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Seeley MC, O'Brien H, Gallagher C, Schild C, Lau DH. Autonomic dysfunction in post-acute sequelae of COVID-19. Eur J Intern Med 2024; 127:161-163. [PMID: 38981767 DOI: 10.1016/j.ejim.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 06/16/2024] [Accepted: 06/26/2024] [Indexed: 07/11/2024]
Affiliation(s)
- Marie-Claire Seeley
- Australian Dysautonomia and Arrhythmia Research Collaborative, Australia; Faculty of Health and Medical Sciences, The University of Adelaide, Australia; South Australian Health and Medical Research Institute, Australia
| | - Howard O'Brien
- Australian Dysautonomia and Arrhythmia Research Collaborative, Australia
| | - Celine Gallagher
- Australian Dysautonomia and Arrhythmia Research Collaborative, Australia; Faculty of Health and Medical Sciences, The University of Adelaide, Australia; South Australian Health and Medical Research Institute, Australia
| | - Caelum Schild
- Australian Dysautonomia and Arrhythmia Research Collaborative, Australia
| | - Dennis H Lau
- Australian Dysautonomia and Arrhythmia Research Collaborative, Australia; Faculty of Health and Medical Sciences, The University of Adelaide, Australia; South Australian Health and Medical Research Institute, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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Svensson A, Svensson-Raskh A, Holmström L, Hallberg C, Bezuidenhout L, Moulaee Conradsson D, Ståhlberg M, Bruchfeld J, Fedorowski A, Nygren-Bonnier M. Individually tailored exercise in patients with postural orthostatic tachycardia syndrome related to post-COVID-19 condition - a feasibility study. Sci Rep 2024; 14:20017. [PMID: 39198662 PMCID: PMC11358431 DOI: 10.1038/s41598-024-71055-5] [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: 02/26/2024] [Accepted: 08/22/2024] [Indexed: 09/01/2024] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) occurs in approximately 30% of people with highly symptomatic post-COVID-19 condition (PCC). It involves several symptoms that limit physical and psychological functions and cause reduced quality of life. Evidence for different treatments of POTS and PCC is limited, and this study aimed to evaluate the feasibility of individually tailored physical exercise. The secondary aim of the study was to evaluate the preliminary effectiveness of this intervention. Twenty-six participants (81% female, median age 41 years) were enrolled and performed individually tailored endurance and strength training, with progression, for twelve weeks. During the intervention period, the participants had weekly support from a physiotherapist. Feasibility was evaluated with good compliance, with 76% adherence to exercise prescription and 96% completing the study protocol. The treatment was safe, and the evaluation methods (questionnaires, physical assessments, and accelerometer monitoring) were judged to be feasible. After the intervention, improvements in symptom burden as well as in psychological and physical functions were observed. In conclusion, future randomized controlled trials can be performed with only minor adjustments and could include questionnaires, physical assessment and accelerometer monitoring, which were demonstrated as feasible by this study.
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Affiliation(s)
- Annie Svensson
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.
- Medical Unit Allied Health Professionals, Women's Health and Allied Health Professionals Theme, Karolinska University Hospital, Stockholm, Sweden.
| | - Anna Svensson-Raskh
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Medical Unit Allied Health Professionals, Women's Health and Allied Health Professionals Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Linda Holmström
- Medical Unit Allied Health Professionals, Women's Health and Allied Health Professionals Theme, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Carl Hallberg
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Medical Unit Allied Health Professionals, Women's Health and Allied Health Professionals Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lucian Bezuidenhout
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Stellenbosch University, Cape Town, South Africa
| | - David Moulaee Conradsson
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Medical Unit Allied Health Professionals, Women's Health and Allied Health Professionals Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Marcus Ståhlberg
- Department of Medicine, Karolinska Institutet, Solna, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - 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 Medicine, Karolinska Institutet, Solna, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Nygren-Bonnier
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Medical Unit Allied Health Professionals, Women's Health and Allied Health Professionals Theme, Karolinska University Hospital, Stockholm, Sweden
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Tidd SJS, Zhang RX, Cantrell C, Nowacki AS, Singh T, Wilson R. Factors associated with initiation of pharmacological therapy and treatment changes in postural orthostatic tachycardia syndrome. Front Neurol 2024; 15:1411960. [PMID: 38966085 PMCID: PMC11222644 DOI: 10.3389/fneur.2024.1411960] [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: 04/03/2024] [Accepted: 06/10/2024] [Indexed: 07/06/2024] Open
Abstract
Purpose Postural Orthostatic Tachycardia Syndrome (POTS) is a heterogenous disorder of the autonomic nervous system that is often disabling. There are no FDA-approved therapies for the treatment of this condition. While some patients recover with baseline non-pharmacological intervention, others require repeated trials of off-label pharmacological therapies. The reasoning for this variable treatment response is unknown. The purpose of this work is to identify potential factors that are associated with higher odds of starting pharmacotherapy and/or a higher rate of POTS treatment changes. Methods Chart review of demographic, disease and treatment descriptions, medical history, and tilt table examinations of 322 POTS patients who were diagnosed between 2018 and 2020 at our tertiary care center was completed. We first identified the most significant factors associated with an increased odds of starting pharmacotherapy using variable selection techniques and logistic regression. We then identified the most significant factors associated with changes in POTS treatment strategies using variable selection techniques and negative binomial regression modeling. A significance level of 0.05 was utilized. Results A total of 752 POTS-specific treatment courses were cataloged, and 429 treatment changes were observed. The most cited reason for a change in management was uncontrolled symptoms. History of migraine headaches, reported fatigue, reported palpitations and a previous POTS diagnosis at an outside institution were found to be associated with a higher odds of starting pharmacotherapy for POTS symptoms (Odds Ratio of 2.40, 1.94, 2.62, 2.08, respectively). History of migraine headaches, reported fatigue, and higher heart rate differences on tilt table examination were found to be associated with an increase in the rate of POTS treatment changes (44, 66, 13% increase in incidence rate, respectively), while reported neck pain was associated with a decrease (27% decrease in incidence rate). Conclusion Our work identifies important areas of focus in the development of high-quality trials involving both the non-pharmacological and pharmacological treatment of POTS and highlights several characteristics of patients that may be more refractory to both baseline non-pharmacological treatments and current pharmacological treatment strategies.
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Affiliation(s)
| | - Ryan X. Zhang
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | | | - Amy S. Nowacki
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, United States
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Tamanna Singh
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, United States
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Robert Wilson
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, United States
- Department of Neuromuscular Medicine, Cleveland Clinic Foundation, Cleveland, OH, United States
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Peebles KC, Jacobs C, Makaroff L, Pacey V. The use and effectiveness of exercise for managing postural orthostatic tachycardia syndrome in young adults with joint hypermobility and related conditions: A scoping review. Auton Neurosci 2024; 252:103156. [PMID: 38401460 DOI: 10.1016/j.autneu.2024.103156] [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: 11/02/2023] [Revised: 02/06/2024] [Accepted: 02/10/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE Postural Orthostatic Tachycardia Syndrome (POTS) is a form of dysautonomia. It may occur in isolation, but frequently co-exists in individuals with hypermobile variants of Ehlers-Danlos Syndrome (EDS) and related conditions (chronic fatigue syndrome [CFS] and fibromyalgia). Exercise is recommended for non-pharmacological POTS management but needs to be individualised. This scoping review explores the current literature on use and effectiveness of exercise-based management for POTS, with specific focus on individuals with joint hypermobility and related conditions who experience hypermobility, and/or pain, and/or fatigue. METHODS A systematic search, to January 2023, of Medline, EMBASE, AMED, CINAHL and the Cochrane library was conducted. Studies that reported on adolescents and adults who had been diagnosed with POTS using standard criteria and underwent an exercise-based training intervention were included. RESULTS Following full-text screening, 10 articles were identified (2 randomised control trials, 4 comparative studies and 4 case reports). One comparative study reported a small subset of participants with EDS and one case report included an individual diagnosed with CFS; the remainder investigated a wider POTS population. Overall, 3 months of endurance followed by resistance exercise, graduating from the horizontal-to-upright position reduced POTS symptoms and improved quality-of-life. CONCLUSION The findings highlight a paucity of higher-level studies documenting exercise for POTS management in people with joint hypermobility and related conditions. Results from the wider POTS population demonstrate exercise is safe and effective. Large, well-designed clinical studies exploring exercise for POTS management adapting to meet the complex musculoskeletal and non-musculoskeletal features of symptomatic joint hypermobility are needed.
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Affiliation(s)
- Karen C Peebles
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.
| | - Charl Jacobs
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Logan Makaroff
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Verity Pacey
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
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Seeley MC, Gallagher C, Lau DH. Emerging Role of Autonomic Modulation by Transcutaneous Vagus Nerve Stimulation: Electrifying Hope in POTS? JACC Clin Electrophysiol 2024; 10:356-358. [PMID: 38300209 DOI: 10.1016/j.jacep.2023.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/29/2023] [Indexed: 02/02/2024]
Affiliation(s)
- Marie-Claire Seeley
- Australian Dysautonomia and Arrhythmia Research Collaborative, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Celine Gallagher
- Australian Dysautonomia and Arrhythmia Research Collaborative, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Dennis H Lau
- Australian Dysautonomia and Arrhythmia Research Collaborative, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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Knoop I, Jones ASK, Gall N, Chilcot J, Pascoe W, Moss-Morris R. Validation of symptom measures in patients under investigation for postural orthostatic tachycardia syndrome (POTS): The Orthostatic Grading Scale (OGS) and the Symptom Screen for Small-fiber Polyneuropathy (SSS). Auton Neurosci 2023; 250:103130. [PMID: 37976608 DOI: 10.1016/j.autneu.2023.103130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/20/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES Postural Orthostatic Tachycardia Syndrome (POTS) presents with a range of poorly delineated symptoms across several domains. There is an urgent need for standardized symptom reporting in POTS, but a lack of validated symptom burden instruments. Our aim was to evaluate the psychometric properties of two symptom burden measures: the Orthostatic Grading Scale (OGS) and the Symptom Screen for Small-Fiber Polyneuropathy (SSS), in patients under investigation for suspected POTS. DESIGN Psychometric validation study. METHODS Confirmatory factor analysis (CFA) tested the factor structure of the SSS and OGS completed by 149 patients under investigation for POTS. Scale reliability and validity were assessed. The uni-dimensionality of the SSS was assessed through principal component analysis (PCA). RESULTS CFA of the OGS revealed that a 1-factor structure had adequate fit. CFA of the SSS revealed that a 5-factor structure had generally appropriate fit supporting the originally proposed 5 factors (1: Gastrointestinal, 2: Somatosensory, 3: Miscellaneous, 4: Microvascular, and 5: Urological). In addition, the SSS demonstrated sufficient uni-dimensionality in the PCA, warranting use of a single total score. Omega coefficients of both measures indicated satisfactory internal reliability (0.668-0.931). Correlations with related constructs (distress (K10 score), r = 0.317-0.404, p < 0.001) and heart rate indices (with the OGS, r = 0.211-0.294, p < 0.05) suggested sound convergent and divergent validity. CONCLUSIONS Initial evidence suggests that the OGS and SSS have good psychometric properties for use in populations with suspected and confirmed POTS.
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Affiliation(s)
- Iris Knoop
- Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - Annie S K Jones
- Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - Nicholas Gall
- Cardiology Department, King's College Hospital, London, United Kingdom
| | - Joseph Chilcot
- Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - William Pascoe
- Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - Rona Moss-Morris
- Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom.
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Seeley MC, Gallagher C, Ong E, Langdon A, Chieng J, Bailey D, Dennis A, McCaffrey N, Lau DH. Poor health-related quality of life in postural orthostatic tachycardia syndrome in comparison with a sex- and age-matched normative population. Clin Auton Res 2023; 33:469-477. [PMID: 37338634 PMCID: PMC10439037 DOI: 10.1007/s10286-023-00955-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 05/18/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE The effect of postural orthostatic tachycardia syndrome (POTS) on health-related quality of life (HrQoL) remains poorly studied. Here, we sought to compare the HrQoL in individuals with POTS to a normative age-/sex-matched population. METHODS Participants enrolled in the Australian POTS registry between 5 August 2021 and 30 June 2022 were compared with propensity-matched local normative population data from the South Australian Health Omnibus Survey. The EQ-5D-5L instrument was used to assess HrQoL across the five domains (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) with global health rating assessed with a visual analog scale (EQ-VAS). A population-based scoring algorithm was applied to the EQ-5D-5L data to calculate utility scores. Hierarchical multiple regression analyses were undertaken to explore predictors of low utility scores. RESULTS A total of 404 participants (n = 202 POTS; n = 202 normative population; median age 28 years, 90.6% females) were included. Compared with the normative population, the POTS cohort demonstrated significantly higher burden of impairment across all EQ-5D-5L domains (all P < 0.001), lower median EQ-VAS (p < 0.001), and lower utility scores (p < .001). The lower EQ-VAS and utility scores in the POTS cohort were universal in all age groups. Severity of orthostatic intolerance symptoms, female sex, fatigue scores, and comorbid diagnosis of myalgic encephalomyelitis/chronic fatigue syndrome were independent predictors of reduced HrQoL in POTS. The disutility in those with POTS was lower than many chronic health conditions. CONCLUSIONS This is the first study to demonstrate significant impairment across all subdomains of EQ-5D-5L HrQoL in the POTS cohort as compared with a normative population. TRIAL REGISTRATION ACTRN12621001034820.
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Affiliation(s)
- Marie-Claire Seeley
- Australian Dysautonomia and Arrhythmia Research Collaborative, The University of Adelaide, Adelaide, Australia
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Celine Gallagher
- Australian Dysautonomia and Arrhythmia Research Collaborative, The University of Adelaide, Adelaide, Australia
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Eric Ong
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Amy Langdon
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Jonathan Chieng
- Australian Dysautonomia and Arrhythmia Research Collaborative, The University of Adelaide, Adelaide, Australia
| | - Danielle Bailey
- Australian Dysautonomia and Arrhythmia Research Collaborative, The University of Adelaide, Adelaide, Australia
| | - Annabelle Dennis
- Australian Dysautonomia and Arrhythmia Research Collaborative, The University of Adelaide, Adelaide, Australia
| | - Nikki McCaffrey
- Deakin Health Economics, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Melbourne, VIC, Australia
| | - Dennis H Lau
- Australian Dysautonomia and Arrhythmia Research Collaborative, The University of Adelaide, Adelaide, Australia.
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia.
- Department of Cardiology, Royal Adelaide Hospital, 1 Port Road, Adelaide, SA, 5000, Australia.
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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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Seeley MC, Gallagher C, Ong E, Langdon A, Chieng J, Bailey D, Page A, Lim HS, Lau DH. High incidence of autonomic dysfunction and postural orthostatic tachycardia syndrome in patients with long-COVID: Implications for management and healthcare planning. Am J Med 2023:S0002-9343(23)00402-3. [PMID: 37391116 PMCID: PMC10307671 DOI: 10.1016/j.amjmed.2023.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Autonomic dysfunction including postural orthostatic tachycardia syndrome (POTS) has been reported in individuals with post-acute sequelae of Covid-19 (PASC). However, the degree of dysautonomia in PASC has not been compared to those with POTS and healthy controls. METHODS All participants were prospectively enrolled between 5th August 2021 and 31st October 2022. Autonomic testing included beat-to-beat hemodynamic monitoring to assess respiratory sinus arrhythmia, Valsalva ratio and orthostatic changes during a 10-minute active standing test as well as Sudomotor assessment. The Composite Autonomic Symptom Score (COMPASS-31) was used to assess symptoms and the Euroquol 5-Dimension survey (EQ-5D-5L) was used to assess health-related quality of life (HrQoL) measures. RESULTS A total of 99 participants (n=33 PASC, n=33 POTS and n=33 healthy controls; median age 32 [18], 85.9% females) were included. Compared to healthy controls, the PASC and POTS cohorts demonstrated significantly reduced respiratory sinus arrhythmia (p<0.001), greater heart rate increase during 10-minute active standing test (p<0.001), greater burden of autonomic dysfunction evidenced by higher COMPASS-31 scores across all subdomains (all p<0.001) and poor HrQoL across all EQ-5D-5L domains (all p<0.001), lower median EQ-VAS (p<0.001) and lower utility scores (p<0.001). The majority (79%) of those with PASC met the internationally established criteria for POTS. CONCLUSION The prevalence of autonomic symptomology or POTS was high in those with PASC, leading to poor HrQoL and high health disutility. Autonomic testing should be routinely undertaken in those with PASC to aid diagnosis and direct appropriate management to improve health outcomes. TRIAL REGISTRATION ANZCTR 12621000476831.
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Affiliation(s)
- Marie-Claire Seeley
- Australian Dysautonomia and Arrhythmia Research Collaborative, Faculty of Health and Medical Sciences, The University of Adelaide; South Australian Health and Medical Research Institute
| | - Celine Gallagher
- Australian Dysautonomia and Arrhythmia Research Collaborative, Faculty of Health and Medical Sciences, The University of Adelaide; South Australian Health and Medical Research Institute
| | - Eric Ong
- Australian Dysautonomia and Arrhythmia Research Collaborative, Faculty of Health and Medical Sciences, The University of Adelaide; College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Amy Langdon
- Australian Dysautonomia and Arrhythmia Research Collaborative, Faculty of Health and Medical Sciences, The University of Adelaide; College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Jonathan Chieng
- Australian Dysautonomia and Arrhythmia Research Collaborative, Faculty of Health and Medical Sciences, The University of Adelaide
| | - Danielle Bailey
- Australian Dysautonomia and Arrhythmia Research Collaborative, Faculty of Health and Medical Sciences, The University of Adelaide
| | - Amanda Page
- Australian Dysautonomia and Arrhythmia Research Collaborative, Faculty of Health and Medical Sciences, The University of Adelaide; South Australian Health and Medical Research Institute; College of Medicine and Public Health, Flinders University, South Australia, Australia; The University of Melbourne, Austin and Northern Health, Victoria, Australia
| | - Han S Lim
- The University of Melbourne, Austin and Northern Health, Victoria, Australia
| | - Dennis H Lau
- Australian Dysautonomia and Arrhythmia Research Collaborative, Faculty of Health and Medical Sciences, The University of Adelaide; South Australian Health and Medical Research Institute.
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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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Tv P, Tran TT, Hao HT, Hau NTH, Jain N, Reinis A. Postural orthostatic tachycardia syndrome-like symptoms following COVID-19 vaccination: An overview of clinical literature. Hum Antibodies 2023:HAB220013. [PMID: 37248893 DOI: 10.3233/hab-220013] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Postural Orthostatic Tachycardia Syndrome (POTS) is a common condition affecting more than 170 people per 100,000 population. However, POTS following COVID-19 vaccination remains a rare reporting in the medical literature. OBJECTIVE We, herein, summarize and highlight the evidence that has been reported regarding POTS-like symptoms following COVID-19 vaccination. METHODS We conducted a literature search and summarized the findings in the form of a narrative commentary. All types of publications (case reports/series, original articles, letters to editors, brief communications etc.) in English language were included. RESULTS Whilst the exact pathogenetic mechanism behind POTS is yet to elucidated, there has been increasing evidence pointing towards an autoimmune dysfunction. Females were found to be predominantly affected (72%) with age range from 17 years to 52 years. Additionally, it seems that POTS-like symptoms could be triggered after immunization with Pfizer- BioNTech, Moderna, and Oxford-AstraZeneca COVID-19 vaccines. The symptoms typically appear within the first week, depending upon previous exposure to the virus and presence of other systemic conditions. In some patients, the condition is self-resolving. However, in others, non-pharmacological interventions coupled with negative ionotropic medications can be used for symptomatic management of the patients. CONCLUSIONS Timely diagnosis and proper treatment are quintessential for ensuring early alleviation (and in some cases complete resolution) of symptoms. Furthermore, there may be episodes of relapse. Overall prognosis of the new-onset POTS-like symptoms is difficult to predict based on current literature.
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Affiliation(s)
- Phu Tv
- Faculty of Medicine, Trà Vinh University, Trà Vinh, Vietnam
| | - Thu Thao Tran
- Faculty of Medicine, Can Tho University of Medicine and Pharmacy, SC\̀acircumflexn Th, Vietnam
| | | | - Nguyen Thi Hien Hau
- Faculty of Medicine, College of Medicine and Pharmacy, Duy Tan University, Danang, Vietnam
| | - Nityanand Jain
- Faculty of Medicine, Riga Stradinš University, Riga, Latvia
| | - Aigars Reinis
- Department of Biology and Microbiology, Riga Stradinš University, Riga, Latvia
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12
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Vasavada AM, Verma D, Sheggari V, Ghetiya S, Chirumamilla PC, Kotak RA, Mahapatra SS, Patel T, Jain M. Choices and Challenges With Drug Therapy in Postural Orthostatic Tachycardia Syndrome: A Systematic Review. Cureus 2023; 15:e38887. [PMID: 37313107 PMCID: PMC10259876 DOI: 10.7759/cureus.38887] [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] [Accepted: 05/11/2023] [Indexed: 06/15/2023] Open
Abstract
The literature on pharmacologic treatments for postural orthostatic tachycardia syndrome (POTS) is inconsistent and unstandardized. Therefore, we aimed to evaluate choices in pharmacologic treatment options for POTS and the challenges encountered in the studies. We searched numerous databases like PubMed, Scopus, Embase, Web of Science, and Google Scholar for literature published before April 8, 2023. The search was done to retrieve potential peer-reviewed articles that explored drug therapy in POTS. Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines were used to conduct the systematic review. Of the 421 potential articles assessed, 17 met the inclusion criteria. Results demonstrated that pharmacologic treatment options for POTS were effective in reducing symptoms of POTS, but most of the studies were underpowered. Several were terminated due to various reasons. Midodrine ivabradine, bisoprolol, fludrocortisone, droxidopa, desmopressin, propranolol, modafinil, methylphenidate, and melatonin have been studied with positive impact but sample sizes that were low in the range of 10-50 subjects. Therefore, we concluded the treatment options effectively improve symptoms of POTS and increase orthostatic tolerance, but more evidence is needed as most studies had a low sample size and thus are underpowered.
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Affiliation(s)
| | - Deepak Verma
- Internal Medicine, Sri Guru Ram Das Institute Of Medical Sciences and Research, Amritsar, IND
| | - Vineetha Sheggari
- Internal Medicine, Dr Vizarath Rasool Khan (VRK) Women's Medical College, Hyderabad, IND
| | - Srushti Ghetiya
- Internal Medicine, Gujarat Medical and Education Research Society (GMERS) Medical College, Junagadh, IND
| | | | - Radhika A Kotak
- Internal Medicine, DY Patil University, School of Medicine, Navi Mumbai, IND
| | - Shruti Sagar Mahapatra
- Internal Medicine, Srirama Chandra Bhanja (SCB) Medical College and Hospital, Cuttack, IND
| | - Tirath Patel
- Surgery, American University of Antigua, St John's, ATG
| | - Manisha Jain
- Internal Medicine, Shri Bhausaheb Hire Government Medical College, Dhule, IND
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13
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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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14
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Narasimhan B, Aggarwal D, Satish P, Kantharia B, Aronow WS. Postural orthostatic tachycardia syndrome: pathophysiology, management, and experimental therapies. Expert Opin Investig Drugs 2022; 31:1017-1025. [PMID: 36094001 DOI: 10.1080/13543784.2022.2121697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Bharat Narasimhan
- Department of Cardiology, Houston Methodist Debakey Cardiovascular Center, Houston, Tx, USA
| | - Devika Aggarwal
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | - Priyanka Satish
- Department of Cardiology, Houston Methodist Debakey Cardiovascular Center, Houston, Tx, USA
| | - Bharat Kantharia
- Cardiovascular and Heart Rhythm Consultants, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Wilbert S. Aronow
- Department of Cardiology, Westchester Medical center/New York Medical College, Valhalla, NY, USA
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15
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Klaas KM, Fischer PR, Segner S, Tsai Owens M, Fahrenkamp A, Geske J, Hofschulte D, Farrell M, Harbeck-Weber C, Biggs BK. Excessive Postural Tachycardia and Postural Orthostatic Tachycardia Syndrome in Youth: Associations With Distress, Impairment, Health Behaviors, and Medication Recommendations. J Child Neurol 2022; 37:599-608. [PMID: 35585700 DOI: 10.1177/08830738221078410] [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] [Indexed: 11/16/2022]
Abstract
Among adolescents with fatigue and postural dizziness, it is unclear how health behaviors and emotional distress relate to the presence of excessive postural tachycardia. We prospectively evaluated adolescents aged 13-22 years presenting with symptoms suggestive of autonomic dysfunction between September 2017 and December 2018. Patients underwent standard 10-minute, 70-degree head-up tilt testing. Clinician diagnoses and recommendations were recorded from the medical record. Patients completed validated self-report measures of lifestyle factors, autonomic symptoms, depression, anxiety, and functional disability. Of 179 patients, 58 were diagnosed with postural orthostatic tachycardia syndrome and 59 had excessive postural tachycardia, with 90.5% concordance between the 2 groups. Presence of excessive postural tachycardia was associated with greater baseline fluid intake and likelihood of medication prescription in their treatment plan. Medication findings were replicated for postural orthostatic tachycardia syndrome diagnosis. Presence of excessive postural tachycardia or postural orthostatic tachycardia syndrome did not differentiate patients on perceived symptom severity, emotional distress, disability, or health behaviors but did appear to determine treatment recommendations.
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Affiliation(s)
| | - Philip R Fischer
- 6915Mayo Clinic, Rochester, MN, USA.,Department of Pediatrics, 591854Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates.,Khalifa University, Abu Dhabi, United Arab Emirates
| | - Sara Segner
- Department of Pediatrics, 5635University of Minnesota, Minneapolis, MN, USA
| | - Michele Tsai Owens
- Department of Psychiatry, 12250Indiana University School of Medicine, Indianapolis, IN, USA
| | - Amy Fahrenkamp
- Department of Pain, Palliative Care, and Integrative Medicine, 50235Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | | | | | - Michael Farrell
- Department of Pediatrics, 5635University of Minnesota, Minneapolis, MN, USA
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16
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Knoop I, Dunwoody L. “You’re always fighting”: the lived experience of people with postural orthostatic tachycardia syndrome (POTS). Disabil Rehabil 2022; 45:1629-1635. [PMID: 35531943 DOI: 10.1080/09638288.2022.2071482] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE Postural orthostatic tachycardia syndrome (POTS) is a debilitating and poorly understood disorder of the autonomic nervous system with many different causes, mostly seen in females of child-bearing age. This study used an illness representation framework to explore the lived experience of those living with a medical diagnosis of POTS. MATERIALS AND METHODS Six individuals (aged 20-42) were recruited from two POTS online support groups. Individual semi-structured interviews were used to explore the five illness representations of identity, cause, consequences, timelines, and cure/controllability. Data were analysed using interpretative phenomenological analysis (IPA). RESULTS Lived experiences were characterised by four overarching themes: "Fighting to be heard", "My individual self-management toolbox", "A mixed bag of emotions", and "I'm expensive in so many ways". CONCLUSIONS Individuals faced considerable physical, psychosocial and financial challenges and felt underserved by healthcare and support provision. Early diagnosis and recognition of symptoms, along with education on self-management may help reduce associated mental health burdens. A biopsychosocial conceptualisation of this condition may help lead to a more integrated approach to care.Implications for rehabilitationLiving with POTS impacts on all aspects of life, including work, family, and social relationships/activities, and has financial burdens.Family doctors need education on the existence of POTS and the importance of providing biopsychosocial support services.More timely diagnosis of POTS is required, with access to specialists who understand the burden of living with POTS.
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Affiliation(s)
- Iris Knoop
- School of Psychology, Ulster University, Coleraine, UK
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17
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Parker WH, Moudgil R, Wilson RG, Tonelli AR, Mayuga KA, Singh TK. COVID-19 and postural tachycardia syndrome: a case series. Eur Heart J Case Rep 2021; 5:ytab325. [PMID: 34993394 PMCID: PMC8716749 DOI: 10.1093/ehjcr/ytab325] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/09/2021] [Accepted: 07/22/2021] [Indexed: 01/25/2023]
Abstract
Background Postural tachycardia syndrome (PTS) is a novel identified sequela of COVID-19 infection. This observational study describes clinical presentation, testing, and treatment response in seven patients diagnosed with PTS following COVID-19 infection. Case summary A total of seven active patients (three collegiate athletes, one recreational athlete, two registered nurses, one hospitality employee), age 24 ± 6 years, and six females were followed for a mean of 152 ± 105 days after contracting COVID-19. Tilt table was performed to establish the diagnosis. The most common presenting symptoms were palpitations (7/7), dyspnoea (6/7), and gastrointestinal complaints (5/7). One patient required hospitalization for symptom management. The mean latency of PTS onset following COVID-19 was 21 ± 15 days. Electrocardiograms (ECGs) demonstrated sinus rhythm in all patients, one with resting sinus tachycardia. Echocardiogram demonstrated normal systolic and diastolic left ventricular function in all patients. On tilt table testing, baseline heart rate (HR) was 72 ± 12 with maximum HR reaching 136 ± 13. Six of seven patients failed to respond to supportive therapy alone, and two patients failed medical management with ivabradine, midodrine, and/or metoprolol. Of three severely symptomatic patients, two demonstrated some degree of clinical recovery with intravenous immunoglobulin (IVIG). Discussion This novel case series describes the development of PTS in the context of COVID-19 infection. Severity of symptoms and response to treatment was heterogeneous. Interestingly, patients were poorly responsive to traditional PTS treatments, but IVIG showed potential as a possible therapeutic strategy for refractory PTS in two patients, particularly following COVID-19 infection.
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Affiliation(s)
- William H Parker
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave, Desk J2-4, Cleveland, OH 44195, USA
| | - Rohit Moudgil
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave, Desk J2-4, Cleveland, OH 44195, USA
| | - Robert G Wilson
- Neuromuscular Center, Neurology Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, USA
| | - Adriano R Tonelli
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, USA
| | - Kenneth A Mayuga
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave, Desk J2-4, Cleveland, OH 44195, USA
| | - Tamanna K Singh
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave, Desk J2-4, Cleveland, OH 44195, USA
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18
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Seeley MC, Thynne TR, Braund WJ, Worthley DL, Gallagher C, Sanders P, Lau DH. Desmopressin as a Novel Long-Term Treatment in Postural Tachycardia Syndrome Patients with Polyuria. Am J Med 2021; 134:e486-e487. [PMID: 33865825 DOI: 10.1016/j.amjmed.2021.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 03/14/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Marie-Claire Seeley
- Centre for Heart Rhythm Disorders, University of Adelaide and Department of Cardiology, Royal Adelaide Hospital, South Australia
| | - Tilenka R Thynne
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia
| | - Wilton J Braund
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia
| | | | - Celine Gallagher
- Centre for Heart Rhythm Disorders, University of Adelaide and Department of Cardiology, Royal Adelaide Hospital, South Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Department of Cardiology, Royal Adelaide Hospital, South Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide and Department of Cardiology, Royal Adelaide Hospital, South Australia.
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19
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Raj SR, Bourne KM, Stiles LE, Miglis MG, Cortez MM, Miller AJ, Freeman R, Biaggioni I, Rowe PC, Sheldon RS, Shibao CA, Diedrich A, Systrom DM, Cook GA, Doherty TA, Abdallah HI, Grubb BP, Fedorowski A, Stewart JM, Arnold AC, Pace LA, Axelsson J, Boris JR, Moak JP, Goodman BP, Chémali KR, Chung TH, Goldstein DS, Darbari A, Vernino S. Postural orthostatic tachycardia syndrome (POTS): Priorities for POTS care and research from a 2019 National Institutes of Health Expert Consensus Meeting - Part 2. Auton Neurosci 2021; 235:102836. [PMID: 34246578 PMCID: PMC8455430 DOI: 10.1016/j.autneu.2021.102836] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/14/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022]
Abstract
The National Institutes of Health hosted a workshop in 2019 to build consensus around the current state of understanding of the pathophysiology of postural orthostatic tachycardia syndrome (POTS) and to identify knowledge gaps that must be addressed to enhance clinical care of POTS patients through research. This second (of two) articles summarizes current knowledge gaps, and outlines the clinical and research priorities for POTS. POTS is a complex, multi-system, chronic disorder of the autonomic nervous system characterized by orthostatic intolerance and orthostatic tachycardia without hypotension. Patients often experience a host of other related disabling symptoms. The functional and economic impacts of this disorder are significant. The pathophysiology remains incompletely understood. Beyond the significant gaps in understanding the disorder itself, there is a paucity of evidence to guide treatment which can contribute to suboptimal care for this patient population. The vast majority of physicians have minimal to no familiarity or training in the assessment and management of POTS. Funding for POTS research remains very low relative to the size of the patient population and impact of the syndrome. In addition to efforts to improve awareness and physician education, an investment in research infrastructure including the development of standardized disease-specific evaluation tools and outcome measures is needed to facilitate effective collaborative research. A national POTS research consortium could facilitate well-controlled multidisciplinary clinical research studies and therapeutic trials. These priorities will require a substantial increase in the number of research investigators and the amount of research funding in this area.
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Affiliation(s)
- 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.
| | - 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
| | - 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, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of 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, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andre Diedrich
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine and Biomedical Engineering, 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
| | | | - 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
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, PA, 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 University 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
| | - Anil Darbari
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Steven Vernino
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
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20
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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: 5] [Impact Index Per Article: 1.7] [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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21
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Seeley MC, Lau DH. Raising the bar in postural orthostatic tachycardia syndrome research: Evidence and challenges. Auton Neurosci 2021; 233:102790. [PMID: 33714702 DOI: 10.1016/j.autneu.2021.102790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Marie-Claire Seeley
- Centre for Heart Rhythm Disorders, University of Adelaide and Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide and Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia.
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22
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Davido B, Seang S, Barizien N, Tubiana R, de Truchis P. 'Post-COVID-19 chronic symptoms' - Author's reply. Clin Microbiol Infect 2021; 27:495-496. [PMID: 32898714 PMCID: PMC7474820 DOI: 10.1016/j.cmi.2020.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Benjamin Davido
- Maladies Infectieuses, Hôpital Universitaire Raymond-Poincaré, AP-HP, Garches, France.
| | - Sophie Seang
- Maladies Infectieuses, Hôpital Universitaire Pitié Salpêtrière, AP-HP, Paris, France
| | - Nicolas Barizien
- Médecine Physique et Réadaptation, Hôpital Foch, Suresnes, France
| | - Roland Tubiana
- Maladies Infectieuses, Hôpital Universitaire Pitié Salpêtrière, AP-HP, Paris, France
| | - Pierre de Truchis
- Maladies Infectieuses, Hôpital Universitaire Raymond-Poincaré, AP-HP, Garches, France
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23
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Wells R, Malik V, Brooks AG, Linz D, Elliott AD, Sanders P, Page A, Baumert M, Lau DH. Cerebral Blood Flow and Cognitive Performance in Postural Tachycardia Syndrome: Insights from Sustained Cognitive Stress Test. J Am Heart Assoc 2020; 9:e017861. [PMID: 33280488 PMCID: PMC7955388 DOI: 10.1161/jaha.120.017861] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background The physiology underlying "brain fog" in the absence of orthostatic stress in postural tachycardia syndrome (POTS) remains poorly understood. Methods and Results We evaluated cognitive and hemodynamic responses (cardiovascular and cerebral: heart rate, blood pressure, end‐tidal carbon dioxide, and cerebral blood flow velocity (CBFv) in the middle cerebral artery at baseline, after initial cognitive testing, and after (30‐minutes duration) prolonged cognitive stress test (PCST) whilst seated; as well as after 5‐minute standing in consecutively enrolled participants with POTS (n=22) and healthy controls (n=18). Symptom severity was quantified with orthostatic hypotensive questionnaire at baseline and end of study. Subjects in POTS and control groups were frequency age‐ and sex‐matched (29±11 versus 28±13 years; 86 versus 72% women, respectively; both P≥0.4). The CBFv decreased in both groups (condition, P=0.04) following PCST, but a greater reduction in CBFv was observed in the POTS versus control group (−7.8% versus −1.8%; interaction, P=0.038). Notably, the reduced CBFv following PCST in the POTS group was similar to that seen during orthostatic stress (60.0±14.9 versus 60.4±14.8 cm/s). Further, PCST resulted in greater slowing in psychomotor speed (6.1% versus 1.4%, interaction, P=0.027) and a greater increase in symptom scores at study completion (interaction, P<0.001) in the patients with POTS, including increased difficulty with concentration. All other physiologic responses (blood pressure and end‐tidal carbon dioxide) did not differ between groups after PCST (all P>0.05). Conclusions Reduced CBFv and cognitive dysfunction were evident in patients with POTS following prolonged cognitive stress even in the absence of orthostatic stress.
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Affiliation(s)
- Rachel Wells
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia.,Department of Medicine Royal Adelaide Hospital Adelaide Australia
| | - Varun Malik
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia.,Department of Cardiology Royal Adelaide Hospital Adelaide Australia
| | - Anthony G Brooks
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia
| | - Dominik Linz
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia.,Department of Cardiology Royal Adelaide Hospital Adelaide Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia.,Department of Cardiology Royal Adelaide Hospital Adelaide Australia
| | - Amanda Page
- Centre for Nutrition and Gastrointestinal Diseases The University of Adelaide Adelaide Australia
| | - Mathias Baumert
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia.,School of Electrical and Electronic Engineering The University of Adelaide Adelaide Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia.,Department of Cardiology Royal Adelaide Hospital Adelaide Australia
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24
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Hasan B, Almasri J, Marwa B, Klaas KM, Fischer PR. Treatment of Postural Orthostatic Tachycardia Syndrome With Medication: A Systematic Review. J Child Neurol 2020; 35:1004-1016. [PMID: 32838632 DOI: 10.1177/0883073820948679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Postural orthostatic tachycardia syndrome has been recognized for decades, but treatment is largely based on anecdotal experience and expert opinion. Pharmacologic treatment is inconsistent and unstandardized. We did a systematic review to identify controlled studies from which informed treatment decisions can be made. METHOD Through a standard systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we identified all English-language studies of a medication treatment for postural orthostatic tachycardia syndrome that included a comparison or control group and followed outcomes for at least 1 week of treatment. RESULTS A total of 626 studies were identified by the search criteria, and 8, involving a total of 499 patients, met the criteria. No studies were adequately similar to allow for meta-analysis. Of the identified 8 studies, 2 were randomized controlled trials and 4 had been subjected to peer review. In individual studies, there was some favorable effect with fludrocortisone, beta blockers, midodrine, and selective serotonin reuptake inhibitors. CONCLUSION There is a paucity of high-quality data about effectiveness of medication in the treatment of postural orthostatic tachycardia syndrome. Nonetheless, 2 randomized trials and 6 other reports show some favorable effects of medication.
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Affiliation(s)
- Bashar Hasan
- Evidence-Based Practice Research Program, 6915Mayo Clinic, MN, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 6915Mayo Clinic, MN, USA
| | - Jehad Almasri
- Evidence-Based Practice Research Program, 6915Mayo Clinic, MN, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 6915Mayo Clinic, MN, USA.,Department of Internal Medicine, 14463Piedmont Athens Regional Hospital, Athens, GA
| | - Bilal Marwa
- Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kelsey M Klaas
- Department of Pediatric and Adolescent Medicine, 6915Mayo Clinic, Rochester, Minnesota, USA
| | - Philip R Fischer
- Department of Pediatric and Adolescent Medicine, 6915Mayo Clinic, Rochester, Minnesota, USA
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25
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Treatment Updates in Postural Tachycardia Syndrome. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00643-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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26
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Gierthmühlen J, Baron R. [Syncopes]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2020; 88:532-546. [PMID: 32818974 DOI: 10.1055/a-1165-7184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Syncopes are defined as sudden and short unconsciousness with loss of muscular tonus which are reversible without further intervention. Differentiation from other short-lasting changes of consciousness as in seizures, blood flow abnormalities of brainstem, metabolic disorders, intoxication or traumatic loss of consciousness is important for further diagnostic and adequate treatment.
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27
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Time Course of Autonomic Symptoms in Postural Orthostatic Tachycardia Syndrome (POTS) Patients: Two-Year Follow-Up Results. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17165872. [PMID: 32823577 PMCID: PMC7460485 DOI: 10.3390/ijerph17165872] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 11/16/2022]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a multifactorial condition capable of chronically reducing the quality of life and the work ability of patients. The study aim was to assess the burden of autonomic symptoms in a cohort of POTS patients over 2 years. Patients’ clinical profiles were assessed by the 31-item Composite Autonomic Symptom Score questionnaire (COMPASS 31) and a visual analog scale (VAS). One-way ANOVA for repeated measures followed by Dunnett’s post-hoc test were used to compare symptoms at baseline and at 1 and 2 years. Out of 42 enrolled patients, 25 had a 1-year follow-up and 12 had a 2-year follow-up. At baseline, the reported burden of autonomic symptoms was high (overall COMPASS 31 = 49.9 ± 14.3 /100). Main complaints were related to orthostatic intolerance according to both COMPASS 31 and VAS. Fourteen patients were rendered inactive because of symptoms. At 1-year follow-up, a statistically significant improvement in pupillomotor function and overall score was detected by the COMPASS 31. These findings were confirmed at 2 years, together with a significant reduction in quality of life impairment, assessed by VAS. However, these improvements did not change patients’ occupational status. Awareness of POTS diagnosis, patient monitoring, and tailored therapies can help to improve patients’ condition.
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28
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Zhang Q, Xu B, Du J. Update of Individualized Treatment Strategies for Postural Orthostatic Tachycardia Syndrome in Children. Front Neurol 2020; 11:525. [PMID: 32655482 PMCID: PMC7325969 DOI: 10.3389/fneur.2020.00525] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 05/13/2020] [Indexed: 11/13/2022] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a heterogeneous disease that predominantly affects children and adolescents. There is a great difference between children and adults in the diagnosis and treatment of POTS patients. POTS in children and adolescents is marked by chronic symptoms of orthostatic intolerance with a heart rate (HR) rise of ≥40 bpm, or heart rate exceeding 130 bpm for 6-12-years-old children and exceeding 125 bpm for those 13-18 years old without orthostatic hypotension, which is different from adult patients. The three major clinical forms of POTS include hypovolemic POTS, neuropathic POTS, and hyperadrenergic POTS; these are distinguished by their major mechanisms. The different subtypes of POTS in children and adolescents each have their own clinical characteristics and biomarkers. Based on these, we propose individualized treatment strategies. Individualized management strategies based on different subtypes of POTS would largely improve the curative effects of drugs for children with POTS. However, a further clinical investigation is still required to better understand the pathophysiology and treatment options.
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Affiliation(s)
- Qingyou Zhang
- 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
| | - Bowen Xu
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, China
- Key Laboratory of Molecular Cardiovascular Sciences, The Ministry of Education, Beijing, China
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29
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Wells R, Hissaria P, Elliott AD, Sanders P, Page A, Baumert M, Lau DH. Plasma Exchange Therapy in Postural Tachycardia Syndrome: A Novel Long-Term Approach? Am J Med 2020; 133:e157-e159. [PMID: 31715171 DOI: 10.1016/j.amjmed.2019.10.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/03/2019] [Accepted: 10/03/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Rachel Wells
- Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Department of Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Pravin Hissaria
- Department of Immunology, Royal Adelaide Hospital, Adelaide, South Australia, Australia; SA Pathology, Adelaide, South Australia, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Amanda Page
- Department of Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Centre for Nutrition and Gastrointestinal Diseases, University of Adelaide, Adelaide, South Australia, Australia
| | - Mathias Baumert
- School of Electrical and Electronic Engineering, University of Adelaide, Adelaide, South Australia, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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30
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Wells R, Paterson F, Bacchi S, Page A, Baumert M, Lau DH. Brain fog in postural tachycardia syndrome: An objective cerebral blood flow and neurocognitive analysis. J Arrhythm 2020; 36:549-552. [PMID: 32528589 PMCID: PMC7280003 DOI: 10.1002/joa3.12325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/15/2020] [Accepted: 02/19/2020] [Indexed: 11/07/2022] Open
Abstract
Background It remains unclear whether brain fog is related to impaired cerebral blood flow (CBF) in postural tachycardia syndrome (POTS) patients. Methods We assessed CBF in the posterior cerebral artery (PCA) using transcranial Doppler with visual stimuli in 11 POTS and 8 healthy subjects in the seated position, followed by neurocognitive testing. Results CBF parameters were similar between the two groups. POTS patients demonstrated significantly longer latency in delayed match to sample response time and greater errors in attention switching task. Conclusions Impaired short-term memory and alertness may underlie the symptom of brain fog in POTS patients, despite normal CBF.
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Affiliation(s)
- Rachel Wells
- Department of Medicine Royal Adelaide Hospital Adelaide SA Australia.,Centre for Heart Rhythm Disorders University of Adelaide Adelaide SA Australia.,Centre for Nutrition and Gastrointestinal Disease University of Adelaide Adelaide SA Australia
| | - Felix Paterson
- Department of Radiology Royal Adelaide Hospital Adelaide SA Australia
| | - Stephen Bacchi
- Department of Medicine Royal Adelaide Hospital Adelaide SA Australia
| | - Amanda Page
- Centre for Nutrition and Gastrointestinal Disease University of Adelaide Adelaide SA Australia.,Nutrition and Metabolism South Australian Health and Medical Research Institute (SAHMRI) Adelaide SA Australia
| | - Mathias Baumert
- Centre for Heart Rhythm Disorders University of Adelaide Adelaide SA Australia.,School of Electrical and Electronic Engineering University of Adelaide Adelaide SA Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders University of Adelaide Adelaide SA Australia.,Department of Cardiology Royal Adelaide Hospital Adelaide SA Australia
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31
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High Submaximal Exercise Heart Rate Impacts Exercise Intolerance in the Postural Orthostatic Tachycardia Syndrome. J Cardiopulm Rehabil Prev 2020; 40:195-201. [PMID: 31972631 DOI: 10.1097/hcr.0000000000000485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE Exercise intolerance is a hallmark of the postural orthostatic tachycardia syndrome (POTS). However, no data are available on the implications of an exaggerated submaximal heart rate (HR) on exercise intolerance in patients. We investigated whether exaggerated HR responses occurring early on during incremental stress testing relate with increased odds of POTS and exercise intolerance. METHODS Clinical characteristics and stress test HRs were compared between adults with POTS achieving ≥85% predicted metabolic equivalents (METs) (EX-TL, n = 101; body mass index [BMI] 24 ± 5 kg·m; 95% women) or <85% (EX-INTL, n = 71; BMI 28 ± 7 kg·m; 79% women) and sedentary controls (n = 30; BMI 36 ± 3 kg·m; 87% women). Multivariate logistic regressions were performed to estimate ORs and the probability of POTS and exercise intolerance associated with exercise HRs. RESULTS Exercise tolerance was increased in EX-TL, but not in EX-INTL (10.0 ± 1.3 and 8.3 ± 1.5 METs vs 8.0 ± 1.6 METs, respectively) versus controls. Absolute peak HR was increased in EX-TL and EX-INTL versus controls (P < .01), whereas percent predicted did not differ. Exercise within the first-to-second stress stages was performed at exaggerated HRs (122 ± 17 bpm vs 103 ± 15 and 113 ± 15 bpm, P < .001) and percent HR reserve in EX-INTL versus controls and EX-TL (49% ± 12% vs 34% ± 11% and 41% ± 11%, P < .001), respectively. In multivariate analyses, peak HR was not significant, whereas increased submaximal HR (either variable) was associated with increased odds of EX-TL or EX-INTL. Lastly, odds of EX-INTL increased as METs decreased, whereas METs was not a predictor of EX-TL. CONCLUSIONS An exaggerated submaximal exercise HR is predictive of POTS and exercise intolerance, and this chronotropic phenotype is exacerbated in patients achieving <85% predicted METs.
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32
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Junghans-Rutelonis AN, Postier A, Warmuth A, Schwantes S, Weiss KE. Pain Management In Pediatric Patients With Postural Orthostatic Tachycardia Syndrome: Current Insights. J Pain Res 2019; 12:2969-2980. [PMID: 31802934 PMCID: PMC6827519 DOI: 10.2147/jpr.s194391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 09/21/2019] [Indexed: 11/23/2022] Open
Abstract
Pediatric patients with postural orthostatic tachycardia syndrome (POTS) often present with co-occurring struggles with chronic pain (POTS+pain) that may limit daily activities. POTS is a clinical syndrome characterized by orthostatic symptoms and excessive postural tachycardia without orthostatic hypotension. Active research from the medical and scientific community has led to controversy over POTS diagnosis and treatment, yet patients continue to present with symptoms associated with POTS+pain, making treatment recommendations critical. This topical review examines the literature on diagnosing and treating pediatric POTS+pain and the challenges clinicians face. Most importantly, clinicians must employ an interdisciplinary team approach to determine the ideal combination of pharmacologic (e.g., fludrocortisone), non-pharmacologic (e.g., physical therapy, integrative medicine), and psychological (e.g., cognitive behavioral therapy, psychoeducation) treatment approaches that acknowledge the complexity of the child's condition, while simultaneously tailoring these approaches to the child's personal needs. We provide recommendations for treatment for youth with POTS+pain based on the current literature.
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Affiliation(s)
- Ashley N Junghans-Rutelonis
- Department of Pain Medicine, Palliative Care, and Integrative Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | - Andrea Postier
- Department of Pain Medicine, Palliative Care, and Integrative Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA.,Children's Minnesota Research Institute, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | - Andrew Warmuth
- Department of Pain Medicine, Palliative Care, and Integrative Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA.,Department of Physical Medicine and Rehabilitation, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | - Scott Schwantes
- Department of Pain Medicine, Palliative Care, and Integrative Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | - Karen E Weiss
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine & Seattle Children's Hospital, Seattle, DC, USA
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33
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Fedorowski A. Postural orthostatic tachycardia syndrome: clinical presentation, aetiology and management. J Intern Med 2019; 285:352-366. [PMID: 30372565 DOI: 10.1111/joim.12852] [Citation(s) in RCA: 168] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a variant of cardiovascular autonomic disorder characterized by an excessive heart rate increase on standing and orthostatic intolerance. POTS affects younger individuals 15-45 years old with a distinct female predominance (≈80%). The prevalence ranges between 0.2% and 1.0% in developed countries. The onset of POTS is typically precipitated by immunological stressors such as viral infection, vaccination, trauma, pregnancy, surgery or psychosocial stress. The most common complaints are dizziness, weakness, rapid heartbeat and palpitation on standing. Moreover, patients often report physical deconditioning and reduced exercise capacity as well as headache, 'brain fog', dyspnoea, gastrointestinal disorders and musculoskeletal pain. The aetiology of POTS is largely unknown and three main hypotheses include an autoimmune disorder, abnormally increased sympathetic activity and catecholamine excess, and sympathetic denervation leading to central hypovolaemia and reflex tachycardia. The golden standard for POTS diagnosis is head-up tilt test with a non-invasive beat-to-beat haemodynamic monitoring. Although long-term prognosis of POTS is poorly explored, around 50% of patients spontaneously recover within 1-3 years. After the diagnosis has been established, patient should be thoroughly educated about non-pharmacological measures alleviating the symptoms. Exercise training may be very effective and counteract deconditioning. In more symptomatic patients, different drugs directed at controlling heart rate, increasing peripheral vasoconstriction and intravascular volume can be tested. However, the overall effects of pharmacological therapy are modest and the most affected patients remain handicapped. Future efforts should focus on better understanding of POTS pathophysiology and designing randomized controlled trials for selection of more effective therapy.
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Affiliation(s)
- A Fedorowski
- Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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