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Hertel A, Black WR, Walton LM, Martin JR, Jones JT. Cardiovascular Symptoms, Dysautonomia, and Quality of Life in Adult and Pediatric Patients with Hypermobile Ehlers-Danlos Syndrome: A Brief Review. Curr Cardiol Rev 2024; 20:CCR-EPUB-137768. [PMID: 38275067 PMCID: PMC11071672 DOI: 10.2174/011573403x271096231203164216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/09/2023] [Accepted: 10/25/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Hypermobile Ehlers-Danlos Syndrome (hEDS) is a connective tissue disorder characterized by joint hypermobility and other systemic manifestations, such as cardiovascular symptoms, musculoskeletal pain, and joint instability. Cardiovascular symptoms, such as lightheadedness and palpitations, and types of dysautonomia, including postural orthostatic tachycardia syndrome (POTS), are frequently reported in adults with hEDS and have been shown to negatively impact quality of life (QoL). OBJECTIVE This brief review will be an overview of co-occurring symptoms in POTS and hEDS to inform potential cardiovascular screening procedures. RESULTS While many patients with hEDS report cardiovascular symptoms, few have structural abnormalities, suggesting that dysautonomia is likely responsible for these symptoms. One validated screening measure for dysautonomia symptom burden is the Composite Autonomic Symptom Scale (COMPASS-31). Studies have found that adults with POTS, hEDS, and both POTS and hEDS have higher COMPASS-31 scores than the general population, suggesting a high symptom burden due to dysautonomia, which leads to impaired QoL. CONCLUSION While studies have examined cardiovascular symptoms and the impact of dysautonomia in adults with and without hEDS, there is scant literature on dysautonomia in pediatric patients with hEDS. Therefore, more studies on cardiovascular symptoms and dysautonomia, as they relate to the quality of life in pediatric patients with hEDS, are needed. This brief review summarizes the current literature on dysautonomia and cardiovascular symptoms in pediatric and adult populations with hEDS.
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Affiliation(s)
- Amanda Hertel
- School of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - William R. Black
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas, USA
- Center for Children's Healthy Lifestyles and Nutrition, Children's Mercy Kansas City, Kansas City, Missouri, USA
- Center for Biobehavioral Health, Abigail Wexner Research Institute at Nationwide Children’s Hospital, The Ohio State University, Columbus, USA
| | - Lindsey Malloy Walton
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas, USA
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri, USA
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Julie R. Martin
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Jordan T. Jones
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas, USA
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri, USA
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
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Mueller B. Episodic Migraine and POTS. Curr Pain Headache Rep 2023; 27:757-763. [PMID: 37804458 DOI: 10.1007/s11916-023-01173-8] [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] [Accepted: 09/15/2023] [Indexed: 10/09/2023]
Abstract
PURPOSE OF REVIEW Migraine is prevalent in patients with postural orthostatic tachycardia syndrome (POTS). The purpose of this review is to summarize and interpret studies that examine stress response systems in patients with migraine, focusing on their relevance to the pathologies associated with POTS. Important structural and functional components of the stress response network are also reviewed. RECENT FINDINGS In patients with migraine, studies examining the autonomic nervous system have demonstrated interictal sympathetic hypofunction and ictal sympathetic hyperfunction, while those focusing on the hypothalamic-pituitary-adrenal axis have demonstrated elevated responsivity. There is evidence that activation of these stress response systems during a migraine episode may exacerbate vascular dysfunction and play a role in the development of central sensitization. Activation of the stress response systems during an episode of migraine has the potential to exacerbate the pathology of POTS. Treatment approaches for the patient with comorbid episodic migraine and POTS should consider the etiology of POTS.
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Affiliation(s)
- Bridget Mueller
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, Box 1139, New York, NY, 10029, USA.
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Mueller BR, Ray C, Benitez A, Robinson-Papp J. Reduced cardiovagal baroreflex sensitivity is associated with postural orthostatic tachycardia syndrome (POTS) and pain chronification in patients with headache. Front Hum Neurosci 2023; 17:1068410. [PMID: 36992793 PMCID: PMC10040804 DOI: 10.3389/fnhum.2023.1068410] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/24/2023] [Indexed: 03/16/2023] Open
Abstract
BackgroundNon-cephalgic symptoms including orthostatic intolerance, fatigue, and cognitive impairment, are common in patients with chronic headache disorders and may result from alterations in the autonomic nervous system. However, little is known about the function of autonomic reflexes, which regulate cardiovascular homeostasis and cerebral perfusion in patients with headache.MethodsAutonomic function testing data from patients with headache collected between January 2018 and April 2022 was retrospectively analyzed. Through review of EMR we determined headache pain chronicity and patient self-report of orthostatic intolerance, fatigue, and cognitive impairment. Composite Autonomic Severity Score (CASS), CASS subscale scores, and cardiovagal and adrenergic baroreflex sensitivities were used to quantify autonomic reflex dysfunction. Descriptive analyses (Mann-Whitney-U or χ2, as appropriate) determined associations between autonomic reflex dysfunction and POTS as well as chronic headache. Binomial logistic regression adjusted for age and sex. Spearman’s rank correlation determined the association between the total CASS score and the number of painless symptoms reported by each participant.ResultsWe identified 34 patients meeting inclusion criteria, of whom there were 16 (47.0%) with orthostatic intolerance, 17 (50.0%) with fatigue, 11 (32.4%) with cognitive complaints, and 11 (32.4%) with Postural Orthostatic Tachycardia Syndrome (POTS). The majority of participants had migraine (n = 24, 70.6%), were female (n = 23, 67.6%) and had a chronic (>15 headache days in a month) headache disorder (n = 26, 76.5%). Reduced cardiovagal baroreflex sensitivity (BRS-V) independently predicted chronic headache [aOR: 18.59 (1.16, 297.05), p = 0.039] and POTS [aOR: 5.78 (1.0, 32.5), p = 0.047]. The total CASS was correlated with the total number of non-painful features in the expected direction (r = 0.46, p = 0.007).ConclusionAbnormal autonomic reflexes may play an important role in pain chronification and the development of POTS in patients with headache.
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George A, Winters B. Postural Orthostatic Tachycardia Syndrome (POTS): A Frequently Missed Diagnosis. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bakır M, Rumeli Ş, Özge A, Türkyılmaz GG. The effect of postdural puncture headache on pre-existing and new-onset headaches after cesarean section: A retrospective study. Heliyon 2022; 8:e11014. [PMID: 36267369 PMCID: PMC9576895 DOI: 10.1016/j.heliyon.2022.e11014] [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: 03/20/2022] [Revised: 07/11/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022] Open
Abstract
Background Obstetric patients are at higher risk of postdural puncture headache (PDPH) than other age- and sex-matched individuals. The debate over the long-term effects of PDPH continues. In this study, we aimed to assess the development of new-onset headaches or worsening of pre-existing chronic headaches in patients who underwent cesarean section under spinal anesthesia and developed PDPH. Methods Forty patients who developed PDPH (Group P) after cesarean section surgery (post-cesarean section–PCS), 80 patients who underwent cesarean section under spinal anesthesia (Group S), and 80 patients who underwent cesarean section under general anesthesia (Group G) were evaluated in the study. Chronic headache and other related symptoms that were present before pregnancy (pre-gestational–PG) and within 12 months after cesarean section were assessed. Results Eight of the 40 patients in Group P had a new-onset chronic headache after cesarean surgery, which was significantly higher than the rates in the other groups (p = 0.001). Of the patients whose pre-existing headache worsened during the PCS period, seven were in Group P, and four were in Group S (p = 0.020), while none was in Group G. According to the multiple logistic regression analysis, the risk of worsening headache increased by 1.51-fold for every 1 unit increase in the PG Numerical Rating Scale (NRS). Conclusion In conclusion, patients who develop PDPH appear to be at higher risk of developing new-onset headaches or worsening of pre-existing headaches compared with those who do not. We believe that keeping a headache diary for patients who will undergo dural puncture for whatever purpose, and also long-term follow-up of these patients for the risk of chronic headaches may increase awareness of this issue.
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Affiliation(s)
- Mesut Bakır
- Division of Algology, Mersin City Education and Research Hospital, Mersin, Turkey,Corresponding author.
| | - Şebnem Rumeli
- Division of Algology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Aynur Özge
- Department of Neurology, Mersin University Faculty of Medicine, Mersin, Turkey
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Iser C, Arca K. Headache and Autonomic Dysfunction: a Review. Curr Neurol Neurosci Rep 2022; 22:625-634. [PMID: 35994191 DOI: 10.1007/s11910-022-01225-3] [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: 07/14/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW We explore the anatomy of the central and peripheral autonomic pathways involved in primary headache as well as the mechanisms for secondary headache associated with disorders of the autonomic nervous system. The prevalence and clinical presentation of cranial and systemic autonomic symptoms in these conditions will be discussed, with a focus on recent studies. RECENT FINDINGS Several small studies have utilized the relationship between headache and the autonomic nervous system to identify potential biomarkers to aid in diagnosis of migraine and cluster headache. Headache in postural orthostatic tachycardia syndrome (POTS) has also been further characterized, particularly in its association with orthostatic headache and spontaneous intracranial hypotension (SIH). This review examines the pathophysiology of primary and secondary headache disorders in the context of the autonomic nervous system. Mechanisms of headache associated with systemic autonomic disorders are also reviewed.
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Affiliation(s)
- Courtney Iser
- Department of Neurology, Mayo Clinic Scottsdale, Scottsdale, AZ, USA
| | - Karissa Arca
- Department of Neurology, Mayo Clinic Scottsdale, Scottsdale, AZ, USA.
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Hollingsworth C, Boyette V, Rich EM, Vas A. Cognition and Postural Tachycardia Syndrome (POTS): Participant-Identified Challenges and Strategies, and Implications for Intervention. Occup Ther Health Care 2022; 36:220-236. [PMID: 34802375 DOI: 10.1080/07380577.2021.2004485] [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: 12/01/2020] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 06/13/2023]
Abstract
Postural Orthostatic Tachycardia Syndrome (POTS) is a condition that affects the autonomic nervous system and can cause both orthostatic and non-orthostatic physical and cognitive symptoms. The goal of this study is to gain meaningful understanding of the cognitive impact of POTS on daily function and to record the strategies participants use to overcome the challenges to help direct occupational therapy treatment. Results show daily function is greatly and negatively impacted by cognitive symptoms resulting from POTS. Participants have discovered strategies and used adaptations to enable them to participate in their daily and meaningful tasks. Using the experiences of those who live with POTS every day to guide interventions, occupational therapy practitioners can better understand and help to improve the autonomy and independence of the clients they treat.
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Affiliation(s)
| | - Valerie Boyette
- School of Occupational Therapy, Texas Woman's University, Dallas, TX, USA
| | - Emily M Rich
- School of Occupational Therapy, Texas Woman's University, Dallas, TX, USA
| | - Asha Vas
- School of Occupational Therapy, Texas Woman's University, Dallas, TX, USA
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Mueller BR, Robinson‐Papp J. Postural orthostatic tachycardia syndrome and migraine: A narrative review. Headache 2022; 62:792-800. [DOI: 10.1111/head.14365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Bridget R. Mueller
- Department of Neurology Icahn School of Medicine at Mount Sinai, Center for Headache and Facial Pain New York New York USA
| | - Jessica Robinson‐Papp
- Department of Neurology Icahn School of Medicine at Mount Sinai New York New York USA
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Kakavand B. Dizziness, Syncope, and Autonomic Dysfunction in Children. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Barbier A, Chen JH, Huizinga JD. Autism Spectrum Disorder in Children Is Not Associated With Abnormal Autonomic Nervous System Function: Hypothesis and Theory. Front Psychiatry 2022; 13:830234. [PMID: 35370829 PMCID: PMC8964964 DOI: 10.3389/fpsyt.2022.830234] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/10/2022] [Indexed: 12/20/2022] Open
Abstract
The quest to understand the pathophysiology of autism spectrum disorder (ASD) has led to extensive literature that purports to provide evidence for autonomic dysfunction based on heart rate and heart rate variability (HRV), in particular respiratory sinus arrhythmia (RSA), a measure of parasympathetic functioning. Many studies conclude that autism is associated with vagal withdrawal and sympathetic hyperactivation based on HRV and electrodermal analyses. We will argue that a critical analysis of the data leads to the hypothesis that autonomic nervous system dysfunction is not a dominant feature of autism. Most children with ASD have normal parasympathetic baseline values and normal autonomic responses to social stimuli. The existing HRV and electrodermal data cannot lead to the conclusion of an over-excitation of the sympathetic nervous system. A small subgroup of ASD children in experimental settings has relatively low RSA values and relatively high heart rates. The data suggest that this is likely associated with a relatively high level of anxiety during study conditions, associated with co-morbidities such as constipation, or due to the use of psychoactive medication. Many studies interpret their data to conform with a preferred hypothesis of autonomic dysfunction as a trait of autism, related to the polyvagal theory, but the HRV evidence is to the contrary. HRV analysis may identify children with ASD having autonomic dysfunction due to co-morbidities.
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Affiliation(s)
- Ashley Barbier
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ji-Hong Chen
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jan D Huizinga
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Rich EM, Vas A, Parsons TD, Krone R, Goodman BP. Functional status in postural tachycardia syndrome. Br J Occup Ther 2021. [DOI: 10.1177/03080226211031807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Postural tachycardia syndrome is a form of orthostatic intolerance that often leads to functional impairment. Methods This survey explored functional status and impact of symptoms in adults ( n = 958) ages 18 to 60 (M = 32.63 ± 10.52 years, 96.7% female) with postural tachycardia syndrome. Results Individuals reported an average of 11 daily life activities impacted by postural tachycardia syndrome with high levels of self-perceived disability. Additionally, 93.4% reported some degree of cognitive impairment and falls occurred in 55.3% of participants annually. Despite frequent falls and functional impairment, participants infrequently (26.9%) utilized therapy services. Conclusion Individuals with postural tachycardia syndrome are at an increased risk of experiencing disability and often require assistance with daily activities. Further research is necessary to understand the potential role of therapy in improving function and quality of life.
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Affiliation(s)
- Emily M Rich
- Department of Occupational Therapy, Texas Woman’s University, Dallas, TX, USA
| | - Asha Vas
- Department of Occupational Therapy, Texas Woman’s University, Dallas, TX, USA
| | - Thomas D Parsons
- Computational Neuropsychological and Simulation (CNS) Laboratory, University of North Texas, Denton, TX, USA
| | - Ryan Krone
- Center for Research Design and Analysis, Texas Woman’s University, Dallas, TX, USA
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Tu Y, Abell TL, Raj SR, Mar PL. Mechanisms and management of gastrointestinal symptoms in postural orthostatic tachycardia syndrome. Neurogastroenterol Motil 2020; 32:e14031. [PMID: 33140561 DOI: 10.1111/nmo.14031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 10/20/2020] [Accepted: 10/20/2020] [Indexed: 01/31/2023]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a disorder of orthostatic intolerance associated with many GI manifestations that can be broadly classified into two different categories: those present all the time (non-positional) and those that occur with orthostatic position change. There are also many conditions that can co-exist with POTS such as mast cell activation syndrome and the hypermobile form of Ehlers-Danlos syndrome (hEDS) that are also oftentimes associated with GI symptoms. In the current issue of Neurogastroenterology and Motility, Tai et al. explored the relationship between functional GI disorders among hEDS patients with and without concomitant POTS and showed that the hEDS-POTS cohort was more likely to have more than one GI organ involved compared to the cohort with hEDS alone, and certain GI symptoms were also more common in the hEDS-POTS cohort. In this review article, we will briefly review the literature surrounding putative mechanisms responsible for GI symptoms in POTS with an emphasis on the contributory role of concomitant hEDS and then discuss management strategies for GI symptoms in POTS.
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Affiliation(s)
- Yixi Tu
- Division of Gastroenterology, Department of Medicine, St. Louis University, St. Louis, MO, USA
| | - Thomas L Abell
- Division of Gastroenterology, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Satish R Raj
- Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Philip L Mar
- Division of Cardiology, Department of Medicine, St. Louis University, St. Louis, MO, USA
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Ganesh R, Bonnes SLR, DiBaise JK. Postural Tachycardia Syndrome: Nutrition Implications. Nutr Clin Pract 2020; 35:818-825. [PMID: 32809263 DOI: 10.1002/ncp.10564] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Postural tachycardia syndrome (POTS) is a syndrome characterized by elevated heart rate without hypotension and most commonly occurs in young females (generally <35 years of age). The prevalence of POTS is on the rise, but the etiology is still under investigation, and there appear to be multiple potential physiologic causes. The majority of these patients experience a multitude of gastrointestinal (GI) and systemic symptoms and conditions that may contribute to functional debility and poor quality of life. Although symptoms generally improve with age, they can still lead to significant issues meeting nutrition and hydration needs. This paper summarizes the understood potential pathophysiology of POTS, associated GI and nutrition issues, general treatment of POTS, and strategies to assess and meet the unique nutrition and hydration needs of these patients.
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Affiliation(s)
- Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Sara L R Bonnes
- Division of General Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - John K DiBaise
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
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Wig R, Oakley CB. Dysautonomia and Headache in the Pediatric Population. Headache 2019; 59:1582-1588. [DOI: 10.1111/head.13659] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Rebecca Wig
- DY Patil School of Medicine Navi Mumbai India
| | - Christopher B. Oakley
- Departments of Neurology and Nursing Johns Hopkins University School of Medicine Baltimore MD USA
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