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Boris JR, Abdallah H, Ahrens S, Chelimsky G, Chelimsky TC, Fischer PR, Fortunato JE, Gavin R, Gilden JL, Gonik R, Grubb BP, Klaas KM, Marriott E, Marsillio LE, Medow MS, Norcliffe-Kaufmann L, Numan MT, Olufs E, Pace LA, Pianosi PT, Simpson P, Stewart JM, Tarbell S, Van Waning NR, Weese-Mayer DE. Creating a data dictionary for pediatric autonomic disorders. Clin Auton Res 2023; 33:301-377. [PMID: 36800049 PMCID: PMC9936127 DOI: 10.1007/s10286-023-00923-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 01/06/2023] [Indexed: 02/18/2023]
Abstract
PURPOSE Whether evaluating patients clinically, documenting care in the electronic health record, performing research, or communicating with administrative agencies, the use of a common set of terms and definitions is vital to ensure appropriate use of language. At a 2017 meeting of the Pediatric Section of the American Autonomic Society, it was determined that an autonomic data dictionary comprising aspects of evaluation and management of pediatric patients with autonomic disorders would be an important resource for multiple stakeholders. METHODS Our group created the list of terms for the dictionary. Definitions were prioritized to be obtained from established sources with which to harmonize. Some definitions needed mild modification from original sources. The next tier of sources included published consensus statements, followed by Internet sources. In the absence of appropriate sources, we created a definition. RESULTS A total of 589 terms were listed and defined in the dictionary. Terms were organized by Signs/Symptoms, Triggers, Co-morbid Disorders, Family History, Medications, Medical Devices, Physical Examination Findings, Testing, and Diagnoses. CONCLUSION Creation of this data dictionary becomes the foundation of future clinical care and investigative research in pediatric autonomic disorders, and can be used as a building block for a subsequent adult autonomic data dictionary.
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Affiliation(s)
- Jeffrey R Boris
- Jeffrey R. Boris, MD LLC, P.O. Box 16, Moylan, PA, 19065, USA.
| | | | | | - Gisela Chelimsky
- Children's Hospital of Richmond, Virginia Commonwealth University Health, Richmond, VA, USA
| | | | - Philip R Fischer
- Mayo Clinic, Rochester, MN, USA
- Sheikh Shakhbout Medical City, Abu Dhabi, UAE
- Khalifa University College of Medicine and Health Sciences, Abu Dhabi, UAE
| | | | | | - Janice L Gilden
- Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Renato Gonik
- University of Florida College of Medicine, Gainesville, FL, USA
| | | | | | - Erin Marriott
- American Family Children's Hospital, Madison, WI, USA
| | - Lauren E Marsillio
- Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Stanley Manne Children's Research Institute, Chicago, IL, USA
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Mohammed T Numan
- University of Texas Houston McGovern Medical School, Houston, TX, USA
| | - Erin Olufs
- University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Paul T Pianosi
- University of Minnesota Medical School, Minneapolis, MN, USA
| | | | | | - Sally Tarbell
- Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | | | - Debra E Weese-Mayer
- Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Stanley Manne Children's Research Institute, Chicago, IL, USA
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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2
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Grubb AF, Grubb BP. Postural orthostatic tachycardia syndrome: New concepts in pathophysiology and management. Trends Cardiovasc Med 2023; 33:65-69. [PMID: 34695573 DOI: 10.1016/j.tcm.2021.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/22/2021] [Accepted: 10/19/2021] [Indexed: 02/07/2023]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a common and therapeutically challenging condition affecting numerous people worldwide. Recent studies have begun to shed light on the pathophysiology of this disorder. At the same time, both non-pharmacologic and pharmacologic therapies have emerged that offer additional treatment options for those afflicted with this condition. This paper reviews new concepts in both the pathophysiology and management of POTS.
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Affiliation(s)
- Alex F Grubb
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Denver, Colorado, USA.
| | - Blair P Grubb
- Division of Cardiology, The University of Toledo Medical Center, Toledo, Ohio, USA
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3
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Elzanaty AM, Royfman R, Maraey A, Saeyeldin A, Meenakshisundaram CHANDRAMOHAN, Khalil M, Aboulnour H, Grubb BP. Abstract P066: Short-term Outcomes Of Hypertensive Crises In Patients With Orthostatic Hypotension. Hypertension 2022. [DOI: 10.1161/hyp.79.suppl_1.p066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Current recommendations in management of supine hypertension-orthostatic hypotension disease (SH-OH) are mainly derived from outpatient studies with the aim of controlling SH while minimizing OH symptoms rather than targeting a specific standing blood pressure value. Data on short term outcomes of patients with OH who are hospitalized with hypertensive (HTN) crises is lacking.
Methods:
The Nationwide Readmission Database 2016-2019 was queried for all hospitalizations of HTN crises. Hospitalizations were stratified according to whether OH was present or not. We employed propensity score to match hospitalizations for patients with OH to those without, at 1:1 ratio. Outcomes evaluated were 30-days readmission with HTN crises or falls, as well as hospital outcomes of in-hospital mortality, acute kidney injury (AKI), acute congestive heart failure (CHF), acute coronary syndrome (ACS), type 2 myocardial infarction (T2MI), aortic dissection, stroke, length of stay (LOS), discharge to nursing home and hospitalization costs.
Results:
We included a total of 9,451 hospitalization (4,735 in the OH group vs 4,716 in the control group). OH group was more likely to be readmitted with falls (Odds ratio [OR]:3.27, p<0.01) but not with HTN crises(p=0.05). Both groups had similar likelihood of developing AKI (p=0.08), stroke/TIA (p=p=0.52), and aortic dissection(p=0.66). Alternatively, OH group were less likely to develop acute CHF (OR:0.54, p<0.01) or ACS (OR:0.39,p<0.01) in the setting of HTN crises than non-OH group. OH group were more likely to have longer LOS and have higher hospitalization costs.
Conclusion:
Patients with OH who are admitted with HTN crises tend to have similar or lower HTN-related complications to non-OH group while having higher likelihood of readmission with falls, LOS and hospitalization costs. Further randomized studies are needed to confirm such findings
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Mayuga KA, Fedorowski A, Ricci F, Gopinathannair R, Dukes JW, Gibbons C, Hanna P, Sorajja D, Chung M, Benditt D, Sheldon R, Ayache MB, AbouAssi H, Shivkumar K, Grubb BP, Hamdan MH, Stavrakis S, Singh T, Goldberger JJ, Muldowney JAS, Belham M, Kem DC, Akin C, Bruce BK, Zahka NE, Fu Q, Van Iterson EH, Raj SR, Fouad-Tarazi F, Goldstein DS, Stewart J, Olshansky B. Sinus Tachycardia: a Multidisciplinary Expert Focused Review. Circ Arrhythm Electrophysiol 2022; 15:e007960. [PMID: 36074973 PMCID: PMC9523592 DOI: 10.1161/circep.121.007960] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sinus tachycardia (ST) is ubiquitous, but its presence outside of normal physiological triggers in otherwise healthy individuals remains a commonly encountered phenomenon in medical practice. In many cases, ST can be readily explained by a current medical condition that precipitates an increase in the sinus rate, but ST at rest without physiological triggers may also represent a spectrum of normal. In other cases, ST may not have an easily explainable cause but may represent serious underlying pathology and can be associated with intolerable symptoms. The classification of ST, consideration of possible etiologies, as well as the decisions of when and how to intervene can be difficult. ST can be classified as secondary to a specific, usually treatable, medical condition (eg, pulmonary embolism, anemia, infection, or hyperthyroidism) or be related to several incompletely defined conditions (eg, inappropriate ST, postural tachycardia syndrome, mast cell disorder, or post-COVID syndrome). While cardiologists and cardiac electrophysiologists often evaluate patients with symptoms associated with persistent or paroxysmal ST, an optimal approach remains uncertain. Due to the many possible conditions associated with ST, and an overlap in medical specialists who see these patients, the inclusion of experts in different fields is essential for a more comprehensive understanding. This article is unique in that it was composed by international experts in Neurology, Psychology, Autonomic Medicine, Allergy and Immunology, Exercise Physiology, Pulmonology and Critical Care Medicine, Endocrinology, Cardiology, and Cardiac Electrophysiology in the hope that it will facilitate a more complete understanding and thereby result in the better care of patients with ST.
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Affiliation(s)
- Kenneth A. Mayuga
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Artur Fedorowski
- Karolinska Institutet & Karolinska University Hospital, Stockholm, Sweden
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, “G.d’Annunzio” University of Chieti-Pescara, Chieti Scalo, Italy
| | | | | | | | | | | | - Mina Chung
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Phoenix, AZ
| | - David Benditt
- University of Minnesota Medical School, Minneapolis, MN
| | | | - Mirna B. Ayache
- MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Hiba AbouAssi
- Division of Endocrinology, Metabolism, and Nutrition, Duke University Medical Center, Durham, NC
| | | | | | | | | | - Tamanna Singh
- Department of Cardiovascular Medicine, Cleveland Clinic, OH
| | | | - James A. S. Muldowney
- Vanderbilt University Medical Center &Tennessee Valley Healthcare System, Nashville Campus, Department of Veterans Affairs, Nashville, TN
| | - Mark Belham
- Cambridge University Hospitals NHS FT, Cambridge, UK
| | - David C. Kem
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Cem Akin
- University of Michigan, Ann Arbor, MI
| | | | - Nicole E. Zahka
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Qi Fu
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas & University of Texas Southwestern Medical Center, Dallas, TX
| | - Erik H. Van Iterson
- Section of Preventive Cardiology & Rehabilitation, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic Cleveland, OH
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Grubb BP. INCIDENTAL DISCOVERY AND MANAGEMENT OF LARGE VESSEL ARTERIAL THROMBI-IN-SITU IN SARS-COV-2. J Am Coll Cardiol 2022. [PMID: 35680184 PMCID: PMC8972341 DOI: 10.1016/s0735-1097(22)03322-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Blair P Grubb
- University of Toledo Medical Center, Toledo, Ohio, USA.
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Ali M, Haji AQ, Kichloo A, Grubb BP, Kanjwal K. Inappropriate sinus tachycardia: a review. Rev Cardiovasc Med 2021; 22:1331-1339. [PMID: 34957774 DOI: 10.31083/j.rcm2204139] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 11/06/2022] Open
Abstract
Inappropriate sinus tachycardia (IST) has been defined as a resting heart rate of >100 beats per minute and an average 24-hour heart rate >90 bpm with distressing symptoms resulting from the persistent tachycardia. IST is prevalent in 1% of the middle-aged population, mostly females. Rarely can elderly patients also present with IST. Possible mechanisms of IST include intrinsic sinus node abnormality, beta-adrenergic receptor stimulating autoantibody, beta-adrenergic receptor supersensitivity, muscarinic receptor autoantibody, or hyposensitivity, impaired baroreflex control, depressed efferent parasympathetic/vagal function, nociceptive stimulation, central autonomic overactivity, aberrant neurohumoral modulation, etc. Symptoms associated with IST are palpitations, chest pain, fatigue, shortness of breath, presyncope, and syncope. Despite these distressing symptoms, IST has not been associated with tachycardia-associated cardiomyopathy or increased major cardiovascular events. Various treatment options for patients with IST are ivabradine, beta-adrenergic blockers, calcium channel blockers, psychiatric evaluation, and exercise training. Although, endocardial radiofrequency ablation targeting the sinus node has been used as a treatment modality for otherwise treatment-refractory IST, the results have been dismal. The other modalities used for refractory IST treatment are endocardial modification of the sinus node using radiofrequency energy, combined endo and epicardial ablation of the sinus node, thoracoscopic epicardial ablation of the sinus node, sinus node sparing thoracoscopic and endocardial hybrid ablation. The goal of this review is to provide the readership with the pathophysiological basis of IST and its management options.
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Affiliation(s)
- Muzaffar Ali
- Department of Cardiology, Khyber Medical Institute Srinagar, 190010 Jammu and Kashmir, India
| | - Abdul Qadir Haji
- Department of Cardiology, Walter Reed Medical Center, Bethesda, MD 20814, USA
| | - Asim Kichloo
- Department of Internal Medicine, Central Michigan University, Mt Pleasant, MI 48859, USA
| | - Blair P Grubb
- Division of Cardiology, University of Toledo, Toledo, OH 43606, USA
| | - Khalil Kanjwal
- Section of Electrophysiology, McLaren Greater Lansing Hospital, Lansing, MI 48910, USA
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7
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Ali M, Pachon Maetos JC, Kichloo A, Masudi S, Grubb BP, Kanjwal K. Management strategies for vasovagal syncope. Pacing Clin Electrophysiol 2021; 44:2100-2108. [PMID: 34748224 DOI: 10.1111/pace.14402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 10/18/2021] [Accepted: 10/31/2021] [Indexed: 11/30/2022]
Abstract
Vasovagal syncope (VVS) (or neurocardiogenic syncope) is a common clinical condition that is challenging to both physicians and patients alike. Severe episodes of recurrent syncope can result in physical injury as well as psychological distress. This article provides a brief overview of current management strategies and a detailed overview of therapeutic modalities such as closed loop stimulation (CLS) and cardioneuroablation (CNA).
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Affiliation(s)
- Muzaffar Ali
- Sheri Kashmir Institute, Department of Cardiology, Srinagar, Jammu and Kashmir, India
| | | | - Asim Kichloo
- Central Michigan University, Internal Medicine, Saginaw, Michigan, USA.,Samaritan Medical Center, Internal Medicine, Watertown, New York, USA
| | - Sundas Masudi
- University of Liverpool School of Medicine, Liverpool, UK
| | - Blair P Grubb
- Division of cardiology, University of Toledo, Toledo, Ohio, USA
| | - Khalil Kanjwal
- Section of Cardiac electrophysiology, McLaren Greater Lansing, Lansing, Michigan, USA
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8
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Raj SR, Bourne KM, Stiles LE, Miglis MG, Cortez MM, Miller AJ, Freeman R, Biaggioni I, Rowe PC, Sheldon RS, Shibao CA, Diedrich A, Systrom DM, Cook GA, Doherty TA, Abdallah HI, Grubb BP, Fedorowski A, Stewart JM, Arnold AC, Pace LA, Axelsson J, Boris JR, Moak JP, Goodman BP, Chémali KR, Chung TH, Goldstein DS, Darbari A, Vernino S. Postural orthostatic tachycardia syndrome (POTS): Priorities for POTS care and research from a 2019 National Institutes of Health Expert Consensus Meeting - Part 2. Auton Neurosci 2021; 235:102836. [PMID: 34246578 PMCID: PMC8455430 DOI: 10.1016/j.autneu.2021.102836] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/14/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022]
Abstract
The National Institutes of Health hosted a workshop in 2019 to build consensus around the current state of understanding of the pathophysiology of postural orthostatic tachycardia syndrome (POTS) and to identify knowledge gaps that must be addressed to enhance clinical care of POTS patients through research. This second (of two) articles summarizes current knowledge gaps, and outlines the clinical and research priorities for POTS. POTS is a complex, multi-system, chronic disorder of the autonomic nervous system characterized by orthostatic intolerance and orthostatic tachycardia without hypotension. Patients often experience a host of other related disabling symptoms. The functional and economic impacts of this disorder are significant. The pathophysiology remains incompletely understood. Beyond the significant gaps in understanding the disorder itself, there is a paucity of evidence to guide treatment which can contribute to suboptimal care for this patient population. The vast majority of physicians have minimal to no familiarity or training in the assessment and management of POTS. Funding for POTS research remains very low relative to the size of the patient population and impact of the syndrome. In addition to efforts to improve awareness and physician education, an investment in research infrastructure including the development of standardized disease-specific evaluation tools and outcome measures is needed to facilitate effective collaborative research. A national POTS research consortium could facilitate well-controlled multidisciplinary clinical research studies and therapeutic trials. These priorities will require a substantial increase in the number of research investigators and the amount of research funding in this area.
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Affiliation(s)
- Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Kate M Bourne
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lauren E Stiles
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA; Dysautonomia International, East Moriches, NY, USA
| | - Mitchell G Miglis
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Melissa M Cortez
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Amanda J Miller
- Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, Boston, MA, USA; Center for Autonomic and Peripheral Nerve Disorders, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Italo Biaggioni
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Cyndya A Shibao
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andre Diedrich
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine and Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David M Systrom
- Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Glen A Cook
- Department of Neurology, Uniformed Services University, Bethesda, MD, USA
| | - Taylor A Doherty
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of California at San Diego, La Jolla, CA, USA
| | | | - Blair P Grubb
- Division of Cardiology, Department of Medicine, The University of Toledo Medical Center, USA
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Julian M Stewart
- Center for Hypotension, Departments of Pediatrics and Physiology, New York Medical College, Valhalla, NY USA
| | - Amy C Arnold
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Laura A Pace
- Center for Genomic Medicine and Department of Pediatrics, Division of Medical Genetics and Genomics, University of Utah, Salt Lake City, UT, USA
| | - Jonas Axelsson
- Department of Clinical Immunology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Jeffrey P Moak
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Brent P Goodman
- Neuromuscular Division, Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA
| | - Kamal R Chémali
- Department of Neurology, Eastern Virginia Medical School, Division of Neurology, Neuromuscular and Autonomic Center, Sentara Healthcare, Norfolk, VA, USA
| | - Tae H Chung
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David S Goldstein
- Autonomic Medicine Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Anil Darbari
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Steven Vernino
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
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9
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Vernino S, Bourne KM, Stiles LE, Grubb BP, Fedorowski A, Stewart JM, Arnold AC, Pace LA, Axelsson J, Boris JR, Moak JP, Goodman BP, Chémali KR, Chung TH, Goldstein DS, Diedrich A, Miglis MG, Cortez MM, Miller AJ, Freeman R, Biaggioni I, Rowe PC, Sheldon RS, Shibao CA, Systrom DM, Cook GA, Doherty TA, Abdallah HI, Darbari A, Raj SR. Postural orthostatic tachycardia syndrome (POTS): State of the science and clinical care from a 2019 National Institutes of Health Expert Consensus Meeting - Part 1. Auton Neurosci 2021; 235:102828. [PMID: 34144933 DOI: 10.1016/j.autneu.2021.102828] [Citation(s) in RCA: 95] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/10/2021] [Accepted: 05/30/2021] [Indexed: 12/13/2022]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a chronic and often disabling disorder characterized by orthostatic intolerance with excessive heart rate increase without hypotension during upright posture. Patients often experience a constellation of other typical symptoms including fatigue, exercise intolerance and gastrointestinal distress. A typical patient with POTS is a female of child-bearing age, who often first displays symptoms in adolescence. The onset of POTS may be precipitated by immunological stressors such as a viral infection. A variety of pathophysiologies are involved in the abnormal postural tachycardia response; however, the pathophysiology of the syndrome is incompletely understood and undoubtedly multifaceted. Clinicians and researchers focused on POTS convened at the National Institutes of Health in July 2019 to discuss the current state of understanding of the pathophysiology of POTS and to identify priorities for POTS research. This article, the first of two articles summarizing the information discussed at this meeting, summarizes the current understanding of this disorder and best practices for clinical care. The evaluation of a patient with suspected POTS should seek to establish the diagnosis, identify co-morbid conditions, and exclude conditions that could cause or mimic the syndrome. Once diagnosed, management typically begins with patient education and non-pharmacologic treatment options. Various medications are often used to address specific symptoms, but there are currently no FDA-approved medications for the treatment of POTS, and evidence for many of the medications used to treat POTS is not robust.
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Affiliation(s)
- Steven Vernino
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kate M Bourne
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lauren E Stiles
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA; Dysautonomia International, East Moriches, NY, USA
| | - Blair P Grubb
- Division of Cardiology, Department of Medicine, The University of Toledo Medical Center, USA
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Julian M Stewart
- Center for Hypotension, Departments of Pediatrics and Physiology, New York Medical College, Valhalla, NY, USA
| | - Amy C Arnold
- Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laura A Pace
- Center for Genomic Medicine and Department of Pediatrics, Division of Medical Genetics and Genomics, University of Utah, Salt Lake City, UT, USA
| | - Jonas Axelsson
- Department of Clinical Immunology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Jeffrey P Moak
- Department of Pediatrics, George Washington Univeristy School of Medicine and Health Sciences, Washington, DC, USA
| | - Brent P Goodman
- Neuromuscular Division, Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA
| | - Kamal R Chémali
- Department of Neurology, Eastern Virginia Medical School, Division of Neurology, Neuromuscular and Autonomic Center, Sentara Healthcare, Norfolk, VA, USA
| | - Tae H Chung
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David S Goldstein
- Autonomic Medicine Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Andre Diedrich
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine and Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mitchell G Miglis
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Melissa M Cortez
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Amanda J Miller
- Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, Boston, MA, USA; Center for Autonomic and Peripheral Nerve Disorders, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Italo Biaggioni
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Departments of Medicine and Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Cyndya A Shibao
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Departments of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David M Systrom
- Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Glen A Cook
- Department of Neurology, Uniformed Services University, Bethesda, MD, USA
| | - Taylor A Doherty
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of California at San Diego, La Jolla, CA, USA
| | | | - Anil Darbari
- Pediatric Gastroenterology, Children's National Hospital, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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10
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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11
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Grubb BP. High Sodium Intake in Patients With Postural Orthostatic Tachycardia Syndrome: A Practice "Worth Its Salt". J Am Coll Cardiol 2021; 77:2185-2186. [PMID: 33926654 DOI: 10.1016/j.jacc.2021.03.229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Blair P Grubb
- Cardiac Electrophysiology Program and Autonomic Disorders Clinic, University of Toledo Medical Center, Toledo, Ohio, USA.
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12
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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13
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Hendrix A, Nesheiwat Z, Towheed A, Brar V, Grubb BP. Adalimumab as a potential treatment for postural orthostatic tachycardia syndrome. HeartRhythm Case Rep 2021; 7:56-58. [PMID: 33505857 PMCID: PMC7813764 DOI: 10.1016/j.hrcr.2020.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Andrew Hendrix
- Department of Internal Medicine, The University of Toledo Medical Center, Toledo, Ohio
| | - Zeid Nesheiwat
- Department of Internal Medicine, The University of Toledo Medical Center, Toledo, Ohio
| | - Arooge Towheed
- Department of Cardiac Electrophysiology, The Georgetown University / Medstar Washington Hospital Center, Washington, District of Columbia
| | - Vijaywant Brar
- Department of Cardiac Electrophysiology, The Georgetown University / Medstar Washington Hospital Center, Washington, District of Columbia
| | - Blair P Grubb
- Division of Cardiovascular Medicine, The University of Toledo Medical Center, Toledo, Ohio
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14
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Kanjwal K, Jamal S, Kichloo A, Grubb BP. New-onset Postural Orthostatic Tachycardia Syndrome Following Coronavirus Disease 2019 Infection. J Innov Card Rhythm Manag 2020; 11:4302-4304. [PMID: 33262898 PMCID: PMC7685310 DOI: 10.19102/icrm.2020.111102] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 08/24/2020] [Indexed: 01/27/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2. We report a case of new-onset postural orthostatic tachycardia syndrome in an otherwise healthy female patient following COVID-19 infection. The patient presented with fatigue, orthostatic palpitations, dizziness, and presyncope. She underwent head-up tilt-table testing and the findings were suggestive of postural orthostatic tachycardia syndrome.
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Affiliation(s)
| | - Sameer Jamal
- Hackensack University Medical Center, Hackensack, NJ, USA
| | - Asim Kichloo
- McLaren Greater Lansing Hospital, Lansing, MI, USA.,Central Michigan University, Saginaw, MI, USA
| | - Blair P Grubb
- The University of Toledo Medical Center, Toledo, OH, USA
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15
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Abstract
Background The etiology of postural orthostatic tachycardia syndrome (POTS) is yet to be established. The disorder is often misdiagnosed as chronic anxiety or a panic disorder because the autonomic failure in these patients is not severe. A growing body of evidence suggests that POTS may be an autoimmune disorder. Antinuclear antibodies and elevations of ganglionic, adrenergic, and muscarinic acetylcholine receptor antibodies have all been reported. Methods and Results We collected detailed clinical symptoms of 55 patients diagnosed with POTS. We also evaluated serum levels of autoantibodies against 4 subtypes of G‐protein coupled adrenergic receptors and 5 subtypes of G‐protein coupled muscarinic acetylcholine receptors by ELISA. Our patients had a multitude of comorbidities, were predominantly young females, and reported viral‐like symptoms preceding episodes of syncope. We detected a significant number of patients with elevated levels of autoantibodies against the adrenergic alpha 1 receptor (89%) and against the muscarinic acetylcholine M4 receptor (53%). Surprisingly, elevations of muscarinic receptor autoantibodies appeared to be dependent upon elevation of autoantibodies against the A1 adrenergic receptor! Four patients had elevations of G‐protein coupled autoantibodies against all 9 receptor subtypes measured in our study. Five POTS patients had no elevation of any autoantibody; similarly, controls were also negative for autoantibody elevations. There was a weak correlation of clinical symptom severity with G‐protein coupled autoantibodies. Conclusions Our observations provide further evidence that, in most cases, POTS patients have at least 1 elevated G‐protein coupled adrenergic autoantibody and, in some instances, both adrenergic and muscarinic autoantibodies, supporting the hypothesis that POTS may be an autoimmune disorder.
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16
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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 Clin Electrophysiol 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] [What about the content of this article? (0)] [Affiliation(s)] [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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17
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Grubb BP. Editorial commentary: Pacing for syncope: Progress and promise. Trends Cardiovasc Med 2018; 28:427. [PMID: 29853425 DOI: 10.1016/j.tcm.2018.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 04/19/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Blair P Grubb
- Heart and Vascular Center, 3000 Arlington Ave. Toledo, OH 43614, United States.
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18
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Grubb BP. The Fallen. Pacing Clin Electrophysiol 2018; 41:672-673. [DOI: 10.1111/pace.13330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 03/15/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Blair P. Grubb
- Distinguished University Professor of Medicine and Pediatrics; The University of Toledo Medical Center; Toledo OH USA
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19
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Abstract
The benefit of conventional pacing in vasovagal syncope remains controversial and is currently recommended for patients with recurrent syncope and documented asystole. In the last two decades, a growing body of evidence has emerged supporting the use of a new sensing technique called closed loop stimulation or CLS, to treat refractory vasovagal syncope. CLS uses a sensing algorithm that can detect variation in cardiac contractility and respond to drop in blood pressure by increasing the heart rate. Multiple observational and randomized studies have assessed its efficacy and showed its superiority to conventional pacing in reducing the burden of syncopal attacks in patients with cardio-inhibitory vasovagal syncope.
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Affiliation(s)
- Mohammed Ruzieh
- Penn State Heart and Vascular Institute, 500 University Drive, PO Box 850, MC H047, Hershey, PA 17033, United States.
| | - Blair P Grubb
- Penn State Heart and Vascular Institute, 500 University Drive, PO Box 850, MC H047, Hershey, PA 17033, United States
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20
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Ruzieh M, Grubb BP. Orthostatic intolerance and postural tachycardia syndrome: new insights into pathophysiology and treatment. Herzschrittmacherther Elektrophysiol 2018; 29:183-186. [PMID: 29696346 DOI: 10.1007/s00399-018-0563-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 04/03/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Mohammed Ruzieh
- Cardiology, The Pennsylvania State Heart and Vascular Institute, Hershey, PA, USA
| | - Blair P Grubb
- Division of Cardiovascular Medicine, The University of Toledo Medical Center, 3000 Arlington Ave., 43614, Toledo, OH, USA.
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21
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Ruzieh M, Dziuba M, Hofmann JP, Grubb BP. Surgical and dental considerations in patients with postural tachycardia syndrome. Auton Neurosci 2018; 215:119-120. [PMID: 29678416 DOI: 10.1016/j.autneu.2018.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/03/2018] [Accepted: 04/11/2018] [Indexed: 11/27/2022]
Affiliation(s)
| | | | | | - Blair P Grubb
- University of Toledo Medical Center, Toledo, OH, USA.
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22
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Grubb BP. Touch. Pacing Clin Electrophysiol 2018; 41:433-434. [DOI: 10.1111/pace.13305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 02/11/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Blair P. Grubb
- Distinguished University Professor of Medicine and Pediatrics; The University of Toledo Medical Center, University of Toledo; 3000 Arlington Ave Toledo Ohio 43614 USA
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23
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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:peds.2017-1673. [PMID: 29222399 PMCID: PMC5744271 DOI: 10.1542/peds.2017-1673] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [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)
| | | | | | | | - John E. Fortunato
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
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24
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2017; 136:e60-e122. [DOI: 10.1161/cir.0000000000000499] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Win-Kuang Shen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | | | - David G. Benditt
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mitchell I. Cohen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Daniel E. Forman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Zachary D. Goldberger
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Blair P. Grubb
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mohamed H. Hamdan
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Andrew D. Krahn
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mark S. Link
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Brian Olshansky
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Satish R. Raj
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Roopinder Kaur Sandhu
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Dan Sorajja
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Benjamin C. Sun
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Clyde W. Yancy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
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25
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm 2017; 14:e155-e217. [PMID: 28286247 DOI: 10.1016/j.hrthm.2017.03.004] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Indexed: 12/26/2022]
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26
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2017; 70:620-663. [PMID: 28286222 DOI: 10.1016/j.jacc.2017.03.002] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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27
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2017; 136:e25-e59. [PMID: 28280232 DOI: 10.1161/cir.0000000000000498] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Win-Kuang Shen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | | | - David G Benditt
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mitchell I Cohen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Daniel E Forman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Zachary D Goldberger
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Blair P Grubb
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mohamed H Hamdan
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Andrew D Krahn
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mark S Link
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Brian Olshansky
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Satish R Raj
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Roopinder Kaur Sandhu
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Dan Sorajja
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Benjamin C Sun
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Clyde W Yancy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison.,Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
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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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Kanjwal K, Grubb BP. Utility of High-Output His Pacing during Difficult AV Node Ablation. An Underutilized Strategy. Pacing Clin Electrophysiol 2016; 39:616-9. [PMID: 26873425 DOI: 10.1111/pace.12829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 01/25/2016] [Accepted: 01/29/2016] [Indexed: 11/26/2022]
Abstract
Atrioventricular (AV) node ablation is a commonly performed procedure for patients with chronic drug refractory atrial fibrillation (AF) with episodes of rapid ventricular response. We report on a 72-year-old man who had difficulty managing chronic drug refractory AFs with frequent hospitalizations for rapid ventricular rate. The patient was taken to the electrophysiology laboratory for AV node ablation. Extensive mapping and localization techniques of the compact AV node and ablation in the region were unsuccessful. Subsequently, high-output His bundle pacing using 20 mA at 2 ms of output energy was performed in an attempt to localize the His bundle in areas where high-output pacing resulted in a narrower QRS complex. Further ablations in the areas where pacing produced a narrower QRS complex resulted in complete heart block. This case highlights the importance of using this simple pacing maneuver to achieve complete heart block in patients in whom standard strategies to localize and ablate the compact AV node are unsuccessful.
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Affiliation(s)
- Khalil Kanjwal
- Department of Cardiology, Michigan Cardiovascular Institute, Central Michigan University, Saginaw, Michigan
| | - Blair P Grubb
- Department of Cardiology, University of Toledo, Toledo, Ohio
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30
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Abstract
Orthostatic hypotension commonly affects elderly patients and those suffering from diabetes mellitus and Parkinson's disease. It is a cause of significant morbidity in the affected patients. The goal of this review is to outline the pathophysiology, evaluation, and management of the patients suffering from orthostatic hypotension.
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Affiliation(s)
- Khalil Kanjwal
- aDivision of Cardiology, Johns Hopkins Medical Institute, Baltimore, Maryland bDivision of Cardiology, Heart and Vascular Institute, Einstein Medical Center Philadelphia, Pennsylvania cDivision of Cardiology, University of Toledo Medical Center, Toledo, Ohio, USA
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31
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Kanjwal K, Masudi S, Grubb BP. Syncope in Children and Adolescents. Adolesc Med State Art Rev 2015; 26:692-711. [PMID: 27282019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
MESH Headings
- Adolescent
- Aortic Valve Stenosis/complications
- Aortic Valve Stenosis/diagnosis
- Aortic Valve Stenosis/therapy
- Arrhythmias, Cardiac/complications
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/therapy
- Autonomic Nervous System Diseases/complications
- Autonomic Nervous System Diseases/diagnosis
- Autonomic Nervous System Diseases/therapy
- Breath Holding
- Cardiomyopathies/complications
- Cardiomyopathies/diagnosis
- Cardiomyopathies/therapy
- Cardiomyopathy, Hypertrophic/complications
- Cardiomyopathy, Hypertrophic/diagnosis
- Cardiomyopathy, Hypertrophic/therapy
- Child
- Diagnosis, Differential
- Electrocardiography
- Electrocardiography, Ambulatory
- Epilepsy/diagnosis
- Heart Diseases/complications
- Heart Diseases/diagnosis
- Heart Diseases/therapy
- Humans
- Hypertension, Pulmonary/complications
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/therapy
- Phobic Disorders/diagnosis
- Phobic Disorders/therapy
- Postural Orthostatic Tachycardia Syndrome/complications
- Postural Orthostatic Tachycardia Syndrome/diagnosis
- Postural Orthostatic Tachycardia Syndrome/therapy
- Syncope/diagnosis
- Syncope/etiology
- Syncope/therapy
- Syncope, Vasovagal/diagnosis
- Syncope, Vasovagal/therapy
- Tilt-Table Test
- Video Recording
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32
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Sheldon RS, Grubb BP, Olshansky B, Shen WK, Calkins H, Brignole M, Raj SR, Krahn AD, Morillo CA, Stewart JM, Sutton R, Sandroni P, Friday KJ, Hachul DT, Cohen MI, Lau DH, Mayuga KA, Moak JP, Sandhu RK, Kanjwal K. 2015 heart rhythm society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm 2015; 12:e41-63. [PMID: 25980576 DOI: 10.1016/j.hrthm.2015.03.029] [Citation(s) in RCA: 557] [Impact Index Per Article: 61.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Indexed: 01/14/2023]
Affiliation(s)
| | | | | | | | | | | | - Satish R Raj
- Libin Cardiovascular Institute of Alberta, Alberta, Canada; Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Carlos A Morillo
- Department of Medicine, Cardiology Division, McMaster University Population Health Research Institute, Hamilton, Canada
| | | | - Richard Sutton
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | - Karen J Friday
- (13)Stanford University School of Medicine, Stanford, California
| | | | - Mitchell I Cohen
- Phoenix Children's Hospital, University of Arizona School of Medicine-Phoenix, Arizona Pediatric Cardiology/Mednax, Phoenix, Arizona
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide; Department of Cardiology, Royal Adelaide Hospital; and South Australian Health and Medical Research Institute, Adelaide, Australia
| | | | - Jeffrey P Moak
- Children's National Medical Center, Washington, District of Columbia
| | - Roopinder K Sandhu
- University of Alberta, Department of Medicine, Division of Cardiology, Alberta, Canada
| | - Khalil Kanjwal
- Michigan Cardiovascular Institute, Central Michigan University, Saginaw, Michigan
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Abstract
Rituximab (a monoclonal antibody directed against CD 20) therapy can be acutely complicated by infusion reactions and cardiac arrhythmia on rare occasions. We report the first case of a new onset left bundle branch block (LBBB) after rituximab therapy for Wegener's vasculitis.
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Affiliation(s)
- Mujeeb Sheikh
- Department of Medicine, Division of Cardiovascular Medicine, University of Toledo Medical Center, Toledo, Ohio, U.S.A
| | - Ankush Moza
- Department of Medicine, Division of Cardiovascular Medicine, University of Toledo Medical Center, Toledo, Ohio, U.S.A
| | - Blair P Grubb
- Department of Medicine, Division of Cardiovascular Medicine, University of Toledo Medical Center, Toledo, Ohio, U.S.A
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Vacek TP, Yu S, Rehman S, Grubb BP, Kosinski D, Verghese C, Eltahawy EA, Shafiq Q. Recurrent myocardial infarctions in a young football player secondary to thrombophilia, associated with elevated factor VIII activity. Int Med Case Rep J 2014; 7:147-54. [PMID: 25382985 PMCID: PMC4222711 DOI: 10.2147/imcrj.s68416] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Myocardial infarction (MI) due to coronary atherosclerosis in young adults is uncommon; rare causes such as cocaine abuse, arterial dissection, and thromboembolism should be considered. A 21-year-old football player, and otherwise healthy African American man, developed chest pain during exercise while bench-pressing 400 lbs. Acute MI was diagnosed based on physical examination, electrocardiography findings, and elevated cardiac enzymes. Coronary arteriography showed a thrombus occluding the proximal left anterior descending artery (LAD). Aggressive antiplatelet therapy with aspirin, clopidogrel, and eptifibatide was pursued, in addition to standard post-MI care. This led to the successful resolution of symptoms and dissolution of the thrombus, demonstrated by repeat coronary arteriography. Five months later, he presented with similar symptoms during exercise after lifting heavy weights, and was found to have another acute MI. Coronary arteriography again showed a thrombus occluding the LAD. No evidence of coronary artery dissection or vasospasm was found. Only mild atherosclerotic plaque burden was observed on both occasions by intravascular ultrasound. A bare metal stent was placed at the site as it was thought this site had acted as a nidus for small plaque rupture and thrombus formation. Elevated serum factor VIII activity at 205% (reference range 60%–140%) was found, a rare cause of hypercoagulability. Further workup revealed a patent foramen ovale during a Valsalva maneuver by transesophageal echocardiography. Both events occurred during weight lifting, which can transiently increase right heart pressure in a similar way to the Valsalva maneuver. In light of all the findings, we concluded that an exercise-related increase in factor VIII activity led to coronary arterial thrombosis in the presence of a small ruptured plaque. Alternatively, venous clots may have traversed the patent foramen ovale and occluded the LAD. In addition to continuing aggressive risk factor modification, anticoagulation therapy with warfarin was initiated with close follow-up.
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Affiliation(s)
- Thomas P Vacek
- Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Shipeng Yu
- Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Shahnaz Rehman
- Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Blair P Grubb
- Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Daniel Kosinski
- Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Cherian Verghese
- Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Ehab A Eltahawy
- Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Qaiser Shafiq
- Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
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35
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Grubb BP. No man left behind. Pacing Clin Electrophysiol 2014; 37:387-8. [PMID: 24372343 DOI: 10.1111/pace.12333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Blair P Grubb
- Distinguished University Professor of Medicine and Pediatrics College of Medicine Health Science Campus The University of Toledo Toledo, Ohio, USA.
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Grubb BP, Karabin B. Syncope in the athlete. Herzschrittmacherther Elektrophysiol 2012; 23:72-75. [PMID: 22836673 DOI: 10.1007/s00399-012-0185-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 06/08/2012] [Indexed: 06/01/2023]
Abstract
Syncope in the athlete requires a complete evaluation, as this may be the only warning prior to an episode of sudden cardiac death. This should include a detailed history which includes specific details of the event as well as bystander descriptions when possible. Following the history should be a careful physical examination and subsequent diagnostic testing based on the individual's needs. The purpose of the evaluation is to determine if structural or electrical heart disease is present that may lead to sudden death. If absent, the patient, family and staff can be reassured that it is safe to resume athletic activity. Careful attention to the athlete with syncope may both prevent potential disasters in some, while at the same time enjoyment of intense physical activity in others.
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Affiliation(s)
- B P Grubb
- Cardiology, The University of Toledo College of Medicine, 3000 Arlington Avenue, 43614, Toledo, OH, USA.
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37
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Sheikh M, Hasan S, Kanjwal Y, Schwann T, Grubb BP. Syncope as an Initial Manifestation of Atypical Lipomatous Hypertrophy of the Interatrial Septum. J Card Surg 2012; 27:454-7. [DOI: 10.1111/j.1540-8191.2012.01465.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kanjwal K, Saeed B, Karabin B, Kanjwal Y, Grubb BP. Clinical presentation and management of patients with hyperadrenergic postural orthostatic tachycardia syndrome. A single center experience. Cardiol J 2012; 18:527-31. [PMID: 21947988 DOI: 10.5603/cj.2011.0008] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND We present our single center experience of 27 patients of hyperadrenergic postural orthostatic tachycardia syndrome (POTS). METHODS In a retrospective analysis, we reviewed the charts of 300 POTS patients being followed at our autonomic center from 2003 to 2010, and found 27 patients eligible for inclusion in this study. POTS was defined as symptoms of orthostatic intolerance (of greater than six months' duration) accompanied by a heart rate increase of at least 30 bpm (or a rate that exceeds 120 bpm) that occurs in the first 10 min of upright posture or head up tilt test (HUTT) occurring in the absence of other chronic debilitating disorders. Patients were diagnosed as having the hyperadrenergic form based on an increase in their systolic blood pressure of ≥ 10 mm Hg during the HUTT (2) with concomitant tachycardia or their serum catecholamine levels (serum norepinephnrine level ≥ 600 pg/mL) upon standing. RESULTS Twenty seven patients, aged 39 ± 11 years, 24, (89%) of them female and 22 (82%) Caucasian were included in this study. Most of these patients were refractory to most of the first and second line treatments, and all were on multiple combinations of medications. CONCLUSIONS Hyperadrenergic POTS should be identified and differentiated from neuropathic POTS. These patients are usually difficult to treat and there are no standardized treatment protocols known at this time for patients with hyperadrenergic POTS.
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Affiliation(s)
- Khalil Kanjwal
- Department of Medicine,University of Toledo Medical Center, Toledo, OH, USA
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39
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Bruhl SR, Vetteth S, Rees M, Grubb BP, Khouri SJ. Post-reperfusion syndrome during renal transplantation: a retrospective study. Int J Med Sci 2012; 9:391-6. [PMID: 22859898 PMCID: PMC3410282 DOI: 10.7150/ijms.4468] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Accepted: 07/09/2012] [Indexed: 11/18/2022] Open
Abstract
Post-reperfusion syndrome (PRS) is a serious, widely reported complication following the reperfusion of an ischemic tissue or organ. We sought to determine the prevalence, risk factors and short-term outcomes of PRS related renal transplantation. We conducted a retrospective, case-control study of patients undergoing renal transplantation between July 2006 and March 2008. Identification of PRS was based on a drop in mean arterial pressure by at least 15% within 5 minutes of donor kidney reperfusion. Of the 150 consecutive renal transplantations reviewed, 6 patients (4%) met criteria for post-reperfusion syndrome. Univariate analysis showed that an age over 60, diabetes mellitus, Asian race, and extended criteria donors increased the odds of developing PRS by 4.8 times (95% CI [1.2, 20]; P=.0338), 4.5 times (95% CI [1.11, 18.8]; P=.0378), 35.5 times (95% CI [3.94, 319.8]; P=0.0078) and 9.6 times (95% CI [1.19, 76.28] P=0.0115) respectively. Short term follow-up revealed increased graft failure rate within 6 months (6% vs. 16% P=0.0125) and almost twice the number of hospital days post-transplant in PRS cohorts (5.43 ± 2.29 vs. 10.8 ± 7.29 P=<0.0001). Despite limited reporting, PRS appears to be a relatively common complication of renal transplantation and is associated with increase morbidity.
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40
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Kanjwal K, Karabin B, Kanjwal Y, Saeed B, Grubb BP. Autonomic dysfunction presenting as orthostatic intolerance in patients suffering from mitochondrial cytopathy. Clin Cardiol 2011; 33:626-629. [PMID: 20960537 DOI: 10.1002/clc.20805] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Disturbances in autonomic nervous system function have been reported to occur in patients suffering from mitochondrial cytopathies. However, there is paucity of literature on the occurrence of orthostatic intolerance (OI) in these patients. We report on a series of patients diagnosed with mitochondrial cytopathy who developed features of autonomic dysfunction in the form of OI. METHODS This was a single-center report on a series of 6 patients who were followed in our clinic for orthostatic intolerance. All of these patients had a diagnosis of mitochondrial cytopathy on the basis of muscle biopsy and were being followed at a center specializing in the treatment of mitochondrial disorders. This study was approved by our local institutional review board. Each of the patients had suffered from symptoms of fatigue, palpitations, near syncope, and syncope. The diagnosis of OI was confirmed by head-up tilt test. Collected data included demographic information, presenting symptoms, laboratory data, tilt-table response, and treatment outcomes. RESULTS Six patients (3 females) were identified for inclusion in this report. The mean age of the group was 48 ± 8 years (range, 40-60 years). All of these patients underwent head-up tilt table testing and all had a positive response that reproduced their clinical symptoms. Among those having an abnormal tilt-table pattern, 1 had a neurocardiogenic response, 1 had a dysautonomic response, and 4 had a postural orthostatic tachycardia response. All but 1 patient reported marked symptom relief with pharmacotherapy. The patient who failed pharmacotherapy received a dual-chamber closed-loop pacemaker and subsequently reported marked improvement in her symptoms with elimination of her syncope. CONCLUSIONS Orthostatic intolerance might be a significant feature of autonomic nervous system dysfunction in patients suffering from mitochondrial cytopathy.
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Affiliation(s)
- Khalil Kanjwal
- Section of Electrophysiology, Division of Cardiology, Division of Internal Medicine
| | - Beverly Karabin
- Section of Electrophysiology, Division of Cardiology, Division of Internal Medicine
| | - Yousuf Kanjwal
- Section of Electrophysiology, Division of Cardiology, Division of Internal Medicine
| | - Bilal Saeed
- Department of Medicine, The University of Toledo Medical Center, Toledo, Ohio
| | - Blair P Grubb
- Section of Electrophysiology, Division of Cardiology, Division of Internal Medicine
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Grubb BP. Songs from a distant time. Pacing Clin Electrophysiol 2011; 34:1578-9. [PMID: 21251022 DOI: 10.1111/j.1540-8159.2010.03009.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Blair P Grubb
- Health Science Campus, The University of Toledo, Toledo, Ohio, USA.
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42
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Kanjwal K, Karabin B, Kanjwal Y, Grubb BP. Postural orthostatic tachycardia syndrome following Lyme disease. Cardiol J 2011; 18:63-66. [PMID: 21305487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND A subgroup of patients suffering from Lyme disease (LD) may initially respond to antibiotics only to later develop a syndrome of fatigue, joint pain and cognitive dysfunction referred to as 'post treatment LD syndrome'. We report on a series of patients who developed autonomic dysfunction in the form of postural orthostatic tachycardia syndrome (POTS). METHODS All of the patients in this report had suffered from LD in the past and were successfully treated with antibiotics. All patients were apparently well, until years later when they presented with fatigue, cognitive dysfunction and orthostatic intolerance. These patients were diagnosed with POTS on the basis of clinical features and results of the tilt table (HUTT) testing. RESULTS Five patients (all women), aged 22-44 years, were identified for inclusion in this study. These patients developed symptoms of fatigue, cognitive dysfunction, orthostatic palpitations and either near syncope or frank syncope. The debilitating nature of these symptoms had resulted in lost of the employment or inability to attend school. Three patients were also suffering from migraine, two from anxiety and depression and one from hypertension. All patients demonstrated a good response to the employed treatment. Four of the five were able to engage in their activities of daily living and either resumed employment or returned to school. CONCLUSIONS In an appropriate clinical setting, evaluation for POTS in patients suffering from post LD syndrome may lead to early recognition and treatment, with subsequent improvement in symptoms of orthostatic intolerance.
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Affiliation(s)
- Khalil Kanjwal
- Section of Electrophysiology, Division of Cardiology, Department of Medicine,The University of Toledo Medical Center, Toledo, USA
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43
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Kanjwal K, Karabin B, Sheikh M, Kanjwal Y, Grubb BP. New onset postural orthostatic tachycardia syndrome following ablation of AV node reentrant tachycardia. J Interv Card Electrophysiol 2010; 29:53-6. [DOI: 10.1007/s10840-010-9506-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Accepted: 06/24/2010] [Indexed: 10/19/2022]
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Kanjwal K, Karabin B, Kanjwal Y, Grubb BP. A case of mistaken identity: asystole causing convulsions identified using implantable loop recorder. Int J Med Sci 2010; 7:209-12. [PMID: 20596359 PMCID: PMC2894218 DOI: 10.7150/ijms.7.209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Accepted: 06/20/2010] [Indexed: 11/28/2022] Open
Abstract
We present herein an interesting tracing of a patient who suffered from recurrent episodes of transient loss of consciousness (TLOC) associated with convulsive activity thought to be due to epilepsy or conversion disorder.
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Affiliation(s)
- Khalil Kanjwal
- Electrophysiology Section, Division of Cardiology, Department of Medicine, The University of Toledo Medical Center, Health Science Campus, Toledo, OH 43614, USA
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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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Kanjwal K, Saeed B, Karabin B, Kanjwal Y, Grubb BP. Comparative clinical profile of postural orthostatic tachycardia patients with and without joint hypermobility syndrome. Indian Pacing Electrophysiol J 2010; 10:173-8. [PMID: 20376184 PMCID: PMC2847867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Autonomic dysfunction is common in patients with the joint hypermobility syndrome (JHS). However, there is a paucity of reported data on clinical features of Postural orthostatic tachycardia syndrome (POTS) in patients suffering from JHS. METHODS This retrospective study was approved by our local Institutional Review Board (IRB). Over a period of 10 years, 26 patients of POTS were identified for inclusion in this study. All these patients had features of Joint Hypermobility Syndrome (by Brighton criterion). A comparison group of 39 patients with other forms of POTS were also followed in the autonomic clinic during the same time. We present a descriptive report on the comparative clinical profile of the clinical features of Postural Orthostatic Tachycardia patients with and without Joint Hypermobility syndrome. The data is presented as a mean+/-SD and percentages wherever applicable. RESULTS Out of 65 patients, 26 patients (all females, 20 Caucasians) had POTS and JHS. The mean age at presentation of POTS was 24+/-13 (range 10-53 years) vs 41+/-12 (range 19-65 years), P=0.0001, Migraine was a common co morbidity 73 vs 29% p=0,001. In two patients POTS was precipitated by pregnancy, and in three by surgery, urinary tract infection and a viral syndrome respectively. The common clinical features were fatigue (58%), orthostatic palpitations (54%), presyncope (58%), and syncope (62%). CONCLUSIONS Patients with POTS and JHS appear to become symptomatic at an earlier age compared to POTS patients without JHS. In addition patients with JHS had a greater incidence of migraine and syncope than their non JHS counterparts.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Kanjwal K, Khaliq A, Grubb BP, Foster W, Kanjwal Y. A tale of two atria. Indian Pacing Electrophysiol J 2010; 10:156-7. [PMID: 20234814 PMCID: PMC2836012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
We present an interesting intracardiac electrogram of a dissimilar atrial rhythm in a patient of bi-atrial orthotopic cardiac transplant.
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Affiliation(s)
- Khalil Kanjwal
- Division of Cardiology, Section of Electrophysiology, The University of Toledo Medical Center, 3000 Arlington ave Toledo Ohio 43614, USA
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Kanjwal K, Karabin B, Kanjwal Y, Grubb BP. Autonomic dysfunction presenting as postural tachycardia syndrome following traumatic brain injury. Cardiol J 2010; 17:482-487. [PMID: 20865679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND Autonomic dysregulation (also called diencephalic epilepsy) has been reported following traumatic brain injuries (TBI). However, until now, postural tachycardia syndrome (POTS) has not been reported as a long-term complication in patients who have suffered a TBI. We report on a series of patients who developed POTS after suffering TBI. METHODS Eight patients who were referred to our center had suffered TBI and developed features of orthostatic intolerance following head trauma. The patients' neurological, neurosurgical and autonomic data (charts and/or physician letters) were then carefully reviewed for demographic characteristics, comorbid conditions, symptoms of orthostatic intolerance, medications and response to medication. These patients were diagnosed as having POTS, primarily based on their clinical features and findings from the head-up tilt test (HUTT). The data presented is observational and descriptive (percentages or means). RESULTS Eight patients (seven of them women) aged 21-41 years had suffered from TBI and had developed features of POTS. All had been normal with no symptoms prior to their TBI. All patients experienced orthostatic dizziness, fatigue, palpitations and near syncope. Six patients suffered from frank syncope. Six patients developed significant cognitive dysfunction, and three developed a chronic pain syndrome following trauma. All of the patients reported severe limitations to their daily activities and had been unable to keep their jobs, and two were housebound. Six patients demonstrated a good response to therapy with various combinations of medication. The symptoms of orthostatic intolerance and syncope improved with the initiation of medical therapy, as well as their reported quality of life. Two patients failed to show any improvement with various combinations of medications and tilt training, and continued to experience orthostatic difficulties. CONCLUSIONS Postural tachycardia syndrome may, in some cases, be a late complication of traumatic brain injury.
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Affiliation(s)
- Khalil Kanjwal
- Division of Cardiology, Section of Electrophysiology, Department of Medicine, Health Sciences Campus, University of Toledo Medical Center, Toledo, OH, USA
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Kanjwal K, Karabin B, Kanjwal Y, Grubb BP. Outcomes of pregnancy in patients with preexisting postural tachycardia syndrome. Pacing Clin Electrophysiol 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] [What about the content of this article? (0)] [Affiliation(s)] [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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