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Coelho FMS, de Carvalho Cremaschi RM, Novak P. Cerebral blood flow and end-tidal CO 2 predict lightheadedness during head-up tilt in patients with orthostatic intolerance. Neurol Sci 2024:10.1007/s10072-024-07673-8. [PMID: 38980457 DOI: 10.1007/s10072-024-07673-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 06/20/2024] [Indexed: 07/10/2024]
Abstract
Orthostatic intolerance (OI) is a common problem. Reliable markers of OI are missing, as orthostatic blood pressure and heart rate poorly correlate with orthostatic symptoms. The objective of this study was to assess the relationship between orthostatic lightheadedness and cerebral blood flow. In this retrospective study patients with OI were evaluated at the Autonomic Laboratory of the Department of Neurology, Brigham and Women's Faulkner Hospital, Boston. The 10-minute head-up tilt test was performed as a part of autonomic testing. Orthostatic lightheadedness was evaluated at every minute of the head-up tilt. Heart rate, blood pressure, capnography, and cerebral blood flow velocity (CBFv) in the middle cerebral artery using transcranial Doppler were measured. Repeated-measures design with a linear mixed-effects model was used to evaluate the relationship between orthostatic lightheadedness and hemodynamic variables. Correlation analyses were done by calculating Pearson's coefficient. Twenty-two patients with OI were compared to nineteen controls. Orthostatic CBFv and end-tidal CO2 decreased in OI patients compared to controls (p < 0.001) and predicted orthostatic lightheadedness. Orthostatic heart rate and blood pressure failed to predict orthostatic lightheadedness. The lightheadedness threshold, which marked the onset of lightheadedness, was equal to an average systolic CBFv decrease of 18.92% and end-tidal CO2 of 12.82%. The intensity of lightheadedness was proportional to the CBFv and end-tidal CO2 decline. Orthostatic lightheadedness correlated with systolic CBFv (r=-0.6, p < 0.001) and end-tidal CO2 (r=-0.33, p < 0.001) decline. In conclusion, orthostatic CBFv and end-tidal CO2 changes predict orthostatic lightheadedness and can be used as objective markers of OI.
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Affiliation(s)
- Fernando Morgadinho Santos Coelho
- Department of Neurology, Brigham and Women's Faulkner Hospital, 1153 Centre Street, Boston, MA, USA
- Departamento de Neurologia e Neurocirurgia, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Renata Maria de Carvalho Cremaschi
- Department of Neurology, Brigham and Women's Faulkner Hospital, 1153 Centre Street, Boston, MA, USA
- Departamento de Neurologia e Neurocirurgia, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Peter Novak
- Department of Neurology, Brigham and Women's Faulkner Hospital, 1153 Centre Street, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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2
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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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3
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Fedorowski A, Fanciulli A, Raj SR, Sheldon R, Shibao CA, Sutton R. Cardiovascular autonomic dysfunction in post-COVID-19 syndrome: a major health-care burden. Nat Rev Cardiol 2024; 21:379-395. [PMID: 38163814 DOI: 10.1038/s41569-023-00962-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 01/03/2024]
Abstract
Cardiovascular autonomic dysfunction (CVAD) is a malfunction of the cardiovascular system caused by deranged autonomic control of circulatory homeostasis. CVAD is an important component of post-COVID-19 syndrome, also termed long COVID, and might affect one-third of highly symptomatic patients with COVID-19. The effects of CVAD can be seen at both the whole-body level, with impairment of heart rate and blood pressure control, and in specific body regions, typically manifesting as microvascular dysfunction. Many severely affected patients with long COVID meet the diagnostic criteria for two common presentations of CVAD: postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia. CVAD can also manifest as disorders associated with hypotension, such as orthostatic or postprandial hypotension, and recurrent reflex syncope. Advances in research, accelerated by the COVID-19 pandemic, have identified new potential pathophysiological mechanisms, diagnostic methods and therapeutic targets in CVAD. For clinicians who daily see patients with CVAD, knowledge of its symptomatology, detection and appropriate management is more important than ever. In this Review, we define CVAD and its major forms that are encountered in post-COVID-19 syndrome, describe possible CVAD aetiologies, and discuss how CVAD, as a component of post-COVID-19 syndrome, can be diagnosed and managed. Moreover, we outline directions for future research to discover more efficient ways to cope with this prevalent and long-lasting condition.
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Affiliation(s)
- Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
- Department of Medicine, Karolinska Institute, Stockholm, Sweden.
- Department of Clinical Sciences, Lund University, Malmö, Sweden.
| | | | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cyndya A Shibao
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Hammersmith Hospital, National Heart & Lung Institute, Imperial College, London, UK
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Moak JP, Ramwell CB, Gordish-Dressman H, Sule SD, Bettini E. Small fiber neuropathy in children, adolescents, and young adults with chronic orthostatic intolerance and postural orthostatic tachycardia syndrome: A retrospective study. Auton Neurosci 2024; 253:103163. [PMID: 38537312 DOI: 10.1016/j.autneu.2024.103163] [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: 07/19/2023] [Revised: 02/11/2024] [Accepted: 03/07/2024] [Indexed: 05/28/2024]
Abstract
PURPOSE To determine in children, adolescent and young adult (CAYA) patients presenting with Orthostatic Intolerance (OI) or Postural Orthostatic Tachycardia Syndrome (POTS) associated with the additional symptoms of neuropathic discomfort (pain, paresthesia and/or allodynia): 1) the incidence of small fiber neuropathy, and 2) assess if there was serologic evidence for an underlying inflammatory or autoimmune state. METHODS A cohort of 109 CAYA patients with the above symptoms underwent epidermal skin biopsy for nerve fiber density. Blood biomarkers for inflammation were tested (CRP, ESR, ANA, complement (C3), thyroid function testing with antibodies (thyroid peroxidase antibody and thyroglobulin antibody), and cytokine panel 13). Patients completed a Quality of Health questionnaire. Statistical analysis was performed using Wilcoxon rank sum tests. RESULTS In CAYA patients with OI or POTS and neuropathic symptoms, skin biopsy for small fiber neuropathy was abnormal in 53 %. The sample population was predominantly female and Caucasian with moderately decreased perceived quality of health. OI /POTS patients with small fiber neuropathy had a 3-fold probability of having a positive ANA or anti-thyroid antibody, suggesting an underlying autoimmune or inflammatory process. CONCLUSION Our data suggest a link between OI and POTS and small fiber neuropathy. Small fiber neuropathy was found by skin biopsy in over half of the patients tested. OI and Postural orthostatic tachycardia patients with small fiber neuropathy expressed multiple markers suggesting an underlying autoimmune or inflammatory process. Future research will be done to evaluate the symptomatic implication of SFN and whether immune or pharmacologic manipulation can alter patient symptoms.
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Affiliation(s)
- Jeffrey P Moak
- Division of Cardiology, Children's National Hospital, Washington, DC, United States of America.
| | - Carolyn B Ramwell
- Division of Cardiology, Children's National Hospital, Washington, DC, United States of America
| | - Heather Gordish-Dressman
- Division of Biostatistics and Study Methodology, Children's National Hospital, Washington, DC, United States of America
| | - Sangeeta D Sule
- Division of Rheumatology, Children's National Hospital, Washington, DC, United States of America
| | - Elizabeth Bettini
- Division of Cardiology, Children's National Hospital, Washington, DC, United States of America
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5
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Cantrell C, Reid C, Walker CS, Stallkamp Tidd SJ, Zhang R, Wilson R. Post-COVID postural orthostatic tachycardia syndrome (POTS): a new phenomenon. Front Neurol 2024; 15:1297964. [PMID: 38585346 PMCID: PMC10998446 DOI: 10.3389/fneur.2024.1297964] [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: 09/20/2023] [Accepted: 03/12/2024] [Indexed: 04/09/2024] Open
Abstract
Background The impact of COVID-19 has been far-reaching, and the field of neurology is no exception. Due to the long-hauler effect, a variety of chronic health consequences have occurred for some post-COVID patients. A subset of these long-hauler patients experienced symptoms of autonomic dysfunction and tested positive for postural orthostatic tachycardia syndrome (POTS) via autonomic testing. Methods We conducted a chart review of a convenience sample from patients seen by neurologists at our tertiary care center for suspicion of post-COVID POTS. Patients included in our study had clearly defined POTS based on clinical criteria and positive tilt table test, were 81.25% female, and had an average age of approximately 36. Out of 16 patients, 12 had a confirmed positive COVID test result, with the remaining 4 having strong clinical suspicion for COVID infection. Our analysis examined the most bothersome 3 symptoms affecting each patient per the neurologist's note at their initial visit for post-COVID POTS, clinical presentation, comorbidities, neurological exam findings, autonomic testing results, and COMPASS-31 autonomic questionnaire and PROMIS fatigue survey results. Results Palpitations (68.75%) and fatigue (62.5%) were the most common of the impactful symptoms reported by patients in their initial Cleveland Clinic neurology visit. The most frequent comorbidities in our sample were chronic migraines (37.5%), irritable bowel syndrome (IBS) (18.75%), and Raynaud's (18.75%). Neurological exam findings and autonomic testing results other than tilt table yielded variable findings without clear trends. Survey results showed substantial autonomic symptom burden (COMPASS-31 autonomic questionnaire average score 44.45) and high levels of fatigue (PROMIS fatigue survey average score 64.64) in post-COVID POTS patients. Conclusion Our sample of post-COVID POTS patients are similar to the diagnosed POTS general population including in comorbidities and autonomic testing. Fatigue was identified by patients as a common and debilitating symptom. We hope that our study will be an early step toward further investigation of post-COVID POTS with focus on the trends identified in this chart review.
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Affiliation(s)
| | - Conor Reid
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, United States
| | - Claudia S. Walker
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, United States
| | | | - Ryan Zhang
- Keck School of Medicine, University of Southern California, Los Angeles, CA, 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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6
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Ståhlberg M, Mahdi A, Johansson M, Fedorowski A, Olshansky B. Cardiovascular dysautonomia in postacute sequelae of SARS-CoV-2 infection. J Cardiovasc Electrophysiol 2024; 35:608-617. [PMID: 37877234 DOI: 10.1111/jce.16117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/15/2023] [Accepted: 10/16/2023] [Indexed: 10/26/2023]
Abstract
Coronavirus disease 2019 (COVID-19) has led to a worldwide pandemic that continues to transform but will not go away. Cardiovascular dysautonomia in postacute sequelae of severe acute respiratory syndrome coronavirus 2 infection has led to persistent symptoms in a large number of patients. Here, we define the condition and its associated symptoms as well as potential mechanisms responsible. We provide a careful and complete overview of the topic addressing novel studies and a generalized approach to the management of individuals with this complex and potentially debilitating problem. We also discuss future research directions and the important knowledge gaps to be addressed in ongoing and planned studies.
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Affiliation(s)
- Marcus Ståhlberg
- Cardiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Ali Mahdi
- Cardiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Madeleine Johansson
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Artur Fedorowski
- Cardiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Sciences, Lund University, Malmö, Sweden
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7
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Stallkamp Tidd SJ, Nowacki AS, Singh T, Hayburn A, Wilson R. Comorbid anxiety is associated with more changes in the Management of Postural Orthostatic Tachycardia Syndrome. Gen Hosp Psychiatry 2024; 87:1-6. [PMID: 38224642 DOI: 10.1016/j.genhosppsych.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 01/10/2024] [Accepted: 01/10/2024] [Indexed: 01/17/2024]
Abstract
OBJECTIVE Postural Orthostatic Tachycardia Syndrome (POTS) is not an anxiety disorder, but it shares similar symptomatology. The impact of this comorbidity on management is unknown. This information may lead to better strategies to improve the care of this subgroup. METHOD The electronic medical records of 322 patients seen at our institution between 2018 and 2022 with confirmed POTS diagnoses were analyzed. Demographics, anxiety comorbidities, questionnaire responses, and treatment course changes were collected. Negative binomial regression models examined if the presence of an anxiety disorder was associated with the number of POTS treatment course changes offset by observation time. RESULTS When adjusted for sex, age, baseline GAD-7 score, and baseline PROMIS global mental health score, those with a diagnosis of an anxiety disorder had2.6 times the incident rate of treatment changes for POTS management (IRR = 2.66 (95% CI: 1.43-4.95)). CONCLUSION Individuals carrying the diagnosis of an anxiety disorder had an increase in the incident rate of treatment changes for POTS therapy. This finding may be due to the underlying pathophysiology and treatment of anxiety disorders, the effect of bias, and difficulty with symptom differentiation. More work needs to be done to determine how to best care for POTS patients with comorbid anxiety.
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Affiliation(s)
| | - Amy S Nowacki
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA; Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Tamanna Singh
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA; Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Anna Hayburn
- Department of Neuromuscular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robert Wilson
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA; Department of Neuromuscular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
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8
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Goerlich E, Chung TH, Hong GH, Metkus TS, Gilotra NA, Post WS, Hays AG. Cardiovascular effects of the post-COVID-19 condition. NATURE CARDIOVASCULAR RESEARCH 2024; 3:118-129. [PMID: 39196189 DOI: 10.1038/s44161-023-00414-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 12/13/2023] [Indexed: 08/29/2024]
Abstract
Throughout the COVID-19 pandemic, the new clinical entity of the post-COVID-19 condition, defined as a multisystemic condition of persistent symptoms following resolution of an acute severe acute respiratory syndrome coronavirus 2 infection, has emerged as an important area of clinical focus. While this syndrome spans multiple organ systems, cardiovascular complications are often the most prominent features. These include, but are not limited to, myocardial injury, heart failure, arrhythmias, vascular injury/thrombosis and dysautonomia. As the number of individuals with the post-COVID-19 condition continues to climb and overwhelm medical systems, summarizing existing information and knowledge gaps in the complex cardiovascular effects of the post-COVID-19 condition has become critical for patient care. In this Review, we explore the current state of knowledge of the post-COVID-19 condition and identify areas where additional research is warranted. This will provide a framework for better understanding the cardiovascular manifestations of the post-COVID-19 condition with a focus on pathophysiology, diagnosis and management.
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Affiliation(s)
- Erin Goerlich
- Division of Cardiology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Tae H Chung
- Department of Physical Medicine and Rehabilitation and Department of Neurology, The Johns Hopkins University, Baltimore, MD, USA
| | - Gloria H Hong
- Division of Cardiology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Thomas S Metkus
- Division of Cardiology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Nisha A Gilotra
- Division of Cardiology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Wendy S Post
- Division of Cardiology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Allison G Hays
- Division of Cardiology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA.
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Delk V, Ballock H, Kavin U, Mennito S. Postural Symptoms in an Adolescent With Marfan Syndrome. Clin Pediatr (Phila) 2024; 63:272-274. [PMID: 37060285 DOI: 10.1177/00099228231167837] [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] [Indexed: 04/16/2023]
Affiliation(s)
- Victoria Delk
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Hannah Ballock
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Umakanthan Kavin
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Sarah Mennito
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
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10
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Robbins NM, Peltier A, Baker JR. Comment to the article "Standing tests lack reliability to diagnose all adolescents who have postural tachycardia syndrome". Clin Auton Res 2024; 34:203-204. [PMID: 38072868 DOI: 10.1007/s10286-023-01007-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 11/28/2023] [Indexed: 03/17/2024]
Affiliation(s)
- N M Robbins
- Department of Neurology, Geisel School of Medicine at Dartmouth, Hanover, NH, 03756, USA.
| | - A Peltier
- Department of Neurology, Vanderbilt University, Nashville, TN, USA
| | - J R Baker
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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11
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Lyonga Ngonge A, Nyange C, Ghali JK. Novel pharmacotherapeutic options for the treatment of postural orthostatic tachycardia syndrome. Expert Opin Pharmacother 2024; 25:181-188. [PMID: 38465412 DOI: 10.1080/14656566.2024.2319224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/12/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Postural tachycardia syndrome (POTS) is a disorder characterized by a constellation of symptoms including lightheadedness, fatigue, and palpitations when upright, associated with an increase in the heart rate (HR) of > 30 beats per minute when changing from a lying down to standing position or head-up tilt position and not associated with orthostatic hypotension. The causes as well as the management of POTS are not quite fully understood. AREAS COVERED We performed a literature review on the diagnosis and management of POTS, and this article includes an overview of novel pharmacotherapeutic options for the treatment of (POTS), although an effective treatment has not been established. EXPERT OPINION POTS is a clinical syndrome characterized by a constellation of symptoms that are nonspecific. No single etiology or unified hypothesis could be identified. In fact, multiple pathophysiological mechanisms have been proposed, and none of the suggested medications have been approved by the FDA for this indication. Further understanding of the autonomic nervous system and its adjustment to standing position is needed to provide better management strategies.
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Affiliation(s)
| | - Christabel Nyange
- Division of Cardiovascular Disease, Morehouse School of Medicine, Atlanta, GA, USA
| | - Jalal K Ghali
- Division of Cardiovascular Disease, Morehouse School of Medicine, Atlanta, GA, USA
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12
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McMaster MW, Dey S, Fishkin T, Wang A, Frishman WH, Aronow WS. The Impact of Long COVID-19 on the Cardiovascular System. Cardiol Rev 2024:00045415-990000000-00198. [PMID: 38285646 DOI: 10.1097/crd.0000000000000654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
Long coronavirus disease (COVID) is the development or persistence of symptoms after an acute SARS-CoV-2 (COVID-19) infection. Fewer patients are developing acute COVID-19 infections, but patients with long COVID continue to have alarming long-term sequelae. Many cardiac magnetic resonance imaging studies show significant changes in cardiac structure after a COVID-19 infection, suggestive of an increased burden of many cardiovascular diseases, notably myocarditis. The pathophysiology of COVID-19 requires viral binding to angiotensin-converting enzyme 2 protein receptors throughout the body, which are upregulated by inflammation. Consequently, the numerous preexisting conditions that worsen or prolong inflammation enhance this binding and have differing effects on patients based on their unique immune systems. These pathophysiological changes drive long COVID cardiac sequelae such as inappropriate sinus tachycardia, postural orthostatic tachycardia, and other types of orthostatic intolerance. Increased screening for long COVID and low-risk interventions such as exercise regimens could alleviate the suffering endured by patients with long COVID. Many studies such as the Researching COVID to Enhance Recovery Initiative (RECOVER) trials at the National Institutes of Health are exploring potential treatments for long COVID patients.
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Affiliation(s)
- Matthew W McMaster
- From the Departments of Cardiology and Medicine, Westchester Medical Center, Valhalla, NY
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13
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Hulsey B. Recognizing postural orthostatic tachycardia syndrome in primary care. JAAPA 2023; 36:14-19. [PMID: 37943688 DOI: 10.1097/01.jaa.0000991396.00397.be] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
ABSTRACT Postural orthostatic tachycardia syndrome (POTS) is a complex autonomic disorder characterized by abnormal tachycardia on standing. This disorder predominantly affects young women, with a peak incidence between ages 20 and 30 years. POTS often is associated with a variety of symptoms, including dizziness, palpitations, fatigue, generalized weakness, anxiety, and exercise intolerance, which can significantly impair patient quality of life. Primary care providers (PCPs) often are the first healthcare professionals to whom patients present. This article provides an overview of POTS, including diagnostic criteria and the importance of a thorough clinical evaluation to rule out other causes of symptoms. PCPs play a critical role in the comprehensive approach to care, involving patient education, lifestyle modifications, and treatment to improve outcomes and enhance patient quality of life.
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Affiliation(s)
- Brittney Hulsey
- Brittney Hulsey is an assistant professor at A.T. Still University in Mesa, Ariz., and practices at Village Medical in Gilbert, Ariz. The author has disclosed no potential conflicts of interest, financial or otherwise
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14
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Parks A, Hogg-Johnson S. Autonomic nervous system dysfunction in pediatric sport-related concussion: a systematic review. THE JOURNAL OF THE CANADIAN CHIROPRACTIC ASSOCIATION 2023; 67:246-268. [PMID: 38283159 PMCID: PMC10814701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Objective To identify, appraise and synthesize the evidence of autonomic nervous system (ANS) dysfunction following sport-related concussion in pediatric populations. Methods A literature search was conducted using MEDLINE (Ovid), SportDiscus (EBSCO), CINAHL (EBSCO), EMBASE (Ovid) and PsycINFO (Ovid). Studies were selected and appraised using the Joanna Briggs Institute (JBI) critical appraisal tools. Data was extracted from the included studies and qualitatively synthesized. Results Eleven studies were included in the synthesis. There was variability in the methods used to measure ANS function between studies, and sample populations and time to assessment following concussion varied considerably. There was also variability in the direction of change of ANS function between some studies. Conclusion This systematic review identifies that concussion is associated with dysregulation of ANS function in pediatric athletes. We identified some weaknesses in the extant literature which may be due to existing logistical and financial barriers to implementing valid ANS measurements in clinical and sports settings.
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Affiliation(s)
- Andrew Parks
- Division of Graduate Studies, Sports Sciences, Canadian Memorial Chiropractic College
- Private Practice
| | - Sheilah Hogg-Johnson
- Department of Research and Innovation, Canadian Memorial Chiropractic College
- Dalla Lana School of Public Health, University of Toronto
- Institute for Disability and Rehabilitation Research, Ontario Tech University
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Cooper PN, Sutton R. Tilt testing. Pract Neurol 2023; 23:493-500. [PMID: 37726165 DOI: 10.1136/pn-2023-003749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 09/21/2023]
Abstract
Tilt testing can help to diagnose unexplained syncope, by precipitating an episode during cardiac monitoring. The Italian protocol, now most widely used, involves giving sublingual nitroglycerine after 15 min, while monitoring beat-to-beat blood pressure (BP) and recording on video. Tilt testing is time-consuming but it is clinically useful and can guide therapy. Complications are rare. Syncope types include vasovagal syncope where BP falls after >3 min of tilt-up and later the heart rate falls; classic orthostatic hypotension where there is an immediate, progressive BP fall with minimal heart rate change; delayed orthostatic hypotension with a late BP fall after a stable phase but little or no heart rate rise; psychogenic pseudosyncope with apparent loss of consciousness, but no BP fall and a moderate heart rate rise; and postural orthostatic tachycardia syndrome where there is a significant heart rate rise but no BP fall.
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Affiliation(s)
- Paul N Cooper
- Department of Neurology, Manchester Centre for Clinical Neurosciences: Salford Royal Hospital, Salford, UK
- Faculty of Medical & Human Sciences, University of Manchester, Manchester, UK
| | - Richard Sutton
- Department of Cardiology, Imperial College London, London, UK
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16
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Stewart JM, van Dijk JG, Balaji S, Sutton R. A framework to simplify paediatric syncope diagnosis. Eur J Pediatr 2023; 182:4771-4780. [PMID: 37470792 PMCID: PMC10640507 DOI: 10.1007/s00431-023-05114-w] [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: 05/03/2023] [Revised: 07/06/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023]
Abstract
This paper aims to improve the diagnosis of syncope and transient loss of consciousness (TLOC) in children. Diagnostic problems stem, first, from some causes spanning various disciplines, e.g. cardiology, neurology and psychiatry, while the most common cause, vasovagal syncope, is not embraced by any specialty. Second, clinical variability is huge with overlapping signs and symptoms. Third, the approach to TLOC/syncope of the European Society of Cardiology (ESC) is underused in childcare. We explain the ESC guidelines using an additional paediatric literature review. Classification of TLOC and syncope is hierarchic and based on history taking. Loss of consciousness (LOC) is defined using three features: abnormal motor control including falling, reduced responsiveness and amnesia. Adding a < 5 min duration and spontaneous recovery defines TLOC. TLOC simplifies diagnosis by excluding long LOC (e.g. some trauma, intoxications and hypoglycaemia) and focussing on syncope, tonic-clonic seizures and functional TLOC. Syncope, i.e. TLOC due to cerebral hypoperfusion, is divided into reflex syncope (mostly vasovagal), orthostatic hypotension (mostly initial orthostatic hypotension in adolescents) and cardiac syncope (arrhythmias and structural cardiac disorders). The initial investigation comprises history taking, physical examination and ECG; the value of orthostatic blood pressure measurement is unproven in children but probably low. When this fails to yield a diagnosis, cardiac risk factors are assessed; important clues are supine syncope, syncope during exercise, early death in relatives and ECG abnormalities. Conclusions: In adults, the application of the ESC guidelines reduced the number of absent diagnoses and costs; we hope this also holds for children. What is Known: • Syncope and its mimics are very common in childhood, as they are at other ages. • Syncope and its mimics provide considerable diagnostic challenges. What is New: • Application of the hierarchic framework of transient loss of consciousness (TLOC) simplifies diagnosis. • The framework stresses history-taking to diagnose common conditions while keeping an eye on cardiac danger signs.
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Affiliation(s)
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300RC, Leiden, The Netherlands.
| | | | - Richard Sutton
- Department of Cardiology, National Heart & Lung Institute, Hammersmith Hospital Campus, Imperial College, London, UK
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17
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Olshansky B, Ricci F, Fedorowski A. Importance of resting heart rate. Trends Cardiovasc Med 2023; 33:502-515. [PMID: 35623552 DOI: 10.1016/j.tcm.2022.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 11/30/2022]
Abstract
Resting heart rate is a determinant of cardiac output and physiological homeostasis. Although a simple, but critical, parameter, this vital sign predicts adverse outcomes, including mortality, and development of diseases in otherwise normal and healthy individuals. Temporal changes in heart rate can have valuable predictive capabilities. Heart rate can reflect disease severity in patients with various medical conditions. While heart rate represents a compilation of physiological inputs, including sympathetic and parasympathetic tone, aside from the underlying intrinsic sinus rate, how resting heart rate affects outcomes is uncertain. Mechanisms relating resting heart rate to outcomes may be disease-dependent but why resting heart rate in otherwise healthy, normal individuals affects outcomes remains obscure. For specific conditions, physiologically appropriate heart rate reductions may improve outcomes. However, to date, in the normal population, evidence that interventions aimed at reducing heart rate improves outcomes remains undefined. Emerging data suggest that reduction in heart rate via vagal activation and/or sympathetic inhibition is propitious.
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Affiliation(s)
- Brian Olshansky
- Division of Cardiology, Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA.
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G.d'Annunzio" University of Chieti-Pescara, Via dei Vestini, 33, Chieti 66100, Italy; Department of Clinical Sciences, Lund University, 214 28 Malmö, Sweden
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, 214 28 Malmö, Sweden; Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, 171 76 Stockholm, Sweden
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18
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Gómez-Moyano E, Rodríguez-Capitán J, Gaitán Román D, Reyes Bueno JA, Villalobos Sánchez A, Espíldora Hernández F, González Angulo GE, Molina Mora MJ, Thurnhofer-Hemsi K, Molina-Ramos AI, Romero-Cuevas M, Jiménez-Navarro M, Pavón-Morón FJ. Postural orthostatic tachycardia syndrome and other related dysautonomic disorders after SARS-CoV-2 infection and after COVID-19 messenger RNA vaccination. Front Neurol 2023; 14:1221518. [PMID: 37654428 PMCID: PMC10467287 DOI: 10.3389/fneur.2023.1221518] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/21/2023] [Indexed: 09/02/2023] Open
Abstract
The COVID-19 pandemic has caused a challenge for our society due to the post-acute sequelae of the disease. Persistent symptoms and long-term multiorgan complications, known as post-acute COVID-19 syndrome, can occur beyond 4 weeks from the onset of the COVID-19 infection. Postural orthostatic tachycardia syndrome (POTS) is considered a variety of dysautonomia, which is characterized by chronic symptoms that occur with standing and a sustained increase in heart rate, without orthostatic hypotension. POTS can lead to debilitating symptoms, significant disability, and impaired quality of life. In this narrative review, the etiopathogenic basis, epidemiology, clinical manifestations, diagnosis, treatment, prognosis, and socioeconomic impact of POTS, as well as other related dysautonomic disorders, after COVID-19 infection and SARS-CoV-2 postvaccination, were discussed. After a search conducted in March 2023, a total of 89 relevant articles were selected from the PubMed, Google Scholar, and Web of Science databases. The review highlights the importance of recognizing and managing POTS after COVID-19 infection and vaccination, and the approach to autonomic disorders should be known by all specialists in different medical areas. The diagnosis of POTS requires a comprehensive clinical assessment, including a detailed medical history, physical examination, orthostatic vital signs, and autonomic function tests. The treatment of POTS after COVID-19 infection or vaccination is mainly focused on lifestyle modifications, such as increased fluid and salt intake, exercise, and graduated compression stockings. Pharmacotherapy, such as beta-blockers, fludrocortisone, midodrine, and ivabradine, may also be used in selected cases. Further research is needed to understand the underlying mechanisms, risk factors, and optimal treatment strategies for this complication.
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Affiliation(s)
| | - Jorge Rodríguez-Capitán
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Daniel Gaitán Román
- Department of Cardiology, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | | | | | | | | | - Karl Thurnhofer-Hemsi
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Computer Languages and Computer Sciences, University of Malaga, Málaga, Spain
| | - Ana Isabel Molina-Ramos
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Miguel Romero-Cuevas
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Manuel Jiménez-Navarro
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Department of Medicine and Dermatology, University of Malaga, Málaga, Spain
| | - Francisco Javier Pavón-Morón
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
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Sathnur N, Ebin E, Benditt DG. Sinus Node Dysfunction. Cardiol Clin 2023; 41:349-367. [PMID: 37321686 DOI: 10.1016/j.ccl.2023.03.013] [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: 06/17/2023]
Abstract
Sinus node dysfunction (SND) is a multifaceted disorder most prevalent in older individuals, but may also occur at an earlier age. In most cases, the SND diagnosis is ultimately established by documenting its ECG manifestations. EPS has limited utility. The treatment strategy is largely dictated by symptoms and ECG manifestations. Not infrequently, both bradycardia and tachycardia coexist in the same patients, along with other diseases common in the elderly (e.g., hypertension, coronary artery disease), thereby complicating treatment strategy. Prevention of the adverse consequences of both bradyarrhythmia and tachyarrhythmia is important to reduce susceptibility to syncope, falls, and thromboembolic complications.
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Affiliation(s)
- Neeraj Sathnur
- Cardiac Arrhythmia Service, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA; Cardiovascular Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware St SE, Minneapolis, MN 55455, USA; Cardiac Electrophysiology, Park-Nicollet Medical Center, St Louis Park, Minneapolis, MN, USA
| | - Emanuel Ebin
- Cardiac Arrhythmia Service, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA; Cardiovascular Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware St SE, Minneapolis, MN 55455, USA
| | - David G Benditt
- Cardiac Arrhythmia Service, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA; Cardiovascular Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware St SE, Minneapolis, MN 55455, USA.
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20
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Kim KT, Lee SU, Kim JB, Choi JY, Kim BJ, Kim JS. Augmented ocular vestibular-evoked myogenic potentials in postural orthostatic tachycardia syndrome. Clin Auton Res 2023; 33:479-489. [PMID: 37115468 DOI: 10.1007/s10286-023-00943-z] [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: 12/28/2022] [Accepted: 04/08/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE To delineate the association between otolith function and changes in mean orthostatic blood pressure (BP) and heart rate (HR) in patients with postural orthostatic tachycardia syndrome (POTS). METHODS Forty-nine patients with POTS were prospectively recruited. We analyzed the results of ocular vestibular-evoked myogenic potentials (oVEMPs) and cervical vestibular-evoked myogenic potentials (cVEMPs), as well as head-up tilt table tests using a Finometer. The oVEMP and cVEMP responses were obtained using tapping stimuli and 110 dB tone-burst sounds, respectively. We measured maximal changes in 5-s averaged systolic BP (SBP), diastolic BP (DBP), and heart rate (HR) within 15 s and during 10 min after tilting. We compared the results with those of 20 age- and sex-matched healthy participants. RESULTS The n1-p1 amplitude of oVEMPs was larger in patients with POTS than in healthy participants (p = 0.001), whereas the n1 latency (p = 0.280) and interaural difference (p = 0.199) did not differ between the two. The n1-p1 amplitude was a positive predictor for POTS (odds ratio 1.07, 95% confidence interval 1.01-1.13, p = 0.025). Body weight (p = 0.007) and n1-p1 amplitude of oVEMP (p = 0.019) were positive predictors for ΔSBP15s in POTS, whereas aging was a negative predictor (p = 0.005). These findings were not observed in healthy participants. CONCLUSIONS Augmented utricular inputs may be associated with a relative predominance of sympathetic over vagal control of BP and HR, especially for an early response during orthostasis in patients with POTS. Overt sympathoexcitation due to exaggerated utricular input and lack of readaptation may be associated with the pathomechanism of POTS.
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Affiliation(s)
- Keun-Tae Kim
- Department of Neurology, Korea University Medical Center, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, South Korea
| | - Sun-Uk Lee
- Department of Neurology, Korea University Medical Center, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, South Korea.
| | - Jung-Bin Kim
- Department of Neurology, Korea University Medical Center, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, South Korea
| | - Jeong-Yoon Choi
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
- Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Byung-Jo Kim
- Department of Neurology, Korea University Medical Center, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, South Korea
- BK21 FOUR Program in Learning Health Systems, Korea University, Seoul, South Korea
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
- Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea
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21
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Abbate G, De Iulio B, Thomas G, Priday A, Biondi-Zoccai G, Markley R, Abbate A. Postural Orthostatic Tachycardia Syndrome After COVID-19: A Systematic Review of Therapeutic Interventions. J Cardiovasc Pharmacol 2023; 82:23-31. [PMID: 37094584 DOI: 10.1097/fjc.0000000000001432] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/06/2023] [Indexed: 04/26/2023]
Abstract
ABSTRACT Postural orthostatic tachycardia syndrome (POTS) is a clinical syndrome of inappropriate increase in heart rate on standing that has been recently also associated with Coronavirus Disease 2019 (COVID-19) as part of the postacute sequelae of COVID-19 (PASC) or long-COVID. We herein aimed to systematically review reported cases of POTS after COVID-19 and determine the characteristics of the subjects, the diagnostic approach used, and the treatment strategies. We searched the literature according to the following criteria: (1) diagnosis of POTS according to standard definition; (2) timely association with a probable or definite diagnosis of COVID-19; and (3) a description of the individual subject(s). We identified 21 reports meeting criteria between March 2020 and September 2022, including 68 subjects (51 females and 17 males, 3:1 ratio) with a mean age of 34 ± 12 years, with reports deriving from the United States, Norway, Sweden, Israel, Ireland, United Kingdom, Singapore, and Japan. Most cases had mild COVID-19 symptoms. The most common POTS symptoms were palpitations, chest pain, lightheadedness, and debilitating fatigue. The diagnosis was established by means of head-up tilt table or active stand test. Nonpharmacologic treatments (fluids, sodium intake, and compression stockings) were virtually always used, but largely ineffective. Subjects received different treatments, the most common being beta-adrenergic blockers (ie, propranolol), mineral corticosteroids (ie, fludrocortisone), midodrine, and ivabradine. Symptoms tended to improve over time, but most patients remained symptomatic for several months. In conclusion, POTS after COVID-19 is a clinical condition affecting young individuals, and disproportionately young women, occurring as part of PASC-long-COVID, often debilitating, which can be easily diagnosed with a thorough clinical assessment and measuring changes in orthostatic heart rate and blood pressure. POTS after COVID-19 seems to be poorly responsive to nonpharmacological treatments but with symptoms improving with pharmacological interventions. Given the limited data available, additional research is urgently needed with respect to its epidemiology, pathophysiology, and treatments.
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Affiliation(s)
- Gerardina Abbate
- Robert M. Berne Cardiovascular Research Center, University of Virginia, Charlottesville, VA
| | - Beatrice De Iulio
- Robert M. Berne Cardiovascular Research Center, University of Virginia, Charlottesville, VA
| | - Georgia Thomas
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | - Anna Priday
- Robert M. Berne Cardiovascular Research Center, University of Virginia, Charlottesville, VA
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; and
- Mediterranea Cardiocentro, Napoli, Italy
| | - Roshanak Markley
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | - Antonio Abbate
- Robert M. Berne Cardiovascular Research Center, University of Virginia, Charlottesville, VA
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22
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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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23
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Zanin A, Amah G, Chakroun S, Testard P, Faucher A, Le TYV, Slama D, Le Baut V, Lozeron P, Salmon D, Kubis N. Parasympathetic autonomic dysfunction is more often evidenced than sympathetic autonomic dysfunction in fluctuating and polymorphic symptoms of "long-COVID" patients. Sci Rep 2023; 13:8251. [PMID: 37217645 DOI: 10.1038/s41598-023-35086-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/12/2023] [Indexed: 05/24/2023] Open
Abstract
Several disabling symptoms potentially related to dysautonomia have been reported in "long-COVID" patients. Unfortunately, these symptoms are often nonspecific, and autonomic nervous system explorations are rarely performed in these patients. This study aimed to evaluate prospectively a cohort of long-COVID patients presenting severe disabling and non-relapsing symptoms of potential dysautonomia and to identify sensitive tests. Autonomic function was assessed by clinical examination, the Schirmer test; sudomotor evaluation, orthostatic blood pressure (BP) variation, 24-h ambulatory BP monitoring for sympathetic evaluation, and heart rate variation during orthostatism, deep breathing and Valsalva maneuvers for parasympathetic evaluation. Test results were considered abnormal if they reached the lower thresholds defined in publications and in our department. We also compared mean values for autonomic function tests between patients and age-matched controls. Sixteen patients (median age 37 years [31-43 years], 15 women) were included in this study and referred 14.5 months (median) [12.0-16.5 months] after initial infection. Nine had at least one positive SARS-CoV-2 RT-PCR or serology result. Symptoms after SARS-CoV-2 infection were severe, fluctuating and disabling with effort intolerance. Six patients (37.5%) had one or several abnormal test results, affecting the parasympathetic cardiac function in five of them (31%). Mean Valsalva score was significantly lower in patients than in controls. In this cohort of severely disabled long-COVID patients, 37.5% of them had at least one abnormal test result showing a possible contribution of dysautonomia to these nonspecific symptoms. Interestingly, mean values of the Valsalva test were significantly lower in patients than in control subjects, suggesting that normal values thresholds might not be appropriate in this population.
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Affiliation(s)
- Adrien Zanin
- INSERM UMR1144, Université Paris Cité, 75018, Paris, France
- Service de Physiologie Clinique - Explorations Fonctionnelles, AP-HP, DMU DREAM, Hôpital Lariboisière, Université Paris Cité, 75010, Paris, France
| | - Guy Amah
- Service de Physiologie Clinique - Explorations Fonctionnelles, AP-HP, DMU DREAM, Hôpital Lariboisière, Université Paris Cité, 75010, Paris, France
| | - Sahar Chakroun
- Service de Physiologie Clinique - Explorations Fonctionnelles, AP-HP, DMU DREAM, Hôpital Lariboisière, Université Paris Cité, 75010, Paris, France
| | - Pauline Testard
- Service de Physiologie Clinique - Explorations Fonctionnelles, AP-HP, DMU DREAM, Hôpital Lariboisière, Université Paris Cité, 75010, Paris, France
| | - Alice Faucher
- Service de Physiologie Clinique - Explorations Fonctionnelles, AP-HP, DMU DREAM, Hôpital Lariboisière, Université Paris Cité, 75010, Paris, France
| | - Thi Yen Vy Le
- Service de Physiologie Clinique - Explorations Fonctionnelles, AP-HP, DMU DREAM, Hôpital Lariboisière, Université Paris Cité, 75010, Paris, France
| | - Dorsaf Slama
- Department of Immunology and Infectious Diseases, APHP, Cochin-Hôtel-Dieu Hospital, Université Paris Cité, 75004, Paris, France
| | - Valérie Le Baut
- Department of Immunology and Infectious Diseases, APHP, Cochin-Hôtel-Dieu Hospital, Université Paris Cité, 75004, Paris, France
| | - Pierre Lozeron
- INSERM UMR1144, Université Paris Cité, 75018, Paris, France
- Service de Physiologie Clinique - Explorations Fonctionnelles, AP-HP, DMU DREAM, Hôpital Lariboisière, Université Paris Cité, 75010, Paris, France
| | - Dominique Salmon
- Department of Immunology and Infectious Diseases, APHP, Cochin-Hôtel-Dieu Hospital, Université Paris Cité, 75004, Paris, France
| | - Nathalie Kubis
- INSERM UMR1144, Université Paris Cité, 75018, Paris, France.
- Service de Physiologie Clinique - Explorations Fonctionnelles, AP-HP, DMU DREAM, Hôpital Lariboisière, Université Paris Cité, 75010, Paris, France.
- Service de Physiologie Clinique - Explorations Fonctionnelles, Hôpital Lariboisière, 2 rue Ambroise Paré, 75475, Paris CEDEX10, France.
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24
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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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El-Rhermoul FZ, Fedorowski A, Eardley P, Taraborrelli P, Panagopoulos D, Sutton R, Lim PB, Dani M. Autoimmunity in Long Covid and POTS. OXFORD OPEN IMMUNOLOGY 2023; 4:iqad002. [PMID: 37255928 PMCID: PMC10224806 DOI: 10.1093/oxfimm/iqad002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/23/2023] [Accepted: 03/08/2023] [Indexed: 11/10/2023] Open
Abstract
Orthostatic intolerance and other autonomic dysfunction syndromes are emerging as distinct symptom clusters in Long Covid. Often accompanying these are common, multi-system constitutional features such as fatigue, malaise and skin rashes which can signify generalized immune dysregulation. At the same time, multiple autoantibodies are identified in both Covid-related autonomic disorders and non-Covid autonomic disorders, implying a possible underlying autoimmune pathology. The lack of specificity of these findings precludes direct interpretations of cause and association, but their prevalence with its supporting evidence is compelling.
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Affiliation(s)
- Fatema-Zahra El-Rhermoul
- Department of Allergy and Clinical Immunology, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, UK
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital and Karolinska Institute, Stockholm 171 77, Sweden
| | - Philip Eardley
- Imperial Syncope Unit, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | | | | | - Richard Sutton
- National Heart and Lung Institute, Imperial College London, London SW3 6LY, UK
| | - Phang Boon Lim
- Imperial Syncope Unit, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Melanie Dani
- Imperial Syncope Unit, Imperial College Healthcare NHS Trust, London W12 0HS, UK
- Cutrale Perioperative and Ageing Group, Department of Bioengineering, Imperial College London, London W12 0BZ, UK
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26
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Hilz MJ. Cardiovascular autonomic dysfunction: A cause of acute COVID-19 complications and persistent post-COVID-19 complaints? Eur J Neurol 2023; 30:1170-1171. [PMID: 36708076 DOI: 10.1111/ene.15719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 01/29/2023]
Affiliation(s)
- Max J Hilz
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany.,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Narasimhan B, Calambur A, Moras E, Wu L, Aronow W. Postural Orthostatic Tachycardia Syndrome in COVID-19: A Contemporary Review of Mechanisms, Clinical Course and Management. Vasc Health Risk Manag 2023; 19:303-316. [PMID: 37204997 PMCID: PMC10187582 DOI: 10.2147/vhrm.s380270] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/09/2023] [Indexed: 05/21/2023] Open
Abstract
The long-term implications of COVID-19 have garnered increasing interest in recent months, with Long-COVID impacting over 65 million individuals worldwide. Postural orthostatic tachycardia syndrome (POTS) has emerged as an important component of the Long-COVID umbrella, estimated to affect between 2 and 14% of survivors. POTS remains very challenging to diagnose and manage - this review aims to provide a brief overview of POTS as a whole and goes on to summarize the available literature pertaining to POTS in the setting of COVID-19. We provide a review of available clinical reports, outline proposed pathophysiological mechanisms and end with a brief note on management considerations.
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Affiliation(s)
- Bharat Narasimhan
- Department of Cardiology, Debakey Cardiovascular Institute, Houston Methodist, Houston, TX, USA
| | | | - Errol Moras
- Department of Medicine, Icahn School of Medicine; Mount Sinai, New York, NY, USA
| | - Lingling Wu
- Department of Medicine, East Carolina University, Greenvile, NC, USA
| | - Wilbert Aronow
- Department of Cardiology, Westchester Medical Center, Valhalla, NY, USA
- Correspondence: Wilbert Aronow, Department of Cardiology, Westchester Medical Center, New York Medical College, 100 Woods Road, Macy Pavilion, Room 141, Valhalla, NY, 10595, USA, Email
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Spahic JM, Hamrefors V, Johansson M, Ricci F, Melander O, Sutton R, Fedorowski A. Malmö POTS symptom score: Assessing symptom burden in postural orthostatic tachycardia syndrome. J Intern Med 2023; 293:91-99. [PMID: 36111700 PMCID: PMC10087729 DOI: 10.1111/joim.13566] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Postural orthostatic tachycardia syndrome (POTS) is a common cardiovascular autonomic disorder characterized by excessive heart rate (HR) increase on standing and symptoms of orthostatic intolerance, posing significant limitations on functional capacity. No objective tool exists to classify symptom burden in POTS. METHODS We conducted a case-control study in 62 POTS patients and 50 healthy controls to compare symptom burden between groups using the newly developed, self-rating, 12-item, Malmö POTS Score (MAPS; 0-10 per item, total range 0-120) based on patients own perception of symptoms through visual analogue scale assessment. We have also explored correlations between symptom severity assessed by MAPS, basic clinical parameters and postural haemodynamic changes. RESULTS POTS patients showed significantly higher total MAPS score (78 ± 20 vs. 14 ± 12, p < 0.001), higher baseline systolic blood pressure (BP), diastolic BP and HR (p < 0.001) compared with healthy controls. The most prominent symptoms in POTS were palpitations, fatigue and concentration difficulties. Haemodynamic parameters on standing were significantly correlated with palpitations in POTS after adjustment for age and sex (lower systolic and diastolic BP, and higher HR) (p < 0.001 for all). Orthostatic HR was significantly associated with concentration difficulties and total MAPS score. The optimal cut-point value of MAPS to differentiate POTS and healthy controls was ≥42 (sensitivity, 97%; specificity, 98%). CONCLUSIONS Symptom severity, as assessed by MAPS score, is fivefold higher in POTS compared with healthy individuals. The new MAPS score can be useful as a semiquantitative system to assess symptom burden, monitor disease progression and evaluate pre-test likelihood of disease.
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Affiliation(s)
- Jasmina Medic Spahic
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Madeleine Johansson
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Fabrizio Ricci
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Olle Melander
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,National Heart and Lung Institute, Imperial College, London, UK
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Karolinska Institute, Stockholm, Sweden
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Hwang D, Liu X, Rosenberg C, Lee A, Borle S, Ricafrente JQ, Wei J, Shufelt C, Chen LS, Li X, Goldhaber JI, Bairey Merz CN, Chen PS. Sympathetic toggled sinus rate acceleration as a mechanism of sustained sinus tachycardia in chronic orthostatic intolerance syndrome. Heart Rhythm 2022; 19:2086-2094. [PMID: 35995322 DOI: 10.1016/j.hrthm.2022.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The role of sympathetic nerve activity to maintain sinus rate acceleration remains unclear. OBJECTIVE The purpose of this study was to test the hypothesis that sustained (>30 seconds) sinus rate acceleration can be associated with either a sympathetic driven or a sympathetic toggled mechanism. METHODS We used a patch monitor to record skin sympathetic nerve activity (SKNA) and electrocardiogram over 24 hours. Study 1 included chronic orthostatic intolerance (OI) (n = 18), atrial fibrillation (n = 7), and asymptomatic normal control (n = 19) groups. Study 2 included 17 participants with chronic OI not treated with ivabradine, pyridostigmine, or β-blockers. RESULTS While a majority of sinus rate acceleration was driven by persistent SKNA in study 1, some episodes were toggled on and off by SKNA bursts without persistent SKNA elevation. The sympathetic toggled sinus rate acceleration episodes were found in 7 of 18 participants with chronic OI (39%), 2 of 7 participants with atrial fibrillation (29%), and 6 of 19 normal control participants (32%) (P = .847) and were faster and longer in the chronic OI group than in other groups. In study 2, there were a total of 11 episodes of sinus rate acceleration that persisted for >200 seconds. Among these episodes, 6 (35%) were toggled on and off by SKNA bursts. CONCLUSION Sustained sinus rate acceleration (may be toggled on or off) is associated with SKNA bursts in participants with chronic OI, participants with atrial fibrillation, and normal controls. Patients with OI had more frequent and longer episodes than did other groups.
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Affiliation(s)
- Daerin Hwang
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Xiao Liu
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Carine Rosenberg
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Andrew Lee
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sanjana Borle
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joselyn Q Ricafrente
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Janet Wei
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Chrisandra Shufelt
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Division of General Internal Medicine, Mayo Clinic, Jacksonville, Florida
| | - Lan S Chen
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Xiaochun Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Richard M. Fairbanks School of Public Health, Indianapolis, Indiana
| | - Joshua I Goldhaber
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - C Noel Bairey Merz
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Peng-Sheng Chen
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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30
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Gould SJ, Cochrane GD, Johnson J, Hebson CL, Kazamel M. Orthostatic intolerance in post-concussion patients. PHYSICIAN SPORTSMED 2022; 50:429-434. [PMID: 34236936 DOI: 10.1080/00913847.2021.1953357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Orthostatic intolerance (OI) following pediatric concussion is not well understood. Assessing the prevalence of concussion-related OI and how it compares to non-concussion-related OI will improve care for patients suffering with these symptoms. OBJECTIVE: We set out to describe concussion-related OI in adolescence, with particular emphasis on time to recovery and differences from non-concussion-related OI (including male vs. female prevalence). Retrospective chart reviews were completed on post-concussion patients endorsing symptoms of OI. The patients' sex, sport history, previous concussions, time since injury, and recovery time were analyzed and compared between males and females as well as against general OI statistics. Thirty-nine pediatric patients, representing 8.7% of all new patients referred to a specialized concussion clinic over a 13-month interval, were included in the chart review. Mean age of onset was 15.0 ± 2.5 years and 18 (46%) were males. The median times from evaluation to symptom resolution were 120 days. Of 18 patients who completed head-up tilt table testing, 17 (94%) had orthostatic tachycardic response (>40 bpm heart rate increment). Post-concussive OI differs from other orthostatic intolerance etiologies, lacking a strong female predominance and exhibiting a shorter time course to recovery compared to other etiologies of OI (but longer recovery time compared to concussion patients in general). Clinical orthostatic vital signs may not be sensitive for diagnosing orthostatic intolerance in athletes, likely due to higher vagal tone and more efficient skeletal muscle pump.
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Affiliation(s)
- Sara J Gould
- Department of Orthopedic Surgery, University of Alabama at Birmingham (UAB), Birmingham, AL, USA.,Sports Medicine, Children's of Alabama, Birmingham, AL, USA
| | | | | | - Camden L Hebson
- Sports Medicine, Children's of Alabama, Birmingham, AL, USA.,Department of Pediatrics, Division of Pediatric Cardiology, UAB, Birmingham, AL, USA
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31
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Mayuga KA, Fedorowski A, Ricci F, Gopinathannair R, Dukes JW, Gibbons C, Hanna P, Sorajja D, Chung M, Benditt D, Sheldon R, Ayache MB, AbouAssi H, Shivkumar K, Grubb BP, Hamdan MH, Stavrakis S, Singh T, Goldberger JJ, Muldowney JAS, Belham M, Kem DC, Akin C, Bruce BK, Zahka NE, Fu Q, Van Iterson EH, Raj SR, Fouad-Tarazi F, Goldstein DS, Stewart J, Olshansky B. Sinus Tachycardia: a Multidisciplinary Expert Focused Review. Circ Arrhythm Electrophysiol 2022; 15:e007960. [PMID: 36074973 PMCID: PMC9523592 DOI: 10.1161/circep.121.007960] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sinus tachycardia (ST) is ubiquitous, but its presence outside of normal physiological triggers in otherwise healthy individuals remains a commonly encountered phenomenon in medical practice. In many cases, ST can be readily explained by a current medical condition that precipitates an increase in the sinus rate, but ST at rest without physiological triggers may also represent a spectrum of normal. In other cases, ST may not have an easily explainable cause but may represent serious underlying pathology and can be associated with intolerable symptoms. The classification of ST, consideration of possible etiologies, as well as the decisions of when and how to intervene can be difficult. ST can be classified as secondary to a specific, usually treatable, medical condition (eg, pulmonary embolism, anemia, infection, or hyperthyroidism) or be related to several incompletely defined conditions (eg, inappropriate ST, postural tachycardia syndrome, mast cell disorder, or post-COVID syndrome). While cardiologists and cardiac electrophysiologists often evaluate patients with symptoms associated with persistent or paroxysmal ST, an optimal approach remains uncertain. Due to the many possible conditions associated with ST, and an overlap in medical specialists who see these patients, the inclusion of experts in different fields is essential for a more comprehensive understanding. This article is unique in that it was composed by international experts in Neurology, Psychology, Autonomic Medicine, Allergy and Immunology, Exercise Physiology, Pulmonology and Critical Care Medicine, Endocrinology, Cardiology, and Cardiac Electrophysiology in the hope that it will facilitate a more complete understanding and thereby result in the better care of patients with ST.
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Affiliation(s)
- Kenneth A. Mayuga
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Artur Fedorowski
- Karolinska Institutet & Karolinska University Hospital, Stockholm, Sweden
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, “G.d’Annunzio” University of Chieti-Pescara, Chieti Scalo, Italy
| | | | | | | | | | | | - Mina Chung
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Phoenix, AZ
| | - David Benditt
- University of Minnesota Medical School, Minneapolis, MN
| | | | - Mirna B. Ayache
- MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Hiba AbouAssi
- Division of Endocrinology, Metabolism, and Nutrition, Duke University Medical Center, Durham, NC
| | | | | | | | | | - Tamanna Singh
- Department of Cardiovascular Medicine, Cleveland Clinic, OH
| | | | - James A. S. Muldowney
- Vanderbilt University Medical Center &Tennessee Valley Healthcare System, Nashville Campus, Department of Veterans Affairs, Nashville, TN
| | - Mark Belham
- Cambridge University Hospitals NHS FT, Cambridge, UK
| | - David C. Kem
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Cem Akin
- University of Michigan, Ann Arbor, MI
| | | | - Nicole E. Zahka
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Qi Fu
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas & University of Texas Southwestern Medical Center, Dallas, TX
| | - Erik H. Van Iterson
- Section of Preventive Cardiology & Rehabilitation, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic Cleveland, OH
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
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32
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Sebastian SA, Co EL, Panthangi V, Jain E, Ishak A, Shah Y, Vasavada A, Padda I. Postural Orthostatic Tachycardia Syndrome (POTS): An Update for Clinical Practice. Curr Probl Cardiol 2022; 47:101384. [DOI: 10.1016/j.cpcardiol.2022.101384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 08/26/2022] [Indexed: 11/03/2022]
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Kim H, Ayele GM, Atalay RT, Hussien S, Tewoldemedhin B, Michael MB. What Works for One May Not Work for Another: A New Warning for Modafinil. Cureus 2022; 14:e27287. [PMID: 36043022 PMCID: PMC9413809 DOI: 10.7759/cureus.27287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2022] [Indexed: 11/05/2022] Open
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Carmona-Torre F, Mínguez-Olaondo A, López-Bravo A, Tijero B, Grozeva V, Walcker M, Azkune-Galparsoro H, López de Munain A, Alcaide AB, Quiroga J, Del Pozo JL, Gómez-Esteban JC. Dysautonomia in COVID-19 Patients: A Narrative Review on Clinical Course, Diagnostic and Therapeutic Strategies. Front Neurol 2022; 13:886609. [PMID: 35720084 PMCID: PMC9198643 DOI: 10.3389/fneur.2022.886609] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/28/2022] [Indexed: 12/27/2022] Open
Abstract
Introduction On March 11, 2020, the World Health Organization sounded the COVID-19 pandemic alarm. While efforts in the first few months focused on reducing the mortality of infected patients, there is increasing data on the effects of long-term infection (Post-COVID-19 condition). Among the different symptoms described after acute infection, those derived from autonomic dysfunction are especially frequent and limiting. Objective To conduct a narrative review synthesizing current evidence of the signs and symptoms of dysautonomia in patients diagnosed with COVID-19, together with a compilation of available treatment guidelines. Results Autonomic dysfunction associated with SARS-CoV-2 infection occurs at different temporal stages. Some of the proposed pathophysiological mechanisms include direct tissue damage, immune dysregulation, hormonal disturbances, elevated cytokine levels, and persistent low-grade infection. Acute autonomic dysfunction has a direct impact on the mortality risk, given its repercussions on the respiratory, cardiovascular, and neurological systems. Iatrogenic autonomic dysfunction is a side effect caused by the drugs used and/or admission to the intensive care unit. Finally, late dysautonomia occurs in 2.5% of patients with Post-COVID-19 condition. While orthostatic hypotension and neurally-mediated syncope should be considered, postural orthostatic tachycardia syndrome (POTS) appears to be the most common autonomic phenotype among these patients. A review of diagnostic and treatment guidelines focused on each type of dysautonomic condition was done. Conclusion Symptoms deriving from autonomic dysfunction involvement are common in those affected by COVID-19. These symptoms have a great impact on the quality of life both in the short and medium to long term. A better understanding of the pathophysiological mechanisms of Post-COVID manifestations that affect the autonomic nervous system, and targeted therapeutic management could help reduce the sequelae of COVID-19, especially if we act in the earliest phases of the disease.
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Affiliation(s)
- Francisco Carmona-Torre
- Infectious Disease Service, University Clinic of Navarra, Pamplona, Spain.,COVID-19 Department, University Clinic of Navarra, Pamplona, Spain.,Immune and Infectious Inflammatory Diseases Research, IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Ane Mínguez-Olaondo
- Neurology Department, Donostia University Hospital-OSAKIDETZA, San Sebastián, Spain.,ATHENEA Neuroclinics, Policlínica Gipuzkoa Grupo Quironsalud, Donostia, Spain.,Neuroscience Area, Biodonostia Research Institute, San Sebastián, Spain.,Neurology Department, Faculty of Medicine, University of Deusto, Bilbao, Spain.,Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Institute Carlos III, Madrid, Spain
| | - Alba López-Bravo
- Neurology Department, Hospital Reina Sofía de Tudela-OSASUNBIDEA, Tudela, Spain.,Aragon Institute for Health Research (IIS-A), Zaragoza, Spain
| | - Beatriz Tijero
- Neurology Department, Faculty of Medicine, University of Deusto, Bilbao, Spain.,Neurodegenerative Diseases Group Biocruces Bizkaia Health Research Institute, Barakaldo, Spain.,Neurology Department, Cruces University Hospital-OSAKIDETZA, Barakaldo, Spain
| | | | - Michaela Walcker
- ATHENEA Neuroclinics, Policlínica Gipuzkoa Grupo Quironsalud, Donostia, Spain
| | - Harkaitz Azkune-Galparsoro
- Neuroscience Area, Biodonostia Research Institute, San Sebastián, Spain.,Infectious Disease Department, Donostia University Hospital-OSAKIDETZA, San Sebastián, Spain.,Department of Neurosciences, University of the Basque Country (UPV/EHU), Leioa, Spain
| | - Adolfo López de Munain
- Neurology Department, Donostia University Hospital-OSAKIDETZA, San Sebastián, Spain.,ATHENEA Neuroclinics, Policlínica Gipuzkoa Grupo Quironsalud, Donostia, Spain.,Neuroscience Area, Biodonostia Research Institute, San Sebastián, Spain.,Neurology Department, Faculty of Medicine, University of Deusto, Bilbao, Spain.,Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Institute Carlos III, Madrid, Spain.,Department of Neurosciences, University of the Basque Country (UPV/EHU), Leioa, Spain
| | - Ana Belen Alcaide
- COVID-19 Department, University Clinic of Navarra, Pamplona, Spain.,Pulmonary Department, University Clinic of Navarra, Pamplona, Spain
| | - Jorge Quiroga
- COVID-19 Department, University Clinic of Navarra, Pamplona, Spain.,Immune and Infectious Inflammatory Diseases Research, IdiSNA, Navarra Institute for Health Research, Pamplona, Spain.,Internal Medicine Department, University Clinic of Navarra, Pamplona, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Institute Carlos III, Madrid, Spain
| | - Jose Luis Del Pozo
- Infectious Disease Service, University Clinic of Navarra, Pamplona, Spain.,COVID-19 Department, University Clinic of Navarra, Pamplona, Spain.,Immune and Infectious Inflammatory Diseases Research, IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Juan Carlos Gómez-Esteban
- ATHENEA Neuroclinics, Policlínica Gipuzkoa Grupo Quironsalud, Donostia, Spain.,Neurology Department, Faculty of Medicine, University of Deusto, Bilbao, Spain.,Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Institute Carlos III, Madrid, Spain.,Neurodegenerative Diseases Group Biocruces Bizkaia Health Research Institute, Barakaldo, Spain.,Neurology Department, Cruces University Hospital-OSAKIDETZA, Barakaldo, Spain.,Department of Neurosciences, University of the Basque Country (UPV/EHU), Leioa, Spain
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Wang S, Zou R, Cai H, Wang C. Predictive Value of Heart Rate and Blood Pressure on the Prognosis of Postural Tachycardia Syndrome in Children. Front Pediatr 2022; 10:802469. [PMID: 35433537 PMCID: PMC9005773 DOI: 10.3389/fped.2022.802469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/03/2022] [Indexed: 11/13/2022] Open
Abstract
Background To investigate the predictive value of heart rate (HR) and blood pressure (BP) on the prognosis of postural tachycardia syndrome (POTS) in children. Materials and Methods 53 cases of children aged 5 to 15 years who visited in the Pediatric Syncope Specialist Clinic of The Second Xiangya Hospital of Central South University for unexplained syncope or syncope precursor were diagnosed with POTS by head-up tilt test (HUTT) as the POTS group. 38 healthy children aged 5 to 16 years who underwent physical examination at the Child Health Care Clinic of the hospital in the same period were matched as controls (control group). The children with POTS were followed up after 3 months of treatment and were divided into good prognosis group (40 cases) and poor prognosis group (13 cases) according to the results of HUTT re-examination and whether the symptoms improved or not. HR and BP indicators were collected from each group at baseline and during HUTT. Results There were 91 research subjects, of which 45 are males, with a mean age of 11.52 ± 2.13 years. (1) HR at 5 and 10 min (HR 5 and HR 10, respectively), HR difference at 5 and 10 min (HRD 5 and HRD 10, respectively), and HR and BP product at 5 and 10 min (RPP 5 and RPP 10, respectively) were greater in the POTS group than in the control group (P < 0.01). (2) HR 5, HR 10, HRD 5, HRD 10, and RPP 10 in children with POTS were smaller in the good prognosis group than the poor prognosis group (P < 0.01). (3) The area under curve was 0.925 on the four combined indicators (HR 5, HR 10, HRD 5, and HRD 10), predicting a good prognosis of POTS, sensitivity of 99.99%, and specificity of 75.00%. Conclusions HR 5, HR 10, HRD 5, HRD 10, and RPP 10 and the four combined indicators (HR 5, HR 10, HRD 5, and HRD 10) had predictive value for the POTS prognosis in children. The predictive value of the four combined indicators for the POTS prognosis was better than that of the single HR 5, HRD 5, and RPP 10.
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Affiliation(s)
- Shuo Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Neonatology, Xiangya Hospital, Central South University, Changsha, China
| | - Runmei Zou
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Hong Cai
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Cheng Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
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Pearson R, Sheridan CA, Kang K, Brown A, Baham M, Asarnow R, Giza CC, Choe MC. Post-Concussive Orthostatic Tachycardia is Distinct from Postural Orthostatic Tachycardia Syndrome (POTS) in Children and Adolescents. Child Neurol Open 2022; 9:2329048X221082753. [PMID: 35647216 PMCID: PMC9136088 DOI: 10.1177/2329048x221082753] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/14/2022] [Accepted: 02/03/2022] [Indexed: 12/01/2022] Open
Abstract
Background: Orthostatic tachycardia (OT) affects some patients after
concussion/mild traumatic brain injury (mTBI). In this study, we sought to
identify the factors associated with increased risk for OT in patients with
mTBI. Methods: We conducted a retrospective review of 268 patients
(8-25 years) with mTBI/concussion to determine the prevalence of OT, defined as
orthostatic heart rate change ≥40 bpm for those ≤19 years of age and ≥30 bpm on
active standing test for those >19 years of age. Results: Among
the study population, 7% (n = 19) exhibited post-concussive OT. The only
significant difference between OT and non-OT groups was that history of prior
concussion was more prevalent in the OT group. Conclusion: A
substantial subset (7%) of concussion clinic patients exhibit OT. While POTS
literature describes female and adolescent predominance, post-concussive OT had
similar prevalence across age and gender groups in this study, suggesting that
it may be distinct from POTS.
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Affiliation(s)
- Rachel Pearson
- UC-Los Angeles Steve Tisch BrainSPORT Program, UCLA Easton Clinic for Brain Health, Los Angeles, CA, USA
- Division of Pediatric Neurology, UC-Los Angeles Mattel Children’s Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
- Children’s Hospital Orange County, Orange, California, USA
| | - Christopher A. Sheridan
- UC-Los Angeles Steve Tisch BrainSPORT Program, UCLA Easton Clinic for Brain Health, Los Angeles, CA, USA
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kaylee Kang
- UC-Los Angeles Steve Tisch BrainSPORT Program, UCLA Easton Clinic for Brain Health, Los Angeles, CA, USA
| | - Anne Brown
- UC-Los Angeles Steve Tisch BrainSPORT Program, UCLA Easton Clinic for Brain Health, Los Angeles, CA, USA
| | - Michael Baham
- UC-Los Angeles Steve Tisch BrainSPORT Program, UCLA Easton Clinic for Brain Health, Los Angeles, CA, USA
- UC-Irvine School of Medicine, Irvine, CA, USA
| | - Robert Asarnow
- Psychiatry and Biobehavioral Science, University of California-Los Angeles, Los Angeles, CA, USA
| | - Christopher C. Giza
- UC-Los Angeles Steve Tisch BrainSPORT Program, UCLA Easton Clinic for Brain Health, Los Angeles, CA, USA
- Division of Pediatric Neurology, UC-Los Angeles Mattel Children’s Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Meeryo C. Choe
- UC-Los Angeles Steve Tisch BrainSPORT Program, UCLA Easton Clinic for Brain Health, Los Angeles, CA, USA
- Division of Pediatric Neurology, UC-Los Angeles Mattel Children’s Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
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Skin sympathetic nerve activity in patients with chronic orthostatic intolerance. Heart Rhythm 2022; 19:1141-1148. [DOI: 10.1016/j.hrthm.2022.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/25/2022] [Accepted: 03/11/2022] [Indexed: 01/23/2023]
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Wahlgren C, Divanoglou A, Larsson M, Nilsson E, Östholm Balkhed Å, Niward K, Birberg Thornberg U, Lilliecreutz Gudmundsson E, Levi R. Rehabilitation needs following COVID-19: Five-month post-discharge clinical follow-up of individuals with concerning self-reported symptoms. EClinicalMedicine 2022; 43:101219. [PMID: 34901798 PMCID: PMC8645256 DOI: 10.1016/j.eclinm.2021.101219] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/12/2021] [Accepted: 11/12/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This report describes and objectivizes reported problems among a cohort of previously hospitalized COVID-19 patients by clinical examination and determination of the required level of rehabilitation sevices. METHODS This report forms part of the Linköping COVID-19 Study (LinCoS) that included 745 individuals from one of 21 Swedish healthcare regions, Region Östergötland (RÖ), admitted to hospital for COVID-19 during March 1st-May 31st, 2020. In this descriptive ambidirectional cohort study, all 185 individuals who had reported concerning persisting symptoms were invited to a multi-professional clinical assessment of somatic, functional, affective, neuropsychological status and rehabilitation needs. Rehabilitation needs were assessed using three sub-scales of the Rehabilitation Complexity Scale-Extended. FINDINGS Among the 158 (85·4%) cases consenting and included in the analysis, we found a broad array of symptoms and signs attributable to COVID-19 involving respiratory, visual, auditory, motor, sensory and cognitive functions that could be confirmed clinically at five months post-discharge. This translated into 16% [95% CI 13-20] of survivors (70/433) of the total regional cohort of hospitalised patients requiring further rehabilitative interventions at follow-up. Weakness in extremities was reported in 28·5% [21·6, 36·2] (45/158). On examination, clinically overt muscle weakness could be corroborated in 15 individuals (10·5%) [6·1, 16·4]. 48% [40, 56] (76/158) reported cognitive symptoms, while the physician noted overt cognitive impairments in only 3% [1·1, 7·5]. In neuropsychological testing, 37% [28-46] (45/122) performed 1.5 SD below the norm, indicating neurocognitive deficits. Fifty-five individuals (34·8%) [27·4, 42·8] reported new or aggravated pain. In three fourths of them, it exerted a 'moderate' or worse detrimental effect on their ability to work. INTERPRETATION Our study underscores the importance of providing extensive examination of cases with persisting problems after COVID-19, especially since symptoms such as fatigue and breathlessness are highly nonspecific, but may represent significant underlying functional impairments. Robust neurocognitive testing should be performed, as cognitive problems may easily be overlooked during routine medical consultation. In the Swedish context, most rehabilitative interventions could be provided in a primary care setting. A substantial minority of patients should be triaged to specialized rehabilitation services.
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Affiliation(s)
- Carl Wahlgren
- Department of Rehabilitation Medicine and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping S-58185, Sweden
| | - Anestis Divanoglou
- Department of Rehabilitation Medicine and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping S-58185, Sweden
| | - Melanie Larsson
- Department of Rehabilitation Medicine and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping S-58185, Sweden
| | - Emma Nilsson
- Department of Rehabilitation Medicine and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping S-58185, Sweden
| | - Åse Östholm Balkhed
- Department of Infectious Diseases and Department of Biomedical and Clinical Sciences, Linköping University, Linköping S-58185, Sweden
| | - Katarina Niward
- Department of Infectious Diseases and Department of Biomedical and Clinical Sciences, Linköping University, Linköping S-58185, Sweden
| | - Ulrika Birberg Thornberg
- Department of Rehabilitation Medicine and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping S-58185, Sweden
| | - Eva Lilliecreutz Gudmundsson
- Department of Rehabilitation Medicine and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping S-58185, Sweden
| | - Richard Levi
- Department of Rehabilitation Medicine and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping S-58185, Sweden
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39
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Gibbons CH, Silvestri NJ. Autonomic Dysfunction in Neuromuscular Disorders. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00005-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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40
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Struhal W, Hain B. A new light on an old condition. Eur Heart J Case Rep 2021; 5:ytab499. [PMID: 34993411 PMCID: PMC8716748 DOI: 10.1093/ehjcr/ytab499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 09/21/2021] [Accepted: 11/30/2021] [Indexed: 11/14/2022]
Affiliation(s)
- Walter Struhal
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500 Krems, Austria
- Department of Neurology, University Hospital Tulln, Alter Ziegelweg 10, 3430 Tulln, Austria
| | - Barbara Hain
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500 Krems, Austria
- Department of Neurology, University Hospital Tulln, Alter Ziegelweg 10, 3430 Tulln, Austria
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Abstract
Sinus node dysfunction (SND) is a multifaceted disorder most prevalent in older individuals, but may also occur at an earlier age. In most cases, the SND diagnosis is ultimately established by documenting its ECG manifestations. EPS has limited utility. The treatment strategy is largely dictated by symptoms and ECG manifestations. Not infrequently, both bradycardia and tachycardia coexist in the same patients, along with other diseases common in the elderly (e.g., hypertension, coronary artery disease), thereby complicating treatment strategy. Prevention of the adverse consequences of both bradyarrhythmia and tachyarrhythmia is important to reduce susceptibility to syncope, falls, and thromboembolic complications.
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Affiliation(s)
- Neeraj Sathnur
- Cardiac Arrhythmia Service, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA; Cardiovascular Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware St SE, Minneapolis, MN 55455, USA; Cardiac Electrophysiology, Park-Nicollet Medical Center, St Louis Park, Minneapolis, MN, USA
| | - Emanuel Ebin
- Cardiac Arrhythmia Service, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA; Cardiovascular Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware St SE, Minneapolis, MN 55455, USA
| | - David G Benditt
- Cardiac Arrhythmia Service, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA; Cardiovascular Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware St SE, Minneapolis, MN 55455, USA.
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42
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Jiam NT, Murphy OC, Gold DR, Isanhart E, Sinn DI, Steenerson KK, Sharon JD. Nonvestibular Dizziness. Otolaryngol Clin North Am 2021; 54:999-1013. [PMID: 34538360 DOI: 10.1016/j.otc.2021.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Dizziness is a common chief complaint with an extensive differential diagnosis that ranges from peripheral, central, to nonvestibular conditions. An understanding of nonvestibular conditions will aid accurate diagnosis and initiation of appropriate management. Thus, the objective of this article is to present an overview of nonvestibular etiologies that may plague a dizzy patient and the recommended treatment options.
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Affiliation(s)
- Nicole T Jiam
- Department of Otolaryngology-Head & Neck Surgery, University of California San Francisco School of Medicine, 2233 Post Street, UCSF Box 3213, San Francisco, CA 94115, USA
| | - Olwen C Murphy
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Pathology 2-210, Baltimore, MD 21287, USA
| | - Daniel R Gold
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Pathology 2-210, Baltimore, MD 21287, USA
| | - Erin Isanhart
- Angular Momentum Physical Therapy, 4459 Scottsfield Drive, San Jose, CA 95136-1630, USA
| | - Dong-In Sinn
- Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Kristen K Steenerson
- Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA 94304, USA; Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Palo Alto, CA 94303, USA
| | - Jeffrey D Sharon
- Department of Otolaryngology-Head & Neck Surgery, University of California San Francisco School of Medicine, 2233 Post Street, Room 315, San Francisco, CA 94115, USA.
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43
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Levine D, Work B, McDonald S, Harty N, Mabe C, Powell A, Sanford G. Occupational Therapy Interventions for Clients with Ehlers-Danlos Syndrome (EDS) in the Presence of Postural Orthostatic Tachycardia Syndrome (POTS). Occup Ther Health Care 2021; 36:253-270. [PMID: 34520307 DOI: 10.1080/07380577.2021.1975200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is often seen in clients with Ehlers-Danlos syndrome (EDS), primarily hypermobile EDS. Research has shown clients with EDS and POTS may experience limitations affecting not only their physical function, but also their social, emotional, and mental well-being. Using a client-centered approach, occupational therapy practitioners assess health, well-being, symptomatology (fatigue, muscle pain, dizziness, etc.), participation and engagement in occupation, and provide interventions to improve quality of life. This paper will address occupational therapy interventions to treat common symptomatology for clients with EDS in the presence of POTS, including environmental modifications, use of adaptive equipment and orthoses, exercise and fall prevention, energy conservation and pacing, sleep hygiene, and routine and habit development to promote optimal engagement in meaningful occupations.
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Affiliation(s)
- David Levine
- Department of Physical Therapy, The University of Tennessee at Chattanooga, Chattanooga, TN, USA
| | - Brittany Work
- Department of Occupational Therapy, The University of Tennessee at Chattanooga, Chattanooga, TN, USA
| | - Susan McDonald
- Department of Occupational Therapy, The University of Tennessee at Chattanooga, Chattanooga, TN, USA
| | - Nicole Harty
- Department of Occupational Therapy, The University of Tennessee at Chattanooga, Chattanooga, TN, USA
| | - Carolee Mabe
- Department of Occupational Therapy, The University of Tennessee at Chattanooga, Chattanooga, TN, USA
| | - Alison Powell
- Department of Occupational Therapy, The University of Tennessee at Chattanooga, Chattanooga, TN, USA
| | - Graceline Sanford
- Department of Occupational Therapy, The University of Tennessee at Chattanooga, Chattanooga, TN, USA
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44
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Lavie CJ. Special Assorted Topics 2021. Prog Cardiovasc Dis 2021; 67:1. [PMID: 34412824 DOI: 10.1016/j.pcad.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School-the University of Queensland School of Medicine in New Orleans, United States of America.
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45
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Kohno R, Cannom DS, Olshansky B, Xi SC, Krishnappa D, Adkisson WO, Norby FL, Fedorowski A, Benditt DG. Mast Cell Activation Disorder and Postural Orthostatic Tachycardia Syndrome: A Clinical Association. J Am Heart Assoc 2021; 10:e021002. [PMID: 34398691 PMCID: PMC8649306 DOI: 10.1161/jaha.121.021002] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Recently there has been increased interest in a possible association between mast cell activation (MCA) disorder and postural orthostatic tachycardia syndrome (POTS). This study examined the frequency with which symptoms and laboratory findings suggesting MCA disorder occurred in patients diagnosed with POTS. Methods and Results Data were obtained from patients in whom symptoms and orthostatic testing were consistent with a POTS diagnosis. Individuals with <4 months symptom duration, evident ongoing inflammatory disease, suspected volume depletion, or declined consent were excluded. All patients had typical POTS symptoms; some, however, had additional nonorthostatic complaints not usually associated with POTS. The latter patients underwent additional testing for known MCA biochemical mediators including prostaglandins, histamine, methylhistamine, and plasma tryptase. The study comprised 69 patients who met POTS diagnostic criteria. In 44 patients (44/69, 64%) additional nonorthostatic symptoms included migraine, allergic complaints, skin rash, or gastrointestinal symptoms. Of these 44 patients, 29 (66%) exhibited at least 1 laboratory abnormality suggesting MCA disorder, and 11/29 patients had 2 or more such abnormalities. Elevated prostaglandins (n=16) or plasma histamine markers (n=23) were the most frequent findings. Thus, 42% (29/69) of patients initially diagnosed with POTS exhibited both additional symptoms and at least 1 elevated biochemical marker suggesting MCA disorder. Conclusions Laboratory findings suggesting MCA disorder were relatively common in patients diagnosed with POTS and who present with additional nonorthostatic gastrointestinal, cutaneous, and allergic symptoms. While solitary abnormal laboratory findings are not definitive, they favor MCA disorder being considered in such cases.
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Affiliation(s)
- Ritsuko Kohno
- Cardiac Arrhythmia Center Cardiovascular Division University of Minnesota Minneapolis MN
| | - David S Cannom
- Hospital of the Good Samaritan Los Angeles CA.,University of Southern California Keck School of Medicine Los Angeles CA
| | | | - Shijun Cindy Xi
- University of Southern California Keck School of Medicine Los Angeles CA
| | - Darshan Krishnappa
- Cardiac Arrhythmia Center Cardiovascular Division University of Minnesota Minneapolis MN
| | - Wayne O Adkisson
- Cardiac Arrhythmia Center Cardiovascular Division University of Minnesota Minneapolis MN
| | - Faye L Norby
- Smidt Heart Institute Cedars-Sinai Heart System Los Angeles CA
| | - Artur Fedorowski
- Departments of Cardiology and Medicine (Karolinska) Karolinska University Hospital, Karoloinska Instiute, and Lund University Stockholm Sweden.,Department of Clinical Sciences (Lund) Karolinska University Hospital, Karoloinska Instiute, and Lund University Malmo Sweden
| | - David G Benditt
- Cardiac Arrhythmia Center Cardiovascular Division University of Minnesota Minneapolis MN
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Benditt DG, Sutton R. Improved Acute Orthostatic Tolerance in POTS by Lower Body Compression: Both Beneficial and Sufficient? J Am Coll Cardiol 2021; 77:297-299. [PMID: 33478653 DOI: 10.1016/j.jacc.2020.11.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 11/10/2020] [Indexed: 11/18/2022]
Affiliation(s)
- David G Benditt
- Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA.
| | - Richard Sutton
- Department of Cardiology, National Heart and Lung Institute, Imperial College, Hammersmith Hospital, London, United Kingdom
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47
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Monaco C, Sorgente A, Ramak R, Chierchia GB, La Meir M, de Asmundis C. Ablation therapy of postural orthostatic tachycardia syndrome, inappropriate sinus tachycardia and primary electrical diseases: new insights in invasive treatment options in severely symptomatic patients. Herzschrittmacherther Elektrophysiol 2021; 32:323-329. [PMID: 34228177 DOI: 10.1007/s00399-021-00778-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/01/2021] [Indexed: 10/20/2022]
Abstract
Achieving the goal management of some arrhythmic syndromes can be challenging; medical treatment for inappropriate sinus tachycardia (IST) and postural orthostatic tachycardia syndrome (POTS) may be ineffective, necessitating multidisciplinary team treatment. Implantable defibrillator devices (ICDs), along with anti-arrhythmic drugs (AADs), remain the first-line treatment for primary electrical diseases that pose a risk of sudden cardiac death (SCD). Ablation of the arrhythmogenic substrate is not always suggested in patients with these pathologies, but it may be a valuable support for reducing arrhythmic burden, improving quality of life, and treating pathologies that are resistant to pharmacological treatment; however, this option is not often considered due to the potential risks associated with an invasive approach. Minimally invasive hybrid ablation in these syndromes, such as a hybrid thoracoscopic approach and the use of non-invasive mapping systems, reduces post-surgery complications and ensures the best possible outcome for the patient.
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Affiliation(s)
- Cinzia Monaco
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Antonio Sorgente
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Robbert Ramak
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Gian Battista Chierchia
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Mark La Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis, Laarbeeklaan 101, 1090, Brussels, Belgium.
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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: 24] [Impact Index Per Article: 8.0] [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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Podzolkov VI, Bragina AE, Tarzimanova AI, Vasil'eva LV, Batrakova EP, Lobova NV, Bykova EE, Khachuroeva MM. Post-COVID Syndrome and Tachycardia: Theoretical Base and Treatment Experience. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-04-08] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The coronavirus pandemic showed not only an increase in levels of excess morbidity and mortality in the acute phase, but also persisting symptoms 4 weeks after the onset of the disease. A review of international studies on the prevalence and diversity of the manifestations of postcoid syndrome is presented. The data on such a manifestation of post-COVID syndrome as postural orthostatic tachycardia syndrome (POTS) are accumulating. Pathogenetic mechanisms, modern diagnostic criteria and research data on the prevalence of this syndrome are presented in the article. The Canadian Cardiovascular Society has proposed medications as a treatment for POTS, including the sinus node If channel inhibitor ivabradine. Data from several studies showing the effectiveness of this drug for POTS, including after suffering COVID-19, are presented in the article. Clinical data on the prevalence of tachycardia among patients admitted to the Sechenov University hospital are presented. About 18% of patients with hypertension and 21% of patients with normal blood pressure had a high heart rate. A clinical example of the use of ivabradine in a patient after a coronavirus infection is presented. Drug interactions and individual tolerance of ivabradine in patients after coronavirus infection are being discussed. The authors put forward the hypothesis about the further prospect of using ivabradine in the treatment of clinical manifestations of postcoid syndrome on the basis of literature data and their own experience.
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Affiliation(s)
- V. I. Podzolkov
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. E. Bragina
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. I. Tarzimanova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - L. V. Vasil'eva
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - E. P. Batrakova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - N. V. Lobova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - E. E. Bykova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - M. M. Khachuroeva
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
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Abstract
Background: Mast cells (MCs) have been implicated in a spectrum of allergic, immunologic, and infectious inflammatory conditions that involve different organ systems. MC activation can occur through several different surface receptors other than the well known IgE mediated pathway. Methods: We use two representative case reports from our practice to summarize what is currently known about MCAS disorders (reality) so that the clinician can more easily differentiate these conditions from other complex unexplained conditions that are being associated with MC activation (myth). Results: Many complex MC-related conditions, such as clonal MC diseases, have been well characterized but other MC-related disorders, such as MC activation syndrome (MCAS) and idiopathic anaphylaxis, still remain poorly defined. The current consensus recommendations for a diagnosis of MCAS require clinical symptoms of anaphylaxis that correlate with elevation of a MC activation biomarker(s), which improves with H1-antihistamines. Conclusion: Clinical symptoms of MCAS can overlap with other conditions, including neurogenic disorders, e.g., dysautonomia, which necessitate the importance for the clinician to render an accurate diagnosis so that appropriate treatment is provided.
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