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A Review of the Wide Range of Indications and Uses of Implantable Loop Recorders: A Review of the Literature. HEARTS 2022. [DOI: 10.3390/hearts3020007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Implantable loop recorders (ILR) are devices that are implanted subcutaneously on the chest, which enables the continuous monitoring of arrhythmias for up to three years. These devices have an important role in helping to make a diagnosis and supporting decisions about the best patient management. There are currently three companies that produce ILRs. The Reveal DX and XT device is produced by Medtronic. The Confirm device is produced by Abbott. The Biomonitor III device is produced by Biotronik. The established indications for ILR include the management of transient loss of consciousness and the diagnosis of undocumented palpitations; however, they are also used for less established applications, including atrial fibrillation (AF) monitoring and risk stratification in patients with previous myocardial infarction or inherited cardiomyopathies. There is also diverse literature exploring the use of these devices in other populations, including patients with conditions such as congenital heart disease, amyloidosis, stroke, obstructive sleep apnea, renal transplant and patients who undergo procedures such as AF ablation and coronary artery bypass graft. In this review, we describe how the use of ILR has been applied in different settings, including patients with cardiac and non-cardiac conditions as well as post-cardiac procedures. We then discuss the potential issues related to using ILR in these other indications.
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Kanjwal K, Kichloo A, Qadir R, Grubb BP. Further Observations on the Use of Pacemakers in Patients with Postural Orthostatic Tachycardia Syndrome with Demonstrated Asystole. J Innov Card Rhythm Manag 2021; 12:4447-4450. [PMID: 33777484 PMCID: PMC7987426 DOI: 10.19102/icrm.2021.120307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 10/15/2020] [Indexed: 12/02/2022] Open
Abstract
A subgroup of postural orthostatic tachycardia syndrome (POTS) patients may also have features of neurocardiogenic syncope (NCS). Syncope and presyncope are predominant clinical features in this subgroup of patients. Asystole has been reported as the cause of some recurrent syncopal episodes following evaluation with an implantable loop recorder (ILR). We present our experience of pacing in a group of patients with POTS and NCS, which resulted in the complete elimination of syncope. We reviewed the charts of 500 patients at the University of Toledo Medical Center from 2003 to 2013 and identified 40 patients who were eligible for inclusion in this study. Patients were included in this study if they had clinical features of POTS and unusually frequent episodes of syncope. All study participants subsequently underwent ILR implantation. Forty patients, including 32 (80%) women, aged 33 ± 13 years were included in this study. All patients demonstrated prolonged asystole (> 6 seconds) or severe bradycardia (heart rate < 30 bpm) during their syncope. Ten patients demonstrated an asystole of more than 10 seconds and also had prolonged and convulsive syncope. All patients had abrupt syncope without any warning signs. All 40 patients underwent dual-chamber pacemaker implantation. Syncope was eliminated in all 40 patients following pacemaker implantation; however, they continued to experience orthostatic tachycardia. Our findings support that dual-chamber pacing may help to eliminate syncope in a subgroup of POTS patients with recurrent syncope and prolonged asystole on ILR.
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Affiliation(s)
- Khalil Kanjwal
- Division of Cardiology, McLaren Greater Lansing Hospital, Michigan State University, Lansing, MI, USA
| | - Asim Kichloo
- Division of Internal Medicine, Central Michigan University, Mount Pleasant, MI, USA
| | - Rehana Qadir
- Division of Internal Medicine, McLaren Greater Lansing Hospital, Michigan State University, Lansing, MI, USA
| | - Blair P Grubb
- Division of Cardiology, University of Toledo, Toledo, OH, USA
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Kanjwal K, Qadir R, Ruzieh M, Grubb BP. Role of implantable loop recorders in patients with postural orthostatic tachycardia syndrome. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:1201-1203. [PMID: 29989177 DOI: 10.1111/pace.13441] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/25/2018] [Accepted: 06/26/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We previously reported on a subgroup of postural orthostatic tachycardia syndrome (POTS) patients who may also have features of neurocardiogenic syncope as well. In this subgroup of patients, we found syncope and presyncope were predominant clinical features. To understand the mechanism of syncope in this subgroup, we identified 39 patients who underwent loop recorder insertion. METHODS We reviewed charts of 450 patients who had POTS and syncope seen at the University of Toledo Medical Center from 2003 to 2017. Thirty-nine patients had at least four episodes of syncope in the last 6 months and were included for this study. All of these patients had a prior evaluation with a Holter and an event monitor which were inconclusive. RESULTS Thirty-nine patients, 33 (85%) women, aged 20-46 years, were included in this study. All patients demonstrated prolonged asystole (>6 seconds) or severe bradycardia (heart rate < 30 beats/min) during their syncope on implantable loop recorder (IRL). Fifteen patients demonstrated an asystole of >10 seconds and also had prolonged and convulsive syncope. All patients had abrupt syncope without any warning sign. All patients underwent dual-chamber pacemaker implantation using a closed loop stimulation algorithm. Syncope were completely eliminated in all patients following pacemaker implantation; however, they continued to have orthostatic tachycardia. CONCLUSION POTS patients with unusually frequent syncope should be considered for ILR implantation if other monitoring modalities like 48-hour Holter monitor or event recorder are inconclusive. ILR may identify a subgroup of POTS patients who may benefit from pacemaker implantations.
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Affiliation(s)
| | - Rehana Qadir
- McLaren Greater Lansing Hospital, Lansing, MI, USA
| | | | - Blair P Grubb
- University of Toledo Medical Center, Toledo, OH, USA
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Anjum I, Sohail W, Hatipoglu B, Wilson R. Postural Orthostatic Tachycardia Syndrome and Its Unusual Presenting Complaints in Women: A Literature Minireview. Cureus 2018; 10:e2435. [PMID: 29876157 PMCID: PMC5988200 DOI: 10.7759/cureus.2435] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 03/26/2018] [Indexed: 01/26/2023] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a heterogeneous disorder of the autonomic nervous system that is defined by symptoms of orthostatic intolerance. According to the current criteria for adults, currently, POTS is defined as a heart rate increment of 30 beats/minute or more after 10 minutes of standing in the absence of orthostatic hypotension. There is a vast majority that remains misdiagnosed due to the heterogeneity of the disorder. Due to a lack of Food and Drug Administration (FDA) approved therapy, alternative therapies and over the counter medications are used to alleviate the symptoms. This is an uncommon presentation observed primarily in women, as it is more prevalent in females.
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Affiliation(s)
- Ibrar Anjum
- Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, Houston, USA
| | - Wafa Sohail
- Dow Medical College, Dow University of Health Sciences (DUHS), Karachi, Pakistan
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Stewart JM, Boris JR, Chelimsky G, Fischer PR, Fortunato JE, Grubb BP, Heyer GL, Jarjour IT, Medow MS, Numan MT, Pianosi PT, Singer W, Tarbell S, Chelimsky TC. Pediatric Disorders of Orthostatic Intolerance. Pediatrics 2018; 141:e20171673. [PMID: 29222399 PMCID: PMC5744271 DOI: 10.1542/peds.2017-1673] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2017] [Indexed: 01/18/2023] Open
Abstract
Orthostatic intolerance (OI), having difficulty tolerating an upright posture because of symptoms or signs that abate when returned to supine, is common in pediatrics. For example, ∼40% of people faint during their lives, half of whom faint during adolescence, and the peak age for first faint is 15 years. Because of this, we describe the most common forms of OI in pediatrics and distinguish between chronic and acute OI. These common forms of OI include initial orthostatic hypotension (which is a frequently seen benign condition in youngsters), true orthostatic hypotension (both neurogenic and nonneurogenic), vasovagal syncope, and postural tachycardia syndrome. We also describe the influences of chronic bed rest and rapid weight loss as aggravating factors and causes of OI. Presenting signs and symptoms are discussed as well as patient evaluation and testing modalities. Putative causes of OI, such as gravitational and exercise deconditioning, immune-mediated disease, mast cell activation, and central hypovolemia, are described as well as frequent comorbidities, such as joint hypermobility, anxiety, and gastrointestinal issues. The medical management of OI is considered, which includes both nonpharmacologic and pharmacologic approaches. Finally, we discuss the prognosis and long-term implications of OI and indicate future directions for research and patient management.
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Affiliation(s)
| | - Jeffrey R Boris
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - John E Fortunato
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Baruscotti M, Bianco E, Bucchi A, DiFrancesco D. Current understanding of the pathophysiological mechanisms responsible for inappropriate sinus tachycardia: role of the If "funny" current. J Interv Card Electrophysiol 2016; 46:19-28. [PMID: 26781742 DOI: 10.1007/s10840-015-0097-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 12/28/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND Together with the afferent branches of the autonomic nervous system, the sinoatrial node (SAN) forms a functional unit whose function is to fire rhythmic action potentials at a rate optimal for coping with the metabolic needs of the body. Dysfunctional behavior of this complex unit may thus result in SAN rhythm disorders. Among these disorders, there is the inappropriate sinus tachycardia (IST) which occurs when an unjustified fast SAN rate is present. METHODS We here present a critical review of the role of pacemaker f/HCN channels in cardiac rhythm generation and modulation and their involvement in IST. RESULTS Recent evidence demonstrates that a familial form of IST is associated with a gain-of-function mutation in the HCN4 pacemaker channel (R524Q) which confers an increased sensitivity to the second messenger cAMP, a key mediator in sympathetic modulation. CONCLUSIONS This finding is consistent with the general view that hypersympathetic tone is one of the causes of IST and introduces the novel concept of defective funny channel-dependent tachyarrhythmias.
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Affiliation(s)
- Mirko Baruscotti
- Department of Biosciences, Centro Interuniversitario di Medicina Molecolare e Biofisica Applicata, University of Milano, via Celoria 26, 20133, Milano, Italy.
| | - Elisabetta Bianco
- Cardiovascular Department, "Ospedali Riuniti di Trieste", University Hospital, Trieste, Italy
| | - Annalisa Bucchi
- Department of Biosciences, Centro Interuniversitario di Medicina Molecolare e Biofisica Applicata, University of Milano, via Celoria 26, 20133, Milano, Italy
| | - Dario DiFrancesco
- Department of Biosciences, Centro Interuniversitario di Medicina Molecolare e Biofisica Applicata, University of Milano, via Celoria 26, 20133, Milano, Italy.
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Clinical presentation of inappropriate sinus tachycardia and differential diagnosis. J Interv Card Electrophysiol 2015; 46:33-41. [PMID: 26329720 DOI: 10.1007/s10840-015-0051-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 08/14/2015] [Indexed: 10/23/2022]
Abstract
Inappropriate sinus tachycardia (IST) is a syndrome characterized by a sinus tachycardia not related to a medical condition, to a physiological response, or to medication or drugs and associated with symptoms, often invalidating and altering the quality of life of affected patients. It occurs predominantly in adolescents and young adults, and in the female sex. The diagnosis requires a complete work-up in order to exclude other causes of sinus tachycardia and one or several additional tests: 24-h ECG ambulatory recordings, echocardiogram, exercise testing, and autonomous nervous system assessment. It should be differentiated from the postural orthostatic tachycardia syndrome, with which it shares a number of symptoms, and other supraventricular tachycardias originating in the high right atrium. An electrophysiological study should be considered in selected cases in order to differentiate IST from other supraventricular tachycardias. The mechanism is still unclear, and possible etiologies may include intrinsic abnormality of the sinus node, autonomic dysfunction, hypersensitivity of the sinus node to catecholamines, blunted vagal system, or a combination of the above. The authors emphasize the wide spectrum of clinical presentations and the need to better define the IST and the criteria required to ascertain its diagnosis.
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De Wandele I, Rombaut L, Leybaert L, Van de Borne P, De Backer T, Malfait F, De Paepe A, Calders P. Dysautonomia and its underlying mechanisms in the hypermobility type of Ehlers–Danlos syndrome. Semin Arthritis Rheum 2014; 44:93-100. [DOI: 10.1016/j.semarthrit.2013.12.006] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 12/20/2013] [Accepted: 12/24/2013] [Indexed: 11/26/2022]
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Deng W, Liu Y, Liu AD, Holmberg L, Ochs T, Li X, Yang J, Tang C, Du J, Jin H. Difference between supine and upright blood pressure associates to the efficacy of midodrine on postural orthostatic tachycardia syndrome (POTS) in children. Pediatr Cardiol 2014; 35:719-25. [PMID: 24253613 DOI: 10.1007/s00246-013-0843-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 11/06/2013] [Indexed: 11/25/2022]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is common, and has a serious impact on children's quality of life. Midodrine hydrochloride, an α1-adrenoreceptor agonist, is an effective treatment. The study was designed to examine the therapeutic efficacy of midodrine hydrochloride by quantifying changes in blood pressure during the head-up test (HUT), in children with POTS. Overall, 104 out of 110 children with POTS were treated with midodrine hydrochloride and successfully followed-up. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) changes were analyzed during the HUT. In a retrospective analysis, a receiver operating characteristic (ROC) curve was used to analyze the therapeutic predictive value of pre-treatment changes in SBP, DBP, and a combination of both, from the supine position to standing, in the subjects. The increase of SBP and DBP from the supine position to standing in responders were significantly lower than that of the non-responders. The ROC curve showed that midodrine hydrochloride for children with POTS would be predicted to be effective when the pre-treatment increase of SBP was ≤ 0 mmHg, or when the pre-treatment increase of DBP was ≤ 6.5 mmHg (from the supine position to standing), yielding a sensitivity of 72% and specificity of 88%. The area under the curve was 0.744 and 0.809, respectively. Hence, the results suggested that looking at the changes in blood pressure during the HUT was useful in predicting the response to midodrine hydrochloride in children with POTS.
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Affiliation(s)
- Wenjun Deng
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, China
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Diagnosis and management of postural orthostatic tachycardia syndrome: A brief review. J Geriatr Cardiol 2012; 9:61-7. [PMID: 22783324 PMCID: PMC3390096 DOI: 10.3724/sp.j.1263.2012.00061] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Revised: 12/27/2011] [Accepted: 01/06/2012] [Indexed: 12/17/2022] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) has been recognized since at least 1940. A review of the literature identifies differences in the definition for this condition and wide variations in treatment and outcomes. This syndrome appears to describe a group of conditions with differing pathophysiology, which requires treatment tailored to the true underlying disorder. Patients need to be fully evaluated to guide treatment. Further research is required to effectively classify the range of underlying pathophysiology that can produce this syndrome and to guide optimal management.
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12
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Use of Methylphenidate in the Treatment of Patients Suffering From Refractory Postural Tachycardia Syndrome. Am J Ther 2012; 19:2-6. [DOI: 10.1097/mjt.0b013e3181dd21d2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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KANJWAL KHALIL, SHEIKH MUJEEB, KARABIN BEVERLY, KANJWAL YOUSUF, GRUBB BLAIRP. Neurocardiogenic Syncope Coexisting with Postural Orthostatic Tachycardia Syndrome in Patients Suffering from Orthostatic Intolerance: A Combined form of Autonomic Dysfunction. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 34:549-54. [DOI: 10.1111/j.1540-8159.2010.02994.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kanjwal K, Karabin B, Kanjwal Y, Grubb BP. Autonomic dysfunction presenting as postural orthostatic tachycardia syndrome in patients with multiple sclerosis. Int J Med Sci 2010; 7:62-7. [PMID: 20309394 PMCID: PMC2840604 DOI: 10.7150/ijms.7.62] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Accepted: 03/10/2010] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Autonomic dysfunction is common in patients suffering from multiple sclerosis (MS) and orthostatic dizziness occurs in almost 50% of these patients. However, there have been no reports on postural orthostatic tachycardia syndrome (POTS) in patients suffering from MS. METHODS The patients were included for analysis in this study if they had POTS with either a prior history of MS or having developed MS while being followed for POTS. Postural orthostatic tachycardia (POTS) is defined as symptoms of orthostatic intolerance(>6 months) accompanied by a heart rate increase of at least 30 beats/min (or a rate that exceeds 120 beats/min) that occurs in the first 10 minutes of upright posture or head up tilt test (HUTT) occurring in the absence of other chronic debilitating disorders. We identified nine patients with POTS who were suffering from MS as well. Each of these patients had been referred from various other centers for second opinions. RESULTS The mean age at the time of diagnosis of POTS was 49+/-9 years and eight of the 9 patients were women. Five patients (55%) had hyperlipidemia, 3 (33%) migraine and 2 (22%) patients had coronary artery disease and diabetes each. Fatigue and palpitations (on assuming upright posture) were the most common finding in our patients (9/9). All patients also had orthostatic dizziness. Syncope was seen in 5/9(55%) of patients. Four patients (44%), who did not have clear syncope, were having episodes of near syncope. The presence of POTS in our study population resulted in substantial limitation of daily activities. Following recognition and treatment of POTS, 6/9(66%), patients were able to resume daily activities of living. Their symptoms (especially fatigue and orthostatic intolerance) improved. The frequency and severity of syncope also improved. Three (33%) patients failed to show a good response to treatment. CONCLUSION Patients suffering from MS may manifest autonomic dysfunction by developing POTS. Early recognition and proper management may help improve the symptoms of POTS.
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Affiliation(s)
- Khalil Kanjwal
- Department of Medicine, Division of Cardiology Section of Electrophysiology, The University of Toledo, Toledo, OH 43614, USA
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Kernan S, Tobias JD. Perioperative care of an adolescent with postural orthostatic tachycardia syndrome. Saudi J Anaesth 2010; 4:23-7. [PMID: 20668563 PMCID: PMC2900049 DOI: 10.4103/1658-354x.62611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a disorder characterized by postural tachycardia in combination with orthostatic symptoms without associated hypotension. Symptoms include light-headedness, palpitations, fatigue, confusion, and anxiety, which are brought on by assuming the upright position and usually relieved by sitting or lying down. Given the associated autonomic dysfunction that occurs with POTS, various perioperative concerns must be considered when providing anesthetic care for such patients. We present an adolescent with POTS who required anesthetic care during posterior spinal fusion for the treatment of scoliosis. The potential perioperative implications of this syndrome are discussed.
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Affiliation(s)
- Scott Kernan
- University of Missouri, School of Medicine University of Missouri, Columbia, Missouri, USA
| | - Joseph D Tobias
- Departments of Anesthesiology and Pediatrics, University of Missouri, Columbia, Missouri, USA
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Kanjwal K, Karabin B, Kanjwal Y, Grubb BP. Outcomes of pregnancy in patients with preexisting postural tachycardia syndrome. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:1000-3. [PMID: 19659618 DOI: 10.1111/j.1540-8159.2009.02430.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Postural orthostatic tachycardia syndrome (POTS) occurs more commonly in women than in men and often affects women of childbearing age. Many of these women wish to have children, yet there are little reported data on the outcomes of pregnancy in patients with POTS. To date there has been one report of two patients with POTS who successfully completed pregnancy. We report the outcomes of 22 women with preexisting POTS who became pregnant. OBJECTIVE To assess the outcome of pregnancy in patients with preexisting POTS. METHODS AND RESULTS Twenty-two patients, age 30 +/- 7 years, with POTS became pregnant. Migraine was the common comorbidity found in 40% of patients. Medications used were beta-blockers (18%), midiodrine (31%), selective serotonin reuptake inhibitors (31%), fludrocortisone (13%), combination (40%), and none (18%). During pregnancy, symptoms of POTS remained unchanged in three (13%), improved in 12 (55%), and worsened in seven (31%) patients. One patient who had recurrent episodes of syncope without aura was found to have complete heart block and received a cardiac pacemaker. All patients completed pregnancy successfully. There were no stillbirths. One patient developed hyperemesis. Eighteen patients had vaginal delivery and four patients delivered by cesarian section. No other complications of pregnancy were encountered. Congenital abnormalities were encountered in the form of one atrial septal defect, one ventricular septal defect, and one Down's syndrome. Postpartum symptoms of POTS remained stable in 15 (69%) patients and worsened in seven (31%) patients. CONCLUSION Based on our observation, patients with POTS can safely complete pregnancy if they desire to do so. POTS should not be considered a contraindication to pregnancy per se.
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Affiliation(s)
- Khalil Kanjwal
- Pacing and Electrophysiology section, Division of Cardiology, Department of Medicine, University of Toledo Medical Center, Toledo, Ohio 43614, USA
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Medi C, Kalman JM, Freedman SB. Supraventricular tachycardia. Med J Aust 2009; 190:255-60. [DOI: 10.5694/j.1326-5377.2009.tb02388.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2008] [Accepted: 10/02/2008] [Indexed: 11/17/2022]
Affiliation(s)
- Caroline Medi
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, VIC
- Department of Medicine, University of Melbourne, Melbourne, VIC
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, VIC
- Department of Medicine, University of Melbourne, Melbourne, VIC
| | - Saul B Freedman
- Department of Cardiology, Concord Clinical School, Concord Hospital, Sydney, NSW
- Vascular Biology Laboratory, ANZAC Research Institute, University of Sydney, Sydney, NSW
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Hainstock MR, Gruchala NE, Fike N, Samson RA, Klewer SE, Barber BJ. Postural orthostatic tachycardia in a teenager with Klinefelter syndrome. CONGENIT HEART DIS 2009; 3:440-2. [PMID: 19037986 DOI: 10.1111/j.1747-0803.2008.00218.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
To our knowledge this is the first reported case of postural orthostatic tachycardia syndrome (POTS) in a patient with Klinefelter syndrome. We describe a classic clinical presentation of POTS in an adolescent male with Klinefelter syndrome. Although the etiology of POTS appears to be multifactorial, there is a strong female predominance that suggests a genetic basis. Our patient with Klinefelter syndrome may further support a link with POTS to the X chromosome.
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Affiliation(s)
- Michael R Hainstock
- University of Arizona College of Medicine, Department of Pediatrics, Tucson, AZ, USA.
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Piovesan EJ, Sobreira CF, Scola RH, Lorenzoni PJ, Lange MC, Werneck LC, Smith D, Silberstein S. Episodic migraine associated with postural orthostatic tachycardia syndrome and vasovagal syncope: migraine triggers neuromediated syncope. ARQUIVOS DE NEURO-PSIQUIATRIA 2009; 66:77-9. [PMID: 18392420 DOI: 10.1590/s0004-282x2008000100018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Elcio Juliato Piovesan
- Neurology Service, Internal Medicine Department, Hospital de Clínicas, Federal University of Paraná, Curitiba, PR, Brazil.
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Treatment questions in POTS with hypertension and syncope. Open Med (Wars) 2008. [DOI: 10.2478/s11536-008-0021-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractA 27-year old man experienced recurrent syncope with prodromal palpitations and resultant injury. The features of these episodes suggested a potentially neurally-mediated mechanism. Head-up tilt test revealed the postural orthostatic tachycardia syndrome (POTS). Within the first minutes of upright posture during the total head-up tilt testing, a heart rate increase of >30 beats/min and to a maximum of 150 beats/min was documented in the patient. At the end of passive tilting, the patient lost consciousness in the absence of hypotension while in sinus rhythm of 140 bpm. The 12-lead ECG and electrophysiological study showed no abnormalities. The patient received a beta-adrenergic blocker, a selective central imidazoline receptor agonist and psychiatric therapy, resulting in only a short-term improvement.
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Benditt DG, Sakaguchi S. Syncope. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Affiliation(s)
- Win K Shen
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA.
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Corbett WL, Reiter CM, Schultz JR, Kanter RJ, Habib AS. Anaesthetic management of a parturient with the postural orthostatic tachycardia syndrome: a case report. Br J Anaesth 2006; 97:196-9. [PMID: 16698864 DOI: 10.1093/bja/ael105] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Postural orthostatic tachycardia syndrome encompasses a group of disorders characterized by orthostatic intolerance. We describe the anaesthetic management of analgesia for labour and of Caesarean section in a parturient suffering from this disorder. Worsening of her symptoms during pregnancy was managed with an increase in the dose of beta-blockers taken by the patient. Epidural analgesia was instigated early to attenuate the stress of labour and avoid consequent triggering of a tachycardic response. Slow titration of epidural analgesia and anaesthesia after an adequate fluid preload was undertaken to minimize hypotension and subsequent tachycardia. Neuraxial opioid, combined with non-steroidal anti-inflammatory drugs and bilateral iliohypogastric and ilioinguinal nerve blocks were used to optimize postoperative analgesia.
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Affiliation(s)
- W L Corbett
- Department of Anaesthesiology, Box 3094, Duke University Medical Center, Durham, NC 27710, USA
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Brooks JK, Francis LAP. Postural orthostatic tachycardia syndrome: Dental treatment considerations. J Am Dent Assoc 2006; 137:488-93. [PMID: 16637478 DOI: 10.14219/jada.archive.2006.0221] [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: 11/20/2022]
Abstract
BACKGROUND Postural orthostatic tachycardia syndrome (POTS) is a chronic, relatively common autonomic disorder typically affecting younger females. It is distinguished by a dramatic increase in heart rate on the assumption of an upright posture from the supine position. METHODS The authors provide an overview of the demographics, clinical assessment, diagnostic features, differential diagnoses, pathogeneses and medical treatment of patients with POTS, with an emphasis on the clinical treatment of the dental patient affected by the syndrome. CONCLUSION Patients frequently exhibit symptoms of lightheadedness, fatigue, palpitations and syncope. Patients with POTS may have Ehlers-Danlos syndrome, mitral valve prolapse, chronic fatigue syndrome or, rarely, the Brugada syndrome. Despite widespread dissemination of information regarding POTS in the medical literature, scant information on it has appeared in dental publications. PRACTICE IMPLICATIONS Dentists need to be familiar with the clinical features of POTS and be prepared to treat patients at risk of developing syncope.
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Affiliation(s)
- John K Brooks
- Department of Diagnostic Sciences and Pathology, Baltimore College of Dental Surgery, Dental School, University of Maryland, Baltimore, MD 21201, USA.
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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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Glatter KA, Tuteja D, Chiamvimonvat N, Hamdan M, Park JK. Pregnancy in Postural Orthostatic Tachycardia Syndrome. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2005; 28:591-3. [PMID: 15955196 DOI: 10.1111/j.1540-8159.2005.50026.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Postural orthostatic tachycardia syndrome (POTS) is a rare disease characterized by syncope, sinus tachycardia, and orthostasis due to autonomic dysfunction. METHODS AND RESULTS Two women aged 26 and 24 years with severe POTS became pregnant. Both women experienced hyperemesis gravidarum with subsequent marked improvement in their POTS symptoms until 6 months gestation, when their syncope and sinus tachycardia caused clinical decompensation. Both patients delivered healthy babies at 37 weeks by elective cesarean section. CONCLUSION In long-term follow-up, both women reported improvement in their prepartum symptoms. We describe the first report, to our knowledge, of two successful pregnancy outcomes in severe POTS, including the first report of midodrine use in pregnant women.
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Affiliation(s)
- Kathryn A Glatter
- Department of Adult Cardiology, University of California-Davis, 4860 Y Street, Suite 2820, Sacramento, CA 95817, USA.
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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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Affiliation(s)
- Julian M Stewart
- Department of Pediatrics and Physiology, New York Medical College Valhalla, New York, USA.
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Morishima I, Sone T, Tsuboi H, Mukawa H, Satoda M, Uesugi M. Asymptomatic Brugada Syndrome Associated with Postural Orthostatic Tachycardia Syndrome:. Does Autonomic Disorder Increase Propensity for Future Arrhythmic Events? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:537-40. [PMID: 15078411 DOI: 10.1111/j.1540-8159.2004.00477.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Autonomic imbalance may work as a modifying factor for initiating lethal arrhythmia in patients with Brugada syndrome. A 26-year-old man with episodes of near syncope was given a diagnosis of an autonomic disorder, postural orthostatic tachycardia syndrome (POTS). The patient spontaneously showed typical Brugada-type ECG, and ventricular fibrillation was induced by programmed electrical stimulation, which allowed the further diagnosis of Brugada syndrome. Although it seems that Brugada syndrome is asymptomatic, its uncommon association of POTS may increase the risk for future arrhythmic events in this patient.
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Affiliation(s)
- Itsuro Morishima
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan.
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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: 71] [Impact Index Per Article: 3.4] [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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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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Abstract
OBJECTIVES We hypothesized that transient hypotension associated with the symptom of lightheadedness with standing is a common phenomenon in healthy adolescents but may be mistaken for orthostatic intolerance. STUDY DESIGN We studied 23 healthy adolescents, combining upright tilt to 70 degrees and to 35 degrees (in 12 patients) with continuous heart rate and blood pressure (BP) measurements. We measured peripheral blood flow and venous pressure in the arms and legs by using venous plethysmography. RESULTS Healthy subjects with normal vasoconstrictive responses to sustained upright tilt uniformly have a transient fall in BP during 70 degrees upright tilt that varies from almost undetectable to large decreases in BP easily exceeding the 20-mm Hg threshold for orthostatic hypotension. Large decreases are associated with short-lived symptoms of lightheadedness and are most marked in those with the largest calf blood flow. The higher the flow, the lower the BP falls. There is appropriate reflex tachycardia. CONCLUSIONS We conclude that transient orthostatic hypotension is common in many healthy adolescents, especially after prolonged recumbency, and is related to dependent vascular tone.
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Affiliation(s)
- Julian M Stewart
- Department of Pediatric, The Center for Pediatric Hypotension, New York Medical College, Valhalla 10595, USA
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