Excessive Postural Tachycardia and [POTS] in ...: Associations With Distress, Impairment, Health Behaviors, and Medication Recommendations, 2022,Klaas

[Andy]

Full title: Excessive Postural Tachycardia and Postural Orthostatic Tachycardia Syndrome in Youth: Associations With Distress, Impairment, Health Behaviors, and Medication Recommendations

Abstract

Among adolescents with fatigue and postural dizziness, it is unclear how health behaviors and emotional distress relate to the presence of excessive postural tachycardia. We prospectively evaluated adolescents aged 13-22 years presenting with symptoms suggestive of autonomic dysfunction between September 2017 and December 2018. Patients underwent standard 10-minute, 70-degree head-up tilt testing. Clinician diagnoses and recommendations were recorded from the medical record. Patients completed validated self-report measures of lifestyle factors, autonomic symptoms, depression, anxiety, and functional disability.

Of 179 patients, 58 were diagnosed with postural orthostatic tachycardia syndrome and 59 had excessive postural tachycardia, with 90.5% concordance between the 2 groups. Presence of excessive postural tachycardia was associated with greater baseline fluid intake and likelihood of medication prescription in their treatment plan. Medication findings were replicated for postural orthostatic tachycardia syndrome diagnosis. Presence of excessive postural tachycardia or postural orthostatic tachycardia syndrome did not differentiate patients on perceived symptom severity, emotional distress, disability, or health behaviors but did appear to determine treatment recommendations.

Paywall, https://journals.sagepub.com/doi/10.1177/08830738221078410

 

[DokaGirl]

Puzzling that excessive POTS was associated with greater baseline fluid intake, when ME experts say to help with OI try hydrating well.

Can anyone explain this?
Or, is my ME brain just not comprehending.

 

[Trish]

58 were diagnosed with postural orthostatic tachycardia syndrome and 59 had excessive postural tachycardia, with 90.5% concordance between the 2 groups.

Can someone explain the difference between these 2 diagnoses.

 

[Arnie Pye]

Who decides how much postural orthostatic tachycardia is just the right amount, rather than being excessive?

 

[rvallee]

Puzzling that excessive POTS was associated with greater baseline fluid intake, when ME experts say to help with OI try hydrating well.

Can anyone explain this?
Or, is my ME brain just not comprehending.

I think they noticed pwPOTS drink more water but don't understand that they do to manage the symptoms. Clinical psychology can only do associations, so they don't know how to interpret information that has a reason for being, since they probably disagree with that reason (thus making themselves the target of their study).

So as is tradition an effect is sort of presented as a possible cause, because somehow the idea is that being more naïve than a spring chicken is good psychological science.

 

[duncan]

Seems to me if a study has the word "health" in any way near the word "behavior", someone is going to get screwed.

 

[SNT Gatchaman]

Can someone explain the difference between these 2 diagnoses.

I'll try and get the paper itself to confirm, but "excessive postural tachycardia" isn't a term that obviously crops up in a pubmed search. I assume they made an arbitrary cut-off for their paper, for example 10 or maybe 20 bpm, that is below the defined 30 bpm rise in adults or 40 bpm rise in adolescents.

Edit: nope. They are using "excessive postural tachycardia", defined as >30 or >40 bpm depending on age alone; and "postural orthostatic tachycardia syndrome" as the aforementioned with symptoms of orthostatic intolerance (eg light-headedness, fainting).

Who decides how much postural orthostatic tachycardia is just the right amount, rather than being excessive?

100%. As Van Campen etc have demonstrated, the vast majority of pwME and pwLC have decreased cerebral perfusion on tilt-table. Many do not demonstrate HR or BP changes. I think the diagnosis of POTS will ultimately be subsumed into the ME / postviral disease spectrum - it's just currently the specific diagnosis you get because you went to a cardiologist with objectively measurable symptoms/signs.

 

[DokaGirl]

I think they noticed pwPOTS drink more water but don't understand that they do to manage the symptoms. Clinical psychology can only do associations, so they don't know how to interpret information that has a reason for being, since they probably disagree with that reason (thus making themselves the target of their study).

So as is tradition an effect is sort of presented as a possible cause, because somehow the idea is that being more naïve than a spring chicken is good psychological science.

Ah, I think you may have it there @rvallee

Again, blame the client, even though they are following medical expert's advice. Unless a psychologist also has a medical degree, it seems exceedingly unwise to provide any actual biomedical advice to clients.

 

[SNT Gatchaman]

This paper is not open-access, so some liberal quoting —

there is ongoing debate within our field as to whether or not the finding of excessive postural tachycardia is even relevant to a diagnosis of postural orthostatic tachycardia syndrome.

Emotional distress and functional impairment are common among individuals with postural orthostatic tachycardia syndrome. ... it is conceivable that youth with excessive postural tachycardia and a postural orthostatic tachycardia syndrome diagnosis would experience greater emotional distress and functional disability compared with youth presenting with similar symptoms not meeting diagnostic criteria for postural orthostatic tachycardia syndrome, data addressing this question are lacking.

Considering that lifestyle modifications are foundational to current management of postural orthostatic tachycardia syndrome and other forms of autonomic dysfunction, it is conceivable that individuals who are already engaging in recommended lifestyle habits (eg, water and salt intake, physical activity) would be less likely to meet criteria for postural orthostatic tachycardia syndrome.

Understanding the associations of modifiable lifestyle factors with symptoms and signs at presentation would provide evidence that lifestyle factors could play a role in the symptom severity and perhaps development of “full blown” postural orthostatic tachycardia syndrome.

Therapeutic decisions about medication use are sometimes based on whether or not postural tachycardia accompanies the symptoms, but there is a paucity of data to actually guide medication use decisions.

... excessive postural tachycardia on 10-minute head-up tilt test, defined as a sustained heart rate increase of ≥40 beats per minute.

This prospective study of 179 adolescents with symptoms suggestive of autonomic dysfunction found no difference in presenting autonomic symptom severity, level of emotional distress, degree of disability, prepresentation salt intake, or pre-presentation physical activity levels between those with and without excessive postural tachycardia and postural orthostatic tachycardia syndrome vs. non-postural orthostatic tachycardia syndrome diagnoses.

... adds to ongoing discussion that a finding of excessive postural tachycardia or assignment of postural orthostatic tachycardia syndrome diagnosis may not be the most essential clinical feature defining the clinical entity or informing clinical management decisions in adolescents with disorders of chronic orthostatic intolerance.

The presence of excessive postural tachycardia, however, was associated with greater fluid intake and with increased likelihood of medication prescription

This study confirms previous work which found that autonomic symptoms and the degree of disability in patients with chronic orthostatic intolerance did not differ based on the presence or absence of excessive postural tachycardia.

It is still not clear whether the finding of excessive postural tachycardia is pathologically linked to the development of symptoms and disability or whether it is an unrelated co-occurrence. These data suggest that excessive postural tachycardia is at least not a reliable marker of the degree of autonomic symptoms or of disability in a referral population of patients experiencing chronic symptoms.

It could be imagined that postural orthostatic tachycardia syndrome is at an extreme end of the spectrum of autonomic dysfunction and that lifestyle choices (generous fluid and salt intake, regular sleep, and exercise) predispose patients to less progression to postural tachycardia. Our data, however, do not support that notion. In our patients, prepresentation intake and exercise behaviors did not relate to whether or not they had excessive postural tachycardia.

Our study found that degree of autonomic symptomatology, emotional distress, and functional disability were the same between patients with and without postural orthostatic tachycardia syndrome diagnosis or a finding of excessive postural tachycardia.

 

[rvallee]

Understanding the associations of modifiable lifestyle factors with symptoms and signs at presentation would provide evidence that lifestyle factors could play a role in the symptom severity and perhaps development of “full blown” postural orthostatic tachycardia syndrome.

Those are all adjustments, effects to the cause. This makes as much sense as observing that poor people have no savings and that therefore having no savings is what makes people poor, so poor people should just be encouraged to save money and they won't be poor anymore.

Or in the same idea: people die at excessive rates in hospitals therefore sick people should be especially mindful of avoiding hospitals.

Of all things what I don't get from EBM is the complete absence of common sense. It's just not there, it's all a giant false attribution error.

It could be imagined that postural orthostatic tachycardia syndrome is at an extreme end of the spectrum of autonomic dysfunction and that lifestyle choices (generous fluid and salt intake, regular sleep, and exercise) predispose patients to less progression to postural tachycardia. Our data, however, do not support that notion.

Such as calling symptom management "lifestyle choices". Being in the rave scene is a lifestyle choice, making necessary adjustments to disabling symptoms is not. This is ridiculous.