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Tavolinejad H, Poopak A, Sadeghian S, Bozorgi A, Oraii A, Mollazadeh R, Emkanjoo Z, Kiarsi M, Shahabi J, Jalali A, Alaeddini F, Ariannejad H, Yadangi S, Oraii S, Kheirkhah J, Assadianrad M, Aminorroaya A, Tajdini M. Compression stockings for treating vasovagal syncope (COMFORTS-II) trial: Rationale and design of a triple-blind, multi-center, randomized controlled trial. Am Heart J 2022; 249:57-65. [PMID: 35405100 DOI: 10.1016/j.ahj.2022.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/31/2022] [Accepted: 04/05/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Reduced venous return is an important trigger of vasovagal syncope (VVS). Elastic compression stockings (ECS) can modify venous return and be of therapeutic interest; however, evidence for ECS efficacy in VVS is scarce. This randomized controlled trial was designed to address the issue. METHODS COMFORTS-II is a multicenter, triple-blind, parallel design, randomized controlled trial aimed to assess the efficacy of ECS in preventing VVS recurrences. Using central online randomization, 268 participants will be allocated to 2 arms (1:1 ratio), wearing intervention ECS (25-30 mm Hg pressure) or sham ECS (≤10 mm Hg pressure). All participants will receive standard VVS treatment in the form of education, and lifestyle modification recommendations (drinking 2-3 l/d of fluids and consuming 10 g/d-roughly half a tablespoon-of table salt). Adherence to ECS treatment will be evaluated through diary sheets, and compared between study arms. Follow-up continues for 1 year, and is conducted via a 24/7 phone line available to patients and trimonthly visits. The co-primary outcomes are proportion of participants with any syncopal recurrence and time to first syncopal episode. Secondary outcomes include frequency of VVS spells, time intervals between recurrences, and incidence of any patient-reported adverse effects. CONCLUSION To the best of our knowledge, COMFORTS-II is the first clinical trial to assess ECS efficacy among patients with VVS, addressing an important gap in evidence for VVS treatments.
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Affiliation(s)
- Hamed Tavolinejad
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Poopak
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeed Sadeghian
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Bozorgi
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Reza Mollazadeh
- Department of Cardiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Emkanjoo
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular, Medical & Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohamadreza Kiarsi
- Department of Cardiology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Javad Shahabi
- Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Arash Jalali
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Farshid Alaeddini
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamid Ariannejad
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Somayeh Yadangi
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Jalal Kheirkhah
- Department of Cardiology, Healthy Heart Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Mohammad Assadianrad
- Department of Cardiology, Healthy Heart Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Arya Aminorroaya
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Masih Tajdini
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
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van Campen C(LMC, Rowe PC, Visser FC. Compression Stockings Improve Cardiac Output and Cerebral Blood Flow during Tilt Testing in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) Patients: A Randomized Crossover Trial. MEDICINA (KAUNAS, LITHUANIA) 2021; 58:medicina58010051. [PMID: 35056360 PMCID: PMC8781100 DOI: 10.3390/medicina58010051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/24/2021] [Accepted: 12/28/2021] [Indexed: 12/12/2022]
Abstract
Background and Objectives: Orthostatic intolerance (OI) is a clinical condition in which symptoms worsen upon assuming and maintaining upright posture and are ameliorated by recumbency. OI has a high prevalence in patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Limited data are available to guide the treatment of OI in ME/CFS patients. We and others have previously described patient-reported subjective improvement in symptoms using compression stockings. We hypothesized that these subjective reports would be accompanied by objective hemodynamic improvements. Materials and Methods: We performed a randomized crossover trial in 16 ME/CFS patients. Each underwent two 15-min head-up tilt table tests, one with and one without wearing knee-high compression stockings that provided 20–25 mm Hg compression. The order of the tests was randomized. We measured heart rate and blood pressure as well as cardiac output and cerebral blood flow (CBF) using extracranial Doppler of the internal carotid and vertebral arteries. Results: There were no differences in supine measurements between the 2 baseline measurements. There were no differences in heart rate and blood pressure at either end-tilt testing period. Compared to the test with the stockings off, the mean percentage reduction in cardiac output during the test with compression stockings on was lower, 15 (4)% versus 27 (6)% (p < 0.0001), as was the mean percentage CBF reduction, 14 (4)% versus 25 (5)% (p < 0.0001). Conclusion: In ME/CFS patients with orthostatic intolerance symptoms, cardiac output and CBF are significantly reduced during a tilt test. These abnormalities were present without demonstrable heart rate and blood pressure changes and were ameliorated by the use of compression stockings.
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Affiliation(s)
| | - Peter C. Rowe
- Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA;
| | - Frans C. Visser
- Stichting CardioZorg, Planetenweg 5, 2132 HN Hoofddorp, The Netherlands
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Ganesh R, Bonnes SLR, DiBaise JK. Postural Tachycardia Syndrome: Nutrition Implications. Nutr Clin Pract 2020; 35:818-825. [PMID: 32809263 DOI: 10.1002/ncp.10564] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Postural tachycardia syndrome (POTS) is a syndrome characterized by elevated heart rate without hypotension and most commonly occurs in young females (generally <35 years of age). The prevalence of POTS is on the rise, but the etiology is still under investigation, and there appear to be multiple potential physiologic causes. The majority of these patients experience a multitude of gastrointestinal (GI) and systemic symptoms and conditions that may contribute to functional debility and poor quality of life. Although symptoms generally improve with age, they can still lead to significant issues meeting nutrition and hydration needs. This paper summarizes the understood potential pathophysiology of POTS, associated GI and nutrition issues, general treatment of POTS, and strategies to assess and meet the unique nutrition and hydration needs of these patients.
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Affiliation(s)
- Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Sara L R Bonnes
- Division of General Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - John K DiBaise
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
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Abstract
Postural orthostatic tachycardia syndrome (POTS) is a clinically heterogeneous disorder with multiple contributing pathophysiologic mechanisms manifesting as symptoms of orthostatic intolerance in the setting of orthostatic tachycardia (increase in heart rate by at least 30 beats per minute upon assuming an upright position) without orthostatic hypotension. The three major pathophysiologic mechanisms include partial autonomic neuropathy, hypovolemia, and hyperadrenergic state. Patients often will exhibit overlapping characteristics from more than one of these mechanisms. The approach to the treatment of POTS centers on treating the underlying pathophysiologic mechanism. Stockings, abdominal binders, and vasoconstrictors are used to enhance venous return in partial neuropathic POTS. Exercise and volume expansion are the main treatment strategies for hypo-volemic POTS. For hyperadrenergic POTS, beta-blockers and avoidance of norepinephrine reuptake inhibitors is important. Attempts should be made to discern which pathophysiologic mechanism(s) may be afflicting patients so that treatment regimens can be individualized.
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Affiliation(s)
- Philip L. Mar
- Division of Cardiology, Department of Medicine, St. Louis University School of Medicine, St. Louis, Missouri 63110, USA
| | - Satish R. Raj
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta T2N 4Z6, Canada
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
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Fu Q, Levine BD. Exercise and non-pharmacological treatment of POTS. Auton Neurosci 2018; 215:20-27. [PMID: 30001836 DOI: 10.1016/j.autneu.2018.07.001] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/29/2018] [Accepted: 07/01/2018] [Indexed: 12/11/2022]
Abstract
Recent research has demonstrated that cardiovascular deconditioning (i.e., cardiac atrophy and hypovolemia) contributes significantly to the Postural Orthostatic Tachycardia Syndrome (POTS) and its functional disability. Therefore, physical reconditioning with exercise training and volume expansion via increased salt and fluid intake should be initiated early in the course of treatment for patients with POTS if possible. The use of horizontal exercise (e.g., rowing, swimming, recumbent bike, etc.) at the beginning is a critical strategy, allowing patients to exercise while avoiding the upright posture that elicits their POTS symptoms. As patients become increasingly fit, the duration and intensity of exercise should be progressively increased, and upright exercise can be gradually added as tolerated. Supervised training is preferable to maximize functional capacity. Other non-pharmacological interventions, which include: 1) chronic volume expansion via sleeping in the head-up position; 2) reduction in venous pooling during orthostasis by lower body compression garments extending at least to the xiphoid or with an abdominal binder; and 3) physical countermeasure maneuvers, such as squeezing a rubber ball, leg crossing, muscle pumping, squatting, negative-pressure breathing, etc., may also be effective in preventing orthostatic intolerance and managing acute clinical symptoms in POTS patients. However, randomized clinical trials are needed to evaluate the efficacies of these non-pharmacological treatments of POTS.
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Affiliation(s)
- Qi Fu
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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Rivas E, Smith JD, Sherman NW. Leg compressions improve ventilatory efficiency while reducing peak and post exercise blood lactate, but does not improve perceived exertion, exercise economy or aerobic exercise capacity in endurance-trained runners. Respir Physiol Neurobiol 2016; 237:1-6. [PMID: 28013058 DOI: 10.1016/j.resp.2016.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 11/02/2016] [Accepted: 12/05/2016] [Indexed: 11/19/2022]
Abstract
PURPOSE The objective of this study was to determine if leg compressions would alter cardiorespiratory and perceived exertion measures during rest, submaximal and maximal exercise in endurance-trained runners. METHOD Thirteen young, endurance trained runners (10 males, 20.9±3y, 58.9±5.7mlkgmin-1) completed a randomized design, leg compressions and non-compression control condition. The incremental graded exercise test consisted of baseline rest and submaximal intensities at 23%, 70%, 75%, 85% and then a progressive increase to 100% VO2max. Running economy (RE), rating of perceived exertion (RPE), breathing rate (BR), heart rate (HR), ventilation (VE), blood lactate, VO2max and ventilatory efficiency (VE/VO2) were the primary outcome variables. RESULTS Relative to the control condition, VO2 at rest, during submaximal and at max were not different. Additionally, RE, RPE, BR, and HR were similar under both conditions. Leg compressions reduced lactate at VO2max by 11% (P<0.05) and at 10min post-exercise recovery by 18% (P<0.01). Additionally, peak VE was significantly reduced in the compression condition by 8% (P<0.0001) relative to the control condition. Ventilatory efficiency was improved in compressions compared to control condition at 85 and 100% VO2max (condition×time interaction, P<0.0001). CONCLUSION These data suggest that leg compressions do not alter RE, RPE, BR, HR, or VO2, during exercise. However, compressions may be beneficial for submaximal and maximal ventilatory efficiency while improving lactate clearance at VO2max and during recovery in trained runners.
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Affiliation(s)
- Eric Rivas
- Division of Rehabilitation Sciences, The University of Texas Medical Branch at Galveston, Galveston, TX, USA.
| | - John D Smith
- College of Education and Human Development, Texas A&M University-San Antonio, San Antonio, TX, USA
| | - Nestor W Sherman
- Department of Health & Kinesiology, Human Performance Laboratory, Texas A&M University-Kingsville, Kingsville, TX, USA
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