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Muacevic A, Adler JR, Chaudhuri D, Khan KI, Al Shouli R, Allakky A, Ferguson AA, Khan AI, Hamid P. Anxiety and Depression as Risk Factors for Vasovagal Syncope and Potential Treatment Targets: A Systematic Review. Cureus 2022; 14:e32793. [PMID: 36694488 PMCID: PMC9858696 DOI: 10.7759/cureus.32793] [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: 10/15/2022] [Accepted: 12/21/2022] [Indexed: 12/24/2022] Open
Abstract
Vasovagal syncope (VVS) is a transient, sudden loss of consciousness followed by complete resolution, usually due to a paradoxical autonomic reaction that results in hypotension and/or bradycardia. In this study, we assessed the correlation between VVS and a patient's psychiatric status, as well as if this association could be a target in the treatment of those patients. We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched the available literature using the following databases: PubMed, Google Scholar, and ScienceDirect, with last access on July 21, 2022. The search resulted in 1691 articles, and inclusion and exclusion criteria were applied to nine remaining articles, all of which were accepted after using the quality assessment tools, four observational and four randomized controlled trials (RCTs). Four of the included studies assessed the correlation among vasovagal syncope, psychosocial impairment, and quality of life. We found a consistent correlation among VVS, psychosocial impairment, and quality of life (QoL), meaning that VVS patients usually have some degree of psychosocial impairment, especially in the form of anxiety and depression, and a poorer QoL in comparison to their healthy counterparts. The use of psychotherapy and antidepressants was proven to be effective in VVS in RCTs, but further evidence is needed.
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Narasimhan B, Aggarwal D, Satish P, Kantharia B, Aronow WS. Postural orthostatic tachycardia syndrome: pathophysiology, management, and experimental therapies. Expert Opin Investig Drugs 2022; 31:1017-1025. [PMID: 36094001 DOI: 10.1080/13543784.2022.2121697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Bharat Narasimhan
- Department of Cardiology, Houston Methodist Debakey Cardiovascular Center, Houston, Tx, USA
| | - Devika Aggarwal
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | - Priyanka Satish
- Department of Cardiology, Houston Methodist Debakey Cardiovascular Center, Houston, Tx, USA
| | - Bharat Kantharia
- Cardiovascular and Heart Rhythm Consultants, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Wilbert S. Aronow
- Department of Cardiology, Westchester Medical center/New York Medical College, Valhalla, NY, USA
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Shimmura M, Takase KI. Clinical utility of serum prolactin and lactate concentrations to differentiate epileptic seizures from non-epileptic attacks in the emergency room. Seizure 2022; 95:75-80. [PMID: 35016147 DOI: 10.1016/j.seizure.2021.12.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 01/14/2023] Open
Abstract
PURPOSE To evaluate the diagnostic utility of serum prolactin (PRL) and lactate (LAC) concentrations for patients presenting with either or both convulsions and transient loss of consciousness (TLOC) in the emergency room (ER). METHODS This was a retrospective single-center study conducted in a tertiary care hospital ER. Medical records of consecutive patients who presented with convulsions or TLOC between January 2018 and December 2020 were reviewed. Patients with an ER diagnosis of epileptic seizures, psychogenic non-epileptic seizure (PNES), and syncope were selected for analysis. Serum PRL and LAC concentrations were measured within 3 h of the event and compared between groups. RESULTS Among the 440 eligible patients, 173 (39.3%) were included for analysis. Serum PRL concentration was significantly higher in patients with epileptic seizures with convulsions than in those with PNES with convulsions (p < 0.001) and convulsive syncope (p = 0.023). Serum LAC concentration was not significantly elevated in patients with convulsive syncope. Using a PRL cut-off value of 24.0 ng/mL, serum PRL concentration had 100.0% sensitivity and 82.9% specificity for differentiating between PNES and other attacks without convulsions. CONCLUSION Elevated serum PRL with normal serum LAC concentration in patients who have attacks with convulsions suggests convulsive syncope. Serum PRL concentration is useful in the diagnosis of PNES with convulsions. However, serum LAC concentration is not useful as a routine screening test for attacks without convulsions in the ER.
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Affiliation(s)
- Mitsunori Shimmura
- Department of Neurology, Iizuka Hospital, 3-83 Yoshio-machi, Iizuka, Fukuoka 820-8505, Japan.
| | - Kei-Ichiro Takase
- Department of Neurology, Iizuka Hospital, 3-83 Yoshio-machi, Iizuka, Fukuoka 820-8505, Japan
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Harnish PR, Shastri P, Grubb BP. Sick Sinus Syndrome Can Be Associated with Postural Tachycardia Syndrome and Inappropriate Sinus Tachycardia Syndrome. J Innov Card Rhythm Manag 2021; 12:4526-4531. [PMID: 34035985 PMCID: PMC8139308 DOI: 10.19102/icrm.2021.120503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 11/09/2020] [Indexed: 11/21/2022] Open
Abstract
As a known phenomenon, crossover between sinus node dysfunction and common atrial tachyarrhythmias—most notably, atrial fibrillation and atrial flutter—in older individuals has previously been seen. Here, we present one of the first case series demonstrating a similar relationship between sinus node dysfunction and much rarer etiologies of tachyarrhythmia—that is, postural tachycardia syndrome and inappropriate sinus tachycardia. The exact pathological mechanisms behind these arrhythmias as well as the observation of concurrent nodal dysfunction are poorly understood. Here, we propose both potential mechanistic pathways as well as an initial treatment algorithm for sinus node dysfunction based upon the existing evidence.
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Affiliation(s)
- Paul R Harnish
- Division of Cardiovascular Medicine, Department of Medicine, University of Toledo, Toledo, OH, USA
| | - Pinang Shastri
- Department of Medicine, University of Toledo, Toledo, OH, USA
| | - Blair P Grubb
- Division of Cardiovascular Medicine, Department of Medicine, University of Toledo, Toledo, OH, USA
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Y Lei L, S Chew D, K Sandhu R, S Sheldon R, R Raj S. Non-Pharmacological and Pharmacological Management of Cardiac Dysautonomia Syndromes. J Atr Fibrillation 2020; 13:2395. [PMID: 33024496 DOI: 10.4022/jafib.2395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/10/2020] [Accepted: 03/16/2020] [Indexed: 11/10/2022]
Abstract
Vasovagal syncope, postural orthostatic tachycardia syndrome, and inappropriate sinus tachycardia comprise a heterogenous group of common autonomic disorders that are associated with significant symptoms that impair quality of life. Clinical management of these disorders should prioritize conservative non-pharmacological therapies and consider incorporating pharmacological agents for recurrences. The selection and titration of medications may be complicated by the occurrence of potentially overlapping pathophysiological variants, differences in specific clinical presentations, and commonly associated comorbidities. However, with appropriate long-term management and specialist input, most patients note both symptomatic improvement and functional restoration over time.
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Affiliation(s)
- Lucy Y Lei
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Derek S Chew
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.,Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.,Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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van Deursen DN, van den Heuvel OA, Booij J, Berendse HW, Vriend C. Autonomic failure in Parkinson's disease is associated with striatal dopamine deficiencies. J Neurol 2020; 267:1922-1930. [PMID: 32162062 PMCID: PMC7320937 DOI: 10.1007/s00415-020-09785-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/03/2020] [Accepted: 03/05/2020] [Indexed: 12/11/2022]
Abstract
Autonomic dysfunction is a common non-motor symptom in Parkinson's disease (PD). Dopamine and serotonin are known to play a role in autonomic regulation, and, therefore, PD-related degeneration of serotonergic and dopaminergic neurons in these regions may be associated with autonomic dysfunction. We sought to clarify the association between extrastriatal serotonergic and striatal dopaminergic degeneration and the severity of autonomic symptoms, including gastrointestinal, pupillomotor, thermoregulatory, cardiovascular, and urinary dysfunction. We performed hierarchical multiple regression analyses to determine the relationships between (extra)striatal serotonergic and dopaminergic degeneration and autonomic dysfunction in 310 patients with PD. We used [123I]FP-CIT SPECT binding to presynaptic serotonin (SERT) and dopamine (DAT) transporters as a measure of the integrity of these neurotransmitter systems, and the SCOPA-AUT (Scales for Outcomes in Parkinson's Disease-Autonomic) questionnaire to evaluate the perceived severity of autonomic dysfunction. Motor symptom severity, medication status, and sex were added to the model as covariates. Additional analyses were also performed using five subdomains of the SCOPA-AUT: cardiovascular, gastrointestinal, urinary, thermoregulatory, and pupillomotor symptoms. We found that autonomic symptoms were most significantly related to lower [123I]FP-CIT binding ratios in the right caudate nucleus and were mainly driven by gastrointestinal and cardiovascular dysfunction. These results provide a first look into the modest role of dopaminergic projections towards the caudate nucleus in the pathophysiology of autonomic dysfunction in PD, but the underlying mechanism warrants further investigation.
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Affiliation(s)
- Dagmar N van Deursen
- Anatomy and Neurosciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Odile A van den Heuvel
- Anatomy and Neurosciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
- Department of Psychiatry, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Jan Booij
- Department of Radiology and Nuclear Medicine, Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands
| | - Henk W Berendse
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Chris Vriend
- Anatomy and Neurosciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands.
- Department of Psychiatry, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands.
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Chelimsky G, Kovacic K, Simpson P, Nugent M, Basel D, Banda J, Chelimsky T. Benign Joint Hypermobility Minimally Impacts Autonomic Abnormalities in Pediatric Subjects with Chronic Functional Pain Disorders. J Pediatr 2016; 177:49-52. [PMID: 27496265 DOI: 10.1016/j.jpeds.2016.06.091] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/17/2016] [Accepted: 06/30/2016] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To determine if children with benign joint hypermobility (BJH) syndrome and chronic functional pain disorders have more autonomic dysfunction. STUDY DESIGN Retrospective chart review study of pediatric patients seen in the pediatric neurogastroenterology and autonomic clinic who underwent autonomic testing and had either a Beighton score of ≥6 and met Brighton criteria for BJH (with BJH) or a score of ≤2 (no BJH). RESULTS Twenty-one female subjects (10 without BJH) met inclusion criteria; 64% of BJH had diagnosis confirmed by genetics consultation. We evaluated for postural tachycardia syndrome, syncope, orthostatic intolerance, and orthostatic hypotension. None of these diagnoses, as well as baseline heart rate, peak heart rate in first 10 minutes of head up tilt (P = .35 and P = .61, respectively), and sudomotor index (suggestive of autonomic neuropathy) (P = .58), showed differences between the groups. Age of onset of symptoms was also similar (P = .61) (BJH vs without BJH: median [range]:15.6 years [12.9-17.5] vs 15.4 years [11.1-18.2]). There was no difference between groups in complaints of migraine, chronic nausea, chronic fatigue, lightheadedness, dizziness, fainting >3 times/lifetime, delayed onset of sleep, irritable bowel syndrome, dyspepsia, abdominal migraine, functional abdominal pain, constipation, or fibromyalgia. CONCLUSIONS Children with chronic functional pain disorders and BJH have autonomic testing findings and comorbid features compared with a similar cohort of subjects without BJH, suggesting that BJH is not the driver of the autonomic and comorbid disorders.
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Affiliation(s)
- Gisela Chelimsky
- Center for Pediatric Neurogastroenterology, Motility, and Autonomic Disorders, Medical College of Wisconsin, Milwaukee, WI
| | - Katja Kovacic
- Center for Pediatric Neurogastroenterology, Motility, and Autonomic Disorders, Medical College of Wisconsin, Milwaukee, WI
| | - Pippa Simpson
- Division of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, WI
| | - Melodee Nugent
- Division of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, WI
| | - Donald Basel
- Division of Pediatric Genetics, Medical College of Wisconsin, Milwaukee, WI
| | - Julie Banda
- Center for Pediatric Neurogastroenterology, Motility, and Autonomic Disorders, Medical College of Wisconsin, Milwaukee, WI
| | - Thomas Chelimsky
- Center for Pediatric Neurogastroenterology, Motility, and Autonomic Disorders, Medical College of Wisconsin, Milwaukee, WI; Department of Neurology, Medical College of Wisconsin, Milwaukee, WI
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Gunning WT, Karabin BL, Blomquist TM, Grubb BP. Postural orthostatic tachycardia syndrome is associated with platelet storage pool deficiency. Medicine (Baltimore) 2016; 95:e4849. [PMID: 27631244 PMCID: PMC5402587 DOI: 10.1097/md.0000000000004849] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Mechanisms have been postulated to explain postural orthostatic tachycardia syndrome (POTS), however, the etiology of this often debilitating disorder remains unknown. We conducted a retrospective case-control study of 181 POTS patients who exhibited/reported bleeding symptoms for a specific platelet (PL) dysfunction disorder, delta granule storage pool deficiency (δ-SPD).Patients were included only if results of blood tests for δ-SPD were available. Electron microscopy was utilized to diagnose δ-SPD. An ELISA assay was used to determine serotonin (5HT) concentration in PLs and medical record review was employed to collect patients' clinical symptoms.The most common bleeding symptom was easy bruising (71%) but frequent nose bleeds, heavy menstrual bleeding, and a family history of bleeding were also commonly reported. Of the patients studied, 81% were diagnosed with δ-SPD. Our investigation of 5HT concentration extracted from PLs revealed significantly lower levels of 5HT in POTS patients when compared to that of control subjects. Our data suggest that patients with POTS have significant comorbidities including bleeding symptoms and/or family bleeding histories, and have diminished PL 5HT levels supporting the hypothesis that POTS is a low 5HT level disorder. While we describe a significant relationship with POTS and δ-SPD, this finding does not constitute an etiology for POTS.Our results establish an additional comorbidity frequently seen in POTS that could explain a number of disparate symptoms often affecting the severity of POTS.
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Affiliation(s)
- William T. Gunning
- Department of Pathology
- Correspondence: William T. Gunning III, Department of Pathology, University of Toledo Medical Center, 3000 Arlington Avenue, MS 1090, Toledo, OH 43614 (e-mail: )
| | | | | | - Blair P. Grubb
- Department of Medicine, University of Toledo Medical Center, Toledo, OH
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Chelimsky G, Simpson P, McCabe N, Zhang L, Chelimsky T. Autonomic Testing in Women with Chronic Pelvic Pain. J Urol 2016; 196:429-34. [PMID: 27026035 DOI: 10.1016/j.juro.2016.03.142] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2016] [Indexed: 01/17/2023]
Abstract
PURPOSE We determined whether abnormal autonomic nervous system innervation of the bladder underlies IC (interstitial cystitis)/BPS (bladder pain syndrome) differently than other chronic pelvic pain. MATERIALS AND METHODS In this institutional review board approved protocol 39 healthy controls and 134 subjects were enrolled, including 36 with IC/BPS, 14 with myofascial pelvic pain and 42 with IC/BPS plus myofascial pelvic pain. Three subjects were excluded from study. Autonomic nervous system evaluations included deep breathing, the Valsalva maneuver, and the tilt table and sudomotor tests. The latter evaluates autonomic neuropathy. A modified validated composite autonomic laboratory score was applied. RESULTS Median age in the IC/BPS group was 47.5 years (range 21 to 78), greater than in healthy controls (34 years, range 20 to 75, p = 0.006), the myofascial pelvic pain group (33 years, range 22 to 56, p = 0.004) and the IC/BPS plus myofascial pelvic pain group (38 years, range 18 to 64, p = 0.03). Body mass index did not significantly differ but the myofascial pelvic pain and IC/BPS plus myofascial pelvic pain groups had a higher body mass index than healthy controls (p = 0.05 and 0.03, respectively). Cardiovascular and adrenergic indexes did not differ. The tilt table test showed more orthostatic intolerance in all chronic pelvic pain groups. Tilt table test diagnoses (orthostatic hypotension, postural tachycardia syndrome and reflex syncope) were rare. Baseline heart rate was higher in all chronic pelvic pain groups (p = 0.004). Compared to healthy controls all myofascial pelvic pain groups showed significantly more clear-cut autonomic neuropathy, defined as a sweat score of 3 or greater (vs IC/BPS plus myofascial pelvic pain p = 0.007 and vs myofascial pelvic pain p = 0.03). CONCLUSIONS Some chronic pelvic pain types show autonomic neuropathy and some show vagal withdrawal. In all types orthostatic intolerance likely reflects central sensitization and perhaps catastrophizing. Some of these findings suggest novel therapeutic targets.
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Affiliation(s)
- Gisela Chelimsky
- Medical College of Wisconsin, Milwaukee, Wisconsin; Case Western Reserve University (NM), Cleveland, Ohio
| | - Pippa Simpson
- Medical College of Wisconsin, Milwaukee, Wisconsin; Case Western Reserve University (NM), Cleveland, Ohio
| | - Noel McCabe
- Medical College of Wisconsin, Milwaukee, Wisconsin; Case Western Reserve University (NM), Cleveland, Ohio
| | - Liyun Zhang
- Medical College of Wisconsin, Milwaukee, Wisconsin; Case Western Reserve University (NM), Cleveland, Ohio
| | - Thomas Chelimsky
- Medical College of Wisconsin, Milwaukee, Wisconsin; Case Western Reserve University (NM), Cleveland, Ohio.
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Butler IJ, Lankford JE, Hashmi SS, Numan MT. Biogenic amine metabolism in juvenile neurocardiogenic syncope with dysautonomia. Ann Clin Transl Neurol 2015; 1:251-7. [PMID: 25590038 PMCID: PMC4292742 DOI: 10.1002/acn3.49] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 02/10/2014] [Accepted: 02/12/2014] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE Biogenic amine brain levels and their cerebral metabolism are frequently studied by quantitation of biogenic amine metabolites in cerebrospinal fluid (CSF) compared to age-matched controls. There is a paucity of studies in adolescents and young adults investigating the potential role of disordered cerebral biogenic amine metabolism in young patients who have dysautonomia based on abnormal head-up tilt table (HUTT). METHODS In a cohort of juvenile patients with neurocardiogenic syncope and dysautonomia documented by abnormal HUTT, biogenic amine metabolites of dopamine and serotonin were quantitated in 18 patients (15 females). HUTT testing is an effective clinical method to evaluate posturally induced physiological events in patients suspected of neurocardiogenic syncope with dysautonomia. RESULTS Levels of the dopamine metabolite (homovanillic acid: HVA) and/or the serotonin metabolite (5-hydroxyindoleacetic acid: 5HIAA) were significantly reduced in 13 patients compared to age-matched controls. INTERPRETATION Peripheral biogenic amines and their metabolites have been extensively studied in adults with dysautonomia due to various neurodegenerative disorders (Parkinson disease, multiple system atrophy, primary autonomic failure). Our findings indicate that more than two-thirds of this cohort of young patients with dysautonomia of variable severity have a defect in cerebral biogenic amines, particularly in dopamine and serotonin metabolism.
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Affiliation(s)
- Ian J Butler
- Division of Child and Adolescent Neurology, Department of Pediatrics, The University of Texas Medical School at Houston Houston, Texas
| | - Jeremy E Lankford
- Division of Child and Adolescent Neurology, Department of Pediatrics, The University of Texas Medical School at Houston Houston, Texas
| | - Syed Shahrukh Hashmi
- Pediatric Research Center, Department of Pediatrics, The University of Texas Medical School at Houston Houston, Texas
| | - Mohammed T Numan
- Division of Pediatric Cardiology, Department of Pediatrics, The University of Texas Medical School at Houston Houston, Texas
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Kozlowska K, Palmer DM, Brown KJ, Scher S, Chudleigh C, Davies F, Williams LM. Conversion disorder in children and adolescents: A disorder of cognitive control. J Neuropsychol 2014; 9:87-108. [DOI: 10.1111/jnp.12037] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 10/28/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Kasia Kozlowska
- Psychological Medicine; The Children's Hospital at Westmead; New South Wales Australia
- Disciplines of Psychiatry and of Paediatrics and Child Health; University of Sydney Medical School; New South Wales Australia
- Brain Dynamics Centre at Westmead Hospital and Westmead Millennium Institute; Westmead New South Wales Australia
| | - Donna M. Palmer
- Brain Dynamics Centre at Westmead Hospital and Westmead Millennium Institute; Westmead New South Wales Australia
- University of Sydney Medical School; New South Wales Australia
| | - Kerri J. Brown
- Brain Dynamics Centre at Westmead Hospital and Westmead Millennium Institute; Westmead New South Wales Australia
- University of Sydney Medical School; New South Wales Australia
- NSW Institute of Psychiatry; Parramatta BC New South Wales Australia
| | - Stephen Scher
- Department of Psychiatry; Harvard Medical School; McLean Hospital; Belmont Massachusetts USA
| | - Catherine Chudleigh
- Psychological Medicine; The Children's Hospital at Westmead; New South Wales Australia
| | - Fiona Davies
- Psychological Medicine; The Children's Hospital at Westmead; New South Wales Australia
| | - Leanne M. Williams
- Brain Dynamics Centre at Westmead Hospital and Westmead Millennium Institute; Westmead New South Wales Australia
- University of Sydney Medical School; New South Wales Australia
- Psychiatry and Behavioral Sciences; Stanford University; California USA
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Seligman WH, Low DA, Asahina M, Mathias CJ. Abnormal gastric myoelectrical activity in postural tachycardia syndrome. Clin Auton Res 2012; 23:73-80. [DOI: 10.1007/s10286-012-0185-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 11/09/2012] [Indexed: 10/27/2022]
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Kowey PR, Mudumbi RV, Aquilina JW, DiBattiste PM. Cardiovascular safety profile of dapoxetine during the premarketing evaluation. Drugs R D 2011; 11:1-11. [PMID: 21410293 PMCID: PMC3585760 DOI: 10.2165/11587660-000000000-00000] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The cardiovascular safety profile of dapoxetine, a novel selective serotonin reuptake inhibitor (SSRI) developed as an on-demand oral treatment for premature ejaculation (PE) in men, is evaluated. The cardiovascular assessment of dapoxetine was conducted throughout all stages of drug development, with findings from preclinical safety pharmacology studies, phase I clinical pharmacology studies investigating the effect of dapoxetine on QT/corrected QT (QTc) intervals in healthy men, and phase III, randomized, placebo-controlled studies evaluating the safety (and efficacy) of the drug. Preclinical safety pharmacology studies did not suggest an adverse electrophysiologic or hemodynamic effect with concentrations of dapoxetine up to 2-fold greater than recommended doses. Phase I clinical pharmacology studies demonstrated that dapoxetine did not prolong the QT/QTc interval and had neither clinically significant electrocardiographic effects nor evidence of delayed repolarization or conduction effects, with dosing up to 4-fold greater than the maximum recommended dosage. Phase III clinical studies of dapoxetine in men with PE indicated that dapoxetine was generally safe and well tolerated with the dosing regimens used (30mg and 60mg as required). Events of syncope were reported during the clinical development program, with the majority occurring during study visits (on site) on day 1 following administration of the first dose when various procedures (e.g. orthostatic maneuvers, venipunctures) were performed, suggesting that the procedures contributed to the incidence of syncope. This was consistent with previous reports showing that these and similar factors contribute to or trigger vasovagal syncope. Findings of the dapoxetine development program demonstrate that dapoxetine is associated with vasovagal-mediated (neurocardiogenic) syncope. No other associated significant cardiovascular adverse events were identified.
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Affiliation(s)
- Peter R Kowey
- Division of Cardiovascular Disease, Lankenau Hospital and Institute of Medical Research, Wynnewood, Pennsylvania 19096, USA.
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Patterns of emotional-cognitive functioning in pediatric conversion patients: implications for the conceptualization of conversion disorders. Psychosom Med 2011; 73:775-88. [PMID: 22048837 DOI: 10.1097/psy.0b013e3182361e12] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine patterns of emotion processing in children and adolescents with conversion disorders and to determine whether those patterns are associated with particular clusters of conversion symptoms. Autobiographical narratives were used to investigate the organization of information about distressing feelings and memories. METHODS Structured interviews about attachment relationships and autobiographical events were administered to 76 controls and 76 matched subjects aged 6 to 18 years. Age-appropriate assessments of attachment were used: the School-aged Assessment of Attachment for children and the Transition to Adulthood Attachment Interview for adolescents. Patterns of emotion processing were identified using dynamic-maturational model discourse analysis and categorized into four clusters: inhibitory, normative/balanced, coercive-preoccupied, and mixed inhibitory and coercive-preoccupied. These clusters were then cross-tabulated with the sensorimotor characteristics of children with conversion disorders. RESULTS Emotion processing in children with conversion disorders was categorized as psychological inhibition (57%), psychological coercion-preoccupation (34%), and mixed (9%). Psychological inhibition was associated with negative conversion symptoms (discrete sensorimotor deficits, p = .003) and positive conversion symptoms (tremors and tics, p = .04). Psychological coercion-preoccupation was associated with all other disturbances of motor function: bizarre gaits and postures, whole-body floppiness, and refusals to move (p < .0001). Nonepileptic seizures occurred across both groups (56% versus 42%, p = .8). CONCLUSIONS Contrary to the classic understanding of conversion disorder as a unified diagnostic entity with diverse symptoms, this study identified two distinct subtypes of conversion patients-those using psychological inhibition and those using psychological coercion-preoccupation-whose symptoms fell into discrete clusters. Further research is needed to determine the neural mechanisms underlying these processes.
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Aydin MA, Salukhe TV, Wilke I, Willems S. Management and therapy of vasovagal syncope: A review. World J Cardiol 2010; 2:308-15. [PMID: 21160608 PMCID: PMC2998831 DOI: 10.4330/wjc.v2.i10.308] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Revised: 08/12/2010] [Accepted: 08/19/2010] [Indexed: 02/06/2023] Open
Abstract
Vasovagal syncope is a common cause of recurrent syncope. Clinically, these episodes may present as an isolated event with an identifiable trigger, or manifest as a cluster of recurrent episodes warranting intensive evaluation. The mechanism of vasovagal syncope is incompletely understood. Diagnostic tools such as implantable loop recorders may facilitate the identification of patients with arrhythmia mimicking benign vasovagal syncope. This review focuses on the management of vasovagal syncope and discusses the non-pharmacological and pharmacological treatment options, especially the use of midodrine and selective serotonin reuptake inhibitors. The role of cardiac pacing may be meaningful for a subgroup of patients who manifest severe bradycardia or asystole but this still remains controversial.
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Affiliation(s)
- Muhammet Ali Aydin
- Muhammet Ali Aydin, Tushar V Salukhe, Iris Wilke, Stephan Willems, Department of Electrophysiology, University Heart Center Hamburg, Martinistraße 52, Hamburg 20246, Germany
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18
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Eltahawy EA, Grubb BP. Neurocardiogenic syncope: mechanisms, evaluation and treatment. Future Cardiol 2010; 2:325-34. [PMID: 19804090 DOI: 10.2217/14796678.2.3.325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Syncope is the abrupt and transient loss of consciousness due to a temporary reduction in cerebral blood flow, associated with an absence of postural tone, followed by a rapid and usually complete recovery. It may result from several possible etiologies, ranging from the benign to the potentially fatal. Neurocardiogenic (vasovagal) syncope is the most common of a group of neurally mediated syncopes, characterized by a sudden failure of autonomic regulatory mechanisms to maintain adequate blood pressure and, occasionally, heart rate, to sustain cerebral perfusion and consciousness. The diagnosis may be suggested by a characteristic history and by exclusion of other causes of syncope; however, in some cases, upright tilt table testing may be required to provoke typical hemodynamic responses. Cardiologists and cardiac electrophysiologists are frequently expected to manage patients with suspected neurocardiogenic syncope. The following review aims to provide a basic framework for understanding its pathophysiology, clinical presentations, diagnosis and treatment.
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Affiliation(s)
- Ehab A Eltahawy
- Department of Cardiovascular Diseases, Medical University of Ohio, 3000 Arlington Avenue, Toledo, OH 43614, USA
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19
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Vallurupalli S, Das S. Clinical efficacy of beta1 selective adrenergic blockers in the treatment of neurocardiogenic syncope - a meta-analysis. Clin Pharmacol 2010; 2:163-7. [PMID: 22291501 PMCID: PMC3262373 DOI: 10.2147/cpaa.s12873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Beta1 (B(1)) selective blockers have been widely used for the treatment of neurocardiogenic syncope though clinical trials have shown conflicting degrees of efficacy. OBJECTIVE To study the clinical efficacy of B(1) selective blockers compared to placebo in the treatment of neurocardiogenic syncope. METHODS Four placebo controlled randomized studies were identified after search of existing English language literature. Review Manager (RevMan version 5, Oxford, England) was used for statistical calculations. Both random and fixed effects models were used for analysis. RESULTS There was no demonstrable efficacy of B(1) blockers compared to placebo even after a pre-specified sensitivity analysis. There was a trend towards more adverse events in the beta blocker group compared to placebo (OR = 2.03 CI = 0.83-3.95, p = 0.12). CONCLUSION There is no clinical evidence for justifying the use of B(1) selective blockers in the treatment of adult neurocardiogenic syncope. These agents may in fact lead to a higher rate of adverse events compared to placebo.
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Affiliation(s)
- Srikanth Vallurupalli
- Division of General Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, USA.
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20
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Autonomic testing in functional gastrointestinal disorders: implications of reproducible gastrointestinal complaints during tilt table testing. Gastroenterol Res Pract 2009; 2009:868496. [PMID: 19424509 PMCID: PMC2677655 DOI: 10.1155/2009/868496] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Revised: 02/12/2009] [Accepted: 03/11/2009] [Indexed: 11/18/2022] Open
Abstract
Background: The pathophysiology of functional abdominal pain (FAP) is unknown. The upright portion of a tilt table test triggers typical symptoms in certain children.
Aim: To compare the pathophysiology and treatment response of children with FAP whose gastrointestinal symptoms (GI) were replicated (RGI) by tilt table testing (TTT) to those in whom TTT did not have this effect (NRGI).
Methods: An IRB-approved retrospective review of the autonomic laboratory database identified all children tested for GI complaints. We compared results of TTT, Valsalva maneuver, deep breathing and the axon reflex sweat test. Overall treatment response and that specific to fludrocortisone was ranked from 1 to 5, with 1 “much worse,” 3 “neutral,” and 5 “much better.”
Results: 32/76 identified children had reproducible symptoms on TTT (RGI) and 44 did not (NRGI). The RGI group was younger, had a shorter duration of symptoms, more postural tachycardia syndrome (POTS) and benefited more from fludrocortisone (73% in RGI vs. 25% in NRGI).
Conclusion: Dividing patients with FAP according to the effect of TTT on their symptoms appears to delineate 2 fundamentally different groups, with potentially different pathophysiologies and treatment responses. A prospective study is needed.
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21
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Carew S, Connor MO, Cooke J, Conway R, Sheehy C, Costelloe A, Lyons D. A review of postural orthostatic tachycardia syndrome. Europace 2009; 11:18-25. [PMID: 19088364 DOI: 10.1093/europace/eun324] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
A 21-year-old female reports an 18-month history of light-headedness on standing. This is often associated with palpitations and a feeling of intense anxiety. She has had two black-outs in the past 12 months. She is not taking any regular medications. Her supine blood pressure was 126/84 mmHg with a heart rate of 76 bpm, and her upright blood pressure was 122/80 mmHg with a heart rate of 114 bpm. A full system examination was otherwise normal. She had a 12-lead electrocardiogram performed which was unremarkable. She was referred for head-up tilt testing. She was symptomatic during the test and lost consciousness at 16 min. Figure 1 summarizes her blood pressure and heart rate response to tilting. A diagnosis of postural orthostatic tachycardia syndrome with overlapping vasovagal syncope was made.
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Affiliation(s)
- Sheila Carew
- Blood Pressure Unit, Mid Western Regional Hospital, Limerick, Ireland
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22
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Ondansetron Given Intravenously Attenuates Arterial Blood Pressure Drop Due to Spinal Anesthesia. Reg Anesth Pain Med 2008. [DOI: 10.1097/00115550-200807000-00008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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23
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Abstract
Postural orthostatic tachycardia syndrome (POTS) is an autonomic disturbance which has become better understood in recent years. It is now thought to encompass a group of disorders that have similar clinical features, such as orthostatic intolerance, but individual distinguishing parameters--for example, blood pressure and pulse rate. The clinical picture, diagnosis, and management of POTS are discussed.
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Abstract
Neurocardiogenic syncope is a neurally mediated disorder and is a common cause of syncope. The goal of treatment is to prevent recurrences with the aim of improving quality of life and reducing morbidity. Reassurance, in some cases, may suffice. In others, augmenting central blood volume by increasing fluid and/or salt intake is effective. The role of non-pharmacological physical manoeuvres is increasingly recognised, given the increasing clinical trial data supporting their efficacy. This review summarises the clinical evidence for a variety of pharmacological agents. Of these, midodrine appears to have yielded the most consistent favourable outcome. Its use, however, should be reserved for patients with recurrent and refractory syncope.
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Affiliation(s)
- Lin Y Chen
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, Minnesota, MN 55905, USA.
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25
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Ben-Amotz R, Estrada AH. ECG of the month. Sinus arrhythmia. J Am Vet Med Assoc 2006; 228:518-20. [PMID: 16478422 DOI: 10.2460/javma.228.4.518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Ron Ben-Amotz
- Section of Cardiology, Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL 32610-0126, USA
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26
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Guzman JC, Garcia RG, Dillenburg R, Sieger FS, Lopez-Jaramillo P, Morillo CA. Central serotoninergic response to orthostatic challenge in patients with neurocardiogenic syncope. ACTA ACUST UNITED AC 2006; 8:306-11. [PMID: 16627460 DOI: 10.1093/europace/euj053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
AIMS To determine whether central serotoninergic system activity is impaired by orthostatic challenge in patients with neurocardiogenic syncope (NCS). METHODS AND RESULTS Thirty-five [mean age: 24 (SD): 6 years] patients with a clinical history of NCS and positive head-up tilt test and 35 age-matched healthy volunteers (CON = 25+/-5 years) with negative response were studied. Overnight dexamethasone suppression test (DST) (1.5 mg given at 11 p.m.) was performed to assess the sensitivity of the hypothalamic-pituitary-adrenal axis by measuring next day cortisol (microg/dL) at 8 a.m. and 4 p.m. Cardiac autonomic function, cortisol, and prolactin (ng/dL) were also determined at baseline supine (BAS) and after 5, 10, and 15 min of orthostatic stress (OS) at 60 degrees . No significant differences were observed in cortisol plasma levels after the DST: CON = 0.6+/-0.6 microg/dL vs. NCS = 0.6+/-0.5; P = 0.7. Cardiac autonomic function, cortisol, and prolactin responses were similar in both study groups (CON vs. NCS; P > 0.05) during BAS: cortisol = 8.6+/-4 vs.8.7+/-4 microg/dL and prolactin = 16.8+/-9 vs. 16.8+/-9 ng/dL; OS-5: cortisol = 8.7+/-5 vs. 8.5+/-4 microg/dL and prolactin = 16.9+/-9 vs. 15.8+/-9 ng/dL; OS-10: cortisol = 8.5+/-5 vs. 8.1+/-3 microg/dL; prolactin = 16.2+/-9 vs. 15.8+/-9 ng/dL, and OS-15: cortisol = 9.0+/-5 vs. 8.4+/-4 microg/dL; prolactin = 17.1+/-9 vs. 15.5+/-9 ng/dL. CONCLUSION Central serotoninergic response during orthostatic challenge was not impaired in patients with recurrent NCS. These findings suggest that the activation of the hypothalamic-pituitary-adrenal axis is not altered in patients with recurrent NCS.
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Affiliation(s)
- Juan Camilo Guzman
- Autonomic Physiology Laboratory, Research Institute, Fundacion Cardiovascular de Colombia, Bucaramanga, Santander, Colombia, Ontario, Canada
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27
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Abstract
Sinus tachycardia is the most common rhythm disturbance encountered in clinical practice. Primary sinus tachycardia without an underlying secondary cause, despite often being associated with troublesome symptoms, is often neglected leading to multiple consultations and frustration on part of both the practitioner and the patient. The fact that primary sinus tachycardias are a heterogeneous group of disorders is seldom appreciated; hence, a firm diagnosis is rarely reached and management is haphazard. Furthermore, there may be prognostic implications for prolonged or recurrent sinus tachycardia, making it imperative that this group of arrhythmias receive adequate and appropriate attention. Normal sinus tachycardia (i.e., secondary), inappropriate sinus tachycardia, postural orthostatic tachycardia syndrome (POTS) and sinus node reentry tachycardia make up this group of arrhythmias. Their definitions, clinical features, diagnostic criteria, pathophysiologic mechanisms, and optimum management are discussed in this review.
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Affiliation(s)
- Shamil Yusuf
- Department of Cardiovascular Medicine, St. Georges Hospital Medical School, London, UK.
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28
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Affiliation(s)
- Blair P Grubb
- Cardiology Department of Medicine, the Medical University of Ohio, Toledo, Ohio 43614, USA.
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29
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Affiliation(s)
- Blair P Grubb
- Division of Cardiology, Department of Medicine, Medical College of Ohio, Toledo 43614, USA.
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30
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Abstract
Sinus tachycardia, in the forms of four distinct rhythm disturbances, is frequently encountered in clinical practice but is often overlooked. The most common rhythm, normal sinus tachycardia, whether physiologic, pathologic or iatrogenic, is predominantly catecholamine driven, is virtually asymptomatic and is managed by identifying and treating the underlying cause. The other so-called primary sinus tachycardias, which include inappropriate sinus tachycardia, postural orthostatic tachycardia syndrome and sinus node re-entry tachycardia, have fundamentally different clinical features, basic underlying etiologic mechanisms and treatment strategies. Differentiation of these types from normal sinus tachycardia and from other atrial arrhythmias is crucial for successful management. Accurate diagnosis and appropriate therapy of the sinus tachycardias not only prevents multiple consultations but might also have important long-term prognostic implications.
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Affiliation(s)
- Shamil Yusuf
- Department of Cardiovascular Medicine, St George's Hospital Medical School, London, UK.
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31
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Abstract
This article reviews the existing evolutionary perspectives on the acute stress response habitual faintness and blood-injection-injury type-specific phobia (BIITS phobia). In this article, an alternative evolutionary perspective, based on recent advances in evolutionary psychology, is proposed. Specifically, that fear-induced faintness (eg, fainting following the sight of a syringe, blood, or following a trivial skin injury) is a distinct Homo sapiens-specific extreme-stress survival response to an inescapable threat. The article suggests that faintness evolved in response to middle paleolithic intra-group and inter-group violence (of con-specifics) rather than as a pan-mammalian defense response, as is presently assumed. Based on recent literature, freeze, flight, fight, fright, faint provides a more complete description of the human acute stress response sequence than current descriptions. Faintness, one of three primary physiological reactions involved in BIITS phobia, is extremely rare in other phobias. Since heritability estimates are higher for faintness than for fears or phobias, the author suggests that trait-faintness may be a useful complement to trait-anxiety as an endophenotype in research on the human fear circuitry. Some implications for the forthcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition as well as for clinical, health services, and transcriptomic research are briefly discussed.
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Affiliation(s)
- H Stefan Bracha
- United States Department of Veterans Affairs, Pacific Islands Health Care System, Spark M Matsunaga Medical Center, National Center for Posttraumatic Stress Disorder, Honolulu, HI, USA
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32
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Martinek RM. Witnessed asystole during spinal anesthesia treated with atropine and ondansetron: a case report. Can J Anaesth 2004; 51:226-30. [PMID: 15010403 DOI: 10.1007/bf03019100] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To present a case of asystole during spinal anesthesia that responded to atropine and ondansetron and to discuss the possible pathophysiology with special emphasis on the Bezold-Jarisch reflex and the role of 5-HT3 receptors in mediating bradycardia and sympathoinhibition. CLINICAL FEATURES A 50-yr-old, 97-kg, healthy male presented for elective left high tibial osteotomy. Spinal anesthesia was induced uneventfully at L3-4 with 11.25 mg of hyperbaric 0.75% bupivacaine and morphine 0.25 mg. Thirteen minutes after induction, the incision site was infiltrated with 20 mL of 0.5% bupivacaine with epinephrine 5 microg.mL(-1) for intraoperative hemostasis, resulting in an increase in heart rate from 74 to 90 beats.min(-1). Three minutes after infiltration of the incision site, the patient's heart rate dropped to 48 beats.min(-1), accompanied by a blood pressure of 107/51 mmHg, SpO2 97%, and a sinus bradycardia on the electrocardiogram. The electrocardiographic complexes suddenly disappeared with loss of the pulse oximeter waveform. Pre-drawn atropine 0.6 mg i.v. and ondansetron 4 mg i.v. were administered within seven seconds of the event. After an asystolic period of 30 to 40 sec, but before chest compressions were initiated, vital signs returned to normal with no other sequelae. CONCLUSION Exogenous epinephrine may have triggered the Bezold-Jarisch reflex and subsequent asystole. It is postulated that the combination of atropine and ondansetron may have played a key role in resuscitation by blocking the serotonergic and cholinergic receptors in the afferent and efferent limbs of this vagally-mediated reflex.
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Affiliation(s)
- Robert M Martinek
- Department of Anesthesia, Brantford General Hospital, Brantford, Ontario, Canada.
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33
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Kanjwal MY, Kosinski DJ, Grubb BP. Treatment of postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia. Curr Cardiol Rep 2003; 5:402-6. [PMID: 12917056 DOI: 10.1007/s11886-003-0098-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia are two clinically different entities but with significant overlap of symptoms. Treatment by and large is medical; however, other modalities of treatment are being evaluated.
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Affiliation(s)
- M Yousuf Kanjwal
- Medical College of Ohio, Room 1192 (O), 3000 Arlington Avenue, Toledo, OH 43614-2595, USA.
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34
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Abstract
A wide variety of pharmacologic agents are currently used for the prevention of recurrent neurocardiogenic syncope in children and adolescents. Significant advances in the understanding of this syncopal disorder have occurred in the past decade, and the list of medications recommended has changed, reflecting the evolving understanding of the pathophysiology and development of agents with enhanced efficacy and fewer adverse effects. Clinicians have few randomized controlled trials available to guide their decisions about treating neurocardiogenic syncope, and even fewer when it comes to medications targeting the pediatric population. At the present time, beta-adrenergic receptor blockers, fludrocortisone, and also specific serotonin reuptake inhibitors and midodrine, appear to be favored treatment options. Ideally, specific therapy would be tailored to specific pathophysiologic mechanisms. Unfortunately, at present, specific treatments based on those abnormalities have not been identified.
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Affiliation(s)
- Martial Massin
- Division of Pediatric Cardiology, University of Liège at Regional Hospital Centre La Citadelle, Liège, Belgium.
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35
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Kanjwal Y, Kosinski D, Grubb BP. The postural orthostatic tachycardia syndrome: definitions, diagnosis, and management. Pacing Clin Electrophysiol 2003; 26:1747-57. [PMID: 12877710 DOI: 10.1046/j.1460-9592.2003.t01-1-00262.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Yousuf Kanjwal
- Electrophysiology Section, Division of Cardiology, Department of Medicine, The Medical College of Ohio, Toledo, Ohio 43614, USA
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36
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Yusuf S, Camm AJ. Sinus tachyarrhythmias and the specific bradycardic agents: a marriage made in heaven? J Cardiovasc Pharmacol Ther 2003; 8:89-105. [PMID: 12808482 DOI: 10.1177/107424840300800202] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A relatively novel group of drugs that inhibit the funny current in the sinus node pacemaker cells, the so-called specific bradycardic agents, are likely to play a significant role in the management of a wide range of cardiovascular disorders, including the sinus tachyarrhythmias. This comprehensive review initially provides an insight into these agents, their historical background, and their mechanism of action. It then discusses the differential diagnosis of the sinus tachyarrhythmias (normal sinus tachycardia, inappropriate sinus tachycardia, postural orthostatic tachycardia syndrome, and sinus node reentry tachycardia), elaborates on their pathophysiologic basis, and provides up-to-date evidence-based information on their optimum management. The specific bradycardic agents, by the very nature of their mode of action, may prove ideal therapies for the management of the sinus tachyarrhythmias, and this is explored at every stage.
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Affiliation(s)
- Shamil Yusuf
- Department of Cardiovascular Medicine, St. Georges Hospital Medical School, London, UK.
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37
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Affiliation(s)
- Blair P Grubb
- Electrophysiology Section, Division of Cardiology, Department of Medicine, Medical College of Ohio, Toledo, Ohio 43614-2598, USA.
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38
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O'Donnell D, Hamer A, Horrigan M. Delayed neurally mediated syncope after inferior wall acute myocardial infarction. Am J Cardiol 2002; 90:157-9. [PMID: 12106848 DOI: 10.1016/s0002-9149(02)02441-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- David O'Donnell
- Cardiology Department, Austin and Repatriation Medical Centre, Victoria, Melbourne, Australia
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39
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Affiliation(s)
- Julian M Stewart
- Department of Pediatrics and Physiology, The Center for Pediatric Hypotension, New York Medical College, Valhalla 10595, USA
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40
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Grubb BP, Kanjwal MY, Kosinski DJ. Review: The postural orthostatic tachycardia syndrome: current concepts in pathophysiology diagnosis and management. J Interv Card Electrophysiol 2001; 5:9-16. [PMID: 11248770 DOI: 10.1023/a:1009845521949] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- B P Grubb
- Electrophysiology Section, Division of Cardiology, Department of Medicine, The Medical College of Ohio, Toledo OH 43614-2598, USA.
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41
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Boehm KE, Morris EJ, Kip KT, Karas B, Grubb BP. Diagnosis and management of neurally mediated syncope and related conditions in adolescents. J Adolesc Health 2001; 28:2-9. [PMID: 11137899 DOI: 10.1016/s1054-139x(00)00153-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- K E Boehm
- Division of Adolescent Medicine, Department of Pediatrics, Medical College of Ohio, Mercy Children's Hospital, Toledo, Ohio 43608, USA.
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42
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Affiliation(s)
- B P Grubb
- Medical College of Ohio, Toledo, USA
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43
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Abstract
Neurocardiogenic syncope is a common disorder affecting various individuals of different ages with a wide variety of circumstances and comorbid conditions. Although a large amount of data is available regarding evaluation and treatment options, there is still sufficient latitude for the physician to exercise clinical judgment. We summarize current opinions on treatment here and also add some of our own bias regarding how to manage such patients. The vast majority of patients can be assessed by a reduction of symptomatic episodes with therapy. In all patients, careful follow-up should be made after initiating therapy. Not all patients will obtain complete resolution of symptoms. If episodes of complete syncope are reduced to infrequent dizzy spells, however, this may be satisfactory. In other patients, abrupt syncope may be converted to spells with a sufficient prodromal warning for the patient to take evasive action.
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44
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Staab JP. Diagnosis and treatment of psychologic symptoms and psychiatric disorders in patients with dizziness and imbalance. Otolaryngol Clin North Am 2000; 33:617-36. [PMID: 10815040 DOI: 10.1016/s0030-6665(05)70230-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Patients with dizziness and psychopathology present diagnostic and therapeutic challenges to clinicians in several specialties. Clinical research is beginning to define the medical-psychiatric interactions that produce many of these patients' symptoms. Treatment research is still in its infancy. A model of illness progression is presented to guide physicians through the evaluation of this patient population. Treatment recommendations are based on current clinical experience.
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Affiliation(s)
- J P Staab
- Department of Psychiatry, Balance Center, University of Pennsylvania Health System, Philadelphia, Pennsylvania 19104, USA.
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