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Cited by 160Cardiovascular Syncope and Autonomic DisordersHeart Rate Variability and Autonomic ControlLong-Term Effects of COVID-19

Postural tachycardia syndrome: beyond orthostatic intolerance

Open access
Garland, Emily M., Celedonio, Jorge E., Raj, Satish R.·2015·Current Neurology and Neuroscience Reports
DOI 10.1007/s11910-015-0583-8PMC PMC4664448
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Abstract

Postural tachycardia syndrome (POTS) is a form of chronic orthostatic intolerance for which the hallmark physiological trait is an excessive increase in heart rate with assumption of upright posture. The orthostatic tachycardia occurs in the absence of orthostatic hypotension and is associated with a >6-month history of symptoms that are relieved by recumbence. The heart rate abnormality and orthostatic symptoms should not be caused by medications that impair autonomic regulation or by debilitating disorders that can cause tachycardia. POTS is a "final common pathway" for a number of overlapping pathophysiologies, including an autonomic neuropathy in the lower body, hypovolemia, elevated sympathetic tone, mast cell activation, deconditioning, and autoantibodies. Not only may patients be affected by more than one of these pathophysiologies but also the phenotype of POTS has similarities to a number of other disorders, e.g., chronic fatigue syndrome, Ehlers-Danlos syndrome, vasovagal syncope, and inappropriate sinus tachycardia. POTS can be treated with a combination of non-pharmacological approaches, a structured exercise training program, and often some pharmacological support.

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Crossref · 10.1007/s11910-015-0583-8

Cites

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Claims the paper makes

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  • Premisecitation

    A structured evaluation using DSM-IV-TR criteria did not find a higher incidence of major depressive disorder, anxiety disorders, or substance abuse in POTS patients than in the general population.

    “Yet a structured evaluation using criteria from the Diagnostic and Statistical Manual (fourth edition, text revision) did not identify a higher incidence of major depressive disorder, anxiety disorders, or substance abuse in POTS patients than the general population [27].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [27] Raj V, Haman KL, Raj SR, Byrne D, Blakely RD, Biaggioni I, et al. Psychiatric profile and attention deficits in postural tachycardia syndrome. J Neurol Neurosurg Psychiatry. 2009;80:339–44. source

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  • Premisecitation

    The heart rate increase in POTS patients is not a response to anxiety.

    “Furthermore, the HR increase in patients is not a response to anxiety [28].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [28] Masuki S, Eisenach JH, Johnson CP, Dietz NM, Benrud-Larson LM, Schrage WG, et al. Excessive heart rate response to orthostatic stress in postural tachycardia syndrome is not caused by anxiety. J Appl Physiol (1985). 2007;102:896–903. source

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  • Premisecitation

    The orthostatic tachycardia in POTS is exaggerated in the morning compared with the evening.

    “The orthostatic tachycardia of POTS is exaggerated in the morning compared to the evening.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [18] Brewster JA, Garland EM, Biaggioni I, Black BK, Ling JF, Shibao CA, et al. Diurnal variability in orthostatic tachycardia: implications for the postural tachycardia syndrome. Clin Sci (Lond). 2012;122:25–31. source

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  • Premisecitation

    The tachycardia of POTS is sinus tachycardia.

    “The tachycardia of POTS is a sinus tachycardia.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] Johnson JN, Mack KJ, Kuntz NL, Brands CK, Porter CJ, Fischer PR. Postural orthostatic tachycardia syndrome: a clinical review. Pediatr Neurol. 2010;42:77–85. source

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  • Premisecitation

    POTS is a final common pathway for overlapping pathophysiologies including autonomic neuropathy in the lower body, hypovolemia, elevated sympathetic tone, mast cell activation, deconditioning, and autoantibodies.

    “POTS is a “final common pathway” for a number of overlapping pathophysiologies, including an autonomic neuropathy in the lower body, hypovolemia, elevated sympathetic tone, mast cell activation, deconditioning, and autoantibodies.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [2] Raj SR. The postural tachycardia syndrome (POTS): pathophysiology, diagnosis & management. Indian Pacing Electrophysiol J. 2006;6:84–99.

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  • May combine two claims. 43
  • Classified as probably not a substantial claim. 16

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    Premisecitation

    Chest pain in POTS is rarely due to coronary artery obstruction but may be associated with ECG changes when patients are upright.

    “Chest pain in POTS is rarely from coronary artery obstruction but it may be associated with ECG changes when patients are upright [20].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] Friesinger GC, Biern RO, Likar I, Mason RE. Exercise electrocardiography and vasoregulatory abnormalities. Am J Cardiol. 1972;30:733–40. source

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  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    POTS is a chronic orthostatic intolerance syndrome defined by an excessive upright heart rate increase without orthostatic hypotension, accompanied by symptoms lasting at least six months that improve on lying down.

    “Postural Tachycardia Syndrome (POTS) is a form of chronic orthostatic intolerance for which the hallmark physiological trait is an excessive increase in heart rate with assumption of upright posture.”
    • Also stated in: § Introduction · plain
      “An expert consensus statement [1] defines POTS as a HR increment ≥30 beats/min within 10 minutes of standing or head-up-tilt (HUT) which is sustained in the absence of orthostatic hypotension (a drop >20 mmHg in systolic blood pressure [BP] or >10mmHg in diastolic BP).”
    • Also stated in: § Introduction · plain
      “Patients with POTS experience cardiac and non-cardiac presyncopal symptoms chronically (≥6 months).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [1] Freeman R, Wieling W, Axelrod FB, Benditt DG, Benarroch E, Biaggioni I, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011;21:69–72. source

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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    A diagnosis of POTS requires chronic orthostatic symptoms lasting more than six months and exclusion of prolonged bedrest, deconditioning, medications that impair autonomic regulation, and other chronic debilitating disorders that can cause tachycardia.

    “The HR abnormality must be accompanied by chronic (>6 months) orthostatic symptoms that occur in the absence of prolonged bedrest or deconditioning, use of medications that impair autonomic regulation (vasodilators, diuretics, antidepressants, or anxiolytic agents), or other chronic debilitating disorders that might cause tachycardia (such as dehydration, anemia, or hyperthyroidism) [19].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [19] Raj SR. Postural tachycardia syndrome (POTS). Circulation. 2013;127:2336–42. source

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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The diagnostic heart rate threshold for POTS is at least 30 beats per minute within 10 minutes of standing or head-up tilt in adults, and at least 40 beats per minute in children.

    “An expert consensus statement [1] defines POTS as a HR increment ≥30 beats/min within 10 minutes of standing or head-up-tilt (HUT) which is sustained in the absence of orthostatic hypotension (a drop >20 mmHg in systolic blood pressure [BP] or >10mmHg in diastolic BP).”
    • Also stated in: § Introduction · plain
      “Children must meet a higher HR threshold ≥40 beats/min for a diagnosis due to their greater physiologic orthostatic tachycardia.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1] Freeman R, Wieling W, Axelrod FB, Benditt DG, Benarroch E, Biaggioni I, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011;21:69–72. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Acrocyanosis in POTS is not due to increased venous compliance but may be caused by decreased skin blood flow, possibly related to abnormal cutaneous nitric oxide activity.

    “This acrocyanosis in POTS is not due to increased venous compliance [22;23] but may be caused by a decrease in blood flow to the skin, possibly related to abnormal cutaneous nitric oxide activity [24].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [22] Freeman R, Lirofonis V, Farquhar WB, Risk M. Limb venous compliance in patients with idiopathic orthostatic intolerance and postural tachycardia. J Appl Physiol (1985). 2002;93:636–44. source

      Not checked in the free run.

    • cites [23] Stewart JM. Pooling in chronic orthostatic intolerance: arterial vasoconstrictive but not venous compliance defects. Circulation. 2002;105:2274–81. source

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    • cites [24] Stewart JM, Medow MS, Minson CT, Taneja I. Cutaneous neuronal nitric oxide is specifically decreased in postural tachycardia syndrome. Am J Physiol Heart Circ Physiol. 2007;293:H2161–7. source

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  • May combine two claims.

    Premisecitation

    The orthostatic tachycardia of POTS is greater with head-up tilt than with active standing during prolonged tests, but comparable between the two for the 10-minute period used for diagnosis.

    “Accordingly, the orthostatic tachycardia is greater with the HUT test in both patients with POTS and control subjects with prolonged tests, but the orthostatic tachycardia is comparable between HUT and active stand for the 10 minutes used for the POTS criterion [17].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [17] Plash WB, Diedrich A, Biaggioni I, Garland EM, Paranjape SY, Black BK, et al. Diagnosing postural tachycardia syndrome: comparison of tilt testing compared with standing haemodynamics. Clin Sci (Lond). 2013;124:109–14. This study compared the heart rate (HR) increases with a head up tilt test and a stand test. Over the 10 min used for the POTS HR criterion, there was not a significant difference, but over 30 min, the HR increases were greater with the tilt test than the stand test. source

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    Premisecitation

    Sleep problems in POTS are strongly negatively correlated with the RAND-36 physical health composite score and less strongly with the mental health composite score.

    “A higher measure for sleep problems is strongly negatively correlated with the RAND-36 physical health composite score and significantly, but to a lesser degree, correlated with the mental health composite score [5].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [5] Bagai K, Song Y, Ling JF, Malow B, Black BK, Biaggioni I, et al. Sleep disturbances and diminished quality of life in postural tachycardia syndrome. J Clin Sleep Med. 2011;7:204–10. source

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    Premisecitation

    POTS patients have poorer sleep quality, more daytime sleepiness, greater fatigue, and lower quality of life compared to healthy subjects.

    “POTS patients describe poorer sleep quality, more daytime sleepiness, greater fatigue, and substandard quality of life compared to healthy subjects [5].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [5] Bagai K, Song Y, Ling JF, Malow B, Black BK, Biaggioni I, et al. Sleep disturbances and diminished quality of life in postural tachycardia syndrome. J Clin Sleep Med. 2011;7:204–10. source

      Not checked in the free run.

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    Premisecitation

    A comprehensive neuropsychological evaluation of 28 seated POTS patients found deficits in selective attention, cognitive processing, and executive functioning, but memory function did not differ from healthy controls.

    “A comprehensive neuropsychological evaluation of 28 patients in a seated position found deficits in selective attention and cognitive processing, as well as impaired executive functioning. Memory function did not differ from healthy controls [29].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29] Arnold AC, Haman K, Garland EM, Raj V, Dupont WD, Biaggioni I, et al. Cognitive dysfunction in postural tachycardia syndrome. Clin Sci (Lond). 2015;128:39–45. This recent study formally looked at neurocognitive testing in POTS patients and healthy control subjects. Selective attention, cognitive processing speed, and measures of executive function are reduced in POTS. Follow-up studies looking at therapeutic approaches are underway. source

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    Premisecitation

    Autonomic testing indicated a similar autonomic profile but higher sympathetic tone in POTS patients with CFS.

    “Autonomic testing indicated a similar autonomic profile but higher sympathetic tone in patients with CFS.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [33] Okamoto LE, Raj SR, Peltier A, Gamboa A, Shibao C, Diedrich A, et al. Neurohumoral and haemodynamic profile in postural tachycardia and chronic fatigue syndromes. Clin Sci (Lond). 2012;122:183–92. source

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  • May combine two claims.

    Interpretationreasoning

    A significant minority of POTS patients are diagnosed following a virus-like syndrome, suggesting an autoimmune cause in some patients.

    “A significant minority of POTS patients are diagnosed following a virus-like syndrome. This suggests an autoimmune cause for POTS in some patients.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Many POTS patients have cardiovascular deconditioning and benefit from aerobic exercise and resistance training.

    “Although it may not be clear if deconditioning is a primary problem or secondary to POTS, many patients with POTS do have cardiovascular deconditioning and do benefit from a program of aerobic exercise and resistance training [13].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] Fu Q, Vangundy TB, Galbreath MM, Shibata S, Jain M, Hastings JL, et al. Cardiac origins of the postural orthostatic tachycardia syndrome. J Am Coll Cardiol. 2010;55:2858–68. source

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  • May combine two claims.

    Premisecitation

    When measured during upright posture, norepinephrine is elevated in many POTS patients (>3.55 nmol/L and sometimes >5.91 nmol/L), consistent with sympathetic neuronal activation elicited by standing.

    “When measured during upright posture, norepinephrine is elevated in many patients with POTS [>3.55 nmol/L (600 pg/mL) and sometimes >5.91 nmol/L (1000 pg/mL)], consistent with the sympathetic neuronal activation elicited by standing in these patients [19].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [19] Raj SR. Postural tachycardia syndrome (POTS). Circulation. 2013;127:2336–42. source

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    Interpretationreasoning

    These paradoxical findings suggest that POTS patients might have decreased angiotensin II metabolism and that dysregulation by the renin-angiotensin-aldosterone system might contribute to hypovolemia in POTS.

    “These paradoxical findings suggest that POTS patients might have decreased angiotensin II metabolism and that dysregulation by the renin-angiotensin-aldosterone system might contribute to hypovolemia in POTS [50;51].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [50] Mustafa HI, Garland EM, Biaggioni I, Black BK, Dupont WD, Robertson D, et al. Abnormalities of angiotensin regulation in postural tachycardia syndrome. Heart Rhythm. 2011;8:422–8. source

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    • cites [51] Stewart JM, Glover JL, Medow MS. Increased plasma angiotensin II in postural tachycardia syndrome (POTS) is related to reduced blood flow and blood volume. Clin Sci (Lond). 2006;110:255–63. source

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  • May combine two claims.

    Interpretationcitation

    Compensatory sympathetic activation to maintain adequate vasoconstriction could induce tachycardia via β-ARs, and β1-AR- and β2-AR-activating autoantibodies could also contribute to tachycardia.

    “Compensatory sympathetic activation to maintain adequate vasoconstriction could then induce tachycardia via β-ARs. β1-AR- and β2-AR-activating autoantibodies could also contribute to the tachycardia.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [57] Li H, Yu X, Liles C, Khan M, Vanderlinde-Wood M, Galloway A, et al. Autoimmune basis for postural tachycardia syndrome. J Am Heart Assoc. 2014;3:e000755. This study found the presence of partial agonist alpha-1 adrenergic antibodies and agonist beta-adrenergic autoantibodies in a high percentage of POTS patients. While preliminary, these data suggest a mechanism to explain the relatively common onset of POTS after a viral-like illness. source

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  • May combine two claims.

    Premisecitation

    Some POTS patients present with severe flushing in addition to tachycardia and have an associated mast cell activation disorder.

    “Some POTS patients present with severe flushing in addition to their tachycardia and have an associated mast cell activation disorder.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [56] Shibao C, Arzubiaga C, Roberts LJ, Raj S, Black B, Harris P, et al. Hyperadrenergic postural tachycardia syndrome in mast cell activation disorders. Hypertension. 2005;45:385–90. source

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  • May combine two claims.

    Premisecitation

    The three-month Dallas Program, involving aerobic exercise and resistance training, improves orthostatic and exercise tachycardia, symptoms, and quality of life in POTS.

    “The three-month Dallas Program, which involves aerobic exercise coupled with resistance training, improves orthostatic and exercise tachycardia, symptoms, and quality of life [13;62;63].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [13] Fu Q, Vangundy TB, Galbreath MM, Shibata S, Jain M, Hastings JL, et al. Cardiac origins of the postural orthostatic tachycardia syndrome. J Am Coll Cardiol. 2010;55:2858–68. source

      Not checked in the free run.

    • cites [62] Fu Q, Vangundy TB, Shibata S, Auchus RJ, Williams GH, Levine BD. Exercise training versus propranolol in the treatment of the postural orthostatic tachycardia syndrome. Hypertension. 2011;58:167–75. source

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    • cites [63] Shibata S, Fu Q, Bivens TB, Hastings JL, Wang W, Levine BD. Short-term exercise training improves the cardiovascular response to exercise in the postural orthostatic tachycardia syndrome. J Physiol. 2012;590:3495–505. source

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  • May combine two claims.

    Premisecitation

    POTS patients have a high prevalence of chronic fatigue (48-77%) and of CFS (17-23%).

    “Patients with POTS have a high prevalence of chronic fatigue (48-77%) and of CFS (17-23%) [33;8].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [33] Okamoto LE, Raj SR, Peltier A, Gamboa A, Shibao C, Diedrich A, et al. Neurohumoral and haemodynamic profile in postural tachycardia and chronic fatigue syndromes. Clin Sci (Lond). 2012;122:183–92. source

      Not checked in the free run.

    • cites [8] Sheldon RS, Grubb BP, Olshansky B, Shen WK, Calkins H, Brignole M, et al. 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. The Heart Rhythm Society has recently published its first consensus statement on the diagnosis and treatment of postural tachycardia syndrome (POTS) and other disorders. While not comprehensive, it provides an excellent starting point for a clinician wanting to learn about the management of POTS. source

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  • May combine two claims.

    Premisecitation

    Among POTS patients grouped by CFS criteria, fatigue symptoms, orthostatic HR and BP changes after 10 minutes, supine and upright plasma norepinephrine, and plasma volume were similar between those with and without CFS.

    “When patients were grouped according to whether or not they met the criteria for CFS [33], fatigue symptoms, orthostatic changes in HR and BP after 10 minutes, supine and upright plasma norepinephrine, and plasma volume were similar for the two groups.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [33] Okamoto LE, Raj SR, Peltier A, Gamboa A, Shibao C, Diedrich A, et al. Neurohumoral and haemodynamic profile in postural tachycardia and chronic fatigue syndromes. Clin Sci (Lond). 2012;122:183–92. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Vasovagal syncope and POTS overlap clinically, and both diagnoses may be appropriate for a given patient.

    “Vasovagal syncope and POTS overlap clinically, and both diagnoses may be appropriate for a given patient [8].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Sheldon RS, Grubb BP, Olshansky B, Shen WK, Calkins H, Brignole M, et al. 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. The Heart Rhythm Society has recently published its first consensus statement on the diagnosis and treatment of postural tachycardia syndrome (POTS) and other disorders. While not comprehensive, it provides an excellent starting point for a clinician wanting to learn about the management of POTS. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Plasma norepinephrine is sometimes higher at supine rest and increases more with head-up tilt in POTS.

    “A spectral analysis index of sympathetic function and plasma norepinephrine are sometimes higher at supine rest and increase more with HUT in POTS [53;52].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [53] Garland EM, Raj SR, Black BK, Harris PA, Robertson D. The hemodynamic and neurohumoral phenotype of postural tachycardia syndrome. Neurology. 2007;69:790–8. source

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    • cites [52] Furlan R, Jacob G, Snell M, Robertson D, Porta A, Harris P, et al. Chronic orthostatic intolerance: a disorder with discordant cardiac and vascular sympathetic control. Circulation. 1998;98:2154–9. source

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  • May combine two claims.

    Interpretationcitation

    Sympathetic denervation in POTS obstructs compensatory vascular constriction during upright posture, allowing blood pooling in splanchnic vasculature and lower extremities, leading to decreased venous return, sympathetic activation, and tachycardia.

    “Sympathetic denervation obstructs compensatory vascular constriction during upright posture, allowing blood to pool in the splanchnic vasculature and lower extremities [7;43;8]. The resulting decrease in venous return leads to the sympathetic activation and tachycardia of POTS.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [7] Grubb BP. Postural tachycardia syndrome. Circulation. 2008;117:2814–7. source

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    • cites [43] Stewart JM, Medow MS, Glover JL, Montgomery LD. Persistent splanchnic hyperemia during upright tilt in postural tachycardia syndrome. Am J Physiol Heart Circ Physiol. 2006;290:H665–73. source

      Not checked in the free run.

    • cites [8] Sheldon RS, Grubb BP, Olshansky B, Shen WK, Calkins H, Brignole M, et al. 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. The Heart Rhythm Society has recently published its first consensus statement on the diagnosis and treatment of postural tachycardia syndrome (POTS) and other disorders. While not comprehensive, it provides an excellent starting point for a clinician wanting to learn about the management of POTS. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    18% of POTS patients met criteria for EDS, compared to 0.02% prevalence in the general population and 4% in autonomic clinic patients without POTS.

    “Wallman et al. ascertained the prevalence of EDS in their POTS population: 18% of POTS patients met criteria for EDS, compared to a 0.02% prevalence in the general population and 4% prevalence in their autonomic clinic patients without POTS [34].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [34] Wallman D, Weinberg J, Hohler AD. Ehlers-Danlos syndrome and postural tachycardia syndrome: a relationship study. J Neurol Sci. 2014;340:99–102. This study assessed the incidence of Ehlers-Danlos syndrome in a cohort of POTS patients and found the incidence of EDS in POTS to be 18%, vs. 4% in non-POTS patients from an autonomic clinic, and an estimated prevalence of 0.02% in the general population. source

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    Premisecitation

    Central sympatholytics may cause drowsiness and worsen mental clouding in POTS patients.

    “Central sympatholytics (e.g. clonidine and methyldopa) can also be used to decrease sympathetic tone in patients with prominent hyperadrenergic features, but might produce drowsiness and worsening of the mental clouding [19] (HRS Class IIb) [8].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [19] Raj SR. Postural tachycardia syndrome (POTS). Circulation. 2013;127:2336–42. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Symptoms in POTS can be exacerbated by standing still, exercise, food or alcohol ingestion, or heat exposure.

    “Symptoms can be exacerbated by simple activities of daily life like standing still, exercise, food or alcohol ingestion, or heat exposure [26].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [26] Thieben MJ, Sandroni P, Sletten DM, Benrud-Larson LM, Fealey RD, Vernino S, et al. Postural orthostatic tachycardia syndrome: the Mayo Clinic experience. Mayo Clin Proc. 2007;82:308–13. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The heart rate abnormality and orthostatic symptoms in POTS should not be caused by medications that impair autonomic regulation or by debilitating disorders that can cause tachycardia.

    “The heart rate abnormality and orthostatic symptoms should not be caused by medications that impair autonomic regulation or by debilitating disorders that can cause tachycardia.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [19] Raj SR. Postural tachycardia syndrome (POTS). Circulation. 2013;127:2336–42. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Central sympatholytics are a Heart Rhythm Society Class IIb recommendation.

    “Central sympatholytics (e.g. clonidine and methyldopa) can also be used to decrease sympathetic tone in patients with prominent hyperadrenergic features, but might produce drowsiness and worsening of the mental clouding [19] (HRS Class IIb) [8].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Sheldon RS, Grubb BP, Olshansky B, Shen WK, Calkins H, Brignole M, et al. 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. The Heart Rhythm Society has recently published its first consensus statement on the diagnosis and treatment of postural tachycardia syndrome (POTS) and other disorders. While not comprehensive, it provides an excellent starting point for a clinician wanting to learn about the management of POTS. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    More generalized complaints in POTS include hypermobile joints, exercise intolerance, migraine headaches, sleep disturbances, and fatigue.

    “More generalized complaints in patients with POTS include hypermobile joints, exercise intolerance, migraine headaches, sleep disturbances, and fatigue [19].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [19] Raj SR. Postural tachycardia syndrome (POTS). Circulation. 2013;127:2336–42. source

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  • May combine two claims.

    Premisecitation

    Midodrine improves symptoms and orthostatic tachycardia in POTS.

    “Improvement in symptoms and orthostatic tachycardia can be associated with scalp tingling and goosebumps [58], and midodrine can cause urinary retention [67].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [58] Jacob G, Shannon JR, Black B, Biaggioni I, Mosqueda-Garcia R, Robertson RM, et al. Effects of volume loading and pressor agents in idiopathic orthostatic tachycardia. Circulation. 1997;96:575–80. source

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    Premisecitation

    Abdominal compression with elastic waist-high support hose and abdominal binders can help decrease splanchnic-mesenteric venous pooling during standing, and the increase in venous return and stroke volume can decrease orthostatic tachycardia.

    “Abdominal compression with elastic waist-high support hose and abdominal binders can help decrease splanchnic-mesenteric venous pooling during standing [43]. The increase in venous return and stroke volume can decrease the orthostatic tachycardia [19;59].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [43] Stewart JM, Medow MS, Glover JL, Montgomery LD. Persistent splanchnic hyperemia during upright tilt in postural tachycardia syndrome. Am J Physiol Heart Circ Physiol. 2006;290:H665–73. source

      Not checked in the free run.

    • cites [19] Raj SR. Postural tachycardia syndrome (POTS). Circulation. 2013;127:2336–42. source

      Not checked in the free run.

    • cites [59] Smit AA, Wieling W, Fujimura J, Denq JC, Opfer-Gehrking TL, Akarriou M, et al. Use of lower abdominal compression to combat orthostatic hypotension in patients with autonomic dysfunction. Clin Auton Res. 2004;14:167–75.

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  • May combine two claims.

    Interpretationcitation

    Improvement from the Dallas Program is related to an increase in heart size and increased blood volume, and the improved stroke volume decreases tachycardia.

    “Improvement is related to an increase in the size of the heart and increased blood volume [13]. The improved stroke volume decreases tachycardia.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] Fu Q, Vangundy TB, Galbreath MM, Shibata S, Jain M, Hastings JL, et al. Cardiac origins of the postural orthostatic tachycardia syndrome. J Am Coll Cardiol. 2010;55:2858–68. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Pyridostigmine is a Heart Rhythm Society Class IIb recommendation.

    “Increasing parasympathetic tone with pyridostigmine can also curtail HR in POTS [65] (HRS Class IIb) [8].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Sheldon RS, Grubb BP, Olshansky B, Shen WK, Calkins H, Brignole M, et al. 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. The Heart Rhythm Society has recently published its first consensus statement on the diagnosis and treatment of postural tachycardia syndrome (POTS) and other disorders. While not comprehensive, it provides an excellent starting point for a clinician wanting to learn about the management of POTS. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Intravenous saline (1-2L) can quickly expand blood volume and lessen tachycardia in POTS patients.

    “Intravenous saline (1-2L) can quickly expand blood volume and lessen tachycardia in POTS patients [58].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [58] Jacob G, Shannon JR, Black B, Biaggioni I, Mosqueda-Garcia R, Robertson RM, et al. Effects of volume loading and pressor agents in idiopathic orthostatic tachycardia. Circulation. 1997;96:575–80. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The natural history of POTS is not clear, but it does not appear to increase mortality risk.

    “The natural history of POTS is not clear, but it does not appear to increase the risk of mortality [8].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Sheldon RS, Grubb BP, Olshansky B, Shen WK, Calkins H, Brignole M, et al. 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. The Heart Rhythm Society has recently published its first consensus statement on the diagnosis and treatment of postural tachycardia syndrome (POTS) and other disorders. While not comprehensive, it provides an excellent starting point for a clinician wanting to learn about the management of POTS. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    POTS patients may have orthostatic hypertension and complain of tremor, anxiety, and cold, sweaty extremities.

    “These patients may have orthostatic hypertension (increase in systolic blood pressure >10 mmHg on standing) and complain of tremor, anxiety and cold, sweaty extremities [7;25].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [7] Grubb BP. Postural tachycardia syndrome. Circulation. 2008;117:2814–7. source

      Not checked in the free run.

    • cites [25] Low PA, Sandroni P, Joyner M, Shen WK. Postural tachycardia syndrome (POTS). J Cardiovasc Electrophysiol. 2009;20:352–8. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    POTS can be treated with a combination of non-pharmacological approaches, a structured exercise training program, and often some pharmacological support.

    “POTS can be treated with a combination of non-pharmacological approaches, a structured exercise training program, and often some pharmacological support.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Propranolol acutely reduces orthostatic tachycardia and symptoms at low doses (10-20 mg) without significant fatigue.

    “The non-selective β-AR antagonist propranolol acutely restrains orthostatic tachycardia and symptoms at doses that appear to be low enough (10-20 mg) to avoid the side effect of significant fatigue [64].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [64] Raj SR, Black BK, Biaggioni I, Paranjape SY, Ramirez M, Dupont WD, et al. Propranolol decreases tachycardia and improves symptoms in the postural tachycardia syndrome: less is more. Circulation. 2009;120:725–34. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Excessive tachycardia in POTS occurs during exercise as well as standing, and patients experience significant exercise intolerance.

    “Excessive tachycardia in POTS occurs during exercise as well as during standing [60;61], and patients experience significant exercise intolerance [9;19].”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [60] Masuki S, Eisenach JH, Schrage WG, Dietz NM, Johnson CP, Wilkins BW, et al. Arterial baroreflex control of heart rate during exercise in postural tachycardia syndrome. J Appl Physiol (1985). 2007;103:1136–42. source

      Not checked in the free run.

    • cites [61] Masuki S, Eisenach JH, Schrage WG, Johnson CP, Dietz NM, Wilkins BW, et al. Reduced stroke volume during exercise in postural tachycardia syndrome. J Appl Physiol (1985). 2007;103:1128–35. source

      Not checked in the free run.

    • cites [9] Medow MS, Stewart JM. The postural tachycardia syndrome. Cardiol Rev. 2007;15:67–75. source

      Not checked in the free run.

    • cites [19] Raj SR. Postural tachycardia syndrome (POTS). Circulation. 2013;127:2336–42. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Autonomic problems in POTS may include gastrointestinal complaints, bladder symptoms, and abnormal sudomotor regulation.

    “Autonomic problems in POTS might include gastrointestinal complaints, such as abdominal pain, nausea and irritable bowel syndrome, as well as bladder symptoms and abnormal sudomotor regulation [19;26].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [19] Raj SR. Postural tachycardia syndrome (POTS). Circulation. 2013;127:2336–42. source

      Not checked in the free run.

    • cites [26] Thieben MJ, Sandroni P, Sletten DM, Benrud-Larson LM, Fealey RD, Vernino S, et al. Postural orthostatic tachycardia syndrome: the Mayo Clinic experience. Mayo Clin Proc. 2007;82:308–13. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Midodrine can cause urinary retention.

    “Improvement in symptoms and orthostatic tachycardia can be associated with scalp tingling and goosebumps [58], and midodrine can cause urinary retention [67].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [67] Benarroch EE. Postural tachycardia syndrome: a heterogeneous and multifactorial disorder. Mayo Clin Proc. 2012;87:1214–25. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Midodrine use can be associated with scalp tingling and goosebumps.

    “Improvement in symptoms and orthostatic tachycardia can be associated with scalp tingling and goosebumps [58], and midodrine can cause urinary retention [67].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [58] Jacob G, Shannon JR, Black B, Biaggioni I, Mosqueda-Garcia R, Robertson RM, et al. Effects of volume loading and pressor agents in idiopathic orthostatic tachycardia. Circulation. 1997;96:575–80. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Propranolol is classified as a Class IIb recommendation by the Heart Rhythm Society for POTS.

    “Propranolol is a HRS Class IIb recommendation [8].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Sheldon RS, Grubb BP, Olshansky B, Shen WK, Calkins H, Brignole M, et al. 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. The Heart Rhythm Society has recently published its first consensus statement on the diagnosis and treatment of postural tachycardia syndrome (POTS) and other disorders. While not comprehensive, it provides an excellent starting point for a clinician wanting to learn about the management of POTS. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    DDAVP reduces tachycardia and symptoms in POTS.

    “Although DDAVP reduces tachycardia and symptoms [72;71], it can lead to hyponatremia.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [72] Coffin ST, Black BK, Biaggioni I, Paranjape SY, Orozco C, Black PW, et al. Desmopressin acutely decreases tachycardia and improves symptoms in the postural tachycardia syndrome. Heart Rhythm. 2012;9:1484–90. source

      Not checked in the free run.

    • cites [71] Nwazue VC, Raj SR. Confounders of vasovagal syncope: postural tachycardia syndrome. Cardiol Clin. 2013;31:101–9. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Erythropoietin increases red cell mass and may stimulate vasoconstriction.

    “Erythropoietin increases red cell mass and may also stimulate vasoconstriction [7].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] Grubb BP. Postural tachycardia syndrome. Circulation. 2008;117:2814–7. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Erythropoietin is high cost and requires injection.

    “This, combined with its high cost and the need for injection, makes it a less attractive option [11].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] Johnson JN, Mack KJ, Kuntz NL, Brands CK, Porter CJ, Fischer PR. Postural orthostatic tachycardia syndrome: a clinical review. Pediatr Neurol. 2010;42:77–85. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Octreotide helps maintain venous return during standing in POTS and inhibits the compensatory heart rate increase after acute and chronic administration.

    “This effect during standing helps to maintain venous return in POTS and inhibits the compensatory increase in HR following acute and chronic administration [68;69].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [68] Hoeldtke RD, Bryner KD, Hoeldtke ME, Hobbs G. Treatment of postural tachycardia syndrome: a comparison of octreotide and midodrine. Clin Auton Res. 2006;16:390–5. source

      Not checked in the free run.

    • cites [69] Kanjwal K, Saeed B, Karabin B, Kanjwal Y, Grubb BP. Use of octreotide in the treatment of refractory orthostatic intolerance. Am J Ther. 2012;19:7–10. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Fludrocortisone is a Heart Rhythm Society Class IIb recommendation.

    “Fludrocortisone is a HRS Class IIb recommendation [8].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Sheldon RS, Grubb BP, Olshansky B, Shen WK, Calkins H, Brignole M, et al. 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. The Heart Rhythm Society has recently published its first consensus statement on the diagnosis and treatment of postural tachycardia syndrome (POTS) and other disorders. While not comprehensive, it provides an excellent starting point for a clinician wanting to learn about the management of POTS. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    POTS includes various nonspecific symptoms, some linked to upright posture and some not, producing a clinical picture that overlaps with conditions such as chronic fatigue syndrome.

    “A number of nonspecific symptoms that are both associated with and independent of upright posture create a clinical phenotype that overlaps with other disorders like CFS.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    POTS is not a single disease.

    “POTS is not a single disease.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Midodrine is a Heart Rhythm Society Class IIb recommendation in POTS.

    “Midodrine is a HRS Class IIb recommendation in POTS [8].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Sheldon RS, Grubb BP, Olshansky B, Shen WK, Calkins H, Brignole M, et al. 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. The Heart Rhythm Society has recently published its first consensus statement on the diagnosis and treatment of postural tachycardia syndrome (POTS) and other disorders. While not comprehensive, it provides an excellent starting point for a clinician wanting to learn about the management of POTS. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationnone given

    Treatment for POTS often combines non-pharmacological methods, a structured exercise program, and pharmacological support.

    “POTS can be treated with a combination of non-pharmacological approaches, a structured exercise training program, and often some pharmacological support.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    Octreotide is only available as an injectable, which likely limits its use and patient acceptability.

    “However, octreotide is only available in an injectable form, and this likely limits its use and patient acceptability.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The Heart Rhythm Society cautions against using NET inhibitors or SNRIs in POTS (Class III).

    “The HRS cautions against their use in POTS (HRS Class III) [8].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Sheldon RS, Grubb BP, Olshansky B, Shen WK, Calkins H, Brignole M, et al. 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. The Heart Rhythm Society has recently published its first consensus statement on the diagnosis and treatment of postural tachycardia syndrome (POTS) and other disorders. While not comprehensive, it provides an excellent starting point for a clinician wanting to learn about the management of POTS. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Fludrocortisone stimulates potassium excretion, requiring monitoring for hypokalemia.

    “Fludrocortisone also stimulates potassium excretion, making it necessary to watch for hypokalemia, and it can also worsen migraine headaches [71;19].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [71] Nwazue VC, Raj SR. Confounders of vasovagal syncope: postural tachycardia syndrome. Cardiol Clin. 2013;31:101–9. source

      Not checked in the free run.

    • cites [19] Raj SR. Postural tachycardia syndrome (POTS). Circulation. 2013;127:2336–42. source

      Not checked in the free run.

54 of 54

  • The paper relies on this without support.

    No drugs are approved by the US Food and Drug Administration for the treatment of POTS.

    “The US Food and Drug Administration has not approved any drugs for the treatment of POTS.”

  • The paper relies on this without support.

    Midodrine increases peripheral resistance in POTS by stimulating vasoconstriction.

    “Midodrine, a pro-drug of an α1-AR agonist, can increase peripheral resistance in POTS by stimulating vasoconstriction.”

  • The paper relies on this without support.

    Octreotide acts as a vasoconstrictor, primarily in the splanchnic circulation.

    “The somatostatin analog octreotide is a vasoconstrictor that mainly affects the splanchnic circulation.”

  • The paper relies on this without support.

    Ivabradine slows heart rate by inhibiting the funny channel current in the sinoatrial node without affecting blood pressure.

    “Ivabradine is a cardioselective agent that slows HR via inhibition of the funny channel current (If) in the cardiac sinoatrial node but does not affect BP.”

  • The paper relies on this without support.

    Ivabradine is approved for heart failure in the US and Europe and for angina in Europe.

    “Ivabradine is approved for the treatment of heart failure (US & Europe) and angina (Europe).”

  • The paper relies on this without support.

    Fludrocortisone acts on the mineralocorticoid receptor and quickly boosts sodium reabsorption in the kidney's distal tubules.

    “Fludrocortisone is a synthetic corticosteroid that preferentially binds to the mineralocorticoid receptor and acutely increases sodium reabsorption in the distal tubules of the kidney.”
6 of 6

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Six-month symptom-duration threshold differs

    Minor

    The introduction permits a POTS diagnosis at exactly six months of symptoms, whereas the diagnostic-criteria section requires more than six months.

1 of 1

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Authors
Garland, E. M., Celedonio, J. E., & Raj, S. R.
Affiliations
  • Vanderbilt University (US)
  • University of Calgary (CA)
Corresponding author
Garland, Emily M.
ORCID
Venue
Current Neurology and Neuroscience Reports
Publisher
Springer Science and Business Media LLC
Published
2015-07-22
Volume
15
Issue
9
Pages
60-60
ISSN
  • 1528-4042 (ISSN-L)
  • 1534-6293
DOI
10.1007/s11910-015-0583-8
PMC
PMC4664448
OpenAlex
W1854421037
Cited by
160
References
78
Citations by year
2026: 5 · 2025: 12 · 2024: 13 · 2023: 7 · 2022: 25 · 2021: 20 · 2020: 21 · 2019: 16 · 2018: 19 · 2017: 15 · 2016: 5
FWCI
2.49
Type
journal article
Language
en
Open access
Licence
www.springer.com/tdm (tdm)
Locations
  • Current Neurology and Neuroscience Reports (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Institutes of Health (UL1TR000445, TR000445)
  • National Heart, Lung, and Blood Institute (R01HL071784, P01HL056693, R01HL102387, P01 HL-56693)
  • National Institute of Neurological Disorders and Stroke (U54NS065736)
  • National Center for Advancing Translational Sciences
Topics
  • Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
  • Health Sciences › Medicine › Neurology › Long-Term Effects of COVID-19
Keywords
postural orthostatic tachycardia syndrome, orthostatic intolerance, orthostatic tachycardia, autonomic dysfunction, autonomic neuropathy, hypovolemia, sympathetic hyperactivity, mast cell activation, deconditioning, autoantibodies, chronic fatigue syndrome, Ehlers-Danlos syndrome, vasovagal syncope, inappropriate sinus tachycardia, exercise training, pharmacotherapy
MeSH terms
Chronic Disease, Heart Rate, Humans, Mast Cells, Posture, Orthostatic Intolerance, Postural Orthostatic Tachycardia Syndrome

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-06.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-06.

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