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Cai W, Han X, Tang X, Cao Z, Yu Z, Sun Z, Wu J, Wu Y, Xie H. Uncovering sympathetic nervous system dysfunction in disorders of consciousness via heart rate variability during head-up tilt test. Physiol Rep 2024; 12:e16000. [PMID: 38584117 PMCID: PMC10999365 DOI: 10.14814/phy2.16000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 03/20/2024] [Accepted: 03/22/2024] [Indexed: 04/09/2024] Open
Abstract
Few standardized tools are available for evaluation of disorders of consciousness (DOC). The potential of heart rate variability (HRV) during head-up tilt (HUT) test was investigated as a complementary evaluation tool. Twenty-one DOC patients and 21 healthy participants were enrolled in this study comparing clinical characteristics and HRV time- and frequency-domain outcomes and temporal changes during HUT test. During the 1st-5th min of the HUT, DOC group showed a significant increase and decrease in log low frequency (LF) (p = 0.045) and log normalized high frequency (nHF) (p = 0.02), respectively, compared to the supine position and had lower log normalized LF (nLF) (p = 0.004) and log ratio of low-to-high frequency (LF/HF) (p = 0.001) compared to healthy controls. As the HUT continued from the 6th to the 20th min, DOC group exhibited a significant increase in log LF/HF (16th-20th min) (p < 0.05), along with a decrease in log nHF (6th-10th and 16th-20th min) (p < 0.05) and maintained lower log LF, log nLF, and log LF/HF than controls (p < 0.05). 1st-10th min after returning to the supine position, DOC group demonstrated a significant decrease in log nHF (p < 0.01) and increases in log LF/HF (p < 0.01) and had lower log LF (p < 0.01) and log nLF (p < 0.05) compared to controls. In contrast, the control group exhibited a significant decrease in log nHF (p < 0.05) and increase in log LF/HF (p < 0.05) throughout the entire HUT test. Notably, no significant differences were observed when comparing time-domain outcomes reflecting parasympathetic nervous system between the two groups. HRV during HUT test indicated a delayed and attenuated autonomic response, particularly in the sympathetic nervous system, in DOC patients compared with healthy individuals.
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Affiliation(s)
- Weiqiang Cai
- Department of Rehabilitation Medicine, Huashan HospitalFudan UniversityShanghaiChina
| | - Xu Han
- Department of Rehabilitation Medicine, Huashan HospitalFudan UniversityShanghaiChina
| | - Xinwei Tang
- Department of Rehabilitation Medicine, Huashan HospitalFudan UniversityShanghaiChina
| | - Zuojun Cao
- Department of Rehabilitation Medicine, Huashan HospitalFudan UniversityShanghaiChina
| | - Zi Yu
- Department of Rehabilitation Medicine, Huashan HospitalFudan UniversityShanghaiChina
| | - Zuowen Sun
- Department of Rehabilitation Medicine, Huashan HospitalFudan UniversityShanghaiChina
| | - Junfa Wu
- Department of Rehabilitation Medicine, Huashan HospitalFudan UniversityShanghaiChina
| | - Yi Wu
- Department of Rehabilitation Medicine, Huashan HospitalFudan UniversityShanghaiChina
| | - Hongyu Xie
- Department of Rehabilitation Medicine, Huashan HospitalFudan UniversityShanghaiChina
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Xu BW, Zhang QY, Li XY, Tang CS, Du JB, Liu XQ, Jin HF. A predictive model of response to metoprolol in children and adolescents with postural tachycardia syndrome. World J Pediatr 2023; 19:390-400. [PMID: 36781629 PMCID: PMC10060270 DOI: 10.1007/s12519-022-00677-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 12/16/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND The present work was designed to explore whether electrocardiogram (ECG) index-based models could predict the effectiveness of metoprolol therapy in pediatric patients with postural tachycardia syndrome (POTS). METHODS This study consisted of a training set and an external validation set. Children and adolescents with POTS who were given metoprolol treatment were enrolled, and after follow-up, they were grouped into non-responders and responders depending on the efficacy of metoprolol. The difference in pre-treatment baseline ECG indicators was analyzed between the two groups in the training set. Binary logistic regression analysis was further conducted on the association between significantly different baseline variables and therapeutic efficacy. Nomogram models were established to predict therapeutic response to metoprolol. The receiver-operating characteristic curve (ROC), calibration, and internal validation were used to evaluate the prediction model. The predictive ability of the model was validated in the external validation set. RESULTS Of the 95 enrolled patients, 65 responded to metoprolol treatment, and 30 failed to respond. In the responders, the maximum value of the P wave after correction (Pcmax), P wave dispersion (Pd), Pd after correction (Pcd), QT interval dispersion (QTd), QTd after correction (QTcd), maximum T-peak-to-T-end interval (Tpemax), and T-peak-to-T-end interval dispersion (Tped) were prolonged (all P < 0.01), and the P wave amplitude was increased (P < 0.05) compared with those of the non-responders. In contrast, the minimum value of the P wave duration after correction (Pcmin), the minimum value of the QT interval after correction (QTcmin), and the minimum T-peak-to-T-end interval (Tpemin) in the responders were shorter (P < 0.01, < 0.01 and < 0.01, respectively) than those in the non-responders. The above indicators were screened based on the clinical significance and multicollinearity analysis to construct a binary logistic regression. As a result, pre-treatment Pcmax, QTcmin, and Tped were identified as significantly associated factors that could be combined to provide an accurate prediction of the therapeutic response to metoprolol among the study subjects, yielding good discrimination [area under curve (AUC) = 0.970, 95% confidence interval (CI) 0.942-0.998] with a predictive sensitivity of 93.8%, specificity of 90.0%, good calibration, and corrected C-index of 0.961. In addition, the calibration curve and standard curve had a good fit. The accuracy of internal validation with bootstrap repeated sampling was 0.902. In contrast, the kappa value was 0.769, indicating satisfactory agreement between the predictive model and the results from the actual observations. In the external validation set, the AUC for the prediction model was 0.895, and the sensitivity and specificity were 90.9% and 95.0%, respectively. CONCLUSIONS A high-precision predictive model was successfully developed and externally validated. It had an excellent predictive value of the therapeutic effect of metoprolol on POTS among children and adolescents.
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Affiliation(s)
- Bo-Wen Xu
- Department of Pediatrics, Peking University First Hospital, No. 1, Xi'an-Men Street, West District, Beijing, 100034, China
| | - Qing-You Zhang
- Department of Pediatrics, Peking University First Hospital, No. 1, Xi'an-Men Street, West District, Beijing, 100034, China
| | - Xue-Ying Li
- Department of Medical Statistics, Peking University First Hospital, Beijing, China
| | - Chao-Shu Tang
- Key Lab of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, China
- Department of Physiology and Pathophysiology, Peking University Health Science Centre, Beijing, China
| | - Jun-Bao Du
- Department of Pediatrics, Peking University First Hospital, No. 1, Xi'an-Men Street, West District, Beijing, 100034, China.
- Key Lab of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, China.
| | - Xue-Qin Liu
- Department of Pediatrics, Peking University First Hospital, No. 1, Xi'an-Men Street, West District, Beijing, 100034, 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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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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Lawrence S, Mueller BR, Kwon P, Robinson-Papp J. Phenotyping autonomic neuropathy using principal component analysis. Auton Neurosci 2023; 245:103056. [PMID: 36525943 PMCID: PMC9899306 DOI: 10.1016/j.autneu.2022.103056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/12/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022]
Abstract
To identify autonomic neuropathy (AN) phenotypes, we used principal component analysis on data from participants (N = 209) who underwent standardized autonomic testing including quantitative sudomotor axon reflex testing, and heart rate and blood pressure at rest and during tilt, Valsalva, and standardized deep breathing. The analysis identified seven clusters: 1) normal, 2) hyperadrenergic features without AN, 3) mild AN with hyperadrenergic features, 4) moderate AN, 5) mild AN with hypoadrenergic features, 6) borderline AN with hypoadrenergic features, 7) mild balanced deficits across parasympathetic, sympathetic and sudomotor domains. These findings demonstrate a complex relationship between adrenergic and other aspects of autonomic function.
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Affiliation(s)
- Steven Lawrence
- Vilcek Institute of Graduate Biomedical Sciences, NYU Grossman School of Medicine, USA
| | - Bridget R Mueller
- Department of Neurology, Icahn School of Medicine at Mount Sinai, USA
| | - Patrick Kwon
- Department of Neurology, NYU Grossman School of Medicine, USA
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Deng X, Zhang Y, Liao Y, Du J. Efficacy of β-Blockers on Postural Tachycardia Syndrome in Children and Adolescents: A Systematic Review and Meta-Analysis. Front Pediatr 2019; 7:460. [PMID: 31788462 PMCID: PMC6854016 DOI: 10.3389/fped.2019.00460] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/22/2019] [Indexed: 02/04/2023] Open
Abstract
Background: Postural tachycardia syndrome (POTS) is a severe health problem in children. Short-term β-blockers are recommended for pharmaceutical treatment. However, there have been contradictory data about its efficacy among pediatric patients. Methods and Results: Eight studies comparing β-blockers to conventional treatments for children with POTS were selected, where 497 cases of pediatric POTS were included. The efficacy of β-blockers was evaluated using the effective rate, the change of symptom score, the change of heart rate difference and adverse events. The results were stated as relative ratio (RR) and mean difference (MD) with a 95% confidence interval (95% CI). A random-effects meta-analysis for the effective rate indicated that β-blockers were more effective in treating pediatric POTS than controlled treatment (79.5 vs. 57.3%, RR = 1.50, 95%CI: 1.15-1.96, P < 0.05). A fixed-effects model analysis showed that β-blockers were more effective in lowering the symptom score and the heart rate increment during standing test than controlled treatment with a mean difference of 0.81 (95% CI: 0.44-1.18, P < 0.05) and 3.78 (95% CI: 2.10-5.46, P < 0.05), respectively. There were no reported severe adverse events in included studies. Conclusion: β-blockers are effective in treating POTS in children and adolescents, alleviating orthostatic intolerance, and improving hemodynamic abnormalities.
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Affiliation(s)
- Xinwei Deng
- Department of Pediatrics, Peking University First Hospital, Beijing, China
- Peking University Health Sciences Centre, Beijing, China
- Research Unit of Clinical Diagnosis and Treatment of Pediatric Syncope and Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuyang Zhang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
- Peking University Health Sciences Centre, Beijing, China
| | - Ying Liao
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Junbao Du
- 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
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Habek M, Ruška B, Crnošija L, Adamec I, Junaković A, Krbot Skorić M. Effect of Food Intake on Hemodynamic Parameters during the Tilt-Table Test in Patients with Postural Orthostatic Tachycardia Syndrome. J Clin Neurol 2019; 15:205-210. [PMID: 30877690 PMCID: PMC6444156 DOI: 10.3988/jcn.2019.15.2.205] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 11/26/2018] [Accepted: 11/28/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND AND PURPOSE The aim of this study was to determine the effect of food intake on the heart rate (HR) in postural orthostatic tachycardia syndrome (POTS). METHODS The following five-phase protocol was applied to 41 subjects who had a sustained HR increment of ≥30 beats/min within 10 min of standing in an initial tilt-table test: 1) 10-min supine phase, 2) 10-min 70°-tilted phase, 3) ingestion of 400 mL of Nutridrink Multi Fibre®, 4) 45-min supine phase, and 5) 10-min 70°-tilted phase. Subjects were divided into four groups: A) difference in HR for standing vs. supine (ΔHR) before the meal of ≥30 beats/min (n=13), B) ΔHR <30 beats/min before the meal but ≥30 beats/min after the meal (n=12), and C) ΔHR <30 beats/min both before and after the meal (n=16). Group D consisted of 10 healthy subjects. RESULTS Before the meal, ΔHR was significantly higher in group A than in all of the other groups, and in group B than in group D (p<0.001). After the meal, ΔHR was significantly higher in groups A and B (p<0.001 and p<0.0001, respectively). When we pooled patients (according to their symptoms) from group A and B into a POTS group and from group C and D into a non-POTS group, an increase in HR of 25 beats/min before the meal had a sensitivity of 92.0% and a specificity of 80.8%. After the meal, an increase in HR of 30 beats/min had a sensitivity of 96.0% and a specificity of 96.2%. CONCLUSIONS Food intake can significantly alter the results of the tilt-table test and so should be taken into account when diagnosing POTS.
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Affiliation(s)
- Mario Habek
- Department of Neurology, School of Medicine, University of Zagreb, Zagreb, Croatia.,Department of Neurology, University Hospital Center Zagreb, Referral Center for Autonomic Nervous System Disorders, Zagreb, Croatia.
| | - Berislav Ruška
- Department of Neurology, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Luka Crnošija
- Department of Neurology, University Hospital Center Zagreb, Referral Center for Autonomic Nervous System Disorders, Zagreb, Croatia
| | - Ivan Adamec
- Department of Neurology, University Hospital Center Zagreb, Referral Center for Autonomic Nervous System Disorders, Zagreb, Croatia
| | - Anamari Junaković
- Department of Neurology, University Hospital Center Zagreb, Referral Center for Autonomic Nervous System Disorders, Zagreb, Croatia
| | - Magdalena Krbot Skorić
- Department of Neurology, University Hospital Center Zagreb, Referral Center for Autonomic Nervous System Disorders, Zagreb, Croatia
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Differences in neurohumoral and hemodynamic response to prolonged head-up tilt between patients with high and normal standing norepinephrine forms of postural orthostatic tachycardia syndrome. Auton Neurosci 2017; 205:110-114. [PMID: 28522107 DOI: 10.1016/j.autneu.2017.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 04/18/2017] [Accepted: 05/10/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate the optimal timing for blood sample collection of catecholamines and the possible correlations between neurohumoral and hemodynamic responses to prolonged head-up tilt (HUT) in postural orthostatic tachycardia syndrome (POTS). METHODS Nineteen patients underwent a 30-minute, 70° HUT test. Blood samples (norepinephrine (NE), epinephrine and dopamine) were taken in the 10th minute of supine, and 10th, 20th and 30th minutes of HUT. RESULTS There were no significant differences in the proportion of high and normal standing NE patients in the different time points. Mean NE (nmol/L) values in 10th, 20th and 30th minute of HUT were 4.37, 4.87, and 4.35 in the high standing NE, and 2.49, 2.59 and 2.88 in the normal standing NE group. High standing NE patients had higher blood pressure (BP) during the first 6min of HUT (2nd minute after the HUT systolic BP (sBP): 118.29±15.65 vs. 95.70±13.43, p=0.004; diastolic BP (dBP): 78.71±6.68 vs. 65.10±9.04, p=0.003), while normal standing NE patients exhibited a drop in BP compared to resting values during the same time period. The normal standing NE group exhibited a progressive increase in norepinephrine values during the HUT. CONCLUSION One blood sample taken at the 10th minute of HUT correctly identifies high and normal standing NE POTS patients, but a small number of patients (1 out of 19, 5.2%) can be misidentified. High and normal standing NE POTS patients display distinctly different neurohumoral and hemodynamic responses to HUT.
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