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Cited by 55Cardiovascular Syncope and Autonomic DisordersHeart Rate Variability and Autonomic ControlLong-Term Effects of COVID-19

Postural Hyperventilation as a Cause of Postural Tachycardia Syndrome: Increased Systemic Vascular Resistance and Decreased Cardiac Output When Upright in All Postural Tachycardia Syndrome Variants

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Stewart, Julian M., Pianosi, Paul, Shaban, Mohamed A., Terilli, Courtney, Svistunova, Maria, Visintainer, Paul, Medow, Marvin S.·2018·Journal of the American Heart Association
DOI 10.1161/jaha.118.008854PMC PMC6064900
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Abstract

Background: Postural tachycardia syndrome ( POTS ) is a heterogeneous condition. We stratified patients previously evaluated for POTS on the basis of supine resting cardiac output ( CO ) or with the complaint of platypnea or “shortness of breath” during orthostasis. We hypothesize that postural hyperventilation is one cause of POTS and that hyperventilation‐associated POTS occurs when initial reduction in CO is sufficiently large. We also propose that circulatory abnormalities normalize with restoration of CO 2 . Methods and Results: Fifty‐eight enrollees with POTS were compared with 16 healthy volunteer controls. Low CO in POTS was defined by a resting supine CO <4 L/min. Patients with shortness of breath had hyperventilation with end tidal CO 2 <30 Torr during head‐up tilt table testing. There were no differences in height or weight between control patients and patients with POTS or differences between the POTS groups. Beat‐to‐beat blood pressure was measured by photoplethysmography, and CO was measured by ModelFlow. Systemic vascular resistance was defined as mean arterial blood pressure/ CO . End tidal CO 2 and cerebral blood flow velocity of the middle cerebral artery were only reduced during head‐up tilt in the hyperventilation group, whereas blood pressure was increased compared with control. We corrected the reduced end tidal CO 2 in hyperventilation by addition of exogenous CO 2 into a rebreathing apparatus. With added CO 2 , heart rate, blood pressure, CO, and systemic vascular resistance in hyperventilation became similar to control. Conclusions: We conclude that all POTS is related to decreased CO , decreased central blood volume, and increased systemic vascular resistance and that a variant of POTS is consequent to postural hyperventilation.

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  • Partial autonomic neuropathy in POTS extends beyond the lower extremities into the pelvic and splanchnic circulation.

    “The extent of partial autonomic neuropathy extends beyond the lower extremities into the pelvic and splanchnic circulation.”

    From Postural orthostatic tachycardia syndrome: mechanisms and new therapies (2020) · cites this paper as [23]

  • Doppler ultrasound and plethysmography studies have demonstrated abnormally increased blood flow and pooling in the splanchnic and pelvic circulation of POTS patients both at rest and in an upright position.

    “Both Doppler ultrasound and plethysmography studies have demonstrated abnormally increased blood flow and pooling in the splanchnic and pelvic circulation of POTS patients both at rest and in an upright position (20-24).”

    From Postural orthostatic tachycardia syndrome: mechanisms and new therapies (2020) · cites this paper as [23]

  • POTS patients have significantly greater decreases in thoracic and cerebral blood flow when compared to healthy controls during tilt.

    “Other studies have also demonstrated that POTS patients have significantly greater decreases in thoracic and cerebral blood flow when compared to healthy controls during tilt (21, 23, 25-27).”

    From Postural orthostatic tachycardia syndrome: mechanisms and new therapies (2020) · cites this paper as [23]

  • Cardiac output increases in part due to the skeletal muscle pump.

    “CO increases, in part, due to the skeletal muscle pump236.”

    From Sinus Tachycardia: a Multidisciplinary Expert Focused Review (2022) · cites this paper as [236]

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Authors
Stewart, J. M., Pianosi, P., Shaban, M. A., Terilli, C., Svistunova, M., Visintainer, P., & Medow, M. S.
Affiliations
  • New York Medical College (US)
  • Paediatric Respiratory Medicine King's College Hospital National Health Service Foundation Trust London United Kingdom
  • Baystate Medical Center (US)
Corresponding author
Stewart, Julian M.
ORCID
Venue
Journal of the American Heart Association
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2018-07-03
Volume
7
Issue
13
ISSN
2047-9980 (ISSN-L)
DOI
10.1161/jaha.118.008854
PMC
PMC6064900
OpenAlex
W2810549826
Cited by
55
References
64
Citations by year
2026: 4 · 2025: 6 · 2024: 11 · 2023: 5 · 2022: 6 · 2021: 9 · 2020: 10 · 2019: 2 · 2018: 2
FWCI
5.98
Type
journal article
Language
en
Open access
Licence
cc-by-nc-nd
Locations
  • Journal of the American Heart Association (publishedVersion, cc-by-nc-nd)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by-nc-nd)
  • PubMed Central (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
  • Touro Scholar (Touro College) (submittedVersion, cc-by-nc)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
  • National Heart, Lung, and Blood Institute (R01HL112736, R01HL134674)
  • National Institute of Neurological Disorders and Stroke (R21NS094644)
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, cardiac output, systemic vascular resistance, orthostatic intolerance, end-tidal carbon dioxide, rebreathing, cerebral blood flow velocity, central blood volume
MeSH terms
Adolescent, Adult, Blood Volume, Cardiac Output, Cerebrovascular Circulation, Female, Heart Rate, Humans, Hyperventilation, Lung, Male, Posture, Pulmonary Ventilation, Risk Factors, Vascular Resistance, Case-Control Studies, Postural Orthostatic Tachycardia Syndrome, Young Adult

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