Question About Tilt Table Test

[samannran]

I was diagnosed with NCS and AVNRT in 2003 after a TTT and EP study. I had an ablation for the tachycardia, but my other symptoms only seemed to worsen. I've been under a cardiologist's care ever since. Because my fatigue and many other symptoms have seemed a lot worse lately, my cardio had me do another TTT today. However, he had me stay on my meds. I take Diltiazem and Coreg. My heart rate went up 35 bpm when standing while my bp dropped. My doctor didn't want the adrenaline med injected. I didn't faint, but I was very sick to my stomach and developed a migraine and my usual symptoms. My question is, does this sound like POTS? During my first TTT, my heart rate skyrocketed, and I fainted. However, I didn't get a POTS diagnosis because of the tachycardia found during the ep study was blamed for the fast heart rate.

I've been reading the posts on the forum for a long time now. Any comments/opinions will be greatly appreciated.

Thanks,

Samantha

[MightyMouse]

Hi Samantha,

Ablations are listed on the "What to Avoid" page on the DINET main site... the quote below is taken directly from there.

"Ablations may be detrimental to POTS patients. A Mayo Clinic study reported short-term success in five of seven ablated patients with inappropriate sinus tachycardia and postural orthostatic tachycardia features (Shen, Low, Jahangir, Munger, Friedman, Osborn, Stanton, Packer, Rea & Hammill, 2001). However, long-term outcomes were disappointing in these patients. None of the patients experienced complete eradication of symptoms. A follow-up evaluation showed no vast improvement in symptoms, despite better heart rate control. A later publication states "in our laboratory, sinus node modification, total sinus node ablation, or atrioventricular nodal ablation is not recommended for patients with inappropriate sinus tachycardia who have autonomic evidence of postural orthostatic tachycardia" (Shen, 2002).

Ablations have reportedly been detrimental to some POTS patients who were misdiagnosed as having inappropriate sinus tachycardia. After the apparently successful elimination of their "sinus tachycardia", they were left with profound orthostatic hypotension (Grubb & Karas, 1999)."

Nina

[cardiactec]

as nina said, ablations are contraindicated in the pots patient. however, if you had AVNRT and was symptomatic with this particular rhythm, than ablation for this and not sinus tach due to pots would not cause the symptoms that you have today.

from the sounds of it and what your BP AND HR did with this tilt, granted you were on meds, it doesn't sound like pots. with pots you generally do not see BP drop, actually my neuro in boston told me with pots, usually BP is normal and actually sometimes high in the pots patient. there are people here with low BP issues but from what i have gathered from docs and my own research, hypotension generally is not seen with POTS. you also do not see HR drop with pots, and you mentioned your HR was 35 with your tilt.

i would think your symptoms were due to your already diagnosed NCS issues rather than POTS, as your vitals don't indicate a typical POTS patient presentation. ie: heart rate increase to over 30 BPM with upright tilt with little or no change in BP.

when you had your first tilt table, do you know if you had BOTH sinus tach with upright position AND your AVNRT or was it just AVNRT? or just sinus tach?

with heart rates high enough, especially with AVNRT (rates can get pretty high), this can cause syncopal episodes....so i'm wondering if this is what happened with your first tilt, rather than sinus tachycardia due to pots....?? hence the reason they probably took you in for EP study/ablation. usually docs would not put a patient through an EP study after a tilt test if they didn't see a reason to do it -- a reason WOULD NOT be from sinus tach/POTS but WOULD BE good reason for AVNRT.

[samannran]

My heart rate wasn't 35. It actually increased by 42 beats after being straight up for about six minutes. Last night, I had brain fog and couldn't do the math. Before the ablation, my heart rate was extremely high. I didn't know in 2003 when my doctor diagnosed me that ablations made things worse for dysautonomia patients. He might not have known that five years ago, either. All I know is that I feel awful. I can't stand in one place for very long at all. All of the lifestyle changes that I have made are not alleviating my symptoms. My symptoms are worse.

Thanks for replying,

Samantha

as nina said, ablations are contraindicated in the pots patient. however, if you had AVNRT and was symptomatic with this particular rhythm, than ablation for this and not sinus tach due to pots would not cause the symptoms that you have today.

from the sounds of it and what your BP AND HR did with this tilt, granted you were on meds, it doesn't sound like pots. with pots you generally do not see BP drop, actually my neuro in boston told me with pots, usually BP is normal and actually sometimes high in the pots patient. there are people here with low BP issues but from what i have gathered from docs and my own research, hypotension generally is not seen with POTS. you also do not see HR drop with pots, and you mentioned your HR was 35 with your tilt.

i would think your symptoms were due to your already diagnosed NCS issues rather than POTS, as your vitals don't indicate a typical POTS patient presentation. ie: heart rate increase to over 30 BPM with upright tilt with little or no change in BP.

when you had your first tilt table, do you know if you had BOTH sinus tach with upright position AND your AVNRT or was it just AVNRT? or just sinus tach?

with heart rates high enough, especially with AVNRT (rates can get pretty high), this can cause syncopal episodes....so i'm wondering if this is what happened with your first tilt, rather than sinus tachycardia due to pots....?? hence the reason they probably took you in for EP study/ablation. usually docs would not put a patient through an EP study after a tilt test if they didn't see a reason to do it -- a reason WOULD NOT be from sinus tach/POTS but WOULD BE good reason for AVNRT.

[juliegee]

Hi Sam,

Definately sounds like POTS and NCS, even with your meds. Are your symptoms better with your meds? If not substantially so, maybe you need to try other meds/dosages, etc. Finding a drug combo that works is so hard. Is your cardiologist well veresd in orthostatic intolerance? Hope you can figure out a better regimen soon.

All the best-

Julie

[cardiactec]

your ablation for AVNRT would not cause a worsening of POTS. AVNRT is a type of arrhythmia outside of the normal electrical pathways in the heart. sinus tachy that occurs with POTS IS part of the normal electrical pathway and as long as the doc did not damage the sinus node (the normal part of the electrical pathways) while ablating the AVNRT, the ablation should have no effect on you today and where you are at symptomatically.

your heart rate increase sounds typical of POTS.

as macks mom said, i would try a new med regimen. the diltiazem might be aggravating your symptoms.

good luck to you.

[cardiactec]

how much dilt are you on?

[samannran]

I'm on Diltiazem 120 mg. extended release, and I take a low dose of Coreg (3.125mg.) twice a day. I have tried so many medications and these are the only meds that I can tolerate. The beta blockers that I have tried in the past made my bp go so low that I eventually wound up hospitalized. I have tried Lopressor, Toprol XL, Pindolol, and Atenolol. My bp was too low on these. I've also been on Zoloft. I couldn't tolerate that, either. I am definitely better with meds than without them. I am glad to know that my ablation for AVNRT didn't make me worse. I've been told I have sinus tachycardia. My cardiologist seems to know about POTS and NCS, but his prescription for the fatigue is to exercise. I have told him that after exercising, I need a few days to recuperate. I can't seem to make myself do much after work when I know that I'm going to be miserable. Not to mention, I don't like the way my heart feels at 180 bpm. I mentioned a referral to Cleveland, but he said he wanted to wait and see what the test showed.

how much dilt are you on?