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Knoop I, Gu S, Fareghzadeh S, Jones ASK, Gall N, Moss-Morris R. Exploring the complexities of illness identity and symptom management in seeking a diagnostic label of postural orthostatic tachycardia syndrome (POTS): An inductive approach. Br J Health Psychol 2024; 29:297-316. [PMID: 37845822 DOI: 10.1111/bjhp.12700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 06/06/2023] [Accepted: 10/01/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVES Postural orthostatic tachycardia syndrome (POTS) is a debilitating and under-recognized condition of the autonomic nervous system. This study applied Leventhal's Common-Sense Model of Illness Representations to explore the journey to a diagnosis of POTS and to understand its relevance to poorly understood conditions which have common comorbidities. DESIGN An inductive qualitative approach was used to explore the processes by which patients formulate explanations and management of symptoms within the search for a diagnostic label and to investigate illness identity in the context of existing diagnoses or multimorbidity. METHODS Participants (n = 29) for this nested qualitative study were recruited from a larger longitudinal study of people who had been newly referred to a specialist POTS service. Semi-structured interviews were conducted via video call. Three researchers coded and analysed data using Reflexive Thematic Analysis and elements of Grounded Theory. RESULTS The analysis resulted in three overarching themes: 'Seeking physiological coherence and validation', 'Individual persistence', and 'Navigating the cumulative burden'. 'Accessibility and disparities of health care' was noted as a contextual factor. Receiving a POTS diagnosis was regarded by participants as providing legitimacy and increased access to treatment. Overall, delays in the diagnostic journey and the lack of a clear diagnosis impacted negatively on patients through increased uncertainty and a lack of clear guidance on how to manage symptoms. Findings also suggested there were great complexities in assigning symptoms to labels in the context of multimorbidity. CONCLUSIONS Participants' stories highlighted the urgent need for better recognition of POTS so that the self-regulatory process can be initiated from the early stages of symptom detection.
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Affiliation(s)
- Iris Knoop
- Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Stephanie Gu
- Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Shamim Fareghzadeh
- Neuroscience Section, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Annie S K Jones
- Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Nicholas Gall
- Cardiology Department, King's College Hospital, London, UK
| | - Rona Moss-Morris
- Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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van Zanten S, Sutton R, Hamrefors V, Fedorowski A, de Lange FJ. Tilt table testing, methodology and practical insights for the clinic. Clin Physiol Funct Imaging 2024; 44:119-130. [PMID: 37839043 DOI: 10.1111/cpf.12859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 09/18/2023] [Accepted: 10/04/2023] [Indexed: 10/17/2023]
Abstract
Tilt table testing (TTT) has been used for decades to study short-term blood pressure (BP) and heart rate regulation during orthostatic challenges. TTT provokes vasovagal reflex in many syncope patients as a background of widespread use. Despite the availability of evidence-based practice syncope guidelines, proper application and interpretation of TTT in the day-to-day care of syncope patients remain challenging. In this review, we offer practical information on what is needed to perform TTT, how results should be interpreted including the Vasovagal Syncope International Study classification, why syncope induction on TTT is necessary in patients with unexplained syncope and on indications for TTT in syncope patient care. The minimum requirements to perform TTT are a tilt table with an appropriate tilt-down time, a continuous beat-to-beat BP monitor with at least three electrocardiogram leads and trained staff. We emphasize that TTT remains a valuable asset that adds to history building but cannot replace it, and highlight the importance of recognition when TTT is abnormal even without syncope. Acknowledgement by the patient/eyewitness of the reproducibility of the induced attack is mandatory in concluding a diagnosis. TTT may be indicated when the initial syncope evaluation does not yield a certain, highly likely, or possible diagnosis, but raises clinical suspicion of (1) reflex syncope, (2) orthostatic hypotension (OH), (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT in the patient with a certain, highly likely or possible diagnosis of reflex syncope, may be to educate patients on prodromes. In patients with reflex syncope with OH TTT can be therapeutic to recognize hypotensive symptoms causing near-syncope to perform physical countermanoeuvres for syncope prevention (biofeedback). Detection of hypotensive susceptibility requiring therapy is of special value.
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Affiliation(s)
- Steven van Zanten
- Department of Cardiology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Richard Sutton
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Campus, London, UK
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
- Department of Cardiology, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Frederik J de Lange
- Department of Clinical and Experimental Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Stavrakis S, Chakraborty P, Farhat K, Whyte S, Morris L, Abideen Asad ZU, Karfonta B, Anjum J, Matlock HG, Cai X, Yu X. Noninvasive Vagus Nerve Stimulation in Postural Tachycardia Syndrome: A Randomized Clinical Trial. JACC Clin Electrophysiol 2024; 10:346-355. [PMID: 37999672 DOI: 10.1016/j.jacep.2023.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 09/18/2023] [Accepted: 10/17/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Low-level transcutaneous stimulation of the auricular branch of the vagus nerve at the tragus is antiarrhythmic and anti-inflammatory in animals and humans. Preliminary studies show that transcutaneous vagus nerve stimulation (tVNS) is beneficial in animal models of postural tachycardia syndrome (POTS). OBJECTIVES In this study the authors conducted a sham-controlled, double-blind, randomized clinical trial to examine the effect of tVNS on POTS over a 2-month period relative to sham stimulation. METHODS tVNS (20 Hz, 1 mA below discomfort threshold) was delivered using an ear clip attached to either the tragus (active; n = 12) or the ear lobe (sham; n = 14) for 1 hour daily over a 2-month period. Postural tachycardia was assessed during the baseline and 2-month visit. Heart rate variability based on 5-minute electrocardiogram, serum cytokines, and antiautonomic autoantibodies were measured at the respective time points. RESULTS Mean age was 34 ± 11 years (100% female; 81% Caucasian). Adherence to daily stimulation was 83% in the active arm and 86% in the sham arm (P > 0.05). Postural tachycardia was significantly less in the active arm compared with the sham arm at 2 months (mean postural increase in heart rate 17.6 ± 9.9 beats/min vs 31.7 ± 14.4 beats/min; P = 0.01). Antiadrenergic autoantibodies and inflammatory cytokines were lower in the active arm compared with the sham arm at 2 months (P < 0.05). Heart rate variability was better in the active arm. No device-related side effects were observed. CONCLUSIONS Our results support the emerging paradigm of noninvasive neuromodulation to treat POTS. Mechanistically, this effect appears to be related to reduction of antiautonomic autoantibodies and inflammatory cytokines, and improvement in autonomic tone. Further studies are warranted. (Autoimmune Basis for Postural Tachycardia Syndrome; NCT05043051).
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Affiliation(s)
- Stavros Stavrakis
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
| | | | - Kassem Farhat
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Seabrook Whyte
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Lynsie Morris
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | | | - Brittany Karfonta
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Juvaria Anjum
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - H Greg Matlock
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Xue Cai
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Xichun Yu
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Edwards CC, Edwards CC, Heinlein S, Rowe PC. Case report: Recurrent cervical spinal stenosis masquerading as myalgic encephalomyelitis/chronic fatigue syndrome with orthostatic intolerance. Front Neurol 2023; 14:1284062. [PMID: 38099073 PMCID: PMC10720627 DOI: 10.3389/fneur.2023.1284062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 11/10/2023] [Indexed: 12/17/2023] Open
Abstract
Introduction Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex, chronic, multi-system disorder that is characterized by a substantial impairment in the activities that were well tolerated before the illness. In an earlier report, we had described three adult women who met criteria for ME/CFS and orthostatic intolerance, and had congenital or acquired cervical spinal stenosis. All three experienced substantial global improvements in their ME/CFS and orthostatic intolerance symptoms after recognition and surgical treatment of the cervical stenosis. After a several year period of improvement, one of the individuals in that series experienced a return of ME/CFS and orthostatic intolerance symptoms. Main symptoms and clinical findings Radiologic investigation confirmed a recurrence of the ventral compression of the spinal cord due to a shift of the disc replacement implant at the involved cervical spinal level. Therapeutic intervention Decompression of the spinal cord with removal of the implant and fusion at the original C5-C6 level was once again followed by a similar degree of improvement in function as had been observed after the first operation. Conclusion This recapitulation of the outcomes after surgical management of cervical stenosis provides further evidence in support of the hypothesis that cervical spinal stenosis can exacerbate pre-existing or cause new orthostatic intolerance and ME/CFS. Especially for those with refractory symptoms and neurological signs, surgical interventions may offer relief for selected patients with this complex condition.
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Affiliation(s)
- Charles C. Edwards
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Charles C. Edwards
- Maryland Spine Center, Mercy Medical Center, Baltimore, MD, United States
| | - Scott Heinlein
- Lifestrength Physical Therapy, Inc., Towson, MD, United States
| | - Peter C. Rowe
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Gómez-Moyano E, Rodríguez-Capitán J, Gaitán Román D, Reyes Bueno JA, Villalobos Sánchez A, Espíldora Hernández F, González Angulo GE, Molina Mora MJ, Thurnhofer-Hemsi K, Molina-Ramos AI, Romero-Cuevas M, Jiménez-Navarro M, Pavón-Morón FJ. Postural orthostatic tachycardia syndrome and other related dysautonomic disorders after SARS-CoV-2 infection and after COVID-19 messenger RNA vaccination. Front Neurol 2023; 14:1221518. [PMID: 37654428 PMCID: PMC10467287 DOI: 10.3389/fneur.2023.1221518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/21/2023] [Indexed: 09/02/2023] Open
Abstract
The COVID-19 pandemic has caused a challenge for our society due to the post-acute sequelae of the disease. Persistent symptoms and long-term multiorgan complications, known as post-acute COVID-19 syndrome, can occur beyond 4 weeks from the onset of the COVID-19 infection. Postural orthostatic tachycardia syndrome (POTS) is considered a variety of dysautonomia, which is characterized by chronic symptoms that occur with standing and a sustained increase in heart rate, without orthostatic hypotension. POTS can lead to debilitating symptoms, significant disability, and impaired quality of life. In this narrative review, the etiopathogenic basis, epidemiology, clinical manifestations, diagnosis, treatment, prognosis, and socioeconomic impact of POTS, as well as other related dysautonomic disorders, after COVID-19 infection and SARS-CoV-2 postvaccination, were discussed. After a search conducted in March 2023, a total of 89 relevant articles were selected from the PubMed, Google Scholar, and Web of Science databases. The review highlights the importance of recognizing and managing POTS after COVID-19 infection and vaccination, and the approach to autonomic disorders should be known by all specialists in different medical areas. The diagnosis of POTS requires a comprehensive clinical assessment, including a detailed medical history, physical examination, orthostatic vital signs, and autonomic function tests. The treatment of POTS after COVID-19 infection or vaccination is mainly focused on lifestyle modifications, such as increased fluid and salt intake, exercise, and graduated compression stockings. Pharmacotherapy, such as beta-blockers, fludrocortisone, midodrine, and ivabradine, may also be used in selected cases. Further research is needed to understand the underlying mechanisms, risk factors, and optimal treatment strategies for this complication.
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Affiliation(s)
| | - Jorge Rodríguez-Capitán
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Daniel Gaitán Román
- Department of Cardiology, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | | | | | | | | | - Karl Thurnhofer-Hemsi
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Computer Languages and Computer Sciences, University of Malaga, Málaga, Spain
| | - Ana Isabel Molina-Ramos
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Miguel Romero-Cuevas
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Manuel Jiménez-Navarro
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Department of Medicine and Dermatology, University of Malaga, Málaga, Spain
| | - Francisco Javier Pavón-Morón
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
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Stewart JM, Medow MS. Anticipatory central command on standing decreases cerebral blood velocity causing hypocapnia in hyperpneic postural tachycardia syndrome. J Appl Physiol (1985) 2023; 135:26-34. [PMID: 37227184 PMCID: PMC10281786 DOI: 10.1152/japplphysiol.00016.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 05/16/2023] [Accepted: 05/18/2023] [Indexed: 05/26/2023] Open
Abstract
Fifty percent of patients with postural tachycardia syndrome (POTS) are hypocapnic during orthostasis related to initial orthostatic hypotension (iOH). We determined whether iOH drives hypocapnia in POTS by low BP or decreased cerebral blood velocity (CBv). We studied three groups; healthy volunteers (n = 32, 18 ± 3 yr) were compared with POTS, grouped by presence [POTS-low end-tidal CO2 (↓ETCO2), n = 26, 19 ± 2 yr] or absence [POTS-normal upright end-tidal carbon dioxide (nlCO2), n = 28, 19 ± 3 yr] of standing hypocapnia defined by end-tidal CO2 (ETCO2) ≤ 30 mmHg at steady-state, measuring middle cerebral artery CBv, heart rate (HR), and beat-to-beat blood pressure (BP). After 30 min supine, subjects stood for 5 min. Quantities were measured prestanding, at minimum CBv, minimum BP, peak HR, CBv recovery, BP recovery, minimum HR, steady-state, and 5 min. Baroreflex gain was estimated by α index. iOH occurred with similar frequency and minimum BP in POTS-↓ETCO2 and POTS-nlCO2. Minimum CBv was reduced significantly (P < 0.05) in POTS-↓ETCO2 (48 ± 3 cm/s) preceding hypocapnia compared with POTS-nlCO2 (61 ± 3 cm/s) or Control (60 ± 2 cm/s). The anticipatory increased BP was significantly larger (P < 0.05) in POTS (8 ± 1 mmHg vs. 2 ± 1) and began ∼8 s prestanding. HR increased in all subjects, CBv increased significantly (P < 0.05) in both POTS-nlCO2 (76 ± 2 to 85 ± 2 cm/s) and Control (75 ± 2 to 80 ± 2 cm/s) consistent with central command. CBv decreased in POTS-↓ETCO2 (76 ± 3 to 64 ± 3 cm/s) correlating with decreased baroreflex gain. Cerebral conductance [meanCBv/mean arterial blood pressure (MAP)] was reduced in POTS-↓ETCO2 throughout. Data support the hypothesis that excessively reduced CBv during iOH may intermittently reduce carotid body blood flow, sensitizing that organ and producing postural hyperventilation in POTS-↓ETCO2. Excessive fall in CBv occurs in part during prestanding central command and is a facet of defective parasympathetic regulation in POTS.NEW & NOTEWORTHY Dyspnea is frequent in postural tachycardia syndrome (POTS) and is associated with upright hyperpnea and hypocapnia that drives sinus tachycardia. It is initiated by an exaggerated reduction in cerebral conductance and decreased cerebral blood flow (CBF) that precedes the act of standing. This is a form of autonomically mediated "central command." Cerebral blood flow is further reduced by initial orthostatic hypotension common in POTS. Hypocapnia is maintained during the standing response and might account for persistent postural tachycardia.
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Affiliation(s)
- Julian M Stewart
- Department of Pediatrics, New York Medical College, Valhalla, New York, United States
- Department of Physiology, New York Medical College, Valhalla, New York, United States
| | - Marvin S Medow
- Department of Pediatrics, New York Medical College, Valhalla, New York, United States
- Department of Physiology, New York Medical College, Valhalla, New York, United States
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Igharo D, Thiel JC, Rolke R, Akkaya M, Weis J, Katona I, Schulz JB, Maier A. Skin biopsy reveals generalized small fibre neuropathy in hypermobile Ehlers-Danlos syndromes. Eur J Neurol 2023; 30:719-728. [PMID: 36437696 DOI: 10.1111/ene.15649] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/04/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Ehlers-Danlos syndromes are hereditary disorders of connective tissue that are characterized by joint hypermobility, skin hyperextensibility and tissue fragility. The most common subtype is the hypermobile type. In addition to symptoms of small fibre neuropathy (SFN) due to damage to the small peripheral nerve fibres, with degeneration of the distal nerve endings, autonomic disorders such as postural tachycardia syndrome (PoTS) are frequently reported features in patients with hypermobile Ehlers-Danlos syndrome (hEDS). To date, the underlying pathophysiological mechanisms are still not completely understood. STUDY PURPOSE To better understand pathophysiological mechanisms of small fiber neuropathy and autonomic neuropathy in hypermobile Ehlers-Danlos Syndromes. METHODS We prospectively investigated 31 patients with hEDS compared to 31 healthy controls by using skin biopsy, quantitative sensory testing, tilt-table testing, the painDetect, Small Fibre Neuropathy Screening List and the COMPASS-31 (Composite Autonomic Symptom Score 31) questionnaire. RESULTS Nineteen (61%) patients with hEDS were diagnosed with SFN, and 10 (32%) fulfilled the criteria for PoTS. Patients with hEDS had significantly higher heart rates than controls. According to quantitative sensory testing, these patients had generalized thermal and tactile hypesthesia. Skin biopsy revealed significantly reduced intraepithelial nerve fibre density proximally (thigh) and distally (lower leg) in patients compared to controls. This was consistent with various complaints of pain and sensory disturbances in both the proximal and distal body regions. CONCLUSION These results confirm histologically proven SFN as a common feature in patients with hEDS, revealing a generalized distribution of nerve fibre loss. Regarding the frequently reported autonomic and neuropathic dysfunctions, the findings support SFN as an important, but not the only, underlying pathomechanism.
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Affiliation(s)
- Denver Igharo
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Joana C Thiel
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Roman Rolke
- Department of Palliative Medicine, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Merve Akkaya
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Joachim Weis
- Institute of Neuropathology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Istvan Katona
- Institute of Neuropathology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Jörg B Schulz
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
- JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Andrea Maier
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
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Mejia A, Barrera Gutierrez JC, Vivian E, Shah J, Dickerman R. Robotic assisted kidney auto-transplantation as a safe alternative for treatment of nutcracker syndrome and loin pain haematuria syndrome: A case series report. Int J Med Robot 2023; 19:e2508. [PMID: 36808427 DOI: 10.1002/rcs.2508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/26/2023] [Accepted: 02/13/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Describe the outcomes and safety of robotic-assisted kidney auto-transplantation (RAKAT) in the treatment of nutcracker syndrome (NCS) and loin pain haematuria syndrome (LPHS). METHODS This retrospective study included 32 cases of NCS and LPHS seen during December 2016 to June 2021. RESULTS Three (9%) patients had LPHS and 29 (91%) NCS. All were non-Hispanic whites, and 31 (97%) women. The mean age was 32 years (SD = 10) and the BMI 22.8 (SD = 5). The RAKAT was completed in all patients, 63% had a total improvement of pain. According to the Clavien-Dindo classification, 47% presented with type 1, and 9% with type 3 complications with a mean follow-up of 10.9 months. The incidence of acute kidney injury in post-procedure was 28%. No one required blood transfusions, and there were no deaths during the follow-up. CONCLUSION RAKAT was a feasible procedure with a similar complication rate to those reported for other surgical techniques.
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Affiliation(s)
- Alejandro Mejia
- The Liver Institute, Methodist Dallas Medical Center, Dallas, Texas, USA
| | | | - Elaina Vivian
- Methodist Digestive Institute, Methodist Dallas Medical Center, Dallas, Texas, USA
| | - Jimmy Shah
- Methodist Digestive Institute, Methodist Dallas Medical Center, Dallas, Texas, USA
| | - Richard Dickerman
- The Liver Institute, Methodist Dallas Medical Center, Dallas, Texas, USA
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Hong J, Litt SJ, Moak JP. Cardiac arrhythmias in postural tachycardia syndrome and orthostatic intolerance. Cardiol Young 2023; 33:255-9. [PMID: 35249573 DOI: 10.1017/S1047951122000580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVES There is sparse literature on cardiac arrhythmias and the utility of ambulatory rhythm monitoring in patients with postural tachycardia syndrome and orthostatic intolerance. This study's primary aim was to investigate the prevalence of arrhythmias in this population. Knowing the prevalence and types of arrhythmias in dysautonomia patients could influence the decision to pursue ambulatory rhythm monitoring and ultimately guide therapy. METHODS This retrospective descriptive study examined the frequency of cardiac arrhythmias, as detected by ambulatory rhythm monitoring, in children with postural tachycardia syndrome/orthostatic intolerance or syncope who were seen at the Children's National Hospital Electrophysiology Clinic between January 2001 and December 2020. RESULTS In postural tachycardia syndrome/orthostatic intolerance patients, arrhythmia was detected on 15% of 332 ambulatory rhythm monitors. In syncope patients, arrhythmia was detected on 16% of 157 ambulatory rhythm monitors, not significantly different from the postural tachycardia syndrome/orthostatic intolerance group. The difference in rate of arrhythmia detection between 24-hour Holter and 2-week Zio® monitoring was not statistically significant. CONCLUSION This study suggests that a substantial proportion of postural tachycardia syndrome/orthostatic intolerance patients may have concomitant underlying cardiac arrhythmias, at a frequency similar to what is seen in patients undergoing primary evaluation for cardiac symptoms such as chest pain, palpitations, and syncope. In the appropriate clinical context, physicians caring for postural tachycardia syndrome/orthostatic intolerance patients should consider additional evaluation for arrhythmias beyond sinus tachycardia.
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Diekman S, Chung T. Post-acute sequelae of SARS-CoV-2 (PASC) syndrome presenting as postural orthostatic tachycardia syndrome (POTS). Clin Exp Emerg Med 2023; 10:18-25. [PMID: 36718484 PMCID: PMC10090716 DOI: 10.15441/ceem.22.409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 12/29/2022] [Indexed: 02/01/2023] Open
Abstract
The novel SARS-CoV-2 emerged in 2019, and the global COVID-19 pandemic continues into 2022. It has been known that a subset of patients develops chronic, debilitating symptoms after otherwise complete recovery from acute infection of COVID-19. Multiple terms have been used to describe this constellation of symptoms, including long COVID, long-haul COVID, and post-acute sequelae of SARS-CoV-2 syndrome (PASC). PASC is broadly defined as a wide range of new, returning, or ongoing symptoms at least four weeks after infection. Those patients are often seen in emergency departments after acute COVID- 19 infection, but their symptoms are not adequately managed because the underlying pathophysiology of PASC is not well understood. Among patients with PASC, postural orthostatic tachycardic syndrome (POTS) has been increasingly recognized. POTS is one of the most common forms of autonomic dysfunction and defined by a sustained orthostatic tachycardia during active standing or head-up tilt test in the absence of orthostatic hypotension or other cardiopulmonary diseases. Because POTS is a treatable condition, it is important to recognize POTS among PASC patients. Herein, we reviewed the current literature on POTS and dysautonomia in PASC in order to better understand the overlap and distinction between these pathologies.
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Affiliation(s)
- Sarah Diekman
- Diekman Dysautonomia LLC., Oakland, MD, USA.,Department of Epidemiology, University of North Carolina Gillings School of Public Health, Chapel Hill, NC, USA
| | - Tae Chung
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Norcliffe-Kaufmann L, Palma JA, Martinez J, Camargo C, Kaufmann H. Fear conditioning as a pathogenic mechanism in the postural tachycardia syndrome. Brain 2022; 145:3763-3769. [PMID: 35802513 DOI: 10.1093/brain/awac249] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/18/2022] [Accepted: 06/28/2022] [Indexed: 11/12/2022] Open
Abstract
Despite its increasing recognition and extensive research, there is no unifying hypothesis on the pathophysiology of the postural tachycardia syndrome. In this cross-sectional study, we examined the role of fear conditioning and its association with tachycardia and cerebral hypoperfusion upon standing in 28 patients with postural tachycardia syndrome (31 ± 12 years old, 25 women) and 21 matched controls. We found that patients had higher somatic vigilance (p = 0.0167) and more anxiety (p < 0.0001). They also had a more pronounced anticipatory tachycardia right before assuming the upright position in a tilt-table test (p = 0.015), a physiologic indicator of fear conditioning to orthostasis. While standing, patients had faster heart rate (p < 0.001), higher plasma catecholamine levels (p = 0.020), lower end-tidal CO2 (p = 0.005), and reduced middle cerebral artery blood flow velocity (p = 0.002). Multi-linear logistic regression modeling showed that both epinephrine secretion and excessive somatic vigilance predicted the magnitude of the tachycardia and the hyperventilation. These findings suggest that the postural tachycardia syndrome is a functional psychogenic disorder in which standing may acquire a frightful quality, so that even when experienced alone, it elicits a fearful conditioned response. Heightened somatic anxiety is associated with and may predispose to a fear-conditioned hyperadrenergic state when standing. Our results have therapeutic implications.
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Affiliation(s)
| | - Jose Alberto Palma
- Department of Neurology, New York University School of Medicine, New York, NY, 10019, USA
| | - Jose Martinez
- Department of Neurology, New York University School of Medicine, New York, NY, 10019, USA
| | - Celeste Camargo
- Department of Neurology, New York University School of Medicine, New York, NY, 10019, USA
| | - Horacio Kaufmann
- Department of Neurology, New York University School of Medicine, New York, NY, 10019, USA
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12
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Cheng W, Wang J, Lin J. Biomarkers and Hemodynamic Parameters in the Diagnosis and Treatment of Children with Postural Tachycardia Syndrome and Vasovagal Syncope. Int J Environ Res Public Health 2022; 19:6974. [PMID: 35742222 DOI: 10.3390/ijerph19126974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/02/2022] [Accepted: 06/04/2022] [Indexed: 12/02/2022]
Abstract
In children, vasovagal syncope and postural tachycardia syndrome constitute the major types of orthostatic intolerance. The clinical characteristics of postural tachycardia syndrome and vasovagal syncope are similar but their treatments differ. Therefore, their differential diagnosis is important to guide the correct treatment. Therapeutic methods vary in patients with the same diagnosis because of different pathomechanisms. Hence, in patients with vasovagal syncope or postural tachycardia syndrome, routine treatments have an unsatisfactory efficacy. However, biomarkers could increase the therapeutic efficacy significantly, allowing for an accurate and detailed assessment of patients and leading to improved therapeutic effects. In the present review, we aimed to summarize the current state of research into biomarkers for distinguishing the diagnosis of pediatric vasovagal syncope from that of postural tachycardia syndrome. We also discuss the biomarkers that predict treatment outcomes during personalized therapy for each subtype.
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13
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Ray JC, Pham X, Foster E, Cheema S, Corcoran SJ, Matharu MS, Hutton EJ. The prevalence of headache disorders in Postural Tachycardia Syndrome: A systematic review and meta-analysis of the literature. Cephalalgia 2022; 42:1274-1287. [PMID: 35469447 DOI: 10.1177/03331024221095153] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Headache is a common presentation of postural tachycardia syndrome, yet robust prevalence data is lacking. OBJECTIVES To undertake a systematic review and meta-analysis to estimate the prevalence of headache disorders in postural tachycardia syndrome, and to explore the potential shared pathophysiological mechanisms that underpin these conditions as well as treatment options. METHODS Three databases were searched for publications evaluating prevalence of migraine (primary outcome) and general and orthostatic headache (secondary outcomes) in patients with postural tachycardia syndrome. Two independent reviewers selected studies and extracted data. A random-effects meta-analysis calculated the pooled prevalence of migraine in postural tachycardia syndrome. A narrative literature review explored the pathophysiology and treatment options for concurrent headache disorders and postural tachycardia syndrome. RESULTS Twenty-three articles met inclusion criteria. Estimated pooled prevalence of migraine in postural tachycardia syndrome was 36.8% (95% CI 2.9-70.7%). Various shared pathophysiological pathways for these conditions, as well as proposed treatment strategies, were identified.Limitations: Heterogeneity of study design, populations, and methodology for identifying headache disorders and postural tachycardia syndrome limited the generalisability of results. CONCLUSIONS Migraine is a commonly reported comorbidity in POTS, however the true prevalence cannot be determined from the current literature. Further studies are required to assess this comorbidity and investigate the underlying mechanisms, as well as identify effective treatment strategies.
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Affiliation(s)
- Jason C Ray
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Austin Health, Heidelberg, Victoria, Australia
| | - Xiuxian Pham
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Emma Foster
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Sanjay Cheema
- Headache and Facial Pain Group, University College London Queen Square Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Susan J Corcoran
- Department of Cardiology, Alfred Hospital, Melbourne Victoria, Australia
| | - Manjit S Matharu
- Headache and Facial Pain Group, University College London Queen Square Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Elspeth J Hutton
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
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14
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Wang Y, Sun Y, Zhang Q, Zhang C, Liu P, Wang Y, Tang C, Jin H, Du J. Baseline Corrected QT Interval Dispersion Is Useful to Predict Effectiveness of Metoprolol on Pediatric Postural Tachycardia Syndrome. Front Cardiovasc Med 2022; 8:808512. [PMID: 35127870 PMCID: PMC8812810 DOI: 10.3389/fcvm.2021.808512] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/16/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The study was designed to explore the role of baseline-corrected QT interval dispersion (QTcd) in predicting the effectiveness of metoprolol on pediatric postural tachycardia syndrome (POTS). METHODS There were two groups in the study, the discovery group and the validation group. The children with POTS in the discovery group were treated with oral metoprolol, with the completed necessary medical records, head-up tilt test (HUTT), blood chemistry, and 12-lead ECG before treatment at the pediatrics of Peking University First Hospital, China. According to whether the symptom score (SS) was reduced by more than 2 points after administration with oral metoprolol as compared with that before treatment, the children with POTS were separated into responders and non-responders. The demographic characteristics, hemodynamic indicators, and the QTcd of the two groups were compared, and the estimate of the baseline QTcd in predicting the treatment response to metoprolol was tested through a receiver operating characteristic (ROC) analysis. Other 24 children suffering from POTS who were, administrated with metoprolol at the pediatrics of Peking University First Hospital were included in the validation group. The sensitivity, specificity, and accuracy of the baseline QTcd in the prediction of the effectiveness of metoprolol on POTS were validated in children. RESULTS The pre-treatment baseline QTcd in responders treated with metoprolol was longer than that of the non-responders in the discovery group [(66.3 ± 20.3) ms vs. (45.7 ± 19.9) ms, p = 0.001]. The baseline QTcd was negatively correlated with SS after metoprolol treatment (r = -0.406, p = 0.003). The cut-off value of baseline QTcd for the prediction of the effectiveness of metoprolol on pediatric POTS was 47.9 ms, yielding a sensitivity of 78.9% and a specificity of 83.3%, respectively. The validation group showed that the sensitivity, specificity, and accuracy of the baseline QTcd ≥ 47.9 ms before treatment for estimating the effectiveness of metoprolol on POTS in children were 73.7, 80.0, and 75.0%, respectively. CONCLUSION Baseline QTcd is effective for predicting the effectiveness of metoprolol on pediatric POTS.
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Affiliation(s)
- Yuanyuan Wang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Yan Sun
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Qingyou Zhang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Chunyu Zhang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Ping Liu
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Yuli Wang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Chaoshu Tang
- Key Lab of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, China
- Department of Physiology and Pathophysiology, Health Science Centre, Peking University, Beijing, China
| | - Hongfang Jin
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, China
- Key Lab of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, China
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15
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Abstract
Background: There have been previous reports of enhanced sympathoexcitation in autism spectrum disorder (ASD). However, there has been no formal investigation of autonomic dysfunction in ASD. Also, the joint hypermobile form of Ehlers-Danlos syndrome (hE-DS) that maybe overrepresented in ASD and orthostatic related autonomic dysfunction. This study examined the comorbidity of ASD, autonomic dysfunction and hE-DS in two UK autonomic national referral centers. Proven, documented and globally accepted clinical autonomic investigations were used to assess neuro-cardiovascular autonomic function in a cohort of ASD subjects and in age-matched healthy controls. Methods: Clinical data from 28 referrals with a confirmed diagnosis of ASD over a 10-year period were compared with 19 age-matched healthy controls. Autonomic function was determined using methods established in the centers previously described in detail. Results: 20/28 ASD had a diagnosed autonomic condition; 9 had the postural tachycardia syndrome (PoTS), 4 PoTS and vasovagal syncope (VVS), 3 experienced presyncope, 1 essential hyperhidrosis, 1 orthostatic hypotension, 1 VVS alone and 1 a combination of PoTS, VVS and essential hyperhidrosis. 16/20 ASD with autonomic dysfunction had hE-DS. In ASD, basal heart rate and responses to orthostatic tests of autonomic function were elevated, supporting previous findings of increased sympathoexcitation. However, sympathetic vasoconstriction was impaired in ASD. Conclusion: Intermittent neuro-cardiovascular autonomic dysfunction affecting heart rate and blood pressure was over-represented in ASD. There is a strong association with hE-DS. Autonomic dysfunction may further impair quality of life in ASD, particularly in those unable to adequately express their experience of autonomic symptoms.
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Affiliation(s)
- Andrew P Owens
- Department of Old Age Psychiatry, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, United Kingdom
| | - Christopher J Mathias
- Autonomic Unit, National Hospital Neurology and Neurosurgery, UCLH NHS Trust, London, United Kingdom.,UCL Queen Square Institute of Neurology, University College London, London, United Kingdom.,Neurovascular Medicine Unit, Lindo Wing, St Mary's Hospital, Imperial College NHS Healthcare Trust, London, United Kingdom
| | - Valeria Iodice
- Autonomic Unit, National Hospital Neurology and Neurosurgery, UCLH NHS Trust, London, United Kingdom.,UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
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16
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Yuan P, Lian Z, Wang Y, Wang Y, Zhang C, Du J, Huang Y, Liao Y. Poincaré Plot Is Useful for Distinguishing Vasovagal Syncope From Postural Tachycardia Syndrome in Children. Front Pediatr 2022; 10:758100. [PMID: 35372154 PMCID: PMC8965582 DOI: 10.3389/fped.2022.758100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 02/09/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To explore the role of the Poincaré plot derived from a 24-hour Holter recording in distinguishing vasovagal syncope (VVS) from postural tachycardia syndrome (POTS) in pediatric patients. MATERIALS AND METHODS Pediatric patients with VVS or POTS, hospitalized in Peking University First Hospital between January 2012 and December 2018, were included in a derivation study. The transverse axis (T), longitudinal axis (L), T/L ratio, product T × L, distance between the origin and the proximal end of the longitudinal axis (pro-D), and distance between the origin and distal end of the longitudinal axis (dis-D) of the Poincaré plot were compared between the VVS and POTS groups, and the differential diagnostic performance of the above-mentioned graphic parameters was evaluated using receiver operating characteristic curve analysis. A validation study was conducted in pediatric patients hospitalized between January 2019 and December 2020. RESULTS In school-aged children, the T, L, T/L, T × L, and dis-D values of patients with VVS were greater than those of patients with POTS; in adolescents, the T, T/L, T × L, and pro-D values of patients with VVS were greater than those of patients with POTS. Using a T/L cut-off value of 0.3 to distinguish between the two diseases, the sensitivity and specificity were 91.0 and 90.5%, respectively, for the total participants; 91.6 and 88.9%, respectively, for the school-aged children; and 82.1 and 95.7%, respectively, for the adolescents. In the validation study, a T/L cut-off value of 0.3 yielded an accuracy, sensitivity, and specificity of 81.8, 87.2, and 77.6%, respectively, in the total participants; 76.5, 82.6, and 71.4%, respectively, in the school-aged children; and 89.2, 93.8, and 85.7%, respectively, in the adolescents, in distinguishing VVS from POTS validated by clinical diagnosis. CONCLUSIONS The graphic parameters of the Poincaré plot are significantly different between VVS and POTS in pediatric patients, and the T/L of the Poincaré plot may be a useful measure to help differentiate VVS from POTS in children and adolescents.
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Affiliation(s)
- Piaoliu Yuan
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Zhouhui Lian
- Wang Xuan Institute of Computer Science, Peking University, Beijing, China
| | - Yuanyuan Wang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Yaru Wang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Chunyu Zhang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, China.,Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, China
| | - Yaqian Huang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Ying Liao
- Department of Pediatrics, Peking University First Hospital, Beijing, China
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17
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Wang S, Zou R, Cai H, Wang C. Predictive Value of Heart Rate and Blood Pressure on the Prognosis of Postural Tachycardia Syndrome in Children. Front Pediatr 2022; 10:802469. [PMID: 35433537 PMCID: PMC9005773 DOI: 10.3389/fped.2022.802469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/03/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND To investigate the predictive value of heart rate (HR) and blood pressure (BP) on the prognosis of postural tachycardia syndrome (POTS) in children. MATERIALS AND METHODS 53 cases of children aged 5 to 15 years who visited in the Pediatric Syncope Specialist Clinic of The Second Xiangya Hospital of Central South University for unexplained syncope or syncope precursor were diagnosed with POTS by head-up tilt test (HUTT) as the POTS group. 38 healthy children aged 5 to 16 years who underwent physical examination at the Child Health Care Clinic of the hospital in the same period were matched as controls (control group). The children with POTS were followed up after 3 months of treatment and were divided into good prognosis group (40 cases) and poor prognosis group (13 cases) according to the results of HUTT re-examination and whether the symptoms improved or not. HR and BP indicators were collected from each group at baseline and during HUTT. RESULTS There were 91 research subjects, of which 45 are males, with a mean age of 11.52 ± 2.13 years. (1) HR at 5 and 10 min (HR 5 and HR 10, respectively), HR difference at 5 and 10 min (HRD 5 and HRD 10, respectively), and HR and BP product at 5 and 10 min (RPP 5 and RPP 10, respectively) were greater in the POTS group than in the control group (P < 0.01). (2) HR 5, HR 10, HRD 5, HRD 10, and RPP 10 in children with POTS were smaller in the good prognosis group than the poor prognosis group (P < 0.01). (3) The area under curve was 0.925 on the four combined indicators (HR 5, HR 10, HRD 5, and HRD 10), predicting a good prognosis of POTS, sensitivity of 99.99%, and specificity of 75.00%. CONCLUSIONS HR 5, HR 10, HRD 5, HRD 10, and RPP 10 and the four combined indicators (HR 5, HR 10, HRD 5, and HRD 10) had predictive value for the POTS prognosis in children. The predictive value of the four combined indicators for the POTS prognosis was better than that of the single HR 5, HRD 5, and RPP 10.
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Affiliation(s)
- Shuo Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China.,Department of Neonatology, Xiangya Hospital, Central South University, Changsha, China
| | - Runmei Zou
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Hong Cai
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Cheng Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
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18
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Wang Y, Du J, Li X, Liu P, Wang Y, Liao Y, Jin H. Impact of Comorbidities on the Prognosis of Pediatric Postural Tachycardia Syndrome. Int J Gen Med 2021; 14:8945-8954. [PMID: 34866935 PMCID: PMC8636694 DOI: 10.2147/ijgm.s339805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/29/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To investigate the influence of comorbidities on the prognosis of pediatric postural tachycardia syndrome (POTS). METHODS In this retrospective cohort study, 275 children with POTS admitted to the Department of Pediatrics at Peking University First Hospital were recruited from 2016 to 2019 and followed up. The participants were divided into simple POTS (S-POTS, n=156 cases) and POTS with comorbidities (Co-POTS, n=119 cases) groups according to whether they were complicated with comorbidities. A Cox regression analysis was used to identify the prognostic risk factors for children with POTS, while Kaplan-Meier curves were applied to compare the cumulative symptom remission rate (CSRR) between the two groups. The rehospitalization of the children between the two groups was also compared to explore the influence of comorbidities. RESULTS Twenty-one participants (7.6%) were lost during a median follow-up of 24 months. The Cox regression model showed that comorbidities and body mass index (BMI) were associated with the CSRR of the children with POTS. The CSRR of pediatric POTS alone was 1.748 times higher than that of patients with comorbidities, and the CSRR was decreased by 5.1% for each 1 kg/m2 increase in BMI. The most common comorbidity in children with POTS in this study was allergic disorders, followed by the psychological diseases. The patients in the Co-POTS group had a lower CSRR than those in the S-POTS group (log rank P=0.0001). In addition, compared with those of the S-POTS group, the total number of rehospitalizations was high (P=0.001), and the total hospital stays were long in the Co-POTS group (P<0.001). CONCLUSION Complicating with comorbidities, pediatric patients with POTS had lower CSRR and more rehospitalizations than those without comorbidities. More attention should be given to comorbidities when managing pediatric POTS.
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Affiliation(s)
- Yaru Wang
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, People’s Republic of China
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, People’s Republic of China
- Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, 100034, People’s Republic of China
| | - Xueying Li
- Department of Medical Statistics, Peking University First Hospital, Beijing, 100034, People’s Republic of China
| | - Ping Liu
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, People’s Republic of China
| | - Yuli Wang
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, People’s Republic of China
| | - Ying Liao
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, People’s Republic of China
| | - Hongfang Jin
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, People’s Republic of China
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Cai H, Wang S, Zou R, Liu P, Li F, Wang Y, Wang C. Comparison of the Active Sitting Test and Head-Up Tilt Test for Diagnosis of Postural Tachycardia Syndrome in Children and Adolescents. Front Pediatr 2021; 9:691390. [PMID: 34604136 PMCID: PMC8485704 DOI: 10.3389/fped.2021.691390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 08/16/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: We aimed to compare the hemodynamic responses to the active sitting test with the passive head-up tilt test (HUTT) in children and adolescents with postural tachycardia syndrome (POTS). We hypothesized that sitting tachycardia was also present in POTS patients during sitting. Materials and methods: We tested 30 POTS patients and 31 control subjects (mean age = 12 years, range = 9-16 years) who underwent both active sitting test and HUTT successively. We measured the heart rate (HR) and blood pressure (BP) during each test. Results: For both POTS patients and control subjects, the HUTT produced significantly larger HR and BP increases from 3 to 10 min of postural change than did the sitting test. Moreover, POTS patients with excessive orthostatic tachycardia during the HUTT also had significantly larger increases in HR at all test intervals during the sitting test than did the control subjects. A maximum increase in HR ≥ 22 bpm within 10 min of the sitting test was likely suggested to predict orthostatic tachycardia, yielding a sensitivity and specificity of 83.3 and 83.9%, respectively. Only six of 30 POTS patients (20%) reached the 40-bpm criterion during the sitting test, and no one complained of sitting intolerance symptoms. Conclusions: We have shown that POTS patients also have sitting tachycardia when changing from a supine position to a sitting position. We believe that the active sitting test is a reasonable alternative maneuver in assessing POTS in population groups that cannot tolerate the standing test or HUTT.
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Affiliation(s)
- Hong Cai
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Shuo Wang
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Runmei Zou
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Ping Liu
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Fang Li
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yuwen Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Cheng Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
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20
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Wang YY, Han ZH, Wang YL, Liao Y, Zhang CY, Liu P, Tang CS, Du JB, Jin HF, Huang YQ. Baseline left ventricular ejection fraction associated with symptom improvements in both children and adolescents with postural tachycardia syndrome under metoprolol therapy. Chin Med J (Engl) 2021; 134:1977-1982. [PMID: 34387611 PMCID: PMC8382470 DOI: 10.1097/cm9.0000000000001698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Postural tachycardia syndrome (POTS) is a common childhood disease that seriously affects the patient's physical and mental health. This study aimed to investigate whether pre-treatment baseline left ventricular ejection fraction (LVEF) and left ventricular fractional shortening (LVFS) values were associated with symptom improvement after metoprolol therapy for children and adolescents with POTS. METHODS This retrospective study evaluated 51 children and adolescents with POTS who received metoprolol therapy at the Peking University First Hospital between November 2010 and July 2019. All patients had completed a standing test or basic head-up tilt test and cardiac echocardiography before treatment. Treatment response was evaluated 3 months after starting metoprolol therapy. The pre-treatment baseline LVEF and LVFS values were evaluated for correlations with decreases in the symptom score after treatment (ΔSS). Multivariable analysis was performed using factors with a P value of <0.100 in the univariate analyses and the demographic characteristics. RESULTS A comparison of responders and non-responders revealed no significant differences in demographic, hemodynamic characteristics, and urine specific gravity (all P > 0.050). However, responders had significantly higher baseline LVEF (71.09% ± 4.44% vs. 67.17% ± 4.88%, t = -2.789, P = 0.008) and LVFS values (40.00 [38.00, 42.00]% vs. 36.79% ± 4.11%, Z = -2.542, P = 0.010) than the non-responders. The baseline LVEF and LVFS were positively correlated with ΔSS (r = 0.378, P = 0.006; r = 0.363, P = 0.009), respectively. Logistic regression analysis revealed that LVEF was independently associated with the response to metoprolol therapy in children and adolescents with POTS (odds ratio: 1.201, 95% confidence interval: 1.039-1.387, P = 0.013). CONCLUSIONS Pre-treatment baseline LVEF was associated with symptom improvement after metoprolol treatment for children and adolescents with POTS.
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Affiliation(s)
- Yuan-Yuan Wang
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Zhen-Hui Han
- Department of Pediatrics, Children's Hospital of Kaifeng, Henan 475000, China
| | - Yu-Li Wang
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Ying Liao
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Chun-Yu Zhang
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Ping Liu
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Chao-Shu Tang
- Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing 100191, China
- Department of Physiology and Pathophysiology, Health Science Centre, Peking University, Beijing 100191, China
| | - Jun-Bao Du
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
- Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing 100191, China
| | - Hong-Fang Jin
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Ya-Qian Huang
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
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21
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Goto Y, Sunami Y, Sugaya K, Nakane S, Takahashi K. [A case of chronic postural tachycardia syndrome with positive anti-ganglionic acetylcholine receptor (gAChR) antibody]. Rinsho Shinkeigaku 2021; 61:547-551. [PMID: 34275953 DOI: 10.5692/clinicalneurol.cn-001598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a form of orthostatic intolerance characterized by symptoms such as lightheadedness, fainting, and brain fog that occur with a rapid elevation in heart rate when standing up from a reclining position. The etiology of POTS has yet to be established. However, a growing body of evidence suggests that POTS may be an autoimmune disorder such as autoimmune autonomic ganglionopathy, an acquired, immune-mediated form of diffuse autonomic failure. Many patients have serum antibodies that bind to the ganglionic acetylcholine receptors (gAChRs) in the autonomic ganglia. Herein, we describe a 39-year-old female patient with an eight-year history of orthostatic intolerance. POTS was diagnosed based on the findings of a head-up tilt test, in which a rapid increase in the patient's heart rate from 58 bpm in the lying position to 117 bpm in the upright position without orthostatic hypotension was observed. The POTS symptoms were refractory to various medications except for pyridostigmine bromide, which resulted in a partial resolution of her symptoms. Her serum was found to be strongly positive for anti-gAChR (β4 subunit) autoantibody (2.162 A.I., normal range: below 1.0). Based on these findings, a limited form of autoimmune POTS was diagnosed. After obtaining written informed consent, she was treated with intravenous immunoglobulin (IVIg) 400 mg/kg/day for five days, which led to clinical improvement by reducing her heart rate increase in the upright position. She was able to return to work with IVIg treatment at regular intervals. Our case provides further evidence of a potential autoimmune pathogenesis for POTS. Aggressive immunotherapy may be effective for POTS even in chronic cases.
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Affiliation(s)
- Yuya Goto
- Department of Neurology, Tokyo Metropolitan Neurological Hospital
| | - Yoko Sunami
- Department of Neurology, Tokyo Metropolitan Neurological Hospital
| | - Keizo Sugaya
- Department of Neurology, Tokyo Metropolitan Neurological Hospital
| | - Shunya Nakane
- Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital
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22
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Cai H, Wang S, Zou R, Li F, Zhang J, Wang Y, Xu Y, Wang C. Diagnostic Value of Diurnal Variability of Orthostatic Heart Rate Increment in Children and Adolescents With POTS. Front Pediatr 2021; 9:644461. [PMID: 34055686 PMCID: PMC8157922 DOI: 10.3389/fped.2021.644461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/22/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: This study aims to investigate the diurnal variability of heart rate (HR) increment after standing (ΔHR) in pediatric postural tachycardia syndrome (POTS) and explore appropriate cutoff values of ΔHR at different times for the POTS diagnosis. Materials and Methods: Seventy-eight patients (9-14 years) who presented with orthostatic intolerance symptoms were enrolled. Forty-three patients were diagnosed as POTS (ΔHR ≥40 bpm), and 35 patients were assigned to the non-POTS group (ΔHR <40 bpm). Twenty-six healthy children served as the control group. All subjects completed three standing tests in the morning, afternoon, and evening. Orthostatic HR parameters were analyzed to predict the diagnosis of POTS. Additionally, 41 patients were recruited as an external validation group. Results: Orthostatic HR increments in both the POTS and non-POTS groups exhibited diurnal variability, which was markedly larger in the morning (P < 0.05), whereas it did not differ with the time of day in the control group. Among the POTS patients, 100% met the diagnostic criteria for POTS in the morning, 44.2% in the afternoon, and 27.9% in the evening. Almost half of the POTS patients (51.2%) displayed a positive result only in the morning standing test. However, in the three standing tests at different times, ΔHR from 1 to 10 min after standing and ΔHRmax were the highest in the POTS group compared with in the non-POTS and control groups (P < 0.05). Furthermore, the maximum ΔHR (ΔHRmax) and ΔHR at 5 and 10 min in the afternoon and evening standing tests yielded moderate predictive values for the POTS diagnosis. The external validation test showed that the afternoon ΔHRmax ≥30 bpm to diagnose POTS yielded sensitivity, specificity, and accuracy of 85, 71.4, and 78%, respectively, and the evening ΔHRmax ≥25 bpm yielded sensitivity, specificity, and accuracy of 85, 76.2, and 80.5%, respectively. Conclusions: The orthostatic HR increment exhibits diurnal variability in children and adolescents with POTS that may affect the diagnosis of POTS. Supplementary criteria are proposed for the POTS diagnosis based on diurnal variability.
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Affiliation(s)
- Hong Cai
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Shuo Wang
- Jishou University School of Medicine, Jishou, China
| | - Runmei Zou
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Fang Li
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Juan Zhang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yuwen Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yi Xu
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Cheng Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
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23
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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24
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Petracek LS, Suskauer SJ, Vickers RF, Patel NR, Violand RL, Swope RL, Rowe PC. Adolescent and Young Adult ME/CFS After Confirmed or Probable COVID-19. Front Med (Lausanne) 2021; 8:668944. [PMID: 33996867 PMCID: PMC8116546 DOI: 10.3389/fmed.2021.668944] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 03/29/2021] [Indexed: 12/19/2022] Open
Abstract
Introduction: Fatigue is a common acute symptom following SARS-CoV-2 infection (COVID-19). The presence of persistent fatigue and impaired daily physical and cognitive function has led to speculation that like SARS-CoV-1 infection, COVID-19 will be followed by myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Methods and Results: We describe three adolescent and young adult patients who had confirmed or probable COVID-19 infections early on during the pandemic and were referred for evaluation to the Chronic Fatigue Clinic at the Johns Hopkins Children's Center. All patients reported orthostatic intolerance symptoms within the first 2 weeks of illness, and 10-min passive standing tests were consistent with postural tachycardia syndrome. After 6 months of illness, all three patients met criteria for ME/CFS. Clinical features of interest included strong histories of allergies in all three patients, two of whom had elevations in plasma histamine. Each demonstrated limitations in symptom-free range of motion of the limbs and spine and two presented with pathological Hoffman reflexes. These comorbid features have been reported in adolescents and young adults with ME/CFS. Conclusion: ME/CFS can be triggered by COVID-19 in adolescents and young adults. Further work is needed to determine the pathogenesis of ME/CFS after COVID-19 and optimal methods of treating these patients. Our preliminary study calls attention to several comorbid features that deserve further attention as potential targets for intervention. These include neuromuscular limitations that could be treated with manual forms of therapy, orthostatic intolerance and POTS for which there are multiple medications and non-pharmacologic therapies, treatable allergic and mast cell phenomena, and neurologic abnormalities that may require specific treatment. Larger studies will need to ascertain the prevalence of these abnormalities.
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Affiliation(s)
- Lindsay S. Petracek
- Departments of Pediatrics, The Johns Hopkins University School of Medicine and the Kennedy Krieger Institute, Baltimore, MD, United States
| | - Stacy J. Suskauer
- Departments of Pediatrics, The Johns Hopkins University School of Medicine and the Kennedy Krieger Institute, Baltimore, MD, United States
- Departments of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine and the Kennedy Krieger Institute, Baltimore, MD, United States
| | | | - Neel R. Patel
- Central Florida Heart Care, Maitland, FL, United States
| | | | - Renee L. Swope
- Departments of Pediatrics, The Johns Hopkins University School of Medicine and the Kennedy Krieger Institute, Baltimore, MD, United States
| | - Peter C. Rowe
- Departments of Pediatrics, The Johns Hopkins University School of Medicine and the Kennedy Krieger Institute, Baltimore, MD, United States
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25
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Abstract
Objective: To report a case series of dysautonomia associated with COVID-19 infection. Methods: This is a retrospective review of patients evaluated in the autonomic clinic at our institution with suspected signs and symptoms of dysautonomia who underwent formal evaluation, including autonomic testing. Results: Six patients were identified with signs and symptoms suggestive of dysautonomia who underwent autonomic testing. All patients had symptoms typical of COVID-19 infection, though none were hospitalized for these or other symptoms. All patients reported symptoms of postural lightheadedness and near-syncope, fatigue, and activity intolerance. Five patients reported the onset of autonomic symptoms concomitant with other COVID-19 symptoms, with the other patient reporting symptom onset 6 weeks following initial COVID-19 symptoms. Autonomic testing demonstrated an excessive postural tachycardia in 4 patients, a hypertensive response with head-up tilt in 3 patients, orthostatic hypotension in 1 patient, and sudomotor impairment in 1 of the patients with excessive postural tachycardia. Conclusions: We present clinical features and results of autonomic testing in 6 patients with a history COVID-19 infection. While all patients reported typical features of orthostatic intolerance, fatigue, and activity intolerance, the results of autonomic testing were heterogenous, with orthostatic hypotension in 1 patient, excessive postural tachycardia typical of postural tachycardia syndrome in 4 patients, and postural hypertension in 3 patients.
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Affiliation(s)
- Brent P Goodman
- Department of Neurology, Mayo Clinic, Scottsdale, AZ, United States
| | - Julie A Khoury
- Department of Neurology, Mayo Clinic, Scottsdale, AZ, United States
| | - Janis E Blair
- Infectious Disease, Mayo Clinic, Scottsdale, AZ, United States
| | - Marie F Grill
- Department of Neurology, Mayo Clinic, Scottsdale, AZ, United States
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26
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Jimbo S, Fujita Y, Ishii W, Namiki H, Kato M, Komori A, Abe Y, Kamiyama H, Ayusawa M, Morioka I. Decreased Stroke Volume and Venous Return in School Children with Postural Tachycardia Syndrome. TOHOKU J EXP MED 2021; 253:181-190. [PMID: 33731495 DOI: 10.1620/tjem.253.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In postural tachycardia syndrome (POTS), a subtype of orthostatic intolerance, the changes in hemodynamics due to postural changes are poorly understood. We speculated that inappropriate venous return, which may occur in the upright position in patients with school-aged POTS, could be detected by echocardiography. Our prospective study was conducted with 100 POTS patients (45 boys and 55 girls), aged 13.1 ± 1.5 years and 52 age- and sex-matched healthy subjects (control). Echocardiography was performed in the supine and sitting positions. Cardiac parameters [stroke volume index, cardiac index, heart rate, and the maximum inferior vena cava diameter (max IVC)] were evaluated in addition to pulse pressure. Unlike the control subjects, POTS patients demonstrated decreased stroke volume index (P = 0.02) and max IVC (P < 0.01) irrespective of posture. The rates of max IVC change did not differ between control and POTS groups. The enrolled POTS patients were divided into two subgroups [dilatation (n = 57) and contraction (n = 43)] based on whether the change rate of max IVC was less than zero or not. The contraction group showed a significantly higher heart rate than the dilatation group with respect to posture (P = 0.03), indicating the poor response of peripheral vessels in the lower limbs only in the contraction group. In conclusion, echocardiographic assessment detected decreased stroke volume and venous return in POTS. The changes in max IVC in response to postural changes may indicate an underlying pathophysiology in POTS.
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Affiliation(s)
- Shino Jimbo
- Department of Pediatrics and Child Health, Nihon University School of Medicine
| | - Yukihiko Fujita
- Department of Pediatrics and Child Health, Nihon University School of Medicine
| | - Wakako Ishii
- Department of Pediatrics and Child Health, Nihon University School of Medicine
| | - Hidemasa Namiki
- Department of Pediatrics and Child Health, Nihon University School of Medicine
| | - Masataka Kato
- Department of Pediatrics and Child Health, Nihon University School of Medicine
| | - Akiko Komori
- Department of Pediatrics and Child Health, Nihon University School of Medicine
| | - Yuriko Abe
- Department of Pediatrics and Child Health, Nihon University School of Medicine
| | - Hiroshi Kamiyama
- Department of Pediatrics and Child Health, Nihon University School of Medicine
| | - Mamoru Ayusawa
- Department of Pediatrics and Child Health, Nihon University School of Medicine
| | - Ichiro Morioka
- Department of Pediatrics and Child Health, Nihon University School of Medicine
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27
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Stewart JM, Warsy IA, Visintainer P, Terilli C, Medow MS. Supine Parasympathetic Withdrawal and Upright Sympathetic Activation Underly Abnormalities of the Baroreflex in Postural Tachycardia Syndrome: Effects of Pyridostigmine and Digoxin. Hypertension 2021; 77:1234-1244. [PMID: 33423527 PMCID: PMC7946724 DOI: 10.1161/hypertensionaha.120.16113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Julian M Stewart
- From the Department of Pediatrics (J.M.S., I.A.W., C.T., M.S.M.), New York Medical College, Valhalla.,Departments of Physiology (J.M.S., M.S.M.), New York Medical College, Valhalla
| | - Irfan A Warsy
- From the Department of Pediatrics (J.M.S., I.A.W., C.T., M.S.M.), New York Medical College, Valhalla
| | - Paul Visintainer
- Baystate Medical Center, University of Massachusetts School of Medicine, Worcester (P.V.)
| | - Courtney Terilli
- From the Department of Pediatrics (J.M.S., I.A.W., C.T., M.S.M.), New York Medical College, Valhalla
| | - Marvin S Medow
- From the Department of Pediatrics (J.M.S., I.A.W., C.T., M.S.M.), New York Medical College, Valhalla.,Departments of Physiology (J.M.S., M.S.M.), New York Medical College, Valhalla
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28
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Go S, Yamanaka G, Kasuga A, Kanou K, Takamatsu T, Takeshita M, Morishita N, Morichi S, Ishida Y, Oana S, Kashiwagi Y, Mitsufuji T, Araki N, Kawashima H. Orthostatic Headache in Children Including Postural Tachycardia Syndrome and Orthostatic Hypotension: A Near-Infrared Spectroscopy Study. J Clin Med 2020; 9:E4125. [PMID: 33371330 DOI: 10.3390/jcm9124125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/15/2020] [Accepted: 12/21/2020] [Indexed: 11/17/2022] Open
Abstract
Background and aim: Although head and/or neck pain attributed to orthostatic hypotension is included in international guidelines, its mechanisms and relevance remain unknown. This study examined the term’s relevance and aimed to elucidate the associated clinical features. Methods: An active stand test was performed to evaluate fluctuations in systemic and cerebral circulation in children and adolescents reporting complaints in the absence of a confirmed organic disorder. The subjects were categorized based on orthostatic headache presence/absence, and their characteristics and test results were compared. Results: Postural tachycardia syndrome was observed in 50.0% of children with, and 55.1% without, orthostatic headache. For orthostatic hypotension, the respective values were 31.3% and 30.6%. A history of migraine was more prevalent in children with orthostatic headaches (64.1% vs. 28.6%; p < 0.01). The observed decrease in the cerebral oxygenated hemoglobin level was larger in children with orthostatic headaches (Left: 6.3 (3.2–9.4) vs. 4.1 (0.8–6.1); p < 0.01, Right: 5.3 (3.1–8.6) vs. 4.0 (0.8–5.9); p < 0.01). Conclusion: Fluctuations in cerebral blood flow were associated with orthostatic headaches in children, suggesting that the headaches are due to impaired intracranial homeostasis. As orthostatic headache can have multiple causes, the term “head and/or neck pain attributed to orthostatic (postural) hypotension” should be replaced with a more inclusive term.
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29
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Wells R, Malik V, Brooks AG, Linz D, Elliott AD, Sanders P, Page A, Baumert M, Lau DH. Cerebral Blood Flow and Cognitive Performance in Postural Tachycardia Syndrome: Insights from Sustained Cognitive Stress Test. J Am Heart Assoc 2020; 9:e017861. [PMID: 33280488 PMCID: PMC7955388 DOI: 10.1161/jaha.120.017861] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background The physiology underlying "brain fog" in the absence of orthostatic stress in postural tachycardia syndrome (POTS) remains poorly understood. Methods and Results We evaluated cognitive and hemodynamic responses (cardiovascular and cerebral: heart rate, blood pressure, end‐tidal carbon dioxide, and cerebral blood flow velocity (CBFv) in the middle cerebral artery at baseline, after initial cognitive testing, and after (30‐minutes duration) prolonged cognitive stress test (PCST) whilst seated; as well as after 5‐minute standing in consecutively enrolled participants with POTS (n=22) and healthy controls (n=18). Symptom severity was quantified with orthostatic hypotensive questionnaire at baseline and end of study. Subjects in POTS and control groups were frequency age‐ and sex‐matched (29±11 versus 28±13 years; 86 versus 72% women, respectively; both P≥0.4). The CBFv decreased in both groups (condition, P=0.04) following PCST, but a greater reduction in CBFv was observed in the POTS versus control group (−7.8% versus −1.8%; interaction, P=0.038). Notably, the reduced CBFv following PCST in the POTS group was similar to that seen during orthostatic stress (60.0±14.9 versus 60.4±14.8 cm/s). Further, PCST resulted in greater slowing in psychomotor speed (6.1% versus 1.4%, interaction, P=0.027) and a greater increase in symptom scores at study completion (interaction, P<0.001) in the patients with POTS, including increased difficulty with concentration. All other physiologic responses (blood pressure and end‐tidal carbon dioxide) did not differ between groups after PCST (all P>0.05). Conclusions Reduced CBFv and cognitive dysfunction were evident in patients with POTS following prolonged cognitive stress even in the absence of orthostatic stress.
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Affiliation(s)
- Rachel Wells
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia.,Department of Medicine Royal Adelaide Hospital Adelaide Australia
| | - Varun Malik
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia.,Department of Cardiology Royal Adelaide Hospital Adelaide Australia
| | - Anthony G Brooks
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia
| | - Dominik Linz
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia.,Department of Cardiology Royal Adelaide Hospital Adelaide Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia.,Department of Cardiology Royal Adelaide Hospital Adelaide Australia
| | - Amanda Page
- Centre for Nutrition and Gastrointestinal Diseases The University of Adelaide Adelaide Australia
| | - Mathias Baumert
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia.,School of Electrical and Electronic Engineering The University of Adelaide Adelaide Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia.,Department of Cardiology Royal Adelaide Hospital Adelaide Australia
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30
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Rich EM, Vas A, Boyette V, Hollingsworth C. Daily Life Experiences: Challenges, Strategies, and Implications for Therapy in Postural Tachycardia Syndrome (POTS). Occup Ther Health Care 2020; 36:306-323. [PMID: 32985294 DOI: 10.1080/07380577.2020.1824303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Postural tachycardia syndrome (POTS) is a condition of orthostatic intolerance which often leads to significant functional deficits. This study explores narrative responses from a large cohort (n = 958) of individuals with POTS in describing daily life challenges and the use of strategies to manage these difficulties. Data was coded and emergent themes provided insight into daily life experiences including successful interventions and a wealth of gaps in treatment that remain unaddressed. This led to the development of clinical recommendations for occupational therapy treatment of individuals with POTS. Further research is indicated including clinical trials to demonstrate the efficacy of occupational therapy intervention.
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Affiliation(s)
- Emily M Rich
- School of Occupational Therapy, Texas Woman's University, Dallas, TX, USA
| | - Asha Vas
- School of Occupational Therapy, Texas Woman's University, Dallas, TX, USA
| | - Valerie Boyette
- School of Occupational Therapy, Texas Woman's University, Dallas, TX, USA
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31
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Stewart JM, Kota A, O'Donnell-Smith MB, Visintainer P, Terilli C, Medow MS. The preponderance of initial orthostatic hypotension in postural tachycardia syndrome. J Appl Physiol (1985) 2020; 129:459-466. [PMID: 32702262 DOI: 10.1152/japplphysiol.00540.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Reduced systolic/diastolic blood pressure (BP) by >40/20 mmHg defines initial orthostatic hypotension (IOH). Rapid resolution of hypotension and lightheadedness follows, but tachycardia may be prolonged. We aimed to examine IOH in controls and patients with postural tachycardia syndrome (POTS) using indices of spontaneous fluctuations of heart rate (HR) and systolic BP as measures of cardiac baroreflex differences. We recruited otherwise healthy IOH patients without POTS (n = 20, 16 ± 3 yr), healthy volunteers (n = 32, 17 ± 3 yr), and POTS patients (n = 39, 17 ± 4 yr). Subjects were instrumented for electrocardiography and beat-to-beat BP. After 10 min supine, subjects stood for 5 min. Following supine recovery, subjects underwent 70° head-up tilt for 10 min to test for POTS. BP, HR, and time, referenced to standing, were measured at events during standing: minimum BP, BP recovery, peak HR, HR minimum, and steady state. Baseline HR and BP were higher in POTS compared with healthy groups. IOH occurred in 13% of controls and 51% of POTS patients. The BP minimum was lower in POTS. Parasympathetic modulation of cardiac baroreflex was decreased in all POTS and control-IOH subjects. Sympathetic indices were increased. Events following BP minimum occurred progressively later in all POTS and control-IOH subjects compared with non-IOH controls. IOH is more frequent in POTS than in controls with a lower minimum BP. POTS has markedly reduced heart rate variability and baroreflex, indicating reduced HR buffering of BP. POTS-IOH and control-IOH subjects had similar peak HR despite decreased minimum BP in POTS. IOH data indicate modest parasympathetic and cardiovagal baroreflex deficits in control-IOH subjects. Parasympathetic deficits are more severe in all POTS patients.NEW & NOTEWORTHY Significant initial orthostatic hypotension (IOH) occurs in ~50% of postural tachycardia syndrome (POTS) patients and 13% of controls. Heart rate and blood pressure recovery are prolonged in IOH sustaining lightheadedness; IOH is more prevalent and severe in POTS. Altered cerebral blood flow and cardiorespiratory regulation are more prevalent in POTS. Altered heart rate variability and baroreflex gain may cause nearly instantaneous lightheadedness in POTS. IOH alone fails to confer a strong probability of POTS.
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Affiliation(s)
- Julian M Stewart
- Department of Pediatric, New York Medical College, Valhalla, New York.,Department of Physiology, New York Medical College, Valhalla, New York
| | - Archana Kota
- Department of Pediatric, New York Medical College, Valhalla, New York
| | | | - Paul Visintainer
- Baystate Medical Center, University of Massachusetts School of Medicine, Springfield, Massachusetts
| | - Courtney Terilli
- Department of Pediatric, New York Medical College, Valhalla, New York
| | - Marvin S Medow
- Department of Pediatric, New York Medical College, Valhalla, New York.,Department of Physiology, New York Medical College, Valhalla, New York
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Wang S, Zou R, Cai H, Wang Y, Ding Y, Tan C, Yang M, Li F, Wang C. Heart Rate and Heart Rate Difference Predicted the Efficacy of Metoprolol on Postural Tachycardia Syndrome in Children and Adolescents. J Pediatr 2020; 224:110-114. [PMID: 32464225 DOI: 10.1016/j.jpeds.2020.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/08/2020] [Accepted: 05/13/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate the ability of heart rate (HR) and HR difference during head-up tilt test (HUTT) and to predict clinical improvement related to metoprolol treatment in children and adolescents with postural tachycardia syndrome (POTS). STUDY DESIGN This was a retrospective cohort study. A total of 53 subjects (27 male, aged 6-12 years old, mean age 11.79 ± 1.50 years old) with POTS treated with metoprolol were involved from July 2012 to September 2019. In total, 52 subjects who underwent health examination during the same period were matched as the control group. Subjects in both groups underwent HUTT. The HR distance between 5 minutes and 0 minutes (HR difference 5) and between 10 minutes and 0 minutes (HR difference 10) during HUTT was calculated. RESULTS The POTS group was significantly greater than the control group in HR 5, HR 10, HR difference 5, and HR difference 10 (P < .01). There was no statistical difference in HR 0 between the 2 groups (P > .05). In total, 53 subjects with POTS were followed up for 96.0 (IQR, 40.5, 134.5) days during treatment with metoprolol. HUTT results demonstrated that 58.49% of subjects with POTS had a response and symptom scores were reduced after intervention. HR and HR difference were useful in predicting the efficacy of metoprolol on POTS. When HR 5, HR 10, HR difference 5, and HR difference 10, respectively, were ≥110, 112, 34, and 37 beats/min, the sensitivity and specificity were 82.50% and 69.23%, 84.62% and 69.70%, 85.29% and 89.47%, and 97.56% and 64.86%, respectively. CONCLUSIONS HR and HR difference are helpful to predict the efficacy of metoprolol on POTS in children and adolescents.
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Affiliation(s)
- Shuo Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China; Department of Graduate Management, Jishou University School of Medicine, Jishou, Hunan, China; Department of Pediatrics, The First People's Hospital of Changde City, Changde, Hunan, China
| | - Runmei Zou
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hong Cai
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yuwen Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yiyi Ding
- Department of Pediatrics, The First People's Hospital of Changde City, Changde, Hunan, China
| | - Chuanmei Tan
- Department of Graduate Management, Jishou University School of Medicine, Jishou, Hunan, China
| | - Maosheng Yang
- Department of Graduate Management, Jishou University School of Medicine, Jishou, Hunan, China
| | - Fang Li
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Cheng Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.
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Abstract
Neurally mediated syncope (NMS) is the most common underlying disease of pediatric syncope, which generally includes vasovagal syncope (VVS), postural tachycardia syndrome (POTS), and situational syncope. Allergic diseases involving the respiratory system, digestive system, skin, and other systems are prevalent in children. In recent years, increasing attention has been paid to children with the comorbidity of NMS and allergic diseases. This article reviews the featured clinical manifestations and pathogenesis of the comorbidity according to the progress of related studies. Clinical studies have shown that the comorbidity rate of pediatric VVS and/or POTS with allergic diseases amounts to ~30-40%, referring to the whole population of children with VVS and/or POTS. Additionally, children with the comorbidity present some relatively special clinical characteristics. A series of mechanisms or regulatory factors relating to allergies, such as the imbalance of vasoactive elements, dysfunction of the autonomic nervous system (ANS), and autoimmunity may play a role in the development of the comorbidity. Moreover, 90% of children with cough syncope, a type of situational syncope, have a history of asthma, indicating a potential relationship between asthma and NMS. Further studies exploring the clinical characteristics and pathogenesis of the comorbidity are still needed to aid in the diagnosis and treatment of children with NMS.
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Affiliation(s)
- Yaru Wang
- 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
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, 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
| | - Ying Liao
- Department of Pediatrics, Peking University First Hospital, Beijing, China
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Orjatsalo M, Alakuijala A, Partinen M. Heart Rate Variability in Head-Up Tilt Tests in Adolescent Postural Tachycardia Syndrome Patients. Front Neurosci 2020; 14:725. [PMID: 32848537 PMCID: PMC7432293 DOI: 10.3389/fnins.2020.00725] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/18/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Postural tachycardia syndrome (POTS) is a suspected dysautonomia with symptoms of orthostatic intolerance and abnormally increased heart rate while standing. We aimed to study cardiac autonomic nervous system functioning in head-up tilt (HUT) in adolescents with POTS to find out if parasympathetic tone is attenuated in the upright position. Methods: We compared characteristics of a group of 25 (females 14/25; 56%) adolescents with POTS and 12 (females 4/12; 34%) without POTS aged 9-17 years. We compared heart rate variability with high- and low-frequency oscillations, and their temporal changes in HUT. Results: The high-frequency oscillations, i.e., HF, attenuated in both groups during HUT (p < 0.05), but the attenuation was bigger in POTS (p = 0.04). In the beginning of HUT, low-frequency oscillations, i.e., LF, increased more in POTS (p = 0.01), but in the end of HUT, an attenuation in LF was seen in the POTS group (p < 0.05), but not in the subjects without POTS. There were no associations of previous infections or vaccinations with POTS. Subjects with POTS were sleepier and their overall quality of life was very low. Conclusion: The results imply to an impaired autonomic regulation while standing in POTS, presenting as a lower HF and higher LF in the beginning of HUT and an attenuated LF in the prolonged standing position.
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Affiliation(s)
- Maija Orjatsalo
- Department of Clinical Neurophysiology, HUS Medical Imaging Center, Helsinki University Hospital, Helsinki, Finland.,Department of Neurological Sciences, University of Helsinki, Helsinki, Finland
| | - Anniina Alakuijala
- Department of Clinical Neurophysiology, HUS Medical Imaging Center, Helsinki University Hospital, Helsinki, Finland.,Department of Neurological Sciences, University of Helsinki, Helsinki, Finland
| | - Markku Partinen
- Department of Neurological Sciences, University of Helsinki, Helsinki, Finland.,Vitalmed Helsinki Sleep Clinic, Helsinki, Finland
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Smith EC, Diedrich A, Raj SR, Gamboa A, Shibao CA, Black BK, Peltier A, Paranjape SY, Biaggioni I, Okamoto LE. Splanchnic Venous Compression Enhances the Effects of ß-Blockade in the Treatment of Postural Tachycardia Syndrome. J Am Heart Assoc 2020; 9:e016196. [PMID: 32673517 PMCID: PMC7660715 DOI: 10.1161/jaha.120.016196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background Splanchnic venous pooling induced by upright posture triggers a compensatory increase in heart rate (HR), a response that is exaggerated in patients with postural tachycardia syndrome. To assess whether abdominal compression attenuates orthostatic tachycardia and improves symptoms, 18 postural tachycardia syndrome patients (32±2 years) were randomized to receive either abdominal compression (40 mm Hg applied with an inflatable binder ≈2 minutes before standing) or propranolol (20 mg) in a placebo‐controlled, crossover study. Methods and Results Systolic blood pressure, HR, and symptoms were assessed while seated and standing, before and 2 hours postdrug. As expected, propranolol decreased standing HR compared with placebo (81±2 versus 98±4 beats per minute; P<0.001) and was associated with lower standing systolic blood pressure (93±2 versus 100±2 mm Hg for placebo; P=0.002). Compression had no effect on standing HR (96±4 beats per minute) but increased standing systolic blood pressure compared with placebo and propranolol (106±2 mm Hg; P<0.01). Neither propranolol nor compression improved symptoms compared with placebo. In 16 patients we compared the combination of abdominal compression and propranolol with propranolol alone. The combination had no additional effect on standing HR (81±2 beats per minute for both interventions) but prevented the decrease in standing systolic blood pressure produced by propranolol (98±2 versus 93±2 mm Hg for propranolol; P=0.029), and significantly improved total symptom burden (−6±2 versus −1±2 for propranolol; P=0.041). Conclusions Splanchnic venous compression alone did not improve HR or symptoms but prevented the blood pressure decrease produced by propranolol. The combination was more effective in improving symptoms than either alone. Splanchnic venous compression can be a useful adjuvant therapy to propranolol in postural tachycardia syndrome. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00262470.
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Affiliation(s)
- Emily C Smith
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University School of Medicine Nashville TN.,Division of Clinical Pharmacology Vanderbilt University School of Medicine Nashville TN.,Department of Medicine Vanderbilt University School of Medicine Nashville TN
| | - André Diedrich
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University School of Medicine Nashville TN.,Division of Clinical Pharmacology Vanderbilt University School of Medicine Nashville TN.,Department of Medicine Vanderbilt University School of Medicine Nashville TN.,Department of Biomedical Engineering Vanderbilt University School of Medicine Nashville TN
| | - Satish R Raj
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University School of Medicine Nashville TN.,Division of Clinical Pharmacology Vanderbilt University School of Medicine Nashville TN.,Department of Medicine Vanderbilt University School of Medicine Nashville TN.,Department of Cardiac Sciences Libin Cardiovascular Institute of Alberta University of Calgary Canada
| | - Alfredo Gamboa
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University School of Medicine Nashville TN.,Division of Clinical Pharmacology Vanderbilt University School of Medicine Nashville TN.,Department of Medicine Vanderbilt University School of Medicine Nashville TN
| | - Cyndya A Shibao
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University School of Medicine Nashville TN.,Division of Clinical Pharmacology Vanderbilt University School of Medicine Nashville TN.,Department of Medicine Vanderbilt University School of Medicine Nashville TN
| | - Bonnie K Black
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University School of Medicine Nashville TN.,Division of Clinical Pharmacology Vanderbilt University School of Medicine Nashville TN.,Department of Medicine Vanderbilt University School of Medicine Nashville TN
| | - Amanda Peltier
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University School of Medicine Nashville TN.,Vanderbilt Heart and Vascular Institute Vanderbilt University School of Medicine Nashville TN.,Department of Neurology Vanderbilt University School of Medicine Nashville TN
| | - Sachin Y Paranjape
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University School of Medicine Nashville TN.,Division of Clinical Pharmacology Vanderbilt University School of Medicine Nashville TN.,Department of Medicine Vanderbilt University School of Medicine Nashville TN
| | - Italo Biaggioni
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University School of Medicine Nashville TN.,Division of Clinical Pharmacology Vanderbilt University School of Medicine Nashville TN.,Department of Medicine Vanderbilt University School of Medicine Nashville TN.,Department of Pharmacology Vanderbilt University School of Medicine Nashville TN
| | - Luis E Okamoto
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University School of Medicine Nashville TN.,Division of Clinical Pharmacology Vanderbilt University School of Medicine Nashville TN.,Department of Medicine Vanderbilt University School of Medicine Nashville TN
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37
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Wang S, Zou RM, Cai H, Ding YY, Xiao HH, Wang X, Li F, Wang YW, Wang C. [Efficiency of heart rate and heart rate difference at different time points during head-up tilt test in the diagnosis of postural tachycardia syndrome in children and adolescents]. Zhongguo Dang Dai Er Ke Za Zhi 2020; 22:780-784. [PMID: 32669178 PMCID: PMC7389630 DOI: 10.7499/j.issn.1008-8830.2003133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/14/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To study the efficiency of heart rate (HR) and heart rate difference (HRD) at different time points during head-up tilt test (HUTT) in the diagnosis of postural tachycardia syndrome (POTS) in children and adolescents. METHODS A total of 217 children and adolescents, aged 6-16 years, who were diagnosed with POTS were enrolled as the POTS group, and 73 healthy children and adolescents, matched for sex and age, were enrolled as the control group. The POTS group was further divided into ≤12 years old group with 127 children/adolescents and >12 years old group with 90 children/adolescents. The two groups were compared in terms of HR at baseline and at 5 and 10 minutes of HUTT (HR0, HR5, and HR10 respectively), difference between HR5/HR10 and HR0 (HRD5 and HRD10 respectively). The efficiency of HR5, HR10, HRD5 and HRD10 in the diagnosis of POTS was assessed. RESULTS Compared with the control group, the POTS group had significant increases in HR5, HR10, HRD5, and HRD10 (P<0.05). The coincidence rate of HR or HRD for the diagnosis of POTS in males was higher than that in females at 5 minutes of HUTT (P<0.05), while the coincidence rate of HR or HRD for the diagnosis of POTS in males was lower than that in females at 10 minutes of HUTT (P<0.05). The coincidence rate of HR for the diagnosis of POTS was higher in the >12 years old subgroup (P<0.05), while the coincidence rate of HRD for the diagnosis of POTS was higher in the ≤12 years old subgroup (P<0.05). The combination of HR5, HR10, HRD5, and HRD10 for the diagnosis of POTS had a greater area under the curve (0.974; 95%CI: 0.949-0.989) than HR5, HR10, HRD5, or HRD10 alone, with a sensitivity of 87.80% and a specificity of 95.83%. The diagnostic efficacy of HRD for POTS was higher than that of HR (P<0.05). CONCLUSIONS HR and HRD at different time points during HUTT have a good value in the diagnosis of POTS in children and adolescents, and the accuracy of diagnosis varies with age and gender.
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Affiliation(s)
- Shuo Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, Second Xiangya Hospital, Central South University, Changsha 410011, China.
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Wang S, Zou RM, Cai H, Ding YY, Xiao HH, Wang X, Li F, Wang YW, Wang C. [Efficiency of heart rate and heart rate difference at different time points during head-up tilt test in the diagnosis of postural tachycardia syndrome in children and adolescents]. Zhongguo Dang Dai Er Ke Za Zhi 2020; 22:780-784. [PMID: 32669178 PMCID: PMC7389630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/14/2020] [Indexed: 03/30/2024]
Abstract
OBJECTIVE To study the efficiency of heart rate (HR) and heart rate difference (HRD) at different time points during head-up tilt test (HUTT) in the diagnosis of postural tachycardia syndrome (POTS) in children and adolescents. METHODS A total of 217 children and adolescents, aged 6-16 years, who were diagnosed with POTS were enrolled as the POTS group, and 73 healthy children and adolescents, matched for sex and age, were enrolled as the control group. The POTS group was further divided into ≤12 years old group with 127 children/adolescents and >12 years old group with 90 children/adolescents. The two groups were compared in terms of HR at baseline and at 5 and 10 minutes of HUTT (HR0, HR5, and HR10 respectively), difference between HR5/HR10 and HR0 (HRD5 and HRD10 respectively). The efficiency of HR5, HR10, HRD5 and HRD10 in the diagnosis of POTS was assessed. RESULTS Compared with the control group, the POTS group had significant increases in HR5, HR10, HRD5, and HRD10 (P<0.05). The coincidence rate of HR or HRD for the diagnosis of POTS in males was higher than that in females at 5 minutes of HUTT (P<0.05), while the coincidence rate of HR or HRD for the diagnosis of POTS in males was lower than that in females at 10 minutes of HUTT (P<0.05). The coincidence rate of HR for the diagnosis of POTS was higher in the >12 years old subgroup (P<0.05), while the coincidence rate of HRD for the diagnosis of POTS was higher in the ≤12 years old subgroup (P<0.05). The combination of HR5, HR10, HRD5, and HRD10 for the diagnosis of POTS had a greater area under the curve (0.974; 95%CI: 0.949-0.989) than HR5, HR10, HRD5, or HRD10 alone, with a sensitivity of 87.80% and a specificity of 95.83%. The diagnostic efficacy of HRD for POTS was higher than that of HR (P<0.05). CONCLUSIONS HR and HRD at different time points during HUTT have a good value in the diagnosis of POTS in children and adolescents, and the accuracy of diagnosis varies with age and gender.
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Affiliation(s)
- Shuo Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, Second Xiangya Hospital, Central South University, Changsha 410011, China.
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Kim HA, Bisdorff A, Bronstein AM, Lempert T, Rossi-Izquierdo M, Staab JP, Strupp M, Kim JS. Hemodynamic orthostatic dizziness/vertigo: Diagnostic criteria. J Vestib Res 2020; 29:45-56. [PMID: 30883381 PMCID: PMC9249281 DOI: 10.3233/ves-190655] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 02/25/2019] [Indexed: 11/15/2022]
Abstract
This paper presents the diagnostic criteria for hemodynamic orthostatic dizziness/vertigo to be included in the International Classification of Vestibular Disorders (ICVD). The aim of defining diagnostic criteria of hemodynamic orthostatic dizziness/vertigo is to help clinicians to understand the terminology related to orthostatic dizziness/vertigo and to distinguish orthostatic dizziness/vertigo due to global brain hypoperfusion from that caused by other etiologies. Diagnosis of hemodynamic orthostatic dizziness/vertigo requires: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) orthostatic hypotension, postural tachycardia syndrome or syncope documented on standing or during head-up tilt test; and C) not better accounted for by another disease or disorder. Probable hemodynamic orthostatic dizziness/vertigo is defined as follows: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) at least one of the following accompanying symptoms: generalized weakness/tiredness, difficulty in thinking/concentrating, blurred vision, and tachycardia/palpitations; and C) not better accounted for by another disease or disorder. These diagnostic criteria have been derived by expert consensus from an extensive review of 90 years of research on hemodynamic orthostatic dizziness/vertigo, postural hypotension or tachycardia, and autonomic dizziness. Measurements of orthostatic blood pressure and heart rate are important for the screening and documentation of orthostatic hypotension or postural tachycardia syndrome to establish the diagnosis of hemodynamic orthostatic dizziness/vertigo.
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Affiliation(s)
- Hyun Ah Kim
- Department of Neurology, Keimyung University Dongsan Hospital, Daegu, South Korea
| | - Alexandre Bisdorff
- Department of Neurology, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg
| | - Adolfo M. Bronstein
- Department of Neuro-otology, Division of Brain Sciences, Imperial College London, Charing Cross Hospital Campus, London, UK
| | - Thomas Lempert
- Department of Neurology, Schlosspark-Klinik, Berlin, Germany
| | | | - Jeffrey P. Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology – Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Dizziness Center, Seoul National University Bundang Hospital, Seongnam, South Korea
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Abstract
Postural orthostatic tachycardia syndrome (POTS) is an autonomic disorder characterized by symptoms such as palpitations, dyspnea, chest discomfort, and lightheadedness affecting various systems. The pathophysiology of POTS is not completely understood due to a variety of symptoms showing that the disease is multifactorial. There is no approved uniform management strategy for POTS and hence, no drug has been approved by the United States (US) Food and Drug Administration (FDA) for it. Ivabradine is an FDA-approved drug for stable symptomatic heart failure (HF) and patients with an ejection fraction (EF) of ≤35%. Previous studies have depicted improvement in symptoms of POTS with the use of ivabradine. It is a selective inhibitor of funny sodium channels (If) in the sinoatrial (SA) node cells resulting in the prolongation of the slow diastolic depolarization (phase IV) and reduction in the heart rate (HR). Although beta-adrenoceptor blockers are commonly used to lower HR in patients with POTS, they are less ideal due to numerous adverse effects. This review aims to provide a comprehensive and up-to-date picture of all the studies and case reports that utilized ivabradine for the treatment of POTS along with a precise overview of epidemiology, pathophysiology, and types of POTS. To conclude, we recommend further research on the effectiveness of ivabradine in patients who experience symptoms of POTS. Other than stable chronic angina pectoris, its application in this setting has been proven to be effective and safe. Further evaluation by means of randomized control trials is required to encourage use of this HR-lowering agent in common disorders other than HF and stable angina, i.e. POTS.
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Affiliation(s)
- Faryal Tahir
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Taha Bin Arif
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Zainab Majid
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Jawad Ahmed
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Muhammad Khalid
- Cardiology, Kansas City University of Medicine and Biosciences, Joplin, USA.,Cardiology, Ascension Via Christi Hospital, Pittsburg, USA
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Ishizaki Y, Gomi H. Human papillomavirus vaccination and postural tachycardia syndrome, deconditioning and exercise-induced hyperalgesia: An alternate interpretation of the reported adverse reactions. J Obstet Gynaecol Res 2020; 46:678-683. [PMID: 32153078 DOI: 10.1111/jog.14227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/09/2020] [Accepted: 02/24/2020] [Indexed: 11/30/2022]
Abstract
Human papillomavirus vaccination (HPVV) was included in the national immunization program in 2013 in Japan. However, the Japanese government suspended proactive recommendations 2 months after this decision because various adverse events following the vaccination were reported by the media. More than 6 years have already passed since the suspension of proactive recommendations of all available vaccines in Japan. Although no causal relationship between the adverse effects and HPVV has been confirmed, the Japanese government has not withdrawn the suspension. Thus, it is important to show various possible causes of the adverse events other than HPVV. It is attempted to describe the possible contribution of the misunderstanding regarding the symptoms of postural tachycardia syndrome, deconditioning, and exercise-induced hyperalgesia as the adverse effects of HPVV in this review article.
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Affiliation(s)
- Yuko Ishizaki
- Department of Pediatrics, Kansai Medical University, Osaka, Japan
| | - Harumi Gomi
- Office of Medical Education, Center for Infectious Diseases, International University of Health and Welfare, Chiba, Japan
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42
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Kaipananickal H, Waheed Khan A, Okabe J, Corcoran SJ, Esler MD, El-Osta A. Targeting Treatment Refractory NET by EZH2 Inhibition in Postural Tachycardia Syndrome. Circ Res 2020; 126:1058-1060. [PMID: 32122262 DOI: 10.1161/circresaha.119.315654] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Harikrishnan Kaipananickal
- From the Epigenetics in Human Health and Disease Laboratory (H.K., A.W.K., J.O., A.E.-O.), Monash University, Melbourne, Australia.,Department of Diabetes, Central Clinical School (H.K., A.W.K., J.O., A.E.-O.), Monash University, Melbourne, Australia.,Department of Clinical Pathology, The University of Melbourne, Parkville, Australia (H.K., J.O., A.E.-O.)
| | - Abdul Waheed Khan
- From the Epigenetics in Human Health and Disease Laboratory (H.K., A.W.K., J.O., A.E.-O.), Monash University, Melbourne, Australia.,Department of Diabetes, Central Clinical School (H.K., A.W.K., J.O., A.E.-O.), Monash University, Melbourne, Australia
| | - Jun Okabe
- From the Epigenetics in Human Health and Disease Laboratory (H.K., A.W.K., J.O., A.E.-O.), Monash University, Melbourne, Australia.,Department of Diabetes, Central Clinical School (H.K., A.W.K., J.O., A.E.-O.), Monash University, Melbourne, Australia.,Department of Clinical Pathology, The University of Melbourne, Parkville, Australia (H.K., J.O., A.E.-O.)
| | - Susan J Corcoran
- Baker Heart and Diabetes Institute, Melbourne, Australia (S.J.C., M.D.E., A.E.-O.)
| | - Murray D Esler
- Baker Heart and Diabetes Institute, Melbourne, Australia (S.J.C., M.D.E., A.E.-O.)
| | - Assam El-Osta
- From the Epigenetics in Human Health and Disease Laboratory (H.K., A.W.K., J.O., A.E.-O.), Monash University, Melbourne, Australia.,Department of Diabetes, Central Clinical School (H.K., A.W.K., J.O., A.E.-O.), Monash University, Melbourne, Australia.,Department of Clinical Pathology, The University of Melbourne, Parkville, Australia (H.K., J.O., A.E.-O.).,Baker Heart and Diabetes Institute, Melbourne, Australia (S.J.C., M.D.E., A.E.-O.).,Department of Medicine and Therapeutics (A.E.-O.), The Chinese University of Hong Kong.,Hong Kong Institute of Diabetes and Obesity, Prince of Wales Hospital (A.E.-O.), The Chinese University of Hong Kong.,Li Ka Shing Institute of Health Sciences (A.E.-O.), The Chinese University of Hong Kong.,Department of Technology, Faculty of Health, University College Copenhagen, Biomedical Laboratory Science, Denmark (A.E.-O.)
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43
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Wells R, Paterson F, Bacchi S, Page A, Baumert M, Lau DH. Brain fog in postural tachycardia syndrome: An objective cerebral blood flow and neurocognitive analysis. J Arrhythm 2020; 36:549-552. [PMID: 32528589 PMCID: PMC7280003 DOI: 10.1002/joa3.12325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/15/2020] [Accepted: 02/19/2020] [Indexed: 11/07/2022] Open
Abstract
Background It remains unclear whether brain fog is related to impaired cerebral blood flow (CBF) in postural tachycardia syndrome (POTS) patients. Methods We assessed CBF in the posterior cerebral artery (PCA) using transcranial Doppler with visual stimuli in 11 POTS and 8 healthy subjects in the seated position, followed by neurocognitive testing. Results CBF parameters were similar between the two groups. POTS patients demonstrated significantly longer latency in delayed match to sample response time and greater errors in attention switching task. Conclusions Impaired short-term memory and alertness may underlie the symptom of brain fog in POTS patients, despite normal CBF.
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Affiliation(s)
- Rachel Wells
- Department of Medicine Royal Adelaide Hospital Adelaide SA Australia.,Centre for Heart Rhythm Disorders University of Adelaide Adelaide SA Australia.,Centre for Nutrition and Gastrointestinal Disease University of Adelaide Adelaide SA Australia
| | - Felix Paterson
- Department of Radiology Royal Adelaide Hospital Adelaide SA Australia
| | - Stephen Bacchi
- Department of Medicine Royal Adelaide Hospital Adelaide SA Australia
| | - Amanda Page
- Centre for Nutrition and Gastrointestinal Disease University of Adelaide Adelaide SA Australia.,Nutrition and Metabolism South Australian Health and Medical Research Institute (SAHMRI) Adelaide SA Australia
| | - Mathias Baumert
- Centre for Heart Rhythm Disorders University of Adelaide Adelaide SA Australia.,School of Electrical and Electronic Engineering University of Adelaide Adelaide SA Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders University of Adelaide Adelaide SA Australia.,Department of Cardiology Royal Adelaide Hospital Adelaide SA Australia
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Wang Y, Zhang C, Chen S, Liu P, Wang Y, Tang C, Jin H, Du J. Heart Rate Variability Predicts Therapeutic Response to Metoprolol in Children With Postural Tachycardia Syndrome. Front Neurosci 2019; 13:1214. [PMID: 31780890 PMCID: PMC6861190 DOI: 10.3389/fnins.2019.01214] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 10/28/2019] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To improve the metoprolol therapeutic effectiveness, we aimed to explore whether baseline heart rate variability (HRV) indicators before metoprolol treatment were useful for predicting its efficacy for postural tachycardia syndrome (POTS). METHODS We recruited 45 children with POTS who received metoprolol and 17 healthy controls. All children underwent a standing test or basic head-up tilt test and 24-h dynamic electrocardiography before treatment. After 3 months of metoprolol, therapeutic responsiveness was evaluated. The usefulness of baseline HRV parameters in predicting the effectiveness of metoprolol was studied and the long-term cumulative symptom rate was analyzed. RESULTS The baseline HRV frequency domain indicators for power, ultra-low frequency, very-low frequency, low frequency (LF), high frequency (HF), and total power (TP) as well as time domain indicators were significantly lower for responders than non-responders to metoprolol; however, low-frequency normalized units and LF/HF ratio were markedly greater for responders than non-responders. On series-parallel analysis, combined baseline triangular (TR) index ≤ 33.7 and standard deviation of all normal-to-normal intervals (SDNN) index ≤ 79.0 ms as cut-off values yielded sensitivity, specificity and accuracy of 85.3, 81.8, and 84.4%, respectively, to predict therapeutic responsiveness to metoprolol. On long-term follow-up, the cumulative symptom rate was significantly higher with TR index > 33.7 and SDNN index ≤ 79.0 ms, TR index ≤ 33.7 and SDNN index > 79.0 ms or TR index > 33.7 and SDNN index > 79.0 ms than TR index ≤ 33.7 and SDNN index ≤ 79.0 ms (P < 0.05). CONCLUSION Combined TR index ≤ 33.7 and SDNN index ≤ 79.0 ms were useful preliminary measures to predict therapeutic response to metoprolol in pediatric POTS.
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Affiliation(s)
- Yuanyuan Wang
- 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
| | - Chunyu Zhang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Selena Chen
- Division of Biological Sciences, University of California, San Diego, San Diego, CA, United States
| | - Ping Liu
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Yuli Wang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Chaoshu Tang
- Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, China
- Department of Physiology and Pathophysiology, Health Sciences Centre, Peking University, 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
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, China
- Department of Physiology and Pathophysiology, Health Sciences Centre, Peking University, Beijing, China
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45
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
Lin J, Zhao H, Ma L, Jiao F. Body mass index is decreased in children and adolescents with postural tachycardia syndrome. Turk J Pediatr 2019; 61: 52-58. Our intent was to explore the predictive value of body mass index (BMI) in differentiating between vasovagal syncope (VVS) and postural tachycardia syndrome (POTS) in children and adolescents. A total of 111 children and adolescents with POTS and 154 children and adolescents with VVS were included in our study. The control group included 82 healthy children and adolescents. Height and weight were measured in all participants. The headup tilt test was performed in participants in all groups (POTS, VVS, and control). BMI was significantly lower in children and adolescents with POTS (18.3±3.4) than in children and adolescents with VVS (20.3±4.2) and the control group (20.5±2.9). The receiver operating characteristic curve was performed to determine the predictive value of BMI differentiation between POTS and VVS and showed that a BMI of 19.30 was the cutoff value for the probability of distinction. However, the results (BMI of 19.30) produced unsatisfactory sensitivity (57.1%) and specificity (28.8%) rates of correctly discriminating between patients with POTS and patients with VVS. Children and adolescents with POTS have a lower BMI compared with healthy peers or children and adolescents with VVS.
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Affiliation(s)
- Jing Lin
- School of Public Health, the Third Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, China
| | - Huacai Zhao
- Departments of Urology, the Third Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, China
| | - Lei Ma
- Departments of Pediatrics, the Third Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, China
| | - Fuyong Jiao
- Departments of Pediatrics, the Third Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, China
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Abstract
Postural tachycardia syndrome (POTS) can cause orthostatic headache. However, it is difficult to differentiate POTS from spontaneous intracranial hypotension (SIH) caused by cerebrospinal fluid (CSF) leaks. We herein report a 53-year-old woman who presented with SIH associated with POTS. A cervicothoracic and lumbar epidural blood patch rapidly improved not only the headache but also the orthostatic tachycardia, suggesting POTS secondary to SIH. This case suggests that a CSF leak can cause secondary POTS. Therefore, POTS should be considered in patients with orthostatic headaches, even in the presence of a CSF leak.
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Affiliation(s)
- Yuji Kato
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Japan
| | - Takeshi Hayashi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Japan
| | - Noriko Arai
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Japan
| | - Norio Tanahashi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Japan
| | | | - Masaki Takao
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Japan
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48
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Tao C, Lu W, Lin J, Li H, Li X, Tang C, Du J, Jin H. Long-Term Outcomes of Children and Adolescents With Postural Tachycardia Syndrome After Conventional Treatment. Front Pediatr 2019; 7:261. [PMID: 31316954 PMCID: PMC6610301 DOI: 10.3389/fped.2019.00261] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 06/07/2019] [Indexed: 11/13/2022] Open
Abstract
Objectives: To explore the long-term outcomes of children and adolescents with postural tachycardia syndrome receiving conventional interventions. Materials and Methods: A total of 121 patients were recruited, but 6 (5.0%) of them were lost at follow-up. The detailed clinical data were collected, and the reoccurrence and frequency of orthostatic intolerance symptoms were evaluated with a mean followed-up period of 18.7 months (range, 14-74 months). The Kaplan-Meier curve was used to show the cumulative symptom-free rate of patients over time. Factors influencing the long-term outcomes were examined using the Cox's proportional hazards models. Results: The cumulative symptom-free rate was gradually increased over time. It was 48.4% at the 1-year follow-up and increased to 85.6% at the 6-year follow-up. The duration of symptoms before treatment and the maximum upright heart rate in standing-up test were identified as independent indicators for the long-term outcomes. Each 1-month prolongation in the duration of symptoms before treatment was associated with a 1.2% decrease in the cumulative symptom-free rate. However, each 1-bpm increase in the maximum upright heart rate in standing-up test was associated with a 2.1% increase in the cumulative symptom-free rate. Conclusions: The long-term outcomes of postural tachycardia syndrome patients who received conventional interventions are benign and the cumulative symptom-free rate was gradually increased over time. The prolonged duration of symptoms before treatment and the reduced maximum upright heart rate in standing-up test are the independent risk indicators.
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Affiliation(s)
- Chunyan Tao
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Wenxin Lu
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Jing Lin
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Hongxia Li
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Xueying Li
- Department of Medical Statistics, Peking University First Hospital, Beijing, China
| | - Chaoshu Tang
- Department of Physiology and Pathophysiology, Peking University Health Science Center, 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
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Rodriguez B, Zimmermann R, Gutbrod K, Heinemann D, Z'Graggen WJ. Orthostatic Cognitive Dysfunction in Postural Tachycardia Syndrome After Rapid Water Drinking. Front Neurosci 2019; 13:327. [PMID: 31024242 PMCID: PMC6465605 DOI: 10.3389/fnins.2019.00327] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 03/21/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Postural tachycardia syndrome (POTS) is a form of autonomic dysregulation and is characterized by an excessive heart rate (HR) increment upon the upright body position while blood pressure is maintained. Patients experience typical symptoms of orthostatic intolerance such as dizziness, nausea and cognitive impairments. The present study assessed position-dependent attentional and cognitive functioning in POTS patients compared to healthy subjects and tested the response of cognitive performance to acute water intake. Methods: Data was obtained from eight patients with neuropathic POTS and eight healthy subjects of similar age and gender. All participants completed questionnaires that assessed health-related quality of life and depression and underwent four rounds of neuropsychological testing overall, each before and after the intake of 500 ml still mineral water and both in the supine and in the upright posture. Results: Postural tachycardia syndrome patients showed deficits in working memory (WM) exclusively in the upright position compared to healthy subjects, but no position-dependent impairments in alertness or divided attention. Rapid water ingestion had a beneficial effect on WM in the upright posture, lead to a decrease in HR increment and to an improvement of subjective symptom experience. Conclusion: The results provide support for the occurrence of purely orthostatic cognitive deficits in POTS, especially when increased executive control and cognitive resources are required and document a favorable effect of water intake on cognitive performance. These findings have important implications for the management of cognitive symptoms in POTS as high water intake is an easy and accessible strategy.
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Affiliation(s)
- Belén Rodriguez
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Raya Zimmermann
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Klemens Gutbrod
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Doerthe Heinemann
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Werner J Z'Graggen
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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50
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Wang Y, Zhang C, Chen S, Li X, Jin H, Du J. Frequency Domain Indices of Heart Rate Variability are Useful for Differentiating Vasovagal Syncope and Postural Tachycardia Syndrome in Children. J Pediatr 2019; 207:59-63. [PMID: 30626483 DOI: 10.1016/j.jpeds.2018.11.054] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 11/27/2018] [Accepted: 11/29/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To explore the value of frequency domain indices of heart rate variability (HRV) in the differential diagnosis between pediatric vasovagal syncope and postural tachycardia syndrome (POTS). STUDY DESIGN Eighty-five patients aged 7-16 years with either vasovagal syncope or POTS were enrolled in the experimental group; 18 healthy children served as controls. Holter electrocardiography was used to detect HRV frequency-domain indices in patients with vasovagal syncope, patients with POTS, and control subjects. The differences in HRV indices were compared between the vasovagal syncope and POTS groups. The receiver operating characteristic (ROC) curve was calculated to analyze the predictive value of HRV for the differential diagnosis between vasovagal syncope and POTS in children. In addition, 37 children aged 7-17 years with either vasovagal syncope or POTS were recruited as an external validation group. RESULTS The daytime ultra-low frequency (dULF), nighttime ULF (nULF), daytime very low frequency (dVLF), and nighttime VLF (nVLF) were higher in the vasovagal syncope group compared with the POTS group (P < .01 for dULF, dVLF, and nVLF; P < .05 for nULF). The dULF, nULF, dVLF, and nVLF yielded a sensitivity of 73.3%, 71.1%, 68.9%, and 62.2%, respectively, and a specificity of 72.5%, 62.5%, 60.0%, and 60.0%, respectively, to differentiate vasovagal syncope from POTS. The external validation with clinical diagnostic standard showed that a dULF cutoff value of 36.2 ms2 for differentiating POTS from vasovagal syncope yielded a sensitivity of 71.4%, a specificity of 75.0%, and an accuracy of 73.0%. CONCLUSION dULF may be a useful measure for the differential diagnosis between vasovagal syncope and POTS in adolescents.
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Affiliation(s)
- Yuanyuan Wang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Chunyu Zhang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Selena Chen
- Division of Biological Sciences, University of California, San Diego, La Jolla, CA
| | - Xueying Li
- Department of Medical Statistics, Peking University First Hospital, Beijing, China
| | - Hongfang Jin
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, China; Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, China.
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