo A. Paroxysmal Orthostatic Ventricular Tachycardia in a Patient With Supine Hypertension and Orthostatic Hypotension. J Investig Med High Impact Case Rep 2020; 8:2324709620958303. [PMID: 32911993 PMCID: PMC7488873 DOI: 10.1177/2324709620958303] [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] [Indexed: 11/22/2022] Open
Abstract
Supine orthostatic hypertension with orthostatic hypotension is an autonomic dysfunction where the patients present with hypertension when supine and with decrease in blood pressure while bearing an upright posture. We report on a 74-year-old male who was admitted with dizziness and was found to have profound orthostatic hypotension with supine hypertension. The patient also developed orthostatic paroxysmal premature ventricular beats as well as nonsustained ventricular tachycardia. In this report, we attempt to present the possible mechanism of orthostatic ventricular tachycardia in our patient and the overview of the treatment strategies used in management of patients with supine hypertension and orthostatic hypotension.
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Affiliation(s)
| | | | | | - Majid Mughal
- McLaren Greater Lansing Hospital, Lansing, MI, USA
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19
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Chen G, Du J, Jin H, Huang Y. Postural Tachycardia Syndrome in Children and Adolescents: Pathophysiology and Clinical Management. Front Pediatr 2020; 8:474. [PMID: 32974246 PMCID: PMC7468430 DOI: 10.3389/fped.2020.00474] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 07/06/2020] [Indexed: 12/21/2022] Open
Abstract
Postural tachycardia syndrome (POTS), characterized by chronic (≥6 months) orthostatic intolerance symptoms with a sustained and excessive heart rate increase while standing without postural hypotension, is common in children and adolescents. Despite the unclear pathogenesis of POTS, the present opinion is that POTS is a heterogeneous and multifactorial disorder that includes altered central blood volume, abnormal autonomic reflexes, "hyperadrenergic" status, damaged skeletal muscle pump activity, abnormal local vascular tension and vasoactive factor release, mast cell activation, iron insufficiency, and autoimmune dysfunction. A number of pediatric POTS patients are affected by more than one of these pathophysiological mechanisms. Therefore, individualized treatment strategies are initiated in the management of POTS, including basal non-pharmacological approaches (e.g., health education, the avoidance of triggers, exercise, or supplementation with water and salt) and special pharmacological therapies (e.g., oral rehydration salts, midodrine hydrochloride, and metoprolol). As such, the recent progress in the pathogenesis, management strategies, and therapeutic response predictors of pediatric POTS are reviewed here.
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Affiliation(s)
- Guozhen Chen
- Department of Pediatrics, Peking University First Hospital, Beijing, China
- Department of Pediatrics, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
- Research Unit of Clinical Diagnosis and Treatment of Pediatric Syncope and Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, China
- Key Laboratory of Molecular Cardiovascular Science, The Ministry of Education, Beijing, China
| | - Hongfang Jin
- Department of Pediatrics, Peking University First Hospital, Beijing, China
- Research Unit of Clinical Diagnosis and Treatment of Pediatric Syncope and Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Yaqian Huang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
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20
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Yozgat Y, Temur HO, Coban S, Oner T, Karaarslan U, Yozgat CY, Karadeniz C, Ergor SN, Erenberk U. Short-term efficacy of ORS formulation and propranolol regimen in children with POTS. Arch Pediatr 2020; 27:328-332. [PMID: 32651146 DOI: 10.1016/j.arcped.2020.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/09/2020] [Accepted: 06/01/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND To evaluate the short-term effectiveness of reduced-osmolarity oral rehydration salt formulation (ORS) and propranolol in children diagnosed with postural orthostatic tachycardia syndrome (POTS) in head-up tilt testing (HUTT). METHODS Children were admitted with symptoms of orthostatic intolerance (OI) occurring in a standing position and disappearing in the supine position. Patients with heart rate increments of ≥40bpm and symptoms of OI constituted the pediatric POTS group in HUTT. A total of 70 pediatric patients with POTS were included in the study. POTS patients were divided into two groups based on whether they were prescribed reduced-osmolarity ORS and propranolol or not. The study group comprised patients on a regimen of reduced-osmolarity ORS and propranolol (n=34), while the control group comprised patients who were not prescribed any medication (n=36). The frequency of symptoms and standardized symptom scores were analyzed before and after 3 months of treatment in both groups. RESULTS The post-treatment frequency of syncopal attacks was significantly reduced in both groups (P<0.01 for both groups), but the post-treatment standardized symptom scores were significantly reduced in the pediatric study group compared with the control group (P<0.01). CONCLUSION The frequency of syncopal attacks was significantly reduced and the symptom scores for OI were improved in the study group. The improvement in OI symptom scores was better in the treatment group than in the control group. The control group symptoms persisted and caused extreme difficulty in their daily activities. In view of its clinical efficacy, we strongly advocate the use of combined treatment of reduced-osmolarity ORS and low-dose propranolol in pediatric patients with POTS.
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Affiliation(s)
- Yilmaz Yozgat
- Department of Pediatric Cardiology, Bezmialem Vakif University, Istanbul, Turkey
| | - Hafize Otcu Temur
- Department of Radiology, Bezmialem Vakif University, Istanbul, Turkey
| | - Senay Coban
- Department of Pediatric Cardiology, Istanbul Medipol University, Istanbul, Turkey
| | - Taliha Oner
- Department of Pediatric Cardiology, Izmir Dr. Behcet Uz Children's Hospital, Izmir, Turkey
| | - Utku Karaarslan
- Department of Pediatrics, Izmir Dr. Behcet Uz Children's Hospital, Izmir, Turkey
| | | | - Cem Karadeniz
- Department of Pediatric Cardiology, Izmir Dr. Behcet Uz Children's Hospital, Izmir, Turkey
| | - Serap Nur Ergor
- Department of Neonatology, Bezmialem Vakif University, Istanbul, Turkey
| | - Ufuk Erenberk
- Department of Pediatrics, Bezmialem Vakif University, Istanbul, Turkey
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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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Medow MS, Guber K, Chokshi S, Terilli C, Visintainer P, Stewart JM. The Benefits of Oral Rehydration on Orthostatic Intolerance in Children with Postural Tachycardia Syndrome. J Pediatr 2019; 214:96-102. [PMID: 31405524 PMCID: PMC6815702 DOI: 10.1016/j.jpeds.2019.07.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/11/2019] [Accepted: 07/15/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate whether equal volumes of oral rehydration solution (ORS) or intravenous (IV) saline provide similar improvements in cardiovascular status during controlled orthostatic challenge when administered to subjects with postural tachycardia syndrome (POTS) with orthostatic intolerance. STUDY DESIGN We studied the neurovascular response to fluid loading during orthostatic stress using lower body negative pressure (LBNP) in 10 subjects with POTS with orthostatic intolerance and 15 controls, and on subsequent days before and 1 hour after IV saline infusion or ingestion of ORS. RESULTS Subjects with POTS exhibited reduced tolerance to LBNP (P < .0001) compared with controls (Orthostatic Index of 35 715 ± 3469 vs 93 980 ± 7977, respectively). In POTS, following ORS but not saline infusion, cerebral blood flow velocity (CBFv) was significantly higher than that with no treatment, at -45 mm Hg (P < .0005). Although fluid loading did not confer any advantage in controls, subjects with POTS experienced a significant improvement in orthostatic tolerance following both saline infusion (100 ± 9.7 vs 134.5 ± 17.4; P < .05) and ORS (100 ± 9.7 vs 155.6 ± 15.7; P < .001) when evaluated by normalized orthostatic index (P < .001, compared with untreated baseline). CONCLUSIONS Maintenance of CBFv may have resulted in the improved short-term orthostatic tolerance exhibited by the subjects with POTS following ORS administration. ORS is a convenient, safe, and effective therapy for short-term relief of orthostatic intolerance.
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Affiliation(s)
- Marvin S Medow
- Department of Pediatrics, New York Medical College, Valhalla, NY; Department of Physiology, New York Medical College, Valhalla, NY.
| | | | | | - Courtney Terilli
- Department of Pediatrics, New York Medical College, Valhalla, NY
| | - Paul Visintainer
- Department of Epidemiology and Biostatistics, Baystate Medical Center, University of Massachusetts School of Medicine, Worcester, MA
| | - Julian M Stewart
- Department of Pediatrics, New York Medical College, Valhalla, NY; Department of Physiology, New York Medical College, Valhalla, NY
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23
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Li H, Zhang G, Zhou L, Nuss Z, Beel M, Hines B, Murphy T, Liles J, Zhang L, Kem DC, Yu X. Adrenergic Autoantibody-Induced Postural Tachycardia Syndrome in Rabbits. J Am Heart Assoc 2019; 8:e013006. [PMID: 31547749 PMCID: PMC6806023 DOI: 10.1161/jaha.119.013006] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Previous studies have demonstrated that functional autoantibodies to adrenergic receptors may be involved in the pathogenesis of postural tachycardia syndrome. The objective of this study was to examine the impact of these autoantibodies on cardiovascular responses to postural changes and adrenergic orthosteric ligand infusions in immunized rabbits. Methods and Results Eight New Zealand white rabbits were coimmunized with peptides from the α1-adrenergic receptor and β1-adrenergic receptor (β1AR). Tilt test and separate adrenergic agonist infusion studies were performed on conscious animals before and after immunization and subsequent treatment with epitope-mimetic peptide inhibitors. At 6 weeks after immunization, there was a greater percent increase in heart rate upon tilting compared with preimmune baseline. No significant difference in blood pressure response to tilting was observed. The heart rate response to infusion of the β-adrenoceptor agonist isoproterenol was significantly enhanced in immunized animals, suggesting a positive allosteric effect of β1AR antibodies. In contrast, the blood pressure response to infusion of the α1-adrenergic receptor agonist phenylephrine was attenuated in immunized animals, indicating a negative allosteric effect of α1-adrenergic receptor antibodies. Injections of antibody-neutralizing peptides suppressed the postural tachycardia and reversed the altered heart rate and blood pressure responses to orthosteric ligand infusions in immunized animals at 6 and 30 weeks. Antibody production and suppression were confirmed with in vitro bioassays. Conclusions The differential allosteric effect of α1-adrenergic receptor and β1AR autoantibodies would lead to a hyperadrenergic state and overstimulation of cardiac β1AR. These data support evidence for an autoimmune basis for postural tachycardia syndrome.
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Affiliation(s)
- Hongliang Li
- Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City OK
| | - Gege Zhang
- Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City OK
| | - Liping Zhou
- Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City OK
| | - Zachary Nuss
- Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City OK
| | - Marci Beel
- Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City OK
| | - Brendon Hines
- Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City OK
| | - Taylor Murphy
- Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City OK
| | - Jonathan Liles
- Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City OK
| | - Ling Zhang
- Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City OK
| | - David C Kem
- Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City OK
| | - Xichun Yu
- Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City OK
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24
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Ahmed A, Ruzieh M, Kanjwal S, Kanjwal K. Syndrome of Supine Hypertension with Orthostatic Hypotension: Pathophysiology and Clinical Approach. Curr Cardiol Rev 2019; 16:48-54. [PMID: 31215392 PMCID: PMC7393597 DOI: 10.2174/1573403x15666190617095032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/04/2019] [Accepted: 05/07/2019] [Indexed: 12/20/2022] Open
Abstract
This article is intended to provide guidance and clinical considerations for physicians managing patients suffering from supine hypertension with orthostatic hypotension, referred to as “SH-OH”. We review the normal physiologic response to orthostasis, focusing on the appropriate changes to autonomic output in this state. Autonomic failure is discussed with a generalized overview of the disease and examination of specific syndromes that help shed light on the pathophysiology of SH-OH. The goal of this review is to provide a better framework for clinical evaluation of these patients, review treatment options, and ultimately work toward achieving a better quality of life for patients afflicted with this disease.
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Affiliation(s)
- Aamir Ahmed
- Department of Internal Medicine, Rush University, Chicago, IL 60612, United States
| | - Mohammed Ruzieh
- Penn State Heart and Vascular Institute. Hershey, PA 17033, United States
| | | | - Khalil Kanjwal
- McLaren Greater Lansing Hospital, Lansing, MI 48910, United States
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25
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Miglis MG, Muppidi S. Do astronauts get postural tachycardia syndrome? And other updates on recent autonomic research. Clin Auton Res 2019; 29:263-265. [PMID: 31089931 DOI: 10.1007/s10286-019-00613-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 05/07/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Mitchell G Miglis
- Stanford Neurosciences Health Center, 213 Quarry Road, 2nd Floor, Palo Alto, CA, 94304, USA
| | - Srikanth Muppidi
- Stanford Neurosciences Health Center, 213 Quarry Road, 2nd Floor, Palo Alto, CA, 94304, USA.
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26
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Cheema MA, Zain MA, Ullah W, Cheema K. Is ivabradine a wonder drug for atypical POTS? BMJ Case Rep 2019; 12:12/4/e227789. [PMID: 31005863 DOI: 10.1136/bcr-2018-227789] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Syncope is a sudden loss and gain of consciousness. Traditionally, it is caused by the abnormalities of neurological, cardiac or vasovagal systems. We present a case of a 19-year-old woman presenting with recurrent syncopal episodes with no apparent cause. Examination and investigations were unremarkable for any aetiology except positive tilt tests for postural orthostatic tachycardia syndrome. The purpose of this report is to make physicians aware of the unique presentation of this rare aetiology with recurrent syncopal episodes and the novel management approach.
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Affiliation(s)
| | | | - Waqas Ullah
- Internal Medicine, Abington Hospital - Jefferson Health, Abington, PA, USA
| | - Khadija Cheema
- Internal Medicine, Abington Hospital - Jefferson Health, Abington, PA, USA
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27
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Fedorowski A. Postural orthostatic tachycardia syndrome: clinical presentation, aetiology and management. J Intern Med 2019; 285:352-366. [PMID: 30372565 DOI: 10.1111/joim.12852] [Citation(s) in RCA: 141] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a variant of cardiovascular autonomic disorder characterized by an excessive heart rate increase on standing and orthostatic intolerance. POTS affects younger individuals 15-45 years old with a distinct female predominance (≈80%). The prevalence ranges between 0.2% and 1.0% in developed countries. The onset of POTS is typically precipitated by immunological stressors such as viral infection, vaccination, trauma, pregnancy, surgery or psychosocial stress. The most common complaints are dizziness, weakness, rapid heartbeat and palpitation on standing. Moreover, patients often report physical deconditioning and reduced exercise capacity as well as headache, 'brain fog', dyspnoea, gastrointestinal disorders and musculoskeletal pain. The aetiology of POTS is largely unknown and three main hypotheses include an autoimmune disorder, abnormally increased sympathetic activity and catecholamine excess, and sympathetic denervation leading to central hypovolaemia and reflex tachycardia. The golden standard for POTS diagnosis is head-up tilt test with a non-invasive beat-to-beat haemodynamic monitoring. Although long-term prognosis of POTS is poorly explored, around 50% of patients spontaneously recover within 1-3 years. After the diagnosis has been established, patient should be thoroughly educated about non-pharmacological measures alleviating the symptoms. Exercise training may be very effective and counteract deconditioning. In more symptomatic patients, different drugs directed at controlling heart rate, increasing peripheral vasoconstriction and intravascular volume can be tested. However, the overall effects of pharmacological therapy are modest and the most affected patients remain handicapped. Future efforts should focus on better understanding of POTS pathophysiology and designing randomized controlled trials for selection of more effective therapy.
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Affiliation(s)
- A Fedorowski
- Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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28
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Cutsforth-Gregory JK, Sandroni P. Clinical neurophysiology of postural tachycardia syndrome. HANDBOOK OF CLINICAL NEUROLOGY 2019; 161:429-445. [PMID: 31307619 DOI: 10.1016/b978-0-444-64142-7.00066-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Postural tachycardia syndrome (POTS) is one of several disorders of orthostatic intolerance (OI). It is defined by the development of symptoms of cerebral hypoperfusion or sympathetic activation and a sustained heart rate increment of 30 beats/min or more (40 beats/min for teenagers) within 10min of standing or head-up tilt in the absence of orthostatic hypotension; the standing heart rate is often 120 beats/min or higher. POTS is approximately five times more common in women than men. This heterogeneous syndrome is caused by several pathophysiologic mechanisms (limited autonomic neuropathy, hyperadrenergic state, hypovolemia, venous pooling, deconditioning), which are not mutually exclusive. Anxiety and somatic hypervigilance play significant roles in POTS. Common comorbidities include visceral pain and dysmotility, chronic fatigue and fibromyalgia, migraine, joint hypermobility, mitral valve prolapse, and inappropriate sinus tachycardia. Patients with suspected POTS should undergo comprehensive cardiac and neurologic examinations and autonomic and laboratory tests to determine the most likely pathophysiologic basis of OI. The objectives of POTS management are to (1) increase the time that patients can stand, perform daily activities, and exercise and (2) avoid syncope. Management involves nonpharmacologic (fluid and salt loading, physical countermaneuvers, compression garments, exercise training) and pharmacologic (β-blockers, pyridostigmine, fludrocortisone, midodrine) approaches.
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Affiliation(s)
| | - Paola Sandroni
- Department of Neurology, Mayo Clinic, Rochester, MN, United States.
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29
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Pharmacotherapy for postural tachycardia syndrome. Auton Neurosci 2018; 215:28-36. [DOI: 10.1016/j.autneu.2018.04.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 03/26/2018] [Accepted: 04/30/2018] [Indexed: 11/20/2022]
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30
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Arnold AC, Ng J, Raj SR. Postural tachycardia syndrome - Diagnosis, physiology, and prognosis. Auton Neurosci 2018; 215:3-11. [PMID: 29523389 PMCID: PMC6113123 DOI: 10.1016/j.autneu.2018.02.005] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 02/22/2018] [Accepted: 02/25/2018] [Indexed: 11/29/2022]
Abstract
Postural tachycardia syndrome (POTS) is a heterogeneous clinical syndrome that has gained increasing interest over the past few decades due to its increasing prevalence and clinical impact on health-related quality of life. POTS is clinically characterized by sustained excessive tachycardia upon standing that occurs in the absence of significant orthostatic hypotension and other medical conditions and or medications, and with chronic symptoms of orthostatic intolerance. POTS represents one of the most common presentations of syncope and presyncope secondary to autonomic dysfunction in emergency rooms and in cardiology, neurology, and primary care clinics. The most sensitive method to detect POTS is a detailed medical history, physical examination with orthostatic vital signs or brief tilt table test, and a resting 12-lead electrocardiogram. Additional diagnostic testing may be warranted in selected patients based on clinical signs. While the precise etiology remains unknown, the orthostatic tachycardia in POTS is thought to reflect convergence of multiple pathophysiological processes, as a final common pathway. Based on this, POTS is often described as a clinical syndrome consisting of multiple heterogeneous disorders, with several underlying pathophysiological processes proposed in the literature including partial sympathetic neuropathy, hyperadrenergic state, hypovolemia, mast cell activation, deconditioning, and immune-mediated. These clinical features often overlap, however, making it difficult to categorize individual patients. Importantly, POTS is not associated with mortality, with many patients improving to some degree over time after diagnosis and proper treatment. This review will outline the current understanding of diagnosis, pathophysiology, and prognosis in POTS.
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Affiliation(s)
- Amy C Arnold
- Department of Neural and Behavioral Sciences, Penn State College of Medicine, 500 University Drive, Mail Code H109, Hershey, PA, USA; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jessica Ng
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Satish R Raj
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.
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31
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Stewart JM, Pianosi P, Shaban MA, Terilli C, Svistunova M, Visintainer P, Medow MS. Hemodynamic characteristics of postural hyperventilation: POTS with hyperventilation versus panic versus voluntary hyperventilation. J Appl Physiol (1985) 2018; 125:1396-1403. [PMID: 30138078 DOI: 10.1152/japplphysiol.00377.2018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Upright hyperventilation occurs in ~25% of our patients with postural tachycardia syndrome (POTS). Poikilocapnic hyperventilation alone causes tachycardia. Here, we examined changes in respiration and hemodynamics comprising cardiac output (CO), systemic vascular resistance (SVR), and blood pressure (BP) measured during head-up tilt (HUT) in three groups: patients with POTS and hyperventilation (POTS-HV), patients with panic disorder who hyperventilate (Panic), and healthy controls performing voluntary upright hyperpnea (Voluntary-HV). Though all were comparably tachycardic during hyperventilation, POTS-HV manifested hyperpnea, decreased CO, increased SVR, and increased BP during HUT; Panic patients showed both hyperpnea and tachypnea, increased CO, and increased SVR as BP increased during HUT; and Voluntary-HV were hyperpneic by design and had increased CO, decreased SVR, and decreased BP during upright hyperventilation. Mechanisms of hyperventilation and hemodynamic changes differed among POTS-HV, Panic, and Voluntary-HV subjects. We hypothesize that the hyperventilation in POTS is caused by a mechanism involving peripheral chemoreflex sensitization by intermittent ischemic hypoxia. NEW & NOTEWORTHY Hyperventilation is common in postural tachycardia syndrome (POTS) and has distinctive cardiovascular characteristics when compared with hyperventilation in panic disorder or with voluntary hyperventilation. Hyperventilation in POTS is hyperpnea only, distinct from panic in which tachypnea also occurs. Cardiac output is decreased in POTS, whereas peripheral resistance and blood pressure (BP) are increased. This is distinct from voluntary hyperventilation where cardiac output is increased and resistance and BP are decreased and from panic where they are all increased.
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Affiliation(s)
- Julian M Stewart
- Department of Pediatrics, New York Medical College, Valhalla, New York.,Department of Physiology, New York Medical College, Valhalla, New York
| | - Paul Pianosi
- Paediatric Respiratory Medicine, King's College Hospital National Health Surface Foundation Trust , London , United Kingdom
| | - Mohamed A Shaban
- Department of Pediatrics, New York Medical College, Valhalla, New York
| | - Courtney Terilli
- Department of Pediatrics, New York Medical College, Valhalla, New York
| | - Maria Svistunova
- Department of Pediatrics, New York Medical College, Valhalla, New York
| | - Paul Visintainer
- Epidemiology and Biostatistics, Baystate Medical Center, University of Massachusetts School of Medicine , Worcester, Massachusetts
| | - Marvin S Medow
- Department of Pediatrics, New York Medical College, Valhalla, New York.,Department of Physiology, New York Medical College, Valhalla, New York
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32
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Wells R, Elliott AD, Mahajan R, Page A, Iodice V, Sanders P, Lau DH. Efficacy of Therapies for Postural Tachycardia Syndrome: A Systematic Review and Meta-analysis. Mayo Clin Proc 2018; 93:1043-1053. [PMID: 29937049 DOI: 10.1016/j.mayocp.2018.01.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/04/2018] [Accepted: 01/16/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To identify the evidence base and evaluate the efficacy of each treatment for postural tachycardia syndrome (POTS) in light of a recent consensus statement highlighting the lack of treatment options with clear benefit to risk ratios for this debilitating condition. METHODS The CENTRAL (Cochrane Central Register of Controlled Trials), PubMed, and Embase databases from inception to May 2017 were searched using the terms postural AND tachycardia AND syndrome. A total of 135 full-text publications were screened after excluding duplicates (n=681), conference abstracts (n=467), and records that did not relate to POTS therapy (n=876). We included 28 studies with at least 4 patients with POTS in which symptomatic response was reported after more than 4 weeks of therapy. This review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Two investigators independently performed the data extraction and evaluated the quality of evidence. RESULTS This study comprised 25 case series and 3 small randomized controlled trials that evaluated 755 and 103 patients with POTS, respectively. Interventions directed at increasing intravascular volume, increasing peripheral or splanchnic vascular tone, controlling heart rate, and increasing exercise tolerance demonstrate moderate efficacy (range, 51%-72%). Few data exist on their comparative effectiveness. Significant heterogeneities were seen in terms of patient age, symptom severity, and the measures used to evaluate treatment efficacy. CONCLUSION The current evidence base to guide optimal management of patients with POTS is extremely limited. More high-quality collaborative research with standardized reporting of symptom response and treatment tolerability is urgently needed.
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Affiliation(s)
- Rachel Wells
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Rajiv Mahajan
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Amanda Page
- Centre for Nutrition and Gastrointestinal Diseases, University of Adelaide, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Valeria Iodice
- University College London, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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33
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Stewart JM, Pianosi P, Shaban MA, Terilli C, Svistunova M, Visintainer P, Medow MS. Postural Hyperventilation as a Cause of Postural Tachycardia Syndrome: Increased Systemic Vascular Resistance and Decreased Cardiac Output When Upright in All Postural Tachycardia Syndrome Variants. J Am Heart Assoc 2018; 7:e008854. [PMID: 29960989 PMCID: PMC6064900 DOI: 10.1161/jaha.118.008854] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 06/07/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Postural tachycardia syndrome (POTS) is a heterogeneous condition. We stratified patients previously evaluated for POTS on the basis of supine resting cardiac output (CO) or with the complaint of platypnea or "shortness of breath" during orthostasis. We hypothesize that postural hyperventilation is one cause of POTS and that hyperventilation-associated POTS occurs when initial reduction in CO is sufficiently large. We also propose that circulatory abnormalities normalize with restoration of CO2. METHODS AND RESULTS Fifty-eight enrollees with POTS were compared with 16 healthy volunteer controls. Low CO in POTS was defined by a resting supine CO <4 L/min. Patients with shortness of breath had hyperventilation with end tidal CO2 <30 Torr during head-up tilt table testing. There were no differences in height or weight between control patients and patients with POTS or differences between the POTS groups. Beat-to-beat blood pressure was measured by photoplethysmography, and CO was measured by ModelFlow. Systemic vascular resistance was defined as mean arterial blood pressure/CO. End tidal CO2 and cerebral blood flow velocity of the middle cerebral artery were only reduced during head-up tilt in the hyperventilation group, whereas blood pressure was increased compared with control. We corrected the reduced end tidal CO2 in hyperventilation by addition of exogenous CO2 into a rebreathing apparatus. With added CO2, heart rate, blood pressure, CO, and systemic vascular resistance in hyperventilation became similar to control. CONCLUSIONS We conclude that all POTS is related to decreased CO, decreased central blood volume, and increased systemic vascular resistance and that a variant of POTS is consequent to postural hyperventilation.
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Affiliation(s)
- Julian M Stewart
- Department of Pediatrics, New York Medical College, Valhalla, NY
- Department of Physiology, New York Medical College, Valhalla, NY
| | - Paul Pianosi
- Paediatric Respiratory Medicine, King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Mohamed A Shaban
- Department of Pediatrics, New York Medical College, Valhalla, NY
| | - Courtney Terilli
- Department of Pediatrics, New York Medical College, Valhalla, NY
| | - Maria Svistunova
- Department of Pediatrics, New York Medical College, Valhalla, NY
| | - Paul Visintainer
- Epidemiology and Biostatistics, Baystate Medical Center, University of Massachusetts School of Medicine, Worcester, MA
| | - Marvin S Medow
- Department of Pediatrics, New York Medical College, Valhalla, NY
- Department of Physiology, New York Medical College, Valhalla, NY
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34
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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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35
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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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36
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Ruzieh M, Grubb BP. Orthostatic intolerance and postural tachycardia syndrome: new insights into pathophysiology and treatment. Herzschrittmacherther Elektrophysiol 2018; 29:183-186. [PMID: 29696346 DOI: 10.1007/s00399-018-0563-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 04/03/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Mohammed Ruzieh
- Cardiology, The Pennsylvania State Heart and Vascular Institute, Hershey, PA, USA
| | - Blair P Grubb
- Division of Cardiovascular Medicine, The University of Toledo Medical Center, 3000 Arlington Ave., 43614, Toledo, OH, USA.
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Arnold AC, Ng J, Lei L, Raj SR. Autonomic Dysfunction in Cardiology: Pathophysiology, Investigation, and Management. Can J Cardiol 2017; 33:1524-1534. [PMID: 29102451 PMCID: PMC5705288 DOI: 10.1016/j.cjca.2017.09.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 08/19/2017] [Accepted: 09/06/2017] [Indexed: 12/24/2022] Open
Abstract
Presyncope and syncope are common medical findings, with a > 40% estimated lifetime prevalence. These conditions are often elicited by postural stress and can be recurrent and accompanied by debilitating symptoms of cerebral hypoperfusion. Therefore, it is critical for physicians to become familiar with the diagnosis and treatment of common underlying causes of presyncope and syncope. In some patients, altered postural hemodynamic responses result from a failure of compensatory autonomic nervous system reflex mechanisms. The most common presentations of presyncope and syncope secondary to this autonomic dysfunction include vasovagal syncope, neurogenic orthostatic hypotension, and postural tachycardia syndrome. The most sensitive method for diagnosis is a detailed initial evaluation with medical history, physical examination, and resting electrocardiogram to rule out cardiac syncope. Physical examination should include measurement of supine and standing blood pressure and heart rate to identify the pattern of hemodynamic regulation during orthostatic stress. Additional testing may be required in patients without a clear diagnosis after the initial evaluation. Management of patients should focus on improving symptoms and functional status and not targeting arbitrary hemodynamic values. An individualized structured and stepwise approach should be taken for treatment, starting with patient education, lifestyle modifications, and use of physical counter-pressure manoeuvres and devices to improve venous return. Pharmacologic interventions should be added only when conservative approaches are insufficient to improve symptoms. There are no gold standard approaches for pharmacologic treatment in these conditions, with medications often used off label and with limited long-term data for effectiveness.
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Affiliation(s)
- Amy C Arnold
- Department of Neural and Behavioral Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jessica Ng
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Lucy Lei
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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Xu WR, Jin HF, Du JB. Pathogenesis and Individualized Treatment for Postural Tachycardia Syndrome in Children. Chin Med J (Engl) 2017; 129:2241-5. [PMID: 27625098 PMCID: PMC5022347 DOI: 10.4103/0366-6999.189915] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Objective: Postural tachycardia syndrome (POTS) is one of the major causes of orthostatic intolerance in children. We systematically reviewed the pathogenesis and the progress of individualized treatment for POTS in children. Data Sources: The data analyzed in this review are mainly from articles included in PubMed and EMBASE. Study Selection: The original articles and critical reviews about POTS were selected for this review. Results: Studies have shown that POTS might be related to several factors including hypovolemia, high catecholamine status, abnormal local vascular tension, and decreased skeletal muscle pump activity. In addition to exercise training, the first-line treatments mainly include oral rehydration salts, beta-adrenoreceptor blockers, and alpha-adrenoreceptor agonists. However, reports about the effectiveness of various treatments are diverse. By analyzing the patient's physiological indexes and biomarkers before the treatment, the efficacy of medication could be well predicted. Conclusions: The pathogenesis of POTS is multifactorial, including hypovolemia, abnormal catecholamine state, and vascular dysfunction. Biomarker-directed individualized treatment is an important strategy for the management of POTS children.
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Affiliation(s)
- Wen-Rui Xu
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Hong-Fang Jin
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Jun-Bao Du
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
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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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Ruzieh M, Baugh A, Dasa O, Parker RL, Perrault JT, Renno A, Karabin BL, Grubb B. Effects of intermittent intravenous saline infusions in patients with medication—refractory postural tachycardia syndrome. J Interv Card Electrophysiol 2017; 48:255-260. [DOI: 10.1007/s10840-017-0225-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 01/24/2017] [Indexed: 10/20/2022]
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Roerink ME, Lenders JWM, Schmits IC, Pistorius AMA, Smit JW, Knoop H, van der Meer JWM. Postural orthostatic tachycardia is not a useful diagnostic marker for chronic fatigue syndrome. J Intern Med 2017; 281:179-188. [PMID: 27696568 DOI: 10.1111/joim.12564] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Postural orthostatic tachycardia syndrome (POTS) is considered a diagnostic marker for chronic fatigue syndrome (CFS). OBJECTIVES The aims of this study were to (i) compare POTS prevalence in a CFS cohort with fatigued patients not meeting CFS criteria, and (ii) assess activity, impairment and response to cognitive behavioural therapy (CBT) in CFS patients with POTS (POTS-CFS) and without POTS (non-POTS-CFS). METHODS Prospective cohort study at the Radboud University Medical Centre in the Netherlands. Between June 2013 and December 2014, 863 consecutive patients with persistent fatigue were screened. Patients underwent an active standing test, filled out questionnaires and wore an activity-sensing device for a period of 12 days. RESULTS A total of 419 patients with CFS and 341 non-CFS fatigued patients were included in the study. POTS prevalence in adult patients with CFS was 5.7% vs. 6.9% in non-CFS adults (P = 0.54). In adolescents, prevalence rates were 18.2% and 17.4%, respectively (P = 0.93). Adult patients with POTS-CFS were younger (30 ± 12 vs. 40 ± 13 years, P = 0.001) and had a higher supine heart rate (71 ± 11 vs. 65 ± 9 beats per min, P = 0.009) compared with non-POTS-CFS patients. Severity and activity patterns did not differ between groups. In patients with CFS, criteria for Systemic Exertion Intolerance Disease (SEID) were met in 76% of adults and 67% of adolescents. In these patients with CFS fulfilling the SEID criteria, the prevalence of POTS was not different from that in the overall CFS population. POTS-CFS adolescents had less clinically significant improvement after CBT than non-POTS-CFS adolescents (58% vs. 88%, P = 0.017). CONCLUSION In adults with CFS, the prevalence of POTS was low, was not different from the rate in non-CFS fatigued patients and was not related to disease severity or treatment outcome. In POTS-CFS adolescents, CBT was less successful than in non-POTS-CFS patients. The evaluation of POTS appears to be of limited value for the diagnosis of CFS.
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Affiliation(s)
- M E Roerink
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - J W M Lenders
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands.,Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - I C Schmits
- Expert Centre for Chronic Fatigue, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - A M A Pistorius
- Centre for Molecular and Biomolecular Informatics, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - J W Smit
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - H Knoop
- Expert Centre for Chronic Fatigue, Radboud University Medical Centre, Nijmegen, the Netherlands.,Department of Medical Psychology, Academic Medical Centre (AMC), University of Amsterdam, Amsterdam, the Netherlands
| | - J W M van der Meer
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
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Jones PK, Shaw BH, Raj SR. Clinical challenges in the diagnosis and management of postural tachycardia syndrome. Pract Neurol 2016; 16:431-438. [PMID: 27660311 DOI: 10.1136/practneurol-2016-001405] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2016] [Indexed: 11/04/2022]
Abstract
Postural tachycardia syndrome (POTS) is a multifactorial clinical syndrome defined by an increase in heart rate of ≥30 bpm on standing from supine position (or ≥40 bpm in children). It is associated with symptoms of cerebral hypoperfusion that are worse when upright and improve when in supine position. Patients often have additional symptoms including severe fatigue and difficulty concentrating. There are several possible pathophysiologic mechanisms including hypovolaemia, small-fibre peripheral neuropathy and hyperadrenergic states. POTS can also be associated with several disorders including mastocytosis, Ehlers-Danlos syndrome (hypermobility type) and autoimmune disorders. The treatment is focused on symptom relief and not solely on reducing tachycardia. Given its varying presentations, it is important to employ a practical, mechanism-focused approach to the diagnosis and management of POTS.
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Affiliation(s)
- Pearl K Jones
- Department of Neurology, UT Health Science Center San Antonio, San Antonio, Texas, USA
| | - Brett H Shaw
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary
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Raj S, Sheldon R. Management of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia and Vasovagal Syncope. Arrhythm Electrophysiol Rev 2016; 5:122-9. [PMID: 27617091 PMCID: PMC5013178 DOI: 10.15420/aer.2016.7.2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 04/26/2016] [Indexed: 01/14/2023] Open
Abstract
Postural tachycardia syndrome (POTS), inappropriate sinus tachycardia (IST) and vasovagal syncope (VVS) are relatively common clinical syndromes that are seen by physicians in several disciplines. They are often not well recognised and are poorly understood by physicians, are associated with significant morbidity and cause significant frustration for both patients and their physicians. The 2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia and Vasovagal Syncope provides physicians with an introduction to these disorders and initial recommendations on their investigation and treatment. Here we summarise the consensus statement to help physicians in the management of patients with these frequently distressing problems.
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Affiliation(s)
- Satish Raj
- Libin Cardiovascular Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Robert Sheldon
- Libin Cardiovascular Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Abstract
Postural tachycardia syndrome (POTS) is a form of chronic orthostatic intolerance for which the hallmark physiological trait is an excessive increase in heart rate with assumption of upright posture. The orthostatic tachycardia occurs in the absence of orthostatic hypotension and is associated with a >6-month history of symptoms that are relieved by recumbence. The heart rate abnormality and orthostatic symptoms should not be caused by medications that impair autonomic regulation or by debilitating disorders that can cause tachycardia. POTS is a "final common pathway" for a number of overlapping pathophysiologies, including an autonomic neuropathy in the lower body, hypovolemia, elevated sympathetic tone, mast cell activation, deconditioning, and autoantibodies. Not only may patients be affected by more than one of these pathophysiologies but also the phenotype of POTS has similarities to a number of other disorders, e.g., chronic fatigue syndrome, Ehlers-Danlos syndrome, vasovagal syncope, and inappropriate sinus tachycardia. POTS can be treated with a combination of non-pharmacological approaches, a structured exercise training program, and often some pharmacological support.
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Abstract
This article describes the pathophysiology, clinical presentation, differential diagnosis, diagnosis, and management of postural orthostatic tachycardia syndrome (POTS), a potentially debilitating autonomic disorder that can have many causes and presentations. POTS can be mistaken for panic disorder, inappropriate sinus tachycardia, and chronic fatigue syndrome. Clinician suspicion for the syndrome is key to prompt patient diagnosis and treatment.
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Neurogenic hyperadrenergic orthostatic hypotension: a newly recognized variant of orthostatic hypotension in older adults with elevated norepinephrine (noradrenaline). Clin Sci (Lond) 2015; 129:107-16. [PMID: 25706983 DOI: 10.1042/cs20140766] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Patients with neurogenic orthostatic hypotension (OH) typically have impaired sympathetic nervous system tone and therefore low levels of upright plasma norepinephrine (NE) (noradrenaline). We report a subset of patients who clinically have typical neurogenic OH but who paradoxically have elevated upright levels of plasma NE. We retrospectively studied 83 OH patients evaluated at the Vanderbilt Autonomic Dysfunction Center between August 2007 and May 2013. Based on standing NE, patients were dichotomized into a hyperadrenergic OH group [hyperOH: upright NE ≥ 3.55 nmol/l (600 pg/ml), n=19] or a non-hyperadrenergic OH group [nOH: upright NE < 3.55 nmol/l (600 pg/ml), n=64]. Medical history and data from autonomic testing, including the Valsalva manoeuvre (VM), were analysed. HyperOH patients had profound orthostatic falls in blood pressure (BP), but less severe than in nOH [change in SBP (systolic blood pressure): -53 ± 31 mmHg compared with -68 ± 33 mmHg, P=0.050; change in DBP (diastolic blood pressure): -18 ± 23 mmHg compared with -30 ± 17 mmHg, P=0.01]. The expected compensatory increase in standing heart rate (HR) was similarly blunted in both hyperOH and nOH groups [84 ± 15 beats per minute (bpm) compared with 82 ± 14 bpm; P=0.6]. HyperOH patients had less severe sympathetic failure as evidenced by smaller falls in DBP during phase 2 of VM and a shorter VM phase 4 BP recovery time (16.5 ± 8.9 s compared with 31.6 ± 16.6 s; P<0.001) than nOH patients. Neurogenic hyperOH patients have severe neurogenic OH, but have less severe adrenergic dysfunction than nOH patients. Further work is required to understand whether hyperOH patients will progress to nOH or whether this represents a different disorder.
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Sheldon RS, Grubb BP, Olshansky B, Shen WK, Calkins H, Brignole M, Raj SR, Krahn AD, Morillo CA, Stewart JM, Sutton R, Sandroni P, Friday KJ, Hachul DT, Cohen MI, Lau DH, Mayuga KA, Moak JP, Sandhu RK, Kanjwal K. 2015 heart rhythm society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm 2015; 12:e41-63. [PMID: 25980576 DOI: 10.1016/j.hrthm.2015.03.029] [Citation(s) in RCA: 557] [Impact Index Per Article: 61.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Indexed: 01/14/2023]
Affiliation(s)
| | | | | | | | | | | | - Satish R Raj
- Libin Cardiovascular Institute of Alberta, Alberta, Canada; Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Carlos A Morillo
- Department of Medicine, Cardiology Division, McMaster University Population Health Research Institute, Hamilton, Canada
| | | | - Richard Sutton
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | - Karen J Friday
- (13)Stanford University School of Medicine, Stanford, California
| | | | - Mitchell I Cohen
- Phoenix Children's Hospital, University of Arizona School of Medicine-Phoenix, Arizona Pediatric Cardiology/Mednax, Phoenix, Arizona
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide; Department of Cardiology, Royal Adelaide Hospital; and South Australian Health and Medical Research Institute, Adelaide, Australia
| | | | - Jeffrey P Moak
- Children's National Medical Center, Washington, District of Columbia
| | - Roopinder K Sandhu
- University of Alberta, Department of Medicine, Division of Cardiology, Alberta, Canada
| | - Khalil Kanjwal
- Michigan Cardiovascular Institute, Central Michigan University, Saginaw, Michigan
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Differential Diagnosis of Vasovagal Syncope: Postural Orthostatic Tachycardia. VASOVAGAL SYNCOPE 2015. [PMCID: PMC7123721 DOI: 10.1007/978-3-319-09102-0_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Postural tachycardia syndrome (POTS) is a syndrome defined as an increase in heart rate (HR) of ≥30 bpm within 10 min of assuming an upright posture in the absence of orthostatic hypotension (decrease in blood pressure (BP) >20/10 mmHg). The prevalence of POTS has been estimated as 500,000–3,000,000 patients in the USA. Because it affects mainly women between 13 and 50 years of age, the impact on productivity at work and lifestyle can be devastating. Considerable clinical overlap exists between POTS and vasovagal syncope (VVS) with patients experiencing similar orthostatic symptoms related to insufficient adaptation to blood volume shifts during upright posture. Nevertheless, differences emerge during head up tilt table testing. In patients with POTS, during upright tilt, sympathetic tone increases, there is an early and sustained tachycardia, and patients complain of presyncope without frank syncope. In contrast, patients with VVS experience delayed symptoms and abrupt drops in BP and HR and are more likely to lose consciousness. Treatment of POTS includes exercise and medications directed at decreasing sympathetic tone or increasing blood volume.
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Stewart JM, Del Pozzi AT, Pandey A, Messer ZR, Terilli C, Medow MS. Oscillatory cerebral blood flow is associated with impaired neurocognition and functional hyperemia in postural tachycardia syndrome during graded tilt. Hypertension 2014; 65:636-43. [PMID: 25510829 DOI: 10.1161/hypertensionaha.114.04576] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We hypothesize that upright cognitive impairment in patients with postural tachycardia syndrome (POTS) is caused by reduced cerebral blood flow (CBF). The CBF velocity (CBF(v)) measured by transcranial Doppler ultrasound decreased excessively during 70° tilt in a minority of patients with intermittent hyperpnea/hypocapnia. Incremental tilt showed no difference in mean CBF(v). But N-back memory tasking indicated progressive compromised memory, reduced functional hyperemia, and reduced neurovascular coupling. Orthostasis caused slow oscillations in CBF(v) linked to oscillations in arterial pressure in patients with POTS. We also hypothesize that oscillatory CBF(v) degrades neurovascular coupling. We performed 2-back testing when subjects were in supine position and during incremental tilts to 15°, 30°, 45°, and 60° in 11 patients with POTS and 9 controls. Oscillatory arterial pressure, oscillatory CBF(v), and neurovascular coupling were similar in supine position. The oscillatory arterial pressure increased by 31%, 45%, 67%, and 93% in patients with POTS during tilt and remained unchanged in the controls. Oscillatory CBF(v) increased by 61%, 82%, 161%, and 264% in patients with POTS during tilt and remained unchanged in the controls. Functional hyperemia decreased from 4.1% to 3.0%, 1.1%, 0.2%, and to 0.04% in patients with POTS, but it was unchanged at 4% in the controls. Percent correct N-back responses decreased from 78% to 33% in patients with POTS, whereas they remained at 89% in the controls. In patients with POTS, oscillatory CBF(v) was linearly correlated with functional hyperemia (r(2)=0.76). Increased oscillatory CBF is associated with reduced neurovascular coupling and diminished cognitive performance in patients with POTS.
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Affiliation(s)
- Julian M Stewart
- From the Departments of Pediatrics (J.M.S., A.T.D.P., A.P., Z.R.M., C.T., M.S.M.) and Physiology (J.M.S., M.S.M.), New York Medical College, Valhalla.
| | - Andrew T Del Pozzi
- From the Departments of Pediatrics (J.M.S., A.T.D.P., A.P., Z.R.M., C.T., M.S.M.) and Physiology (J.M.S., M.S.M.), New York Medical College, Valhalla
| | - Akash Pandey
- From the Departments of Pediatrics (J.M.S., A.T.D.P., A.P., Z.R.M., C.T., M.S.M.) and Physiology (J.M.S., M.S.M.), New York Medical College, Valhalla
| | - Zachary R Messer
- From the Departments of Pediatrics (J.M.S., A.T.D.P., A.P., Z.R.M., C.T., M.S.M.) and Physiology (J.M.S., M.S.M.), New York Medical College, Valhalla
| | - Courtney Terilli
- From the Departments of Pediatrics (J.M.S., A.T.D.P., A.P., Z.R.M., C.T., M.S.M.) and Physiology (J.M.S., M.S.M.), New York Medical College, Valhalla
| | - Marvin S Medow
- From the Departments of Pediatrics (J.M.S., A.T.D.P., A.P., Z.R.M., C.T., M.S.M.) and Physiology (J.M.S., M.S.M.), New York Medical College, Valhalla
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