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TU B, LAI ZH, CHEN AY, WENG ZY, CAI SM, ZHANG ZX, ZHOU LK, ZHENG LH, YAO Y. Effectiveness of cardioneuroablation in different subtypes of vasovagal syncope. J Geriatr Cardiol 2024; 21:651-657. [PMID: 38973824 PMCID: PMC11224655 DOI: 10.26599/1671-5411.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Abstract
BACKGROUND Cardioneuroablation (CNA) has shown encouraging results in patients with vasovagal syncope (VVS). However, data on different subtypes was scarce. METHODS This observational study retrospectively enrolled 141 patients [mean age: 40 ± 18 years, 51 males (36.2%)] with the diagnosis of VVS. The characteristics among different types of VVS and the outcomes after CNA were analyzed. RESULTS After a mean follow-up of 4.3 ± 1.5 years, 41 patients (29.1%) experienced syncope/pre-syncope events after CNA. Syncope/pre-syncope recurrence significantly differed in each subtype (P = 0.04). The cardioinhibitory type of VVS had the lowest recurrence rate after the procedure (n = 6, 16.7%), followed by mixed (n = 26, 30.6%) and vasodepressive (n = 9, 45.0%). Additionally, a significant difference was observed in the analyses of the Kaplan-Meier survival curve (P = 0.02). Syncope/pre-syncope burden was significantly reduced after CNA in the vasodepressive type (P < 0.01). Vasodepressive types with recurrent syncope/pre-syncope after CNA have a lower baseline deceleration capacity (DC) level than those without (7.4 ± 1.0 ms vs. 9.0 ± 1.6 ms, P = 0.01). Patients with DC < 8.4 ms had an 8.1 (HR = 8.1, 95% CI: 2.2-30.0, P = 0.02) times risk of syncope/pre-syncope recurrence after CNA compared to patients with DC ≥ 8.4 ms, and this association still existed after adjusting for age and sex (HR = 8.1, 95% CI: 2.2-30.1, P = 0.02). CONCLUSIONS Different subtypes exhibit different event-free rates. The vasodepressive type exhibited the lowest event-free rate, but those patients with DC ≥ 8.4 ms might benefit from CNA.
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Affiliation(s)
- Bin TU
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Cardiac Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Zi-Hao LAI
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ai-Yue CHEN
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Yuan WENG
- Cardiovascular Department, The First Affiliated Hospital, Fujian Medical University, Fujian Institute of Hypertension, Fujian, China
| | - Si-Min CAI
- Department of Cardiovascular, The Second Affiliated Hospital of Zhejiang University School of Medicine,Zhejiang, China
| | - Zhu-Xin ZHANG
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li-Kun ZHOU
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li-Hui ZHENG
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan YAO
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Kell DB, Khan MA, Kane B, Lip GYH, Pretorius E. Possible Role of Fibrinaloid Microclots in Postural Orthostatic Tachycardia Syndrome (POTS): Focus on Long COVID. J Pers Med 2024; 14:170. [PMID: 38392604 PMCID: PMC10890060 DOI: 10.3390/jpm14020170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/16/2024] [Accepted: 01/27/2024] [Indexed: 02/24/2024] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a common accompaniment of a variety of chronic, inflammatory diseases, including long COVID, as are small, insoluble, 'fibrinaloid' microclots. We here develop the argument, with accompanying evidence, that fibrinaloid microclots, through their ability to block the flow of blood through microcapillaries and thus cause tissue hypoxia, are not simply correlated with but in fact, by preceding it, may be a chief intermediary cause of POTS, in which tachycardia is simply the body's exaggerated 'physiological' response to hypoxia. Similar reasoning accounts for the symptoms bundled under the term 'fatigue'. Amyloids are known to be membrane disruptors, and when their targets are nerve membranes, this can explain neurotoxicity and hence the autonomic nervous system dysfunction that contributes to POTS. Taken together as a system view, we indicate that fibrinaloid microclots can serve to link POTS and fatigue in long COVID in a manner that is at once both mechanistic and explanatory. This has clear implications for the treatment of such diseases.
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Affiliation(s)
- Douglas B Kell
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Crown St, Liverpool L69 7ZB, UK
- The Novo Nordisk Foundation Centre for Biosustainability, Building 220, Chemitorvet 200, Technical University of Denmark, 2800 Kongens Lyngby, Denmark
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch Private Bag X1, Matieland 7602, South Africa
| | - Muhammed Asad Khan
- Directorate of Respiratory Medicine, Manchester University Hospitals, Wythenshawe Hospital, Manchester M23 9LT, UK
| | - Binita Kane
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Crown St, Liverpool L69 7ZB, UK
- Manchester University Foundation Trust and School of Biological Sciences, University of Manchester, Manchester M13 9PL, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, 9220 Aalborg, Denmark
| | - Etheresia Pretorius
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Crown St, Liverpool L69 7ZB, UK
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch Private Bag X1, Matieland 7602, South Africa
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Park JW, Okamoto LE, Kim SH, Baek SH, Sung JH, Jeon N, Gamboa A, Shibao CA, Diedrich A, Kim BJ, Biaggioni I. Use of Valsalva Maneuver to Detect Late-Onset Delayed Orthostatic Hypotension. Hypertension 2023; 80:792-801. [PMID: 36695176 PMCID: PMC10023507 DOI: 10.1161/hypertensionaha.122.20098] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 01/08/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND Standard autonomic testing includes a 10-minute head-up tilt table test to detect orthostatic hypotension. Although this test can detect delayed orthostatic hypotension (dOH) between 3 and 10 minutes of standing, it cannot detect late-onset dOH after 10 minutes of standing. METHODS To determine whether Valsalva maneuver responses can identify patients who would require prolonged head-up tilt table test to diagnose late-onset dOH; patients with immediate orthostatic hypotension (onset <3 minutes; n=176), early-onset dOH (onset between 3 and 10 minutes; n=68), and late-onset dOH (onset >10 minutes; n=32) were retrospectively compared with controls (n=114) with normal head-up tilt table test and composite autonomic scoring scale score of 0. RESULTS Changes in baseline systolic blood pressure at late phase 2 (∆SBPVM2), heart rate difference between baseline and phase 3 (∆HRVM3), and Valsalva ratio were lower and pressure recovery time (PRT) at phase 4 was longer in late-onset dOH patients than in controls. Differences in PRT and ∆HRVM3 remained significant after correcting for age. A PRT ≥2.14 s and ∆HRVM3 ≤15 bpm distinguished late-onset dOH from age- and sex-matched controls. Patients with longer PRT (relative risk ratio, 2.189 [1.579-3.036]) and lower ∆HRVM3 (relative risk ratio, 0.897 [0.847-0.951]) were more likely to have late-onset dOH. Patients with longer PRT (relative risk ratio, 1.075 [1.012-1.133]) were more likely to have early-onset than late-onset dOH. CONCLUSIONS Long PRT and short ∆HRVM3 can help to identify patients who require prolonged head-up tilt table test to diagnose late-onset dOH.
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Affiliation(s)
- Jin-Woo Park
- Department of Neurology, Korea University Medicine, Seoul (J.-W.P., S.-H.K., S.-H.B., J.H.S., N.J., B.-J.K.)
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-W.P., L.E.O., A.G., C.A.S., A.D., I.B.)
| | - Luis E Okamoto
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-W.P., L.E.O., A.G., C.A.S., A.D., I.B.)
| | - Sung-Hwan Kim
- Department of Neurology, Korea University Medicine, Seoul (J.-W.P., S.-H.K., S.-H.B., J.H.S., N.J., B.-J.K.)
| | - Seol-Hee Baek
- Department of Neurology, Korea University Medicine, Seoul (J.-W.P., S.-H.K., S.-H.B., J.H.S., N.J., B.-J.K.)
| | - Joo Hye Sung
- Department of Neurology, Korea University Medicine, Seoul (J.-W.P., S.-H.K., S.-H.B., J.H.S., N.J., B.-J.K.)
| | - Namjoon Jeon
- Department of Neurology, Korea University Medicine, Seoul (J.-W.P., S.-H.K., S.-H.B., J.H.S., N.J., B.-J.K.)
| | - Alfredo Gamboa
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-W.P., L.E.O., A.G., C.A.S., A.D., I.B.)
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-W.P., L.E.O., A.G., C.A.S., A.D., I.B.)
| | - André Diedrich
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-W.P., L.E.O., A.G., C.A.S., A.D., I.B.)
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN (A.D.)
| | - Byung-Jo Kim
- Department of Neurology, Korea University Medicine, Seoul (J.-W.P., S.-H.K., S.-H.B., J.H.S., N.J., B.-J.K.)
- BK21 FOUR Program in Learning Health Systems, Korea University, Seoul (B.-J.K.)
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-W.P., L.E.O., A.G., C.A.S., A.D., I.B.)
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Jing X, Chen Q. Dynamic ST‐segment elevation during head‐up tilt test. Ann Noninvasive Electrocardiol 2022; 28:e13029. [DOI: 10.1111/anec.13029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022] Open
Affiliation(s)
- Xianchao Jing
- Department of Cardiology, West China Hospital Sichuan University Chengdu China
| | - Qingyong Chen
- Department of Cardiology, West China Hospital Sichuan University Chengdu China
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van Campen C(LMC, Visser FC. Long-Haul COVID Patients: Prevalence of POTS Are Reduced but Cerebral Blood Flow Abnormalities Remain Abnormal with Longer Disease Duration. Healthcare (Basel) 2022; 10:healthcare10102105. [PMID: 36292552 PMCID: PMC9602558 DOI: 10.3390/healthcare10102105] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/18/2022] [Accepted: 10/20/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Postural orthostatic tachycardia syndrome (POTS) has been described early after the onset of the COVID-19 infection, but also orthostatic hypotension (OH). In the present study, we hypothesized that orthostatic intolerance decreases over time. Methods: In 29 long-haul COVID-19 (LHC) patients, a tilt test was performed, including measurements of cerebral blood flow (CBF) by extracranial Doppler. The time interval between the onset of infection and the tilt test varied between 3 and 28 months. Results: In the first 12 months after the infection, 71% of the LHC patients showed POTS and after 24 months none of them. In the first 12 months, 29% of patients had a normal heart rate and blood pressure response (normHRBP) and after 24 months 75% (distribution of POTS, OH, and a normHRBP over time: p < 0.0001). Linear regression showed that, over time, there was a decrease in the abnormal CBF during the tilt (p = 0.024) but remained abnormal. Conclusion: In LHC patients, hemodynamic abnormalities of a tilt test change over time. Patients studied early after the onset of the disease mainly exhibit POTS, but patients studied later in the time course mainly show a normHRBP or OH. In addition, the abnormal CBF reduction improves over time, but CBF remains abnormal.
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A Novel Methodology for the Synchronous Collection and Multimodal Visualization of Continuous Neurocardiovascular and Neuromuscular Physiological Data in Adults with Long COVID. SENSORS 2022; 22:s22051758. [PMID: 35270905 PMCID: PMC8914998 DOI: 10.3390/s22051758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/13/2022] [Accepted: 02/16/2022] [Indexed: 12/12/2022]
Abstract
Background: Reports suggest that adults with post-COVID-19 syndrome or long COVID may be affected by orthostatic intolerance syndromes, with autonomic nervous system dysfunction as a possible causal factor of neurocardiovascular instability (NCVI). Long COVID can also manifest as prolonged fatigue, which may be linked to neuromuscular function impairment (NMFI). The current clinical assessment for NCVI monitors neurocardiovascular performance upon the application of orthostatic stressors such as an active (i.e., self-induced) stand or a passive (tilt table) standing test. Lower limb muscle contractions may be important in orthostatic recovery via the skeletal muscle pump. In this study, adults with long COVID were assessed with a protocol that, in addition to the standard NCVI tests, incorporated simultaneous lower limb muscle monitoring for NMFI assessment. Methods: To conduct such an investigation, a wide range of continuous non-invasive biomedical sensing technologies were employed, including digital artery photoplethysmography for the extraction of cardiovascular signals, near-infrared spectroscopy for the extraction of regional tissue oxygenation in brain and muscle, and electromyography for assessment of timed muscle contractions in the lower limbs. Results: With the proposed methodology described and exemplified in this paper, we were able to collect relevant physiological data for the assessment of neurocardiovascular and neuromuscular functioning. We were also able to integrate signals from a variety of instruments in a synchronized fashion and visualize the interactions between different physiological signals during the combined NCVI/NMFI assessment. Multiple counts of evidence were collected, which can capture the dynamics between skeletal muscle contractions and neurocardiovascular responses. Conclusions: The proposed methodology can offer an overview of the functioning of the neurocardiovascular and neuromuscular systems in a combined NCVI/NMFI setup and is capable of conducting comparative studies with signals from multiple participants at any given time in the assessment. This could help clinicians and researchers generate and test hypotheses based on the multimodal inspection of raw data in long COVID and other cohorts.
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Tu B, Wu L, Hu F, Fan S, Liu S, Liu L, Ding L, Zheng L, Yao Y. Cardiac Deceleration Capacity as an Indicator for Cardioneuroablation in Patients with Refractory Vasovagal Syncope. Heart Rhythm 2021; 19:562-569. [PMID: 34896621 DOI: 10.1016/j.hrthm.2021.12.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/16/2021] [Accepted: 12/04/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Cardioneuroablation is an emerging therapy for refractory vasovagal syncope (VVS), but the standard enrollment criteria is undetermined. Mainstream studies empirically enroll patients with cardioinhibitory and mixed types of VVS based on the head-up tilt test (HUT). However, a variety of studies have shown that results from HUT exhibit unpleasant reproducibility. OBJECTIVES We aimed to investigate the prognostic value of baseline deceleration capacity in patients with refractory VVS after cardioneuroablation. METHODS This study enrolled 123 patients (mean age, 42.2±17.7 years; males, 54 [43.9%]) with the diagnosis of VVS, of which 16 (13.0%) patients with a negative result of HUT, 8 (6.5%) with vasodepressive, 32 (26.0%) with cardioinhibitory, and 67 (54.5%) with mixed. All patients underwent cardioneuroablation that was performed in the left atrium. RESULTS After a mean follow-up of 4.0±1.1 years, 33 (26.8%) patients experienced syncope/pre-syncope events. Patients with recurrent syncope/pre-syncope have a lower baseline deceleration capacity level than those without (8.9±3.2ms vs. 11.3±3.7ms, P < 0.001). Each 1ms increase in deceleration capacity had a 34% (95%CI: 12%, 50%) reduced risk of syncope/pre-syncope recurrence after cardioneuroablation. Nighttime deceleration capacity had highest discrimination value (AUC: 0.757, 95% CI: 0.657, 0.858). In decision curve analysis, at a high-risk threshold of 51% (nighttime deceleration capacity at a cut-off of 9.9ms), nighttime deceleration capacity enrollment strategy additional benefited 18 per 100 patients for cardioneuroablation without syncope/pre-syncope recurrence compared to the HUT strategy. CONCLUSIONS Baseline nighttime deceleration capacity ≥ 10ms may act as an indication for cardioneuroablation in patients with refractory VVS.
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Affiliation(s)
- Bin Tu
- Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Lingmin Wu
- Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Feng Hu
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Siyang Fan
- Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Shangyu Liu
- Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Limin Liu
- Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Ligang Ding
- Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Lihui Zheng
- Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China.
| | - Yan Yao
- Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China.
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