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Sunami Y, Sugaya K, Takahashi K. G protein-coupled receptors related to autoimmunity in postural orthostatic tachycardia syndrome. Immunol Med 2024:1-8. [PMID: 38900132 DOI: 10.1080/25785826.2024.2370079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Accepted: 06/07/2024] [Indexed: 06/21/2024] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) is characterized by exaggerated orthostatic tachycardia in the absence of orthostatic hypotension. The pathophysiology of POTS may involve hypovolemia, autonomic neuropathy, a hyperadrenergic state, and cardiovascular deconditioning, any of which can co-occur in the same patient. Furthermore, there is growing evidence of the role of autoimmunity in a subset of POTS cases. In recent years, investigators have described an increased rate of autoimmune comorbidities as evidenced by the finding of several types of neural receptor autoantibody and non-specific autoimmune marker in patients with POTS. In particular, the association of the disease with several types of anti-G protein-coupled receptor (GPCR) antibodies and POTS has frequently been noted. A previous study reported that autoantibodies to muscarinic AChRs may play an important role in POTS with persistent, gastrointestinal symptoms. To date, POTS is recognized as one of the sequelae of coronavirus disease 2019 (COVID-19) and its frequency and pathogenesis are still largely unknown. Multiple autoantibody types occur in COVID-related, autonomic disorders, suggesting the presence of autoimmune pathology in these disorders. Herein, we review the association of anti-GPCR autoantibodies with disorders of the autonomic nervous system, in particular POTS, and provide a new perspective for understanding POTS-related autoimmunity.
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Affiliation(s)
- Yoko Sunami
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Keizo Sugaya
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Kazushi Takahashi
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
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Dixit K, Frishman WH. Postural Tachycardia Syndrome and COVID-19: Focus on Ivabradine Therapy. Cardiol Rev 2024; 32:279-284. [PMID: 36729924 DOI: 10.1097/crd.0000000000000503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In this article we discuss the association of postural orthostatic tachycardia syndrome (POTS) with coronavirus-19 (COVID-19), ivabradine's unique mechanism of action, and its use in POTS patients. We highlight the pathophysiology and common etiologies of POTS, including preceding viral infections, vaccines, trauma, surgeries, and other stressors. COVID-19, a viral illness, has been associated with POTS through a variety of mechanisms that are not yet well understood. The initial management strategy for POTS is largely nonpharmacological, focusing on increasing venous return to the heart through physical therapy or other exercise activities. Ivabradine is a selective inhibitor of the funny sodium channels within the sinoatrial node. This unique mechanism of action allows for the reduction of heart rate without any effect on the heart's ionotropic activity. With an increase in the number of POTS cases, especially during the COVID pandemic, the importance of utilizing new medications and management strategies for POTS becomes imperative. Though ivabradine is currently only approved for the management of patients with coronary artery disease and heart failure by the Food and Drug Administration (FDA), it has also proven to be effective at reducing symptoms among patients with refractory POTS, and thus, should be considered for the management of patients who do not respond to initial treatment strategies.
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Affiliation(s)
- Keshav Dixit
- From the Department of Medicine, ISMMS Mount Sinai Morningside-West, New York, New York
| | - William H Frishman
- Departments of Medicine and Cardiology, New York Medical College and Westchester Medical Center, Valhalla, NY
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Cui YX, Du JB, Jin HF. Insights into postural orthostatic tachycardia syndrome after COVID-19 in pediatric patients. World J Pediatr 2024; 20:201-207. [PMID: 38363488 DOI: 10.1007/s12519-024-00796-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 01/02/2024] [Indexed: 02/17/2024]
Affiliation(s)
- Ya-Xi Cui
- Department of Pediatrics, Peking University First Hospital, No.1 Xi-an Men Street, West District, Beijing 100034, China
| | - Jun-Bao Du
- Department of Pediatrics, Peking University First Hospital, No.1 Xi-an Men Street, West District, Beijing 100034, China.
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing 100191, China.
| | - Hong-Fang Jin
- Department of Pediatrics, Peking University First Hospital, No.1 Xi-an Men Street, West District, Beijing 100034, China.
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Vernino S, Hopkins S, Bryarly M, Hernandez RS, Salter A. Randomized controlled trial of intravenous immunoglobulin for autoimmune postural orthostatic tachycardia syndrome (iSTAND). Clin Auton Res 2024; 34:153-163. [PMID: 38311655 DOI: 10.1007/s10286-024-01020-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/23/2024] [Indexed: 02/06/2024]
Abstract
OBJECTIVE This study assesses response to intravenous immunoglobulin (IVIG) in presumed autoimmune postural orthostatic tachycardia syndrome (POTS). BACKGROUND POTS may be associated with autoimmune disorders, serum autoantibodies, or recent infection. Uncontrolled case studies suggest that IVIG is beneficial for treating autoimmune POTS. No previous randomized controlled trials have been conducted. METHODS This single-site randomized controlled trial compared IVIG with intravenous albumin infusions. Albumin comparator ensured blinding and control for effects of volume expansion. Eligible patients with POTS had COMPASS-31 total weighted score ≥ 40 and met predetermined criteria suggesting autoimmunity. Over 12 weeks, participants received eight infusions (0.4 gm/kg each). Four infusions were given weekly followed by four infusions every other week. Primary outcome measure was improvement in COMPASS-31 2 weeks after final infusion. RESULTS A total of 50 participants consented; 30 met inclusion criteria and received study drug (16 IVIG and 14 albumin; 29 female). Group baseline characteristics were well matched; 27 participants completed treatment protocol. Change in COMPASS-31 did not differ between groups (median change [IQR]; IVIG: -5.5 [-23.3, 2.5] versus albumin: -10.6 [-14.1, -4.7]; p-value = 0.629). The IVIG group had a higher response rate (46.7% versus 38.5%), but this was not statistically significant. Adverse events were common but usually mild and did not differ between treatment groups. CONCLUSIONS This small randomized controlled trial of IVIG in POTS found no statistical difference in response compared with albumin infusion. Both groups showed improvement possibly related to volume expansion or other effects obscuring group differences. These findings inform development of future immunomodulatory clinical trials in POTS.
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Affiliation(s)
- Steven Vernino
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Steve Hopkins
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Meredith Bryarly
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Amber Salter
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
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Rigo S, Barbic F, Khalaf K, Bisoglio A, Pani M, Minonzio M, Rinaldi L, Ciccarelli M, Bordoni MG, Verzeletti P, Badilini F, Bonovas S, Piovani D, Shiffer D, Furlan R. The Long-COVID autonomic syndrome in hospitalized patients: A one-year prospective cohort study. Eur J Intern Med 2024; 120:38-45. [PMID: 37652756 DOI: 10.1016/j.ejim.2023.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/29/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023]
Abstract
Long-COVID syndrome is characterized by fatigue, orthostatic intolerance, tachycardia, pain, memory difficulties, and brain fog, which may be associated with autonomic nervous system abnormalities. We aimed to evaluate the short and long-term course of COVID-19 autonomic symptoms and quality of life (QoL) after SARS-CoV-2 infection through a one-year follow-up combined with validated questionnaires. Additionally, we aimed to identify patients with worsening autonomic symptoms at 6 and 12 months by dividing the patient cohort into two sub-groups: the Post-COVID healed Control sub-group (total score<16.4) and the Long-COVID autonomic syndrome sub-group (total score>16.4). This prospective cohort studied 112 SARS-CoV-2 positive patients discharged from Humanitas Research Hospital between January and March 2021. Autonomic symptoms and QoL were assessed using the composite autonomic symptom scale 31 (COMPASS-31) and Short Form Health Survey (SF-36) questionnaires at various time points: before SARS-CoV-2 infection (PRE), at hospital discharge (T0), and at 1 (T1), 3 (T3), 6 (T6), and 12 (T12) months of follow-up. COMPASS-31 total score, Orthostatic Intolerance and Gastrointestinal function indices, QoL, physical functioning, pain, and fatigue scores worsened at T0 compared to PRE but progressively improved at T1 and T3, reflecting the acute phase of COVID-19. Unexpectedly, these indices worsened at T6 and T12 compared to T3. Subgroup analysis revealed that 47% of patients experienced worsening autonomic symptoms at T6 and T12, indicating Long-COVID autonomic syndrome. Early rehabilitative and pharmacological therapy is recommended for patients at the T1 and T3 stages after SARS-CoV-2 infection to minimize the risk of developing long-term autonomic syndrome.
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Affiliation(s)
- Stefano Rigo
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy
| | - Franca Barbic
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy; Internal Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy
| | - Kareem Khalaf
- Department of Gastroenterology, Saint Michael's Hospital, University of Toronto, Toronto, Canada
| | - Andrea Bisoglio
- Department of Neurosurgery, University Vita e Salute S. Raffaele, Milan, Italy
| | - Margherita Pani
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
| | - Maura Minonzio
- Internal Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy
| | - Luca Rinaldi
- Occupational Medicine, IRCCS Salvatore Maugeri, University of Pavia, Pavia, Italy
| | - Michele Ciccarelli
- Internal Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy
| | - Maria Grazia Bordoni
- Vascular Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy
| | | | | | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy
| | - Dana Shiffer
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy; Internal Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy
| | - Raffaello Furlan
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy; Internal Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy.
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Kell DB, Khan MA, Kane B, Lip GYH, Pretorius E. Possible Role of Fibrinaloid Microclots in Postural Orthostatic Tachycardia Syndrome (POTS): Focus on Long COVID. J Pers Med 2024; 14:170. [PMID: 38392604 PMCID: PMC10890060 DOI: 10.3390/jpm14020170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/16/2024] [Accepted: 01/27/2024] [Indexed: 02/24/2024] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a common accompaniment of a variety of chronic, inflammatory diseases, including long COVID, as are small, insoluble, 'fibrinaloid' microclots. We here develop the argument, with accompanying evidence, that fibrinaloid microclots, through their ability to block the flow of blood through microcapillaries and thus cause tissue hypoxia, are not simply correlated with but in fact, by preceding it, may be a chief intermediary cause of POTS, in which tachycardia is simply the body's exaggerated 'physiological' response to hypoxia. Similar reasoning accounts for the symptoms bundled under the term 'fatigue'. Amyloids are known to be membrane disruptors, and when their targets are nerve membranes, this can explain neurotoxicity and hence the autonomic nervous system dysfunction that contributes to POTS. Taken together as a system view, we indicate that fibrinaloid microclots can serve to link POTS and fatigue in long COVID in a manner that is at once both mechanistic and explanatory. This has clear implications for the treatment of such diseases.
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Affiliation(s)
- Douglas B Kell
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Crown St, Liverpool L69 7ZB, UK
- The Novo Nordisk Foundation Centre for Biosustainability, Building 220, Chemitorvet 200, Technical University of Denmark, 2800 Kongens Lyngby, Denmark
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch Private Bag X1, Matieland 7602, South Africa
| | - Muhammed Asad Khan
- Directorate of Respiratory Medicine, Manchester University Hospitals, Wythenshawe Hospital, Manchester M23 9LT, UK
| | - Binita Kane
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Crown St, Liverpool L69 7ZB, UK
- Manchester University Foundation Trust and School of Biological Sciences, University of Manchester, Manchester M13 9PL, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, 9220 Aalborg, Denmark
| | - Etheresia Pretorius
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Crown St, Liverpool L69 7ZB, UK
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch Private Bag X1, Matieland 7602, South Africa
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Tufvesson H, Hamrefors V, Fedorowski A, Hansson M, Ohlsson B. Gastrointestinal symptoms in patients with postural orthostatic tachycardia syndrome in relation to hemodynamic findings and immunological factors. Front Physiol 2024; 15:1342351. [PMID: 38348221 PMCID: PMC10859499 DOI: 10.3389/fphys.2024.1342351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/15/2024] [Indexed: 02/15/2024] Open
Abstract
Gastrointestinal (GI) symptoms are common in postural orthostatic tachycardia syndrome (POTS). We aimed to explore the prevalence and severity of GI symptoms in POTS, and to investigate immunological factors, hemodynamic findings, and their possible association with GI symptoms in POTS. Forty-three patients (93% female, median age 30.6 (26.0-41.0) years), previously diagnosed with POTS and 74 healthy controls (78% female, median age 35.6 (28.8-41.7) years) were included. The participants completed a questionnaire including prevalence of GI symptoms, the irritable bowel syndrome severity scoring system (IBS-SSS), and visual analog scale for IBS (VAS-IBS). All POTS patients were previously examined by tilt test (2010-2021) and the vast majority with more recent active standing test (2017-2021), which included monitoring of heart rate (HR). ΔHR was calculated as difference between supine and upright position. Continuous variables from IBS-SSS and VAS-IBS were correlated to ΔHR. A microarray containing several autoantigens commonly targeted in systemic autoimmune disorders was used to assess prevalent autoantibodies in POTS and controls. Total IgE and S-tryptase were analyzed. GI symptoms were more prevalent and severe in POTS than in controls; nausea being the most prevalent (79.1% vs 4.9%, p < 0.001) and bloating and flatulence being the most severe (median 65 (25-88) vs 0 (0-14), p < 0.001). The median total IBS-SSS was 213 (135-319) in POTS vs 13 (0-54) in controls (p < 0.001). Total IBS-SSS was associated with low psychological wellbeing (r = 0.539, p < 0.001) in POTS. ΔHRmax correlated inversely with abdominal pain (r = -0.406, p = 0.007). After adjustments for psychological wellbeing, total IBS-SSS still associated inversely with ΔHR10min (β: 4.748; 95% CI: -9.172 to -0.324; p = 0.036). Similar results were seen with active standing test. The prevalence of autoantibodies did not differ between POTS and controls (29.4% vs 33.3%, p = 0.803). There was no association between GI symptoms and autoantibody status. Total IgE and tryptase were elevated in a few cases. This study confirms the high prevalence of GI symptoms in POTS. More pronounced tachycardia upon tilt table testing seems to be inversely correlated with severity of chronic GI symptoms in POTS. This study did not support the hypothesis that POTS is associated with immunological factors.
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Affiliation(s)
- Hanna Tufvesson
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Gastroenterology, 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 Medicine, Karolinska Institute, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Monika Hansson
- Department of Medicine, Division of Rheumatology, Karolinska Institute, and Karolinska University Hospital, Stockholm, Sweden
| | - Bodil Ohlsson
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
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Negrut N, Menegas G, Kampioti S, Bourelou M, Kopanyi F, Hassan FD, Asowed A, Taleouine FZ, Ferician A, Marian P. The Multisystem Impact of Long COVID: A Comprehensive Review. Diagnostics (Basel) 2024; 14:244. [PMID: 38337760 PMCID: PMC10855167 DOI: 10.3390/diagnostics14030244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/20/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: COVID-19 was responsible for the latest pandemic, shaking and reshaping healthcare systems worldwide. Its late clinical manifestations make it linger in medical memory as a debilitating illness over extended periods. (2) Methods: the recent literature was systematically analyzed to categorize and examine the symptomatology and pathophysiology of Long COVID across various bodily systems, including pulmonary, cardiovascular, gastrointestinal, neuropsychiatric, dermatological, renal, hematological, and endocrinological aspects. (3) Results: The review outlines the diverse clinical manifestations of Long COVID across multiple systems, emphasizing its complexity and challenges in diagnosis and treatment. Factors such as pre-existing conditions, initial COVID-19 severity, vaccination status, gender, and age were identified as influential in the manifestation and persistence of Long COVID symptoms. This condition is highlighted as a debilitating disease capable of enduring over an extended period and presenting new symptoms over time. (4) Conclusions: Long COVID emerges as a condition with intricate multi-systemic involvement, complicating its diagnosis and treatment. The findings underscore the necessity for a nuanced understanding of its diverse manifestations to effectively manage and address the evolving nature of this condition over time.
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Affiliation(s)
- Nicoleta Negrut
- Department of Psycho-Neuroscience and Recovery, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Georgios Menegas
- Department of Orthopaedics, Achillopouleio General Hospital of Volos, Polymeri 134, 38222 Volos, Greece;
| | - Sofia Kampioti
- Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania (M.B.); (F.D.H.)
| | - Maria Bourelou
- Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania (M.B.); (F.D.H.)
| | - Francesca Kopanyi
- Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania (M.B.); (F.D.H.)
| | - Faiso Dahir Hassan
- Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania (M.B.); (F.D.H.)
| | - Anamaria Asowed
- Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania (M.B.); (F.D.H.)
| | - Fatima Zohra Taleouine
- University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK;
| | - Anca Ferician
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (A.F.)
| | - Paula Marian
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (A.F.)
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Stallkamp Tidd SJ, Cantrell C, Greene BD, Wilson R. Low-Dose Naltrexone Use in Postural Orthostatic Tachycardia Syndrome: A Case Series. Cureus 2023; 15:e43426. [PMID: 37706146 PMCID: PMC10497067 DOI: 10.7759/cureus.43426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2023] [Indexed: 09/15/2023] Open
Abstract
Introduction In recent years, low-dose naltrexone has emerged as a novel off-label therapy for many chronic conditions including postural orthostatic tachycardia syndrome (POTS), however, there is little evidence for its efficacy. Methods In this institutional review board (IRB)-approved case series, the charts of six tilt table-confirmed patients with POTS who underwent a trial of low-dose naltrexone (LDN) at our institution were reviewed. Medical history, subjective description of symptom severity, the continuation of therapy, tolerability, and scores on patient-reported outcome measures (Patient-Reported Outcomes Measurement Information System {PROMIS} Fatigue, PROMIS physical and mental health, Generalized Anxiety Disorder Assessment {GAD}-7, Patient Health Questionnaire {PHQ}-9, and Composite Autonomic Symptom Score {COMPASS}) were collected at therapy initiation and six to 12 months after the start of LDN. Results Three out of six reviewed patients reported an improvement in their POTS after the initiation of LDN. Two patients discontinued the therapy due to a lack of perceived benefit. No side effects or adverse outcomes were reported. The patient-reported outcome measures of PROMIS Fatigue, PROMIS physical and mental health, GAD-7, PHQ-9, and COMPASS showed inconsistent changes over the course of therapy, with some patients showing improvement or stability and others showing worsening. The small sample size and incomplete response rate did not allow for extensive statistical analysis. Conclusion As seen in its use in other conditions, LDN appears to have a favorable safety and side effect profile in patients with POTS but has little evidence for efficacy. Although some patients noted benefit, patient-reported outcome measures show a variable response profile. High-quality randomized controlled trials are needed to determine if the treatment is efficacious and should be used outside of a trial basis.
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Affiliation(s)
| | - Christopher Cantrell
- Neurology, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, USA
| | - Brady D Greene
- Neurology, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, USA
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Fan S, Cui Y, Liao Y, Jin H. Predicting Therapeutic Efficacy of Pharmacological Treatments in Children with Postural Orthostatic Tachycardia Syndrome: A Mini-Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1093. [PMID: 37508589 PMCID: PMC10377884 DOI: 10.3390/children10071093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/12/2023] [Accepted: 06/19/2023] [Indexed: 07/30/2023]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is common in children, with an excessive increment in heart rate when moving from the supine to upright position. It has significant negative impacts on the daily life of pediatric patients. The pathogenesis of POTS includes peripheral vascular dysfunction, central hypovolemia, abnormal autonomic function, a high-adrenergic state, impaired skeletal-muscle pump function, the abnormal release of vasoactive factors, and autoimmune abnormalities. Therefore, the empirical use of pharmacological treatments has limited therapeutic efficacy due to the diversity of its mechanisms. A crucial aspect of managing POTS is the selection of appropriate treatment targeting the specific pathogenesis. This review summarizes the commonly used pharmacological interventions, with a focus on their predictive indicators for treatment response. Factors such as heart rate variability, plasma biomarkers, and cardiac-function parameters are discussed as potential predictors of therapeutic efficacy, enabling the implementation of individualized treatment to improve therapeutic effectiveness. This review consolidates the current knowledge on POTS, encompassing its clinical characteristics, epidemiological patterns, underlying pathogenic mechanisms, and predictive indicators for treatment response. Further research is warranted to enhance the understanding of POTS and facilitate the development of more effective therapeutic approaches for this challenging syndrome.
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Affiliation(s)
- Siying Fan
- Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Yaxi Cui
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Ying Liao
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Hongfang Jin
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing 100191, China
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El-Rhermoul FZ, Fedorowski A, Eardley P, Taraborrelli P, Panagopoulos D, Sutton R, Lim PB, Dani M. Autoimmunity in Long Covid and POTS. OXFORD OPEN IMMUNOLOGY 2023; 4:iqad002. [PMID: 37255928 PMCID: PMC10224806 DOI: 10.1093/oxfimm/iqad002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/23/2023] [Accepted: 03/08/2023] [Indexed: 11/10/2023] Open
Abstract
Orthostatic intolerance and other autonomic dysfunction syndromes are emerging as distinct symptom clusters in Long Covid. Often accompanying these are common, multi-system constitutional features such as fatigue, malaise and skin rashes which can signify generalized immune dysregulation. At the same time, multiple autoantibodies are identified in both Covid-related autonomic disorders and non-Covid autonomic disorders, implying a possible underlying autoimmune pathology. The lack of specificity of these findings precludes direct interpretations of cause and association, but their prevalence with its supporting evidence is compelling.
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Affiliation(s)
- Fatema-Zahra El-Rhermoul
- Department of Allergy and Clinical Immunology, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, UK
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital and Karolinska Institute, Stockholm 171 77, Sweden
| | - Philip Eardley
- Imperial Syncope Unit, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | | | | | - Richard Sutton
- National Heart and Lung Institute, Imperial College London, London SW3 6LY, UK
| | - Phang Boon Lim
- Imperial Syncope Unit, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Melanie Dani
- Imperial Syncope Unit, Imperial College Healthcare NHS Trust, London W12 0HS, UK
- Cutrale Perioperative and Ageing Group, Department of Bioengineering, Imperial College London, London W12 0BZ, UK
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12
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Deng J, Li H, Guo Y, Zhang G, Fischer H, Stavrakis S, Yu X. Transcutaneous vagus nerve stimulation attenuates autoantibody-mediated cardiovagal dysfunction and inflammation in a rabbit model of postural tachycardia syndrome. J Interv Card Electrophysiol 2023; 66:291-300. [PMID: 35118574 PMCID: PMC9349471 DOI: 10.1007/s10840-022-01144-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/30/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Previous studies demonstrated M2 muscarinic acetylcholine receptor-activating autoantibodies (M2R-AAb) were present in some patients with postural tachycardia syndrome (POTS). This study examines how these autoantibodies might contribute to the pathophysiology of POTS, and whether low-level tragus stimulation (LLTS) can ameliorate autoantibody-mediated autonomic dysregulation in the rabbit. METHODS Five New Zealand white rabbits were immunized with a M2R second extracellular loop peptide to produce cholinomimetic M2R-AAb. Tilt test and infusion studies were performed on conscious rabbits before immunization, 6 weeks after immunization, and 8 weeks after immunization with 2-week daily LLTS treatment. Each rabbit served as its own control. RESULTS Compared to preimmune state, an enhanced heart rate increase and decreased parasympathetic activity upon tilting were observed in immunized rabbits. Furthermore, these rabbits demonstrated an attenuated heart rate-slowing response to infusion of the M2R orthosteric agonist arecaidine propargyl ester (APE), suggesting an inhibitory allosteric effect of M2R-AAb. There was also a significant increase in serum inflammatory cytokines in immunized rabbits. LLTS treatment suppressed the postural tachycardia, improved the sympathovagal balance with increased acetylcholine secretion, reduced the levels of inflammatory cytokines, and reversed the attenuated heart rate response to APE in immunized rabbits. No suppression of M2R-AAb expression by LLTS was found during this short-term study period. Receptor-modulating activity of M2R-AAb produced in immunized rabbits was confirmed with in vitro bioassay. CONCLUSIONS Autoantibody inhibition of cholinergic ligand activity may be involved in the development of cardiovagal dysfunction and inflammation associated with POTS, both of which can be improved by vagal stimulation.
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Affiliation(s)
- Jielin Deng
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73117, USA
| | - Hongliang Li
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73117, USA
| | - Yankai Guo
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73117, USA
| | - Gege Zhang
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73117, USA
| | - Hayley Fischer
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73117, USA
| | - Stavros Stavrakis
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73117, USA
| | - Xichun Yu
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73117, USA.
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13
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Low-level tragus stimulation improves autoantibody-induced hyperadrenergic postural tachycardia syndrome in rabbits. Heart Rhythm O2 2023; 4:127-133. [PMID: 36873318 PMCID: PMC9975011 DOI: 10.1016/j.hroo.2022.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Recent studies have demonstrated that antiadrenergic autoantibodies are involved in the pathophysiology of postural orthostatic tachycardia syndrome (POTS). Objective The purpose of this study was to test the hypothesis that transcutaneous low-level tragus stimulation (LLTS) ameliorates autoantibody-induced autonomic dysfunction and inflammation in a rabbit model of autoimmune POTS. Methods Six New Zealand white rabbits were co-immunized with peptides from the α1-adrenergic and β1-adrenergic receptors to produce sympathomimetic antibodies. The tilt test was performed on conscious rabbits before immunization, 6 weeks after immunization, and 10 weeks after immunization with 4-week daily LLTS treatment. Each rabbit served as its own control. Results An enhanced postural heart rate increase in the absence of significant change in blood pressure was observed in immunized rabbits, confirming our previous report. Power spectral analysis of heart rate variability during the tilt test showed a predominance of sympathetic over parasympathetic activity in immunized rabbits as reflected by markedly increased low-frequency power, decreased high-frequency power, and increased low-to-high-frequency ratio. Serum inflammatory cytokines were also significantly increased in immunized rabbits. LLTS suppressed the postural tachycardia, improved the sympathovagal balance with increased acetylcholine secretion, and attenuated the inflammatory cytokine expression. Antibody production and activity were confirmed with in vitro assays, and no antibody suppression by LLTS was found in this short-term study. Conclusion LLTS improves cardiac autonomic imbalance and inflammation in a rabbit model of autoantibody-induced hyperadrenergic POTS, suggesting that LLTS may be used as a novel neuromodulation therapy for POTS.
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14
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Mannan H, Pain CM. Sex adjusted standardized prevalence ratios for celiac disease and other autoimmune diseases in patients with postural orthostatic tachycardia syndrome (POTS): A systematic review and meta-analysis. Heliyon 2023; 9:e12982. [PMID: 36816268 PMCID: PMC9929284 DOI: 10.1016/j.heliyon.2023.e12982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/13/2022] [Accepted: 01/10/2023] [Indexed: 01/15/2023] Open
Abstract
Standardised sex-adjusted prevalence ratios (SSPRs) have not been published for any autoimmune diseases (ADs) in patients with Postural Orthostatic Tachycardia Syndrome (POTS), who are predominantly young females. We performed a systematic review according to PRISMA guidelines of POTS cohorts reporting the prevalence of at least one AD. Only four studies were found: two providing data on celiac disease; and two with data on 'any AD', Hashimoto's thyroiditis, rheumatoid arthritis, systemic lupus erythematosus (SLE), Sjögren's syndrome and celiac disease and (one study) antiphospholipid syndrome. All studies were assessed as being at high risk of bias for estimating AD prevalence in POTS patients, with under-reporting of ADs likely due to the lack of rigorous prospective screening for ADs. A literature search found a 'gold standard' general population (GP) comparator only for celiac disease in the United States, leading to a pooled SSPR in POTS patients of 2.75 with 95% confidence interval (1.06-4.40). The lack of recent high-quality studies on GP prevalence for the other ADs was noteworthy. Exploratory pooled SSPRs were calculated for 'any AD' and for the other five ADs using GP comparator data from a comprehensive review. All pooled SSPRs were greater than one and statistically significant, implying a higher prevalence of these ADs, and any AD, in POTS patients. The magnitude of the exploratory SSPRs was very large for SLE, Sjögren's syndrome and antiphospholipid syndrome, perhaps reflecting the use of non-gold standard GP comparators, which may underestimate AD prevalence. Further research in a large POTS cohort with an appropriately age- and sex-matched GP control group is recommended, to confirm the SSPR for celiac disease and to determine whether SLE, Sjogren's syndrome and antiphospholipid syndrome are indeed many times more prevalent in POTS patients than in the GP. The findings are consistent with POTS itself being an AD.
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Affiliation(s)
- Haider Mannan
- Translational Health Research Institute, Western Sydney University, Campbelltown, NSW 2560, Australia,Corresponding author.
| | - Clare M. Pain
- POTS UK, UK Registered Charity No. 1159813, Henley-in-Arden, B95 6DF, United Kingdom
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15
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Self-reported symptom burden in postural orthostatic tachycardia syndrome (POTS): A narrative review of observational and interventional studies. Auton Neurosci 2023; 244:103052. [PMID: 36525900 DOI: 10.1016/j.autneu.2022.103052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 10/27/2022] [Accepted: 11/13/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Postural Orthostatic Tachycardia Syndrome (POTS) is a chronic health condition affecting mostly women of childbearing age, and significantly impacting their health and quality of life. It is currently poorly understood with no approved licensed treatments. The aim of this systematic review was to contextualize the symptom burden of POTS, and review factors associated with this burden that may guide future treatments. The specific questions were (1) How does symptom burden in POTS compare to the burden in other long term conditions (LTCs), (2) Which factors are associated with POTS symptom burden, and (3) Which interventions show promise in reducing symptom burden in POTS. DATABASES AND DATA TREATMENT Electronic databases (CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, APA PsycArticles, OpenGrey) were searched from inception to January 2022 for observational studies reporting on the association between any biological, psychological or social factors and symptom burden, and randomized controlled trials reporting on interventions for symptom burden in adults with POTS. Two reviewers independently conducted eligibility screening, data extraction and quality assessment. A narrative synthesis was undertaken. RESULTS/CONCLUSION 5159 entries were screened for eligibility. Twenty-nine studies were included (1372 participants with POTS of a total sample size of 2314, 17 High-, 12 Medium-quality), seventeen were observational and twelve were randomized controlled experimental and intervention trials. Overall methodological quality of the evidence was medium-high but heterogeneity was high and sample sizes modest, allowing moderately robust conclusions. Orthostatic symptom burden was higher in POTS than other LTCs. Serum activity against adrenergic α1 receptors, physical functioning, depression, catastrophizing, prolonged cognitive stress testing and anxiety were significantly associated with symptom burden in medium-high quality studies. Preliminary medium-high quality evidence from predominantly proof-of-concept (n = 11) studies and one 3-month 2 × 2 factorial design trial suggest that compression garments, propranolol, pyridostigmine, desmopressin, and bisoprolol may hold promise in reducing symptom burden. Directions for future research include investigating associated factors over time, the development of complex interventions which address both biological and psychosocial factors associated with symptom burden, and effectiveness trials of these interventions. SIGNIFICANCE POTS symptom burden is high, particularly in relation to orthostatic intolerance when compared to other long-term conditions (LTCs). Despite this burden, there are no effectiveness randomized controlled trials of treatment to reduce symptoms in POTS. This review provides a starting point to understanding researched biological and psychosocial factors associated with this burden. There was however inconsistency in the measurement of symptom burden, lowering the confidence of cross-study inferences. A coherent definition of POTS symptom range, severity and impact along with a validated and reliable POTS-specific instrument is currently lacking. A standardized questionnaire to assess POTS symptom burden as a core outcome measure will help clarify future research and clinical practice.
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16
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Muacevic A, Adler JR. Skin Biopsy and Quantitative Sudomotor Axon Reflex Testing in Patients With Postural Orthostatic Tachycardia Syndrome. Cureus 2022; 14:e31021. [PMID: 36349067 PMCID: PMC9629858 DOI: 10.7759/cureus.31021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE No formal diagnostic criteria exist for the neuropathic subtype of postural orthostatic tachycardia syndrome (POTS). Skin biopsy and quantitative sudomotor axon reflex testing (QSORT) are preferred methods of assessment for autonomic small fiber neuropathy (SFN). This study characterizes the utility of these testing methods at a tertiary center and identifies clinical features associated with abnormal testing. METHODS Medical records of 2658 patients undergoing tilt table testing at a single institution between June 2018 and December 2020 were reviewed. Patients with postural orthostatic tachycardia syndrome were included for analysis of intraepidermal nerve fiber density (IENFD), sweat output, comorbidities, symptoms, measures of cardiovascular autonomic function, and serum antibody levels. RESULTS 356 patients (90% female, mean age 31 ± 10) met the diagnostic criteria for postural orthostatic tachycardia syndrome. Of 211 patients who underwent quantitative sudomotor axon reflex testing, 70 (33%) demonstrated reduced sweat output. These patients were more likely to demonstrate sympathetic impairment during the Valsalva maneuver. Of 80 patients who underwent skin biopsies, 19 (24%) demonstrated reduced intraepidermal nerve fiber density. These patients tended to be older and have reduced heart rate variability during deep breathing. Neither test was associated with specific serum antibodies, symptoms, or comorbidities, though there was a trend toward higher rates of comorbid autoimmune disease in patients with abnormal testing. CONCLUSION A subset of patients with postural orthostatic tachycardia syndrome have evidence of small fiber neuropathy. These patients tend to have impaired cardiovascular autonomic function but are otherwise similar to patients with no evidence of small fiber neuropathy.
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17
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Wafa SEI, Chahal CAA, Sawatari H, Khanji MY, Khan H, Asatryan B, Ahmed R, Deshpande S, Providencia R, Deshmukh A, Owens AT, Somers VK, Padmanabhan D, Connolly H. Frequency of Arrhythmias and Postural Orthostatic Tachycardia Syndrome in Patients With Marfan Syndrome: A Nationwide Inpatient Study. J Am Heart Assoc 2022; 11:e024939. [PMID: 36000435 PMCID: PMC9496423 DOI: 10.1161/jaha.121.024939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Marfan syndrome (MFS) is an autosomal dominant connective tissue disorder affecting multiple systems, particularly the cardiovascular system. The leading causes of death in MFS are aortopathies and valvular disease. We wanted to identify the frequency of arrhythmia and postural orthostatic tachycardia syndrome, length of hospital stay, health care-associated costs (HAC), and in-hospital mortality in patients with MFS. Methods and Results The National Inpatient Sample database from 2005 to 2014 was queried using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for MFS and arrhythmias. Patients were classified into subgroups: supraventricular tachycardia, ventricular tachycardia (VT), atrial fibrillation, atrial flutter, and without any type of arrhythmia. Data about length of stay, HAC, and in-hospital mortality were also abstracted from National Inpatient Sample database. Adjusted HAC was calculated as multiplying HAC and cost-to-charge ratio; 12 079 MFS hospitalizations were identified; 1893 patients (15.7%) had an arrhythmia; and 4.9% of the patients had postural orthostatic tachycardia syndrome. Median values of length of stay and adjusted HAC in VT group were the highest among the groups (VT: 6 days, $18 975.8; supraventricular tachycardia: 4 days, $11 906.6; atrial flutter: 4 days, $11 274.5; atrial fibrillation: 5 days, $10431.4; without any type of arrhythmia: 4 days, $8336.6; both P=0.0001). VT group had highest in-patient mortality (VT: 5.3%, atrial fibrillation: 4.1%, without any type of arrhythmia: 2.1%, atrial flutter: 1.7%, supraventricular tachycardia: 0%; P<0.0001) even after adjustment for potential confounders (without any type of arrhythmia versus VT; odds ratio [95% CI]: 3.18 [1.62-6.24], P=0.001). Conclusions Arrhythmias and postural orthostatic tachycardia syndrome in MFS were high and associated with increased length of stay, HAC, and in-hospital mortality especially in patients with VT.
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Affiliation(s)
- Syed Emir Irfan Wafa
- Department of Cardiology Northampton General Hospital Northampton United Kingdom
| | - C Anwar A Chahal
- Division of Cardiology, Department of Medicine University of Pennsylvania Philadelphia PA.,Department of Cardiovascular Diseases Mayo Clinic Rochester MN.,Department of Cardiology, Barts Heart Centre Barts Health NHS Trust London United Kingdom
| | - Hiroyuki Sawatari
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN.,Department of Perioperative and Critical Care Management Hiroshima University Hiroshima Japan
| | - Mohammed Y Khanji
- NIHR Barts Cardiovascular Biomedical Research Centre, Barts and The London School of Medicine and Dentistry Queen Mary University of London London United Kingdom.,Department of Cardiology St. Bartholomew's Hospital London United Kingdom.,Department of Cardiology Newham University Hospital, Barts Health NHS Trust London United Kingdom
| | - Hassan Khan
- Leon H. Charney Division of Cardiology New York University Langone Health New York NY
| | - Babken Asatryan
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Raheel Ahmed
- Department of Cardiology Royal Brompton Hospital London United Kingdom
| | - Saurabh Deshpande
- Sri Jayadeva Institute of Cardiovascular Sciences and Research Bangalore Karnataka
| | - Rui Providencia
- Department of Cardiology, Barts Heart Centre Barts Health NHS Trust London United Kingdom
| | | | - Anjali Tiku Owens
- Division of Cardiology, Department of Medicine University of Pennsylvania Philadelphia PA
| | - Virend K Somers
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | - Deepak Padmanabhan
- Division of Cardiology, Department of Medicine University of Pennsylvania Philadelphia PA.,Department of Cardiovascular Diseases Mayo Clinic Rochester MN.,Sri Jayadeva Institute of Cardiovascular Sciences and Research Bangalore Karnataka
| | - Heidi Connolly
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
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18
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Hall J, Bourne KM, Vernino S, Hamrefors V, Kharraziha I, Nilsson J, Sheldon RS, Fedorowski A, Raj SR. Detection of G Protein-Coupled Receptor Autoantibodies in Postural Orthostatic Tachycardia Syndrome Using Standard Methodology. Circulation 2022; 146:613-622. [PMID: 35766055 PMCID: PMC9390234 DOI: 10.1161/circulationaha.122.059971] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Postural orthostatic tachycardia syndrome (POTS) is a disorder of orthostatic intolerance that primarily affects women of childbearing age. The underlying pathophysiology of POTS is not fully understood, but it has been suggested that autoimmunity may play a role. The aim of this study was to compare concentrations of autoantibodies to cardiovascular G protein-coupled receptors between patients with POTS and healthy controls. METHODS Sera were collected from 116 patients with POTS (91% female; medium age, 29 years) and 81 healthy controls (84% female; medium age, 27 years) from Calgary, Canada, and Malmö, Sweden. Samples were evaluated for autoantibodies to 11 receptors (adrenergic, muscarinic, angiotensin II, and endothelin) using a commercially available enzyme-linked immunosorbent assay. RESULTS Autoantibody concentrations against all of the receptors tested were not significantly different between controls and patients with POTS. The majority of patients with POTS (98.3%) and all controls (100%) had α1 adrenergic receptor autoantibody concentrations above the seropositive threshold provided by the manufacturer (7 units/mL). The proportion of patients with POTS versus healthy controls who fell above the diagnostic thresholds was not different for any tested autoantibodies. Receiver operating characteristic curves showed a poor ability to discriminate between patients with POTS and controls. CONCLUSIONS Patients with POTS and healthy controls do not differ in their enzyme-linked immunosorbent assay-derived autoantibody concentrations to cardiovascular G protein-coupled receptors. These findings suggest that these tests are not useful for establishing the role of autoimmunity in POTS.
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Affiliation(s)
- Juliette Hall
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Canada (J. H., K.M.B., R.S.S., S.R.R.)
| | - Kate M. Bourne
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Canada (J. H., K.M.B., R.S.S., S.R.R.)
| | - Steven Vernino
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX (S.V.)
| | - Viktor Hamrefors
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden (V.H.)
| | - Isabella Kharraziha
- Department of Clinical Sciences, Lund University, Malmö, Sweden (V.H., I.K., J.N., A.F.)
| | - Jan Nilsson
- Department of Clinical Sciences, Lund University, Malmö, Sweden (V.H., I.K., J.N., A.F.)
| | - Robert S. Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Canada (J. H., K.M.B., R.S.S., S.R.R.)
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden (V.H., I.K., J.N., A.F.).,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (A.F.)
| | - Satish R. Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Canada (J. H., K.M.B., R.S.S., S.R.R.).,Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (S.R.R.)
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19
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Sebastian SA, Co EL, Panthangi V, Jain E, Ishak A, Shah Y, Vasavada A, Padda I. Postural Orthostatic Tachycardia Syndrome (POTS): An Update for Clinical Practice. Curr Probl Cardiol 2022; 47:101384. [DOI: 10.1016/j.cpcardiol.2022.101384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 08/26/2022] [Indexed: 11/03/2022]
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20
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Amekran Y, Damoun N, El Hangouche AJ. Postural orthostatic tachycardia syndrome and post-acute COVID-19. Glob Cardiol Sci Pract 2022; 2022:e202213. [PMID: 36339677 PMCID: PMC9629292 DOI: 10.21542/gcsp.2022.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 06/11/2022] [Indexed: 11/05/2022] Open
Abstract
While the acute illness of COVID-19 was the initial focus of concern, there are increasing reports of patients with chronic symptoms, known as long-COVID. Dysautonomia may be a possible post-acute neurological complication explaining the persistent symptoms observed in long COVID. Postural tachycardia syndrome (POTS), a form of dysautonomia characterized by sustained tachycardia and orthostatic intolerance, has been increasingly reported in patients after SARS-CoV-2 infection. In this context, this review aimed to report and discuss the available literature pertaining to post COVID-19 POTS.
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Affiliation(s)
- Youssra Amekran
- Department of Physiology, Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, Tangier, Morocco
| | - Narjisse Damoun
- Department of Physiology, Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, Tangier, Morocco
| | - Abdelkader Jalil El Hangouche
- Department of Physiology, Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, Tangier, Morocco
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21
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Biomarkers and Hemodynamic Parameters in the Diagnosis and Treatment of Children with Postural Tachycardia Syndrome and Vasovagal Syncope. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19126974. [PMID: 35742222 PMCID: PMC9222341 DOI: 10.3390/ijerph19126974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [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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22
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Kitsou V, Blomberg B, Lunde T, Saeed S. Intermittent left bundle branch block with septal flash and postural orthostatic tachycardia syndrome in a young woman with long COVID-19. BMJ Case Rep 2022; 15:15/6/e249608. [PMID: 35672052 PMCID: PMC9174810 DOI: 10.1136/bcr-2022-249608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The emerging entity, long COVID -19 is characterised by long-lasting dyspnoea, fatigue, cognitive dysfunction and other symptoms. Cardiac involvement manifested as conduction abnormalities, left ventricle mechanical dyssynchrony, dyspnoea, palpitation and postural orthostatic tachycardia syndrome (POTS) are common in long COVID-19. The direct viral damage to the myocardium or immune-mediated inflammation are postulated mechanisms. A woman in her forties presented with a 2-month history of chest pain, functional dyspnoea, palpitation and an episode of syncope after having been home-isolated for mild COVID infection. During clinical workup, a clustering of ECG and echocardiographic abnormalities including left bundle branch block, septal flash, and presystolic wave on spectral Doppler echocardiography, and POTS were detected. The echocardiographic findings together with POTS and persistent dyspnoea indicated the presence of a long COVID-19 state. The prevalence and clinical significance of these finding, as well as the impact on long-term prognosis, should be investigated in future studies.
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Affiliation(s)
- Vasiliki Kitsou
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - Bjørn Blomberg
- Department of Clinical Science, University of Bergen, Bergen, Norway
- National Advisory Unit for Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Torbjørn Lunde
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Sahrai Saeed
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
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23
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Chan A, Gao J, Houston M, Willett T, Farhadian B, Silverman M, Tran P, Jaradeh S, Thienemann M, Frankovich J. Children With PANS May Manifest POTS. Front Neurol 2022; 13:819636. [PMID: 35557616 PMCID: PMC9086964 DOI: 10.3389/fneur.2022.819636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/09/2022] [Indexed: 11/22/2022] Open
Abstract
Objectives Pediatric acute-onset neuropsychiatric syndrome (PANS) is characterized by an abrupt-onset of severe psychiatric symptoms including OCD, anxiety, cognitive difficulties, and sleep issues which is thought to be a post-infection brain inflammatory disorder. We observed postural orthostatic tachycardia syndrome (POTS) which resolved with immunomodulation in a patient with Pediatric acute-onset neuropsychiatric syndrome (PANS). Here, we aim to present a case of POTS and to examine the prevalence of (POTS) in our PANS cohort, and compare the clinical characteristics of patients with and without POTS. Study Design We conducted this cohort study of patients meeting PANS criteria who had at least three clinic visits during the study period. We included data from prospectively collected questionnaires and medical record review. We present a case followed by statistical comparisons within our cohort and a Kaplan-Meier analysis to determine the time-dependent risk of a POTS diagnosis. Results Our study included 204 patients: mean age of PANS onset was 8.6 years, male sex (60%), non-Hispanic White (78%). Evidence of POTS was observed in 19/204 patients (9%) with 5/19 having persistent POTS defined as persistent abnormal orthostatic vitals, persistent POTS symptoms, and/or continued need for pharmacotherapy for POTS symptoms for at least 6 months). In this PANS cohort, patients with POTS were more likely to have comorbid joint hypermobility (63 vs 37%, p = 0.04), chronic fatigue (42 vs 18%, p = 0.03), and a family history of chronic fatigue, POTS, palpitations and syncope. An unadjusted logistic regression model showed that a PANS flare (abrupt neuropsychiatric deterioration) was significantly associated with an exacerbation of POTS symptoms (OR 3.3, 95% CI 1.4–7.6, p < 0.01). Conclusions Our study describes a high prevalence of POTS in patients with PANS (compared to the general population) and supports an association between POTS presentation and PANS flare within our cohort.
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Affiliation(s)
- Avis Chan
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States.,Stanford PANS/Immune Behavioral Health Clinic and PANS Research Program at Lucile Packard Children's Hospital, Palo Alto, CA, United States
| | - Jaynelle Gao
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States.,Stanford PANS/Immune Behavioral Health Clinic and PANS Research Program at Lucile Packard Children's Hospital, Palo Alto, CA, United States
| | - Madison Houston
- Stanford PANS/Immune Behavioral Health Clinic and PANS Research Program at Lucile Packard Children's Hospital, Palo Alto, CA, United States.,Department of Human Biology, Stanford University School of Humanities and Sciences, Stanford, CA, United States
| | - Theresa Willett
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States.,Stanford PANS/Immune Behavioral Health Clinic and PANS Research Program at Lucile Packard Children's Hospital, Palo Alto, CA, United States
| | - Bahare Farhadian
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States.,Stanford PANS/Immune Behavioral Health Clinic and PANS Research Program at Lucile Packard Children's Hospital, Palo Alto, CA, United States
| | - Melissa Silverman
- Stanford PANS/Immune Behavioral Health Clinic and PANS Research Program at Lucile Packard Children's Hospital, Palo Alto, CA, United States.,Division of Child and Adolescent Psychiatry and Child Development, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Paula Tran
- Stanford PANS/Immune Behavioral Health Clinic and PANS Research Program at Lucile Packard Children's Hospital, Palo Alto, CA, United States.,Division of Child and Adolescent Psychiatry and Child Development, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Safwan Jaradeh
- Autonomic Disorders Program, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Margo Thienemann
- Stanford PANS/Immune Behavioral Health Clinic and PANS Research Program at Lucile Packard Children's Hospital, Palo Alto, CA, United States.,Division of Child and Adolescent Psychiatry and Child Development, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Jennifer Frankovich
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States.,Stanford PANS/Immune Behavioral Health Clinic and PANS Research Program at Lucile Packard Children's Hospital, Palo Alto, CA, United States
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24
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Opie M, Nuttall M. Pipedreams, the pandemic and PoTS: is the post-COVID-19 era a turning point for PoTS services? THE BRITISH JOURNAL OF CARDIOLOGY 2022; 29:7. [PMID: 35747312 PMCID: PMC9196074 DOI: 10.5837/bjc.2022.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
| | - Michaela Nuttall
- Independent Nurse, Founder of Learn With Nurses, and Trustee, PoTS UK Smart Health Solutions, 2-6 Boundary Road, London, SE1 8HP
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25
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Ganesh R, Grach SL, Ghosh AK, Bierle DM, Salonen BR, Collins NM, Joshi AY, Boeder ND, Anstine CV, Mueller MR, Wight EC, Croghan IT, Badley AD, Carter RE, Hurt RT. The Female-Predominant Persistent Immune Dysregulation of the Post-COVID Syndrome. Mayo Clin Proc 2022; 97:454-464. [PMID: 35135695 PMCID: PMC8817110 DOI: 10.1016/j.mayocp.2021.11.033] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 09/23/2021] [Accepted: 11/19/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To describe the clinical data from the first 108 patients seen in the Mayo Clinic post-COVID-19 care clinic (PCOCC). METHODS After Institutional Review Board approval, we reviewed the charts of the first 108 patients seen between January 19, 2021, and April 29, 2021, in the PCOCC and abstracted from the electronic medical record into a standardized database to facilitate analysis. Patients were grouped into phenotypes by expert review. RESULTS Most of the patients seen in our clinic were female (75%; 81/108), and the median age at presentation was 46 years (interquartile range, 37 to 55 years). All had post-acute sequelae of SARS-CoV-2 infection, with 6 clinical phenotypes being identified: fatigue predominant (n=69), dyspnea predominant (n=23), myalgia predominant (n=6), orthostasis predominant (n=6), chest pain predominant (n=3), and headache predominant (n=1). The fatigue-predominant phenotype was more common in women, and the dyspnea-predominant phenotype was more common in men. Interleukin 6 (IL-6) was elevated in 61% of patients (69% of women; P=.0046), which was more common than elevation in C-reactive protein and erythrocyte sedimentation rate, identified in 17% and 20% of cases, respectively. CONCLUSION In our PCOCC, we observed several distinct clinical phenotypes. Fatigue predominance was the most common presentation and was associated with elevated IL-6 levels and female sex. Dyspnea predominance was more common in men and was not associated with elevated IL-6 levels. IL-6 levels were more likely than erythrocyte sedimentation rate and C-reactive protein to be elevated in patients with post-acute sequelae of SARS-CoV-2 infection.
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Affiliation(s)
| | | | - Aditya K Ghosh
- Department of Internal Medicine, Northeast Georgia Medical Center, Gainesville, GA
| | | | | | | | | | | | | | | | | | | | | | - Rickey E Carter
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL
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26
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Platelet Storage Pool Deficiency and Elevated Inflammatory Biomarkers Are Prevalent in Postural Orthostatic Tachycardia Syndrome. Cells 2022; 11:cells11050774. [PMID: 35269395 PMCID: PMC8909348 DOI: 10.3390/cells11050774] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 02/01/2023] Open
Abstract
A significant number of postural orthostatic tachycardia syndrome (POTS) patients have platelet delta granule storage pool deficiency (δ-SPD). The etiology of POTS is unknown but a number of laboratories, including ours, have reported elevations of G-protein-coupled adrenergic receptor and muscarinic acetylcholine receptor autoantibodies in POTS patients, detected by a variety of techniques, suggesting that the disorder is an autoimmune condition. Thus, it could also be considered an inflammatory disease. In a pilot study, we investigated a limited number of platelet-related cytokines and chemokines and discovered many that were elevated. This case−control study validates our pilot study results that POTS patients have an activated innate immune system. Plasma of 35 POTS patients and 35 patients with unexplained bleeding symptoms and categorized as “non-POTS” subjects was analyzed by multiplex flow cytometry to quantify 16 different innate immune system cytokines and chemokines. Electron microscopy was used to quantify platelet dense granules. Ten of 16 biomarkers of inflammation were elevated in plasma from POTS patients compared to non-POTS subjects, with most of the differences extremely significant, with p values < 0.0001. Of particular interest were elevations of IL-1β and IL-18 and decreased or normal levels of type 1 interferons in POTS patients, suggesting that the etiology of POTS might be autoinflammatory. All POTS patients had δ-SPD. With a growing body of evidence that POTS is an autoimmune disease and having elevations of the innate immune system, our results suggest a potential T-cell-mediated autoimmunity in POTS characteristic of a mixed-pattern inflammatory disease similar to rheumatoid arthritis.
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27
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Bellocchi C, Carandina A, Montinaro B, Targetti E, Furlan L, Rodrigues GD, Tobaldini E, Montano N. The Interplay between Autonomic Nervous System and Inflammation across Systemic Autoimmune Diseases. Int J Mol Sci 2022; 23:ijms23052449. [PMID: 35269591 PMCID: PMC8910153 DOI: 10.3390/ijms23052449] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 12/13/2022] Open
Abstract
The autonomic nervous system (ANS) and the immune system are deeply interrelated. The ANS regulates both innate and adaptive immunity through the sympathetic and parasympathetic branches, and an imbalance in this system can determine an altered inflammatory response as typically observed in chronic conditions such as systemic autoimmune diseases. Rheumatoid arthritis, systemic lupus erythematosus, and systemic sclerosis all show a dysfunction of the ANS that is mutually related to the increase in inflammation and cardiovascular risk. Moreover, an interaction between ANS and the gut microbiota has direct effects on inflammation homeostasis. Recently vagal stimulation techniques have emerged as an unprecedented possibility to reduce ANS dysfunction, especially in chronic diseases characterized by pain and a decreased quality of life as well as in chronic inflammation.
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Affiliation(s)
- Chiara Bellocchi
- Department of Internal Medicine, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy; (A.C.); (B.M.); (E.T.); (L.F.); (E.T.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy;
- Correspondence: (C.B.); (N.M.)
| | - Angelica Carandina
- Department of Internal Medicine, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy; (A.C.); (B.M.); (E.T.); (L.F.); (E.T.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy;
| | - Beatrice Montinaro
- Department of Internal Medicine, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy; (A.C.); (B.M.); (E.T.); (L.F.); (E.T.)
| | - Elena Targetti
- Department of Internal Medicine, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy; (A.C.); (B.M.); (E.T.); (L.F.); (E.T.)
| | - Ludovico Furlan
- Department of Internal Medicine, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy; (A.C.); (B.M.); (E.T.); (L.F.); (E.T.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy;
| | - Gabriel Dias Rodrigues
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy;
- Laboratory of Experimental and Applied Exercise Physiology, Department of Physiology and Pharmacology, Fluminense Federal University, Niterói 24210-130, Brazil
| | - Eleonora Tobaldini
- Department of Internal Medicine, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy; (A.C.); (B.M.); (E.T.); (L.F.); (E.T.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy;
| | - Nicola Montano
- Department of Internal Medicine, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy; (A.C.); (B.M.); (E.T.); (L.F.); (E.T.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy;
- Correspondence: (C.B.); (N.M.)
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Jost K, Rodriguez B, Söll N, Hoepner R, Z'Graggen WJ. Tolerability of COVID-19 mRNA vaccines in patients with postural tachycardia syndrome: a cross-sectional study. F1000Res 2022; 11:215. [PMID: 37822957 PMCID: PMC10562791 DOI: 10.12688/f1000research.109373.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 10/13/2023] Open
Abstract
Background: Postural tachycardia syndrome (POTS) is a form of autonomic dysregulation. There is increasing evidence that the etiology may be immune-mediated in a subgroup of patients. Patients with POTS often experience an exacerbation of their symptoms associated with (viral) infections and often fear the same symptom aggravation after vaccination. In this report we describe the tolerability of messenger ribonucleic acid (mRNA) vaccines against coronavirus disease 19 (COVID-19) and the consequences of a COVID-19 infection on POTS symptoms in our cohort of patients with neuropathic POTS. Methods: We conducted a standardized, checklist-based interview with 23 patients and recorded the acute side effects of mRNA vaccination, acute symptoms of COVID-19 infection as well as the effects of vaccination and COVID-19 infection on POTS symptoms. Results: Of all included patients, 20 patients received two mRNA vaccines without having had a previous COVID-19 infection, and five patients in total had suffered a COVID-19 infection. Of these, three had COVID-19 without and two after being vaccinated. No increased frequency of side effects after both doses of mRNA vaccines was observed. Six patients reported a mild and short-term aggravation of their POTS symptoms beyond the duration of acute vaccine side effects. All five patients who suffered a COVID-19 infection subsequently reported a pronounced and persistent exacerbation of POTS symptoms. Conclusions: Our observations suggest that mRNA vaccines are not associated with a higher frequency of acute side effects in patients with POTS. Symptom exacerbation as a consequence of mRNA vaccination seems to be less frequent and of shorter duration compared to patients who suffered a COVID-19 infection.
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Affiliation(s)
- Karin Jost
- Department of Neurology, Inselspital, University Hospital Bern, Bern, Bern, 3010, Switzerland
| | - Belén Rodriguez
- Department of Neurosurgery, Inselspital, University Hospital Bern, Bern, Bern, 3010, Switzerland
| | - Nicole Söll
- Department of Neurosurgery, Inselspital, University Hospital Bern, Bern, Bern, 3010, Switzerland
| | - Robert Hoepner
- Department of Neurology, Inselspital, University Hospital Bern, Bern, Bern, 3010, Switzerland
| | - Werner J. Z'Graggen
- Department of Neurology, Inselspital, University Hospital Bern, Bern, Bern, 3010, Switzerland
- Department of Neurosurgery, Inselspital, University Hospital Bern, Bern, Bern, 3010, Switzerland
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29
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Lee J. Postural orthostatic tachycardia syndrome in children and adolescents. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2022. [DOI: 10.5124/jkma.2022.65.2.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Postural orthostatic tachycardia syndrome (POTS) is a heterogeneous disorder in children and adolescents. Recently, there have been some data concerning the prevalence of POTS in adults. However, current studies on POTS in children and adolescents are rare. Thus, many young patients with POTS are misdiagnosed with migraine or other diseases.Current Concepts: The diagnosis and treatment of POTS differ between pediatric and adult patients. POTS in children and adolescents is diagnosed with chronic symptoms of orthostatic intolerance, such as a heart rate rise of 40 beat per minute (bpm) or a heart rate exceeding 130 bpm without orthostatic hypotension. There are three major POTS categories: hypovolemic POTS, neuropathic POTS, and hyperadrenergic POTS. These categories are distinguished by their major mechanisms. The different subtypes of POTS in children and adolescents have their own clinical characteristics and laboratory findings.Discussion and Conclusion: Treatment of POTS in children and adolescents should always include lifestyle changes, nutritional adjustments, exercise, and drugs depending on the different subtypes of POTS.
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30
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Gall NP, James S, Kavi L. Observational case series of postural tachycardia syndrome (PoTS) in post-COVID-19 patients. THE BRITISH JOURNAL OF CARDIOLOGY 2022; 29:3. [PMID: 35747313 PMCID: PMC9196071 DOI: 10.5837/bjc.2022.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
There is emerging evidence that a proportion of patients who develop long (post)-COVID-19 have abnormalities in the regulation of their autonomic nervous system manifesting as postural tachycardia syndrome (PoTS). We report a series of 14 patients who developed symptoms and signs compatible with PoTS following clinically diagnosed COVID-19 infection. Their symptoms and clinical findings were consistent with those of patients with non-COVID-related PoTS. The authors recommend an active stand test for patients who present after COVID-19 infection with cardiovascular symptoms including chest pain, palpitations, lightheadedness and breathlessness that are worse with the upright posture. They further recommend training of clinicians and investment in health services to provide for the anticipated significant increase in patients presenting with PoTS and other forms of autonomic dysfunction due to the COVID-19 pandemic.
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Affiliation(s)
| | - Stephen James
- Consultant in Intensive Care and Exercise Capacity, King’s College Hospital Department of Cardiology, London Bridge Hospital, London, SE1 2PR
| | - Lesley Kavi
- General Practitioner, Solihull, Visiting Professor, Birmingham City University, and Trustee and Chair of PoTS UK Seacole Building, Westbourne Road, Edgbaston, Birmingham, B15 3TN
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31
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Afrin LB, Dempsey TT, Weinstock LB. Post-HPV-Vaccination Mast Cell Activation Syndrome: Possible Vaccine-Triggered Escalation of Undiagnosed Pre-Existing Mast Cell Disease? Vaccines (Basel) 2022; 10:127. [PMID: 35062788 PMCID: PMC8779641 DOI: 10.3390/vaccines10010127] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 01/27/2023] Open
Abstract
For nearly a decade, case reports and series have emerged regarding dysautonomias-particularly postural orthostatic tachycardia syndrome (POTS)-presenting soon after vaccination against human papilloma virus (HPV). We too have observed a number of such cases (all following vaccination with the Gardasil product), and have found several to have detectable mast cell activation syndrome (MCAS) as well as histories suggesting that MCAS was likely present long before vaccination. We detail 11 such cases here, posing a hypothesis that HPV vaccination (at least with the Gardasil product) may have triggered or exacerbated MCAS in teenagers previously not recognized to have it. Only recently recognized, MCAS is being increasingly appreciated as a prevalent and chronic multisystem disorder, often emerging early in life and presenting with inflammatory ± allergic phenomena following from known mast cell (MC) mediator effects. There is rising recognition, too, of associations of MCAS with central and peripheral neuropathic disorders, including autonomic disorders such as POTS. Given the recognized potential for many antigens to trigger a major and permanent escalation of baseline MC misbehavior in a given MCAS patient, we hypothesize that in our patients described herein, vaccination with Gardasil may have caused pre-existing (but not yet clinically recognized) MCAS to worsen to a clinically significantly degree, with the emergence of POTS and other issues. The recognition and management of MCAS prior to vaccinations in general may be a strategy worth investigating for reducing adverse events following HPV vaccinations and perhaps even other types of vaccinations.
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Affiliation(s)
- Lawrence B. Afrin
- AIM Center for Personalized Medicine, Purchase, New York, NY 10577, USA;
| | - Tania T. Dempsey
- AIM Center for Personalized Medicine, Purchase, New York, NY 10577, USA;
| | - Leonard B. Weinstock
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA;
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32
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Association of autoantibodies to muscarinic acetylcholine receptors with gastrointestinal symptoms and disease severity in patients with postural orthostatic tachycardia syndrome. Immunol Res 2022; 70:197-207. [PMID: 34993884 DOI: 10.1007/s12026-021-09256-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 12/01/2021] [Indexed: 11/05/2022]
Abstract
Previous studies have reported a relationship between postural orthostatic tachycardia syndrome (POTS) and positivity for serum autoantibodies against G-protein-coupled receptors (GPCRs). However, the role of these autoantibodies in POTS is unclear. The present retrospective study analyzed the autoimmune etiology of POTS in 24 patients using a head-up tilt test to assess for any correlation between the clinical features of POTS and serum levels of autoantibodies against diverse GPCRs. In total, ten assessment items, including autonomic function tests, were analyzed. Of these, persistent, gastrointestinal symptoms and disease severity showed a significant association with the serum level of anti-muscarinic acetylcholine receptor (mAChRs) antibodies (gastrointestinal symptoms, M1, M2, M5; disease severity, M1, M3, M4, M5) [P <0.05]), while no significant association was found between the clinical features and autoantibodies against adrenergic receptors (α1, α2, β1, β2), angiotensin receptor 1, or endothelin receptor A. The patients were further divided into two groups based on the presence or absence of persistent gastrointestinal symptoms and then were characterized by the ten assessment items and neuropsychological tests, including the Wechsler Adult Intelligence Scale score and Self-Rating Depression Scale score. The results demonstrated a clear difference between the two groups in terms of disease severity, age at onset (older or younger than 20 years), and processing speed index (P <0.05), which were highly consistent with the association between these clinical features and the levels of serum anti-mAChR antibodies, particularly the anti-M5 receptor antibody. These findings suggested that anti-mAChR antibodies may play an important role in a subgroup of POTS patients with persistent gastrointestinal symptoms.
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33
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Stavileci B, Özdemir E, Özdemir B, Ereren E, Cengiz M. De-novo development of fragmented QRS during a six-month follow-up period in patients with COVID-19 disease and its cardiac effects. J Electrocardiol 2022; 72:44-48. [PMID: 35306293 PMCID: PMC8917010 DOI: 10.1016/j.jelectrocard.2022.02.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/21/2022] [Accepted: 02/28/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of this study is to examine the probability of de-novo fQRS in patients with mild COVID-19 disease, as an indicator of cardiac injury. METHODS Data of 256 patients with normal admission electrocardiography and no comorbidities between 1.12.2020-31.12.2021, were examined retrospectively 6-month after mild COVID-19 disease. Patients were divided into two groups: fQRS+ group (n = 102) and non-fQRS group (n = 154). Relation between fQRS and other electrocardiography, echocardiographic and laboratory findings were investigated. RESULTS No significant difference was found between the groups among age and gender. Troponin-I and creatine kinase myocardial band values (retrospectively 9.10 ± 1.76 vs 0.74 ± 1.43, 34.05 ± 82.20 vs. 14.68 ± 4.42), COVID-19 IgG levels (45.78 ± 14.82 vs. 36.49 ± 17.68), diastolic dysfunction (39.21% vs. 15.07%), EF value (58.02 ± 1.95 vs. 64.27 ± 3.07), dyspnea (41.17% vs. 6.84%), post-COVID-19 tachycardia syndrome (19.6% vs. 2.74) were more frequent in fQRS+ group compared to non-fQRS group. The EF value was lower in the presence of fQRS in the high lateral leads (57.12 ± 1.99, 58.47 ± 1.79, p:0.018). There was a positive correlation between IgG value and endsystolic diameter, septum thickness and left atrium diameter. In multivariate analysis de-novo fQRS, dyspnea, high troponin and IgG values, diastolic dysfunction, low EF value and left atrial diameter were determined as independent risk factors for post-COVID-19 tachycardia syndrome in follow-up. CONCLUSION In COVID-19 disease de-novo fQRS, dyspnea, high IgG and troponin value, left atrial diameter, lower EF value, diastolic dysfunction were associated with post-COVID-19 tachycardia syndrome. The de-novo fQRS in SARS-COV-2 may be a predictor of future more important adverse cardiovascular outcomes and this should alert clinicians.
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Affiliation(s)
- Berna Stavileci
- Biruni University, Faculty of Medicine, Department of Cardiology, Beşyol Mah. Eski Londra Asfaltı No:10 Küçükçekmece, 34295 İstanbul, Turkey,Corresponding author
| | - Emrah Özdemir
- Biruni University, Faculty of Medicine, Department of Cardiology, Beşyol Mah. Eski Londra Asfaltı No:10 Küçükçekmece, 34295 İstanbul, Turkey
| | - Bahar Özdemir
- İstanbul Bakırköy Dr. Sadi Konuk Training and Research Hospital, Department of Internal Medicine, Zuhuratbaba Mh. Tevfik Sağlam Cd. No:11, 34147, Bakırköy, İstanbul, Turkey
| | - Emrah Ereren
- Samsun Training and Research Hospital, Department of Cardiovascular Surgery, Barış Bulvarı Kadıköy Mah. No:199, İlkadım, 55090 Samsun, Turkey
| | - Mahir Cengiz
- Biruni University, Faculty of Medicine, Department of Internal Medicine, Beşyol Mah. Eski Londra Asfaltı No:10 Küçükçekmece, 34295 İstanbul, Turkey
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El-Abassi RN, Soliman M, Levy MH, England JD. Treatment and Management of Autoimmune Neuropathies. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Postural tachycardia syndrome (POTS) and antiphospholipid syndrome (APS): What do we know so far? Rev Neurol (Paris) 2021; 178:306-314. [PMID: 34895744 DOI: 10.1016/j.neurol.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/05/2021] [Accepted: 10/05/2021] [Indexed: 11/21/2022]
Abstract
As part of the non-criteria clinical manifestations, postural orthostatic tachycardia syndrome (POTS), a multisystem autonomic dysfunction, can co-exist with antiphospholipid syndrome (APS). Several pieces of evidence hint on the autoimmune basis of POTS, and its possible association with several autoimmune diseases, including APS. Indeed, the evidence exists in the etiologies, symptomatology, and treatment options. Although infections, viral ones in particular, stress, and pregnancy are etiologies to both POTS and APS, the exact pathophysiological connection is still to be studied taking into consideration the activity of cytokines in both diseases. Nevertheless, certain immunomodulatory treatments used for the catastrophic or obstetrical forms of APS, such as intravenous immunoglobulins (IVIG) and steroids, have been also used for the treatment of POTS resistant to classical treatments. Therefore, our review aims to highlight the association between POTS and APS, shedding light on the common etiologies explaining the pathophysiology of the two disorders, the diagnostic approach to POTS as a possible clinical criterion of APS, and the treatment of APS in the context of treating POTS.
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36
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Struhal W, Hain B. A new light on an old condition. Eur Heart J Case Rep 2021; 5:ytab499. [PMID: 34993411 PMCID: PMC8716748 DOI: 10.1093/ehjcr/ytab499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 09/21/2021] [Accepted: 11/30/2021] [Indexed: 11/14/2022]
Affiliation(s)
- Walter Struhal
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500 Krems, Austria
- Department of Neurology, University Hospital Tulln, Alter Ziegelweg 10, 3430 Tulln, Austria
| | - Barbara Hain
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500 Krems, Austria
- Department of Neurology, University Hospital Tulln, Alter Ziegelweg 10, 3430 Tulln, Austria
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Ståhlberg M, Reistam U, Fedorowski A, Villacorta H, Horiuchi Y, Bax J, Pitt B, Matskeplishvili S, Lüscher TF, Weichert I, Thani KB, Maisel A. Post-COVID-19 Tachycardia Syndrome: A Distinct Phenotype of Post-Acute COVID-19 Syndrome. Am J Med 2021; 134:1451-1456. [PMID: 34390682 PMCID: PMC8356730 DOI: 10.1016/j.amjmed.2021.07.004] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/05/2021] [Accepted: 07/05/2021] [Indexed: 02/08/2023]
Abstract
In this paper we highlight the presence of tachycardia in post-acute COVID-19 syndrome by introducing a new label for this phenomenon-post-COVID-19 tachycardia syndrome-and argue that this constitutes a phenotype or sub-syndrome in post-acute COVID-19 syndrome. We also discuss epidemiology, putative mechanisms, treatment options, and future research directions in this novel clinical syndrome.
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Affiliation(s)
- Marcus Ståhlberg
- Cardiology, Heart, Vascular and Neuro Theme, Karolinska University Hospital and Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Ulrika Reistam
- Cardiology, Heart, Vascular and Neuro Theme, Karolinska University Hospital and Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Artur Fedorowski
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden; Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Humberto Villacorta
- Division of Cardiology, Fluminense Federal University, Niterói, Rio de Janeiro State, Brazil
| | - Yu Horiuchi
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Jeroen Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Thomas F Lüscher
- Heart Division, Royal Brompton & Harefield Hospitals and National Heart and Lung Institute, Imperial College, London, UK; Center for Molecular Cardiology, University of Zurich, Switzerland
| | - Immo Weichert
- Acute Medicine Department, Ipswich Hospital, East Suffolk and North Essex NHS Foundation Trust, Ipswich, UK
| | - Khalid Bin Thani
- Department of Cardiology, Salmaniya Medical Complex, Manama, Bahrain
| | - Alan Maisel
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla
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Post-Acute Sequelae of COVID-19 and Cardiovascular Autonomic Dysfunction: What Do We Know? J Cardiovasc Dev Dis 2021; 8:jcdd8110156. [PMID: 34821709 PMCID: PMC8621226 DOI: 10.3390/jcdd8110156] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/10/2021] [Indexed: 02/07/2023] Open
Abstract
Post-acute sequelae of SARS-CoV-2 (PASC), or long COVID syndrome, is emerging as a major health issue in patients with previous SARS-CoV-2 infection. Symptoms commonly experienced by patients include fatigue, palpitations, chest pain, dyspnea, reduced exercise tolerance, and “brain fog”. Additionally, symptoms of orthostatic intolerance and syncope suggest the involvement of the autonomic nervous system. Signs of cardiovascular autonomic dysfunction appear to be common in PASC and are similar to those observed in postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia. In this review, we report on the epidemiology of PASC, discuss current evidence and possible mechanisms underpinning the dysregulation of the autonomic nervous system, and suggest nonpharmacological and pharmacological interventions to treat and relieve symptoms of PASC-associated dysautonomia.
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Mathias CJ, Owens A, Iodice V, Hakim A. Dysautonomia in the Ehlers-Danlos syndromes and hypermobility spectrum disorders-With a focus on the postural tachycardia syndrome. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2021; 187:510-519. [PMID: 34766441 DOI: 10.1002/ajmg.c.31951] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 10/22/2021] [Indexed: 12/14/2022]
Abstract
Dysautonomia (autonomic dysfunction) occurs in the Ehlers-Danlos syndromes (EDS) and hypermobility spectrum disorders (HSD). Symptoms include palpitations, dizziness, presyncope, and syncope, especially when standing upright. Symptoms of orthostatic intolerance are usually relieved by sitting or lying and may be exacerbated by stimuli in daily life that cause vasodilatation, such as food ingestion, exertion, and heat. Neurocardiovascular dysautonomia may result in postural tachycardia syndrome (PoTS), a major cause of orthostatic intolerance. It is defined by a rise in heart rate of >30 beats per minute (bpm) in adults and >40 bpm in teenagers while upright, without a fall in blood pressure (BP; orthostatic hypotension). In some, it can be compounded by the presence of low BP. For many, there is delay in clinicians recognizing the nature of the symptoms, and recognizing EDS or HSD, leading to delays in treatment. The onset of PoTS may be linked to an event such as infection, trauma, surgery, or stress. Gastrointestinal and urinary bladder involvement may occur, along with thermoregulatory dysfunction. In some, the mast cell activation syndrome may be contributary, especially if it causes vasodilatation. This paper reviews neurocardiovascular dysautonomia with an emphasis on PoTS, its characteristics, associations, pathophysiology, investigation, and treatment.
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Affiliation(s)
- Christopher J Mathias
- UCL Queen Square Institute of Neurology, University College London, London, UK.,The Lindo Wing, St Mary's Hospital, Imperial College NHS Healthcare Trust, London, UK.,Autonomic Unit, National Hospital Neurology and Neurosurgery, UCLH NHS Trust, London, UK
| | - Andrew Owens
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Valeria Iodice
- UCL Queen Square Institute of Neurology, University College London, London, UK.,Autonomic Unit, National Hospital Neurology and Neurosurgery, UCLH NHS Trust, London, UK
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40
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Bryarly M, Raj SR, Phillips L, Hynan LS, Okamoto LE, Arnold AC, Paranjape SY, Vernino M, Black BK, Vernino S. Ganglionic Acetylcholine Receptor Antibodies in Postural Tachycardia Syndrome. Neurol Clin Pract 2021; 11:e397-e401. [PMID: 34484936 DOI: 10.1212/cpj.0000000000001047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/10/2020] [Indexed: 01/21/2023]
Abstract
Objective Postural tachycardia syndrome (POTS), the most common form of dysautonomia, may be associated with autoimmunity in some cases. Autoantibodies against the ganglionic acetylcholine receptor (gAChR) have been reported in a minority of patients with POTS, but the prevalence and clinical relevance is unclear. Methods Clinical information and serum samples were systematically collected from participants with POTS and healthy control volunteers (n = 294). The level of positive gAChR antibodies was classified as very low (0.02-0.05 nmol/L), low (0.05-0.2 nmol/L), and high (>0.2 nmol/L). Results Fifteen of 217 patients with POTS (7%) had gAChR antibodies (8 very low and 7 low). Six of the 77 healthy controls (8%) were positive (3 very low and 3 low). There were no clinical differences between seropositive and seronegative patients with POTS. Conclusions Prevalence of gAChR antibody did not differ between POTS and healthy controls, and none had high antibody levels. Patients with POTS were not clinically different based on seropositivity. Low levels of gAChR antibodies are not clinically important in POTS.
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Affiliation(s)
- Meredith Bryarly
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Satish R Raj
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Lauren Phillips
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Linda S Hynan
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Luis E Okamoto
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Amy C Arnold
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Sachin Y Paranjape
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Megan Vernino
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Bonnie K Black
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Steven Vernino
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
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Maintenance therapy with subcutaneous immunoglobulin in a patient with immune-mediated neuropathic postural tachycardia syndrome. J Transl Autoimmun 2021; 4:100112. [PMID: 34471867 PMCID: PMC8387908 DOI: 10.1016/j.jtauto.2021.100112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/14/2021] [Accepted: 08/06/2021] [Indexed: 11/20/2022] Open
Abstract
Aims We describe the disease course of a 35-year-old female with an autoimmune mediated neuropathic postural tachycardia syndrome (PoTS), who responded to immunoglobulin therapy and stabilized on maintenance therapy with subcutaneous immunoglobulin (SCIg). Methods We provide longitudinal data of clinical scores, tilt-table results and antibody titers. Results Initial treatment with intravenous immunoglobulin caused infusion-related side-effects whereas SCIg was well tolerated and improved clinical symptoms and quality of life. Clinical improvement correlated with the reduction of serum antibody titers 22 months after first infusion. Conclusions These findings suggest that autoimmune-mediated neuropathic PoTS can be treated sufficiently with IVIg whereas SCIg minimizes side-effects.
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Herrera A, Behm J. Using the PEOP Model to Understand Barriers to Functioning in Postural Orthostatic Tachycardia Syndrome. Occup Ther Health Care 2021; 36:283-305. [PMID: 34431731 DOI: 10.1080/07380577.2021.1967548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Individuals with postural orthostatic tachycardia syndrome (POTS) experience many barriers that lead to decreased functioning and quality of life. At this time, there are limited resources regarding the functional impact of POTS on occupational performance. Therefore, this narrative review demonstrates how occupational therapy practitioners can conceptualize, categorize, and systematically organize their thinking around barriers individuals with POTS experience using the Person-Environment-Occupation-Performance (PEOP) model of practice.
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Affiliation(s)
| | - Joanna Behm
- Master of Occupational Therapy Program, Messiah University, Mechanicsburg, PA, USA
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Implications of Antimuscarinic Autoantibodies in Postural Tachycardia Syndrome. J Cardiovasc Transl Res 2021; 15:438-440. [PMID: 34409582 DOI: 10.1007/s12265-021-10167-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
Functional autoantibodies directed to the M2 muscarinic acetylcholine receptor (M2R) could affect the heart rate directly by altering cardiac M2R activity and/or indirectly by changing vagal-mediated cardiac M2R activity. We measured M2R autoantibody activity in sera from 10 subjects with postural tachycardia syndrome (POTS) and 5 healthy control subjects using a cell-based bioassay. Half of the POTS subjects demonstrated presence of elevated M2R autoantibody activity, while no significant M2R autoantibody activity was found in the healthy subjects. Serum-derived immunoglobulin G (IgG) from antibody-positive POTS patients induced a dose-dependent activation of M2R, which was blocked by the muscarinic antagonist atropine. Moreover, antibody-positive POTS IgG decreased the responsiveness to oxotremorine, an orthosteric muscarinic agonist, indicating an indirect inhibitory effect. These data suggest that M2R autoantibodies may contribute to the pathophysiology of POTS by increasing the normal vagal withdrawal during upright posture through its negative allosteric modulation of M2R activity. M2 muscarinic receptor-activating autoantibodies are present in a subgroup of patients with POTS and act as a negative allosteric modulator of the orthosteric ligand response.
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González-Hermosillo JA, Martínez-López JP, Carrillo-Lampón SA, Ruiz-Ojeda D, Herrera-Ramírez S, Amezcua-Guerra LM, Martínez-Alvarado MDR. Post-Acute COVID-19 Symptoms, a Potential Link with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: A 6-Month Survey in a Mexican Cohort. Brain Sci 2021; 11:760. [PMID: 34201087 PMCID: PMC8227652 DOI: 10.3390/brainsci11060760] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/31/2021] [Accepted: 06/04/2021] [Indexed: 01/17/2023] Open
Abstract
The aim of this study was to describe the clinical evolution during 6 months of follow-up of adults recovered from COVID-19. We tried to determine how many met the definition of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). A total of 130 patients (51.0 ± 14 years, 34.6% female) were enrolled. Symptoms were common, participants reported a median number of 9 (IQR 5-14) symptoms. Fatigue was the most common symptom (61/130; 46.9%). Patients with fatigue were older 53.9 ± 13.5 years compared with 48.5 ± 13.3 years in those without fatigue (p = 0.02) and had a longer length of hospital stay, 17 ± 14 days vs. 13 ± 10 days (p = 0.04). There was no difference in other comorbidities between patients with fatigue and those without it, and no association between COVID-19 severity and fatigue. After multivariate adjustment of all baseline clinical features, only age 40 to 50 years old was positively associated with fatigue, OR 2.5 (95% CI 1.05-6.05) p = 0.03. In our survey, only 17 (13%) patients met the Institute of Medicine's criteria for "systemic exertion intolerance disease," the new name of ME/CFS. In conclusion, in some patients, the features of post-acute COVID-19 syndrome overlap with the clinical features of ME/CFS.
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Affiliation(s)
- J Antonio González-Hermosillo
- Department of Cardiovascular Dysautonomia, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico; (J.A.G.-H.); (J.P.M.-L.); (S.A.C.-L.); (D.R.-O.); (S.H.-R.)
| | - Jhanea Patricia Martínez-López
- Department of Cardiovascular Dysautonomia, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico; (J.A.G.-H.); (J.P.M.-L.); (S.A.C.-L.); (D.R.-O.); (S.H.-R.)
| | - Sofía Antonieta Carrillo-Lampón
- Department of Cardiovascular Dysautonomia, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico; (J.A.G.-H.); (J.P.M.-L.); (S.A.C.-L.); (D.R.-O.); (S.H.-R.)
| | - Dayanara Ruiz-Ojeda
- Department of Cardiovascular Dysautonomia, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico; (J.A.G.-H.); (J.P.M.-L.); (S.A.C.-L.); (D.R.-O.); (S.H.-R.)
| | - Sharon Herrera-Ramírez
- Department of Cardiovascular Dysautonomia, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico; (J.A.G.-H.); (J.P.M.-L.); (S.A.C.-L.); (D.R.-O.); (S.H.-R.)
| | - Luis M. Amezcua-Guerra
- Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico;
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Vernino S, Bourne KM, Stiles LE, Grubb BP, Fedorowski A, Stewart JM, Arnold AC, Pace LA, Axelsson J, Boris JR, Moak JP, Goodman BP, Chémali KR, Chung TH, Goldstein DS, Diedrich A, Miglis MG, Cortez MM, Miller AJ, Freeman R, Biaggioni I, Rowe PC, Sheldon RS, Shibao CA, Systrom DM, Cook GA, Doherty TA, Abdallah HI, Darbari A, Raj SR. Postural orthostatic tachycardia syndrome (POTS): State of the science and clinical care from a 2019 National Institutes of Health Expert Consensus Meeting - Part 1. Auton Neurosci 2021; 235:102828. [PMID: 34144933 DOI: 10.1016/j.autneu.2021.102828] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/10/2021] [Accepted: 05/30/2021] [Indexed: 12/13/2022]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a chronic and often disabling disorder characterized by orthostatic intolerance with excessive heart rate increase without hypotension during upright posture. Patients often experience a constellation of other typical symptoms including fatigue, exercise intolerance and gastrointestinal distress. A typical patient with POTS is a female of child-bearing age, who often first displays symptoms in adolescence. The onset of POTS may be precipitated by immunological stressors such as a viral infection. A variety of pathophysiologies are involved in the abnormal postural tachycardia response; however, the pathophysiology of the syndrome is incompletely understood and undoubtedly multifaceted. Clinicians and researchers focused on POTS convened at the National Institutes of Health in July 2019 to discuss the current state of understanding of the pathophysiology of POTS and to identify priorities for POTS research. This article, the first of two articles summarizing the information discussed at this meeting, summarizes the current understanding of this disorder and best practices for clinical care. The evaluation of a patient with suspected POTS should seek to establish the diagnosis, identify co-morbid conditions, and exclude conditions that could cause or mimic the syndrome. Once diagnosed, management typically begins with patient education and non-pharmacologic treatment options. Various medications are often used to address specific symptoms, but there are currently no FDA-approved medications for the treatment of POTS, and evidence for many of the medications used to treat POTS is not robust.
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Affiliation(s)
- Steven Vernino
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kate M Bourne
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lauren E Stiles
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA; Dysautonomia International, East Moriches, NY, USA
| | - Blair P Grubb
- Division of Cardiology, Department of Medicine, The University of Toledo Medical Center, USA
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Julian M Stewart
- Center for Hypotension, Departments of Pediatrics and Physiology, New York Medical College, Valhalla, NY, USA
| | - Amy C Arnold
- Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laura A Pace
- Center for Genomic Medicine and Department of Pediatrics, Division of Medical Genetics and Genomics, University of Utah, Salt Lake City, UT, USA
| | - Jonas Axelsson
- Department of Clinical Immunology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Jeffrey P Moak
- Department of Pediatrics, George Washington Univeristy School of Medicine and Health Sciences, Washington, DC, USA
| | - Brent P Goodman
- Neuromuscular Division, Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA
| | - Kamal R Chémali
- Department of Neurology, Eastern Virginia Medical School, Division of Neurology, Neuromuscular and Autonomic Center, Sentara Healthcare, Norfolk, VA, USA
| | - Tae H Chung
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David S Goldstein
- Autonomic Medicine Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Andre Diedrich
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine and Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mitchell G Miglis
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Melissa M Cortez
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Amanda J Miller
- Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, Boston, MA, USA; Center for Autonomic and Peripheral Nerve Disorders, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Italo Biaggioni
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Departments of Medicine and Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Cyndya A Shibao
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Departments of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David M Systrom
- Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Glen A Cook
- Department of Neurology, Uniformed Services University, Bethesda, MD, USA
| | - Taylor A Doherty
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of California at San Diego, La Jolla, CA, USA
| | | | - Anil Darbari
- Pediatric Gastroenterology, Children's National Hospital, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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Podzolkov VI, Bragina AE, Tarzimanova AI, Vasil'eva LV, Batrakova EP, Lobova NV, Bykova EE, Khachuroeva MM. Post-COVID Syndrome and Tachycardia: Theoretical Base and Treatment Experience. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-04-08] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The coronavirus pandemic showed not only an increase in levels of excess morbidity and mortality in the acute phase, but also persisting symptoms 4 weeks after the onset of the disease. A review of international studies on the prevalence and diversity of the manifestations of postcoid syndrome is presented. The data on such a manifestation of post-COVID syndrome as postural orthostatic tachycardia syndrome (POTS) are accumulating. Pathogenetic mechanisms, modern diagnostic criteria and research data on the prevalence of this syndrome are presented in the article. The Canadian Cardiovascular Society has proposed medications as a treatment for POTS, including the sinus node If channel inhibitor ivabradine. Data from several studies showing the effectiveness of this drug for POTS, including after suffering COVID-19, are presented in the article. Clinical data on the prevalence of tachycardia among patients admitted to the Sechenov University hospital are presented. About 18% of patients with hypertension and 21% of patients with normal blood pressure had a high heart rate. A clinical example of the use of ivabradine in a patient after a coronavirus infection is presented. Drug interactions and individual tolerance of ivabradine in patients after coronavirus infection are being discussed. The authors put forward the hypothesis about the further prospect of using ivabradine in the treatment of clinical manifestations of postcoid syndrome on the basis of literature data and their own experience.
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Affiliation(s)
- V. I. Podzolkov
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. E. Bragina
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. I. Tarzimanova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - L. V. Vasil'eva
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - E. P. Batrakova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - N. V. Lobova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - E. E. Bykova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - M. M. Khachuroeva
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
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Eftekhari H, Maddock H, Pearce G, Raza S, Kavi L, Lim PB, Osman F, Hayat SA. Understanding the future research needs in Postural Orthostatic Tachycardia Syndrome (POTS): Evidence mapping the POTS adult literature. Auton Neurosci 2021; 233:102808. [PMID: 33901811 DOI: 10.1016/j.autneu.2021.102808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 03/15/2021] [Accepted: 03/27/2021] [Indexed: 01/01/2023]
Abstract
POTS is under diagnosed with an estimated prevalence of 0.2%. North American and Australian researchers, as well as patient groups have called for more research into POTS. However, there has been no comprehensive appraisal of the current POTS evidence base. AIM To map the POTS evidence base. METHODS Two reviewers systematically searched 12 databases until July 1st 2019 using the search term "Postural Tachycardia Syndrome" (n = 7280) and categorised the literature. Inclusion criteria included all adult published literature with no language restrictions. 779 papers are analysed and mapped. RESULTS Seven themes were identified: symptomology and quality of life 16.8% (n = 132), biomedical topics 16.5% (n = 130), co-morbidities 10.3% (n = 81), non-pharmacological management 9.8% (n = 77), aetiologies 6.9% (n = 53), pharmacological management 6.7% (n = 53), and clinical management 6.6% (n = 52). There 45 subthemes. Quality appraisal of the research studies (n = 233) evaluated design, sample size, outcome measures, data analysis and research biases. 74.8% (n = 175) were observational designs and 25.2% (n = 59) were experimental designs (16 using a randomised controlled design, 11 of which had a sample size greater than 21). 47.4% (n = 111) of studies only measured duration of effect for <1 day. 11.5% (n = 27) of studies reported outcomes using an unvalidated subjective measurement tool. CONCLUSION The volume of adult POTS literature is small and the validity and reliability of the research lacks rigour. The evidence map methodology provides POTS researchers with a benchmark for research thus far. This paper adds an in-depth research appraisal to the broad calls for action, highlighting the pressing need for multicentre, good quality research in POTS, to support guidelines and consensus development in the future.
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Affiliation(s)
- H Eftekhari
- University Hospitals Coventry & Warwickshire NHS Trust, United Kingdom of Great Britain and Northern Ireland.
| | - H Maddock
- Faculty of Health and Life Sciences, Coventry University, United Kingdom of Great Britain and Northern Ireland.
| | - G Pearce
- Faculty of Health and Life Sciences, Coventry University, United Kingdom of Great Britain and Northern Ireland.
| | - S Raza
- Biomedical Sciences, Coventry University, United Kingdom of Great Britain and Northern Ireland.
| | - L Kavi
- PoTS UK, United Kingdom of Great Britain and Northern Ireland.
| | - P B Lim
- Imperial College NHS Healthcare Trust, United Kingdom of Great Britain and Northern Ireland.
| | - F Osman
- University Hospitals Coventry & Warwickshire NHS Trust, United Kingdom of Great Britain and Northern Ireland; Warwick Medical School, University of Warwick, Coventry, United Kingdom of Great Britain and Northern Ireland.
| | - S A Hayat
- Heart Hospital, Hamad Medical Corporation, Doha, Qatar.
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48
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Johansson M, Ståhlberg M, Runold M, Nygren-Bonnier M, Nilsson J, Olshansky B, Bruchfeld J, Fedorowski A. Long-Haul Post-COVID-19 Symptoms Presenting as a Variant of Postural Orthostatic Tachycardia Syndrome: The Swedish Experience. JACC Case Rep 2021; 3:573-580. [PMID: 33723532 PMCID: PMC7946344 DOI: 10.1016/j.jaccas.2021.01.009] [Citation(s) in RCA: 105] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/11/2021] [Accepted: 01/15/2021] [Indexed: 01/07/2023]
Abstract
Major clinical centers in Sweden have witnessed an inflow of patients with chronic symptoms following initial outpatient care for coronavirus disease-2019 (COVID-19) infection, suggestive of postural orthostatic tachycardia syndrome. This report presents the first case series of 3 Swedish patients diagnosed with postural orthostatic tachycardia syndrome more than 3 months after the primary COVID-2019 infections. (Level of Difficulty: Intermediate.).
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Affiliation(s)
- Madeleine Johansson
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
- Address for correspondence: Dr. Madeleine Johansson, Department of Clinical Sciences, Lund University, Clinical Research Center, Box 50332, 20213, Malmö 20213, Sweden. @DrMJohansson
| | - Marcus Ståhlberg
- Heart, Vascular, and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Michael Runold
- Department of Respiratory and Allergic Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Nygren-Bonnier
- Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Function Allied Health Professionals, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden
| | - Jan Nilsson
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden
| | - Brian Olshansky
- Department of Internal Medicine, Division of Cardiology, University of Iowa Hospitals, Iowa City, Iowa
| | - Judith Bruchfeld
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Artur Fedorowski
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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49
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Miglis MG, Goodman BP, Chémali KR, Stiles L. Re: 'Post-COVID-19 chronic symptoms' by Davido et al. Clin Microbiol Infect 2020; 27:494. [PMID: 32891765 PMCID: PMC7470728 DOI: 10.1016/j.cmi.2020.08.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 08/17/2020] [Accepted: 08/22/2020] [Indexed: 01/14/2023]
Affiliation(s)
- Mitchell G Miglis
- Department of Neurology and Neurological Science, Autonomic Division, Stanford University, Palo Alto, CA, USA.
| | | | - Kamal R Chémali
- Department of Neurology, Eastern Virginia Medical School, USA; Sentara Neuromuscular & Autonomic Center, Norfolk, VA, USA
| | - Lauren Stiles
- Department of Neurology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
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50
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Chen G, Du J, Jin H, Huang Y. Postural Tachycardia Syndrome in Children and Adolescents: Pathophysiology and Clinical Management. Front Pediatr 2020; 8:474. [PMID: 32974246 PMCID: PMC7468430 DOI: 10.3389/fped.2020.00474] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 07/06/2020] [Indexed: 12/21/2022] Open
Abstract
Postural tachycardia syndrome (POTS), characterized by chronic (≥6 months) orthostatic intolerance symptoms with a sustained and excessive heart rate increase while standing without postural hypotension, is common in children and adolescents. Despite the unclear pathogenesis of POTS, the present opinion is that POTS is a heterogeneous and multifactorial disorder that includes altered central blood volume, abnormal autonomic reflexes, "hyperadrenergic" status, damaged skeletal muscle pump activity, abnormal local vascular tension and vasoactive factor release, mast cell activation, iron insufficiency, and autoimmune dysfunction. A number of pediatric POTS patients are affected by more than one of these pathophysiological mechanisms. Therefore, individualized treatment strategies are initiated in the management of POTS, including basal non-pharmacological approaches (e.g., health education, the avoidance of triggers, exercise, or supplementation with water and salt) and special pharmacological therapies (e.g., oral rehydration salts, midodrine hydrochloride, and metoprolol). As such, the recent progress in the pathogenesis, management strategies, and therapeutic response predictors of pediatric POTS are reviewed here.
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Affiliation(s)
- Guozhen Chen
- Department of Pediatrics, Peking University First Hospital, Beijing, China
- Department of Pediatrics, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
- Research Unit of Clinical Diagnosis and Treatment of Pediatric Syncope and Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, China
- Key Laboratory of Molecular Cardiovascular Science, The Ministry of Education, Beijing, China
| | - Hongfang Jin
- Department of Pediatrics, Peking University First Hospital, Beijing, China
- Research Unit of Clinical Diagnosis and Treatment of Pediatric Syncope and Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Yaqian Huang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
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