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WinterSown
Finding balance, this is the most frequent topic I talk about with my cardiologist. My visits are not dominated by the medical check-up or speaking of drug and management adjustments. No.  We get that out of the way fast and get to the heart of the matter—healing me. My sense of self got battered by dysautonomia as much as my body. Medicine, supplements, food, and water can only go so far in knocking back our symptoms; the rest is up to us.
Balance, this is a wonderful pun.  Dysautonomia, for me, comes with a diagnosis of vertigo, and it comes with balance and gait problems.  Along with physical issues, I need to find balance emotionally because I don’t know what I did to deserve dysautonomia, but I have it. I did nothing to cause it, none of us have, but here it is, and so we have to deal with it. I’m not the self-pity type, but some days I am like “Dang! This is just so wrong.”  Do I want to be in that pit of forever thinking it’s not going to get better? No, I don’t.
I turned toward advocacy; I started writing on forums and joined DINET’s volunteer team. I read posts about how others were handling situations and I learned from them and felt encouraged. I became vocal about my symptoms and my right to describe them and be treated with dignity. I do not forget that we have a fiduciary relationship with our doctors.  Would you tolerate going to the mattress shop and buying a king but they give you a twin to take home? No, you wouldn’t tolerate that. Your relationship with your doctor deserves the same satisfaction. So saying “Excuse me, Doctor, could you rephrase that because it sounds like you said…” should immediately get his or her attention that you have expectations of receiving quality treatment. They do get it, and you should only have to ask once.  It’s up to each of us to speak up when we feel we are not being given the care we want and need.
Physical Therapy gets me out of the house twice a week. My health is way too complicated for a coach at the gym, and my immune system cannot handle so many public germs. My doctor at PT has combined many scripts into a routine for balance and gait, core and overall strength.  I do feel great benefit from the biofeedback approach to PT that I engage in. I used to lose my balance walking up the wheelchair slope at intersections; a few times recently I’ve felt like I was going to fall over backward into the street, but I had the strength to restore my balance and walk up that tiny hill. I didn’t crack my head on the concrete or get run over by a truck. PT WIN. I get light-headed at the top of stairs, but now I have arms strong enough to grab the railing instead of tumbling down the steps like a ragdoll. We recover from vertigo and syncope faster than we recover from bruises and broken bones when we collapse on something very hard.  
At home I have some balance boards for practice, I’ve got stretchy straps, some light hand-weights too, and every day my goal is to use some of it.  I’m up to thirty reps of this and thirty reps of that. When I started, I would sweat at three, but it takes time to build up to double-digit numbers.  You have to be patient with yourself.
I rescued two big puppies that grew into big dogs, so big I walk them one at a time. A couple of years back if one of them just gently tugged me I would trip and fall right over.  Now, I can give them a yank if need be without a hazard to my health. I am doing much better because of the physical training from biofeedback. My doctors renew my scripts when I ask for them because they can see the improvement too.  PT works.
In a few weeks, it will be the two-year anniversary of my diagnosis. My diagnosiversary. “CardioNeuro what? Vaso what? what-Syncope?” It was only a few minutes after I had finished a TTT. I did not faint like many of us do, but I had enough readings for the EP to ask me what makes me feel better. “I go lay down.”  That was it. That was the magic answer. This was only the second time I had met the EP, but it was the first step in getting better. He started changing my medications right then and there. And over the last two years, he has slowly brought me to a safer place where the worst of my symptoms are mostly controlled. I do not often write about my EP, but he has the brains of a genius and the gentle soul of a teddy bear.
A few weeks after the TTT I had a follow-up with my cardiologist. I was already starting to learn from the internet, trying to first look at .org, .edu and .gov sites for valid information without hype or a sales pitch. Instead of being satisfied, I got curious about more than dysautonomia and its effects on our bodies. I got interested in how good doctors can have a positive impact on our health. We have not all had the same experiences with medical professionals, and in the process of seeking a diagnosis, we have met many doctors and nurses who were lacking knowledge of dysautonomia symptoms. It can lead to a frustrating relationship between doctor and patient. That frustration fueled my fire, and I talked about it with the cardiologist. He encouraged me to find answers. I read from NIH, National Institutes of Health, as much as posts and replies on forums, or the inspiring blogs and articles of online magazines. All provide a well-rounded view of what it is to be a dysautonomia patient. My doctor has never told me to study a particular topic or said: “Read these URLs only.” No. Instead, I follow my own path and learn as my interests take me. It has been an experience that I continue to enjoy and practice every day.  He introduced me to self-learning as part of my healing; it has become a large part of my life two years post-diagnosis. I’ve been watching educational videos on YouTube, it’s not all fun and games there, but I watch more than medicine. Search, and you will find videos for anything you want to know on any topic. And learning something new or teaching yourself a new activity is an effective therapy for fighting brain fog and forgetfulness.
Learning to live with chronic illness can be all-consuming. But over time, you will find a balance between managing your health and enjoying your life.  
Return to 02/2019 Table of Contents

edriscoll
We welcome your letters to DINET's Medical Advisors.  Please be aware that the information provided is not meant to be a diagnosis or medical advice.  It is provided to give you background information to discuss with your medical team and general information to keep you well informed about dysautonomia disorders. If you have a question for our advisors, please send to webmaster@dinet.org 
Question from member FIONA: 
I have been recently diagnosed with Dysautonomia following many years of periodic symptoms. I don’t fit into any specific category at the moment although I also suffer from adrenaline surges which suggest an overactive SNS. My body literally crashed last September and I have been desperately trying to deal with my daily symptoms since then. My TTT showed unstable fluctuations in my BP although I didn’t pass out. I still await blood results for lying/standing norepinephrine levels.
I’m emailing your team as my most worrisome and debilitating symptoms are now from Orthostatic headaches. Once upright, I quickly feel discomfort/pressure/pain in the back of my neck and head. This intensifies and I then feel weak in my extremities, slightly nauseous and need to lie down immediately. If I don’t lie down fast enough, my SNS triggers adrenaline surges which spike my BP, raise my HR, flush my face and cause me to feel terror as if my head will explode. The intensity and duration of these surges is unpredictable and I always feel exhausted afterward.
I’m especially concerned as my ability to remain upright has slowly decreased over the past few weeks due to this headache issue. It’s now difficult to even walk a few steps without the head pressure feeling. In addition, I have suffered from painful shoulder muscles for many years. My other Dysautonomia symptoms wax and wane but this is quite unbearable. I also suffer from migraines and am perimenopausal.
Have you a likely explanation for why these headaches are occurring? Is my brain simply starved of oxygen? I’m guessing that my SNS is then acting in an overcompensatory manner? Have you any advice on coping mechanisms? I just don’t know what my new normal is or how to begin to work through this.
Any help/advice greatly appreciated.
Answer from Dr. Satish Raj:
I am sorry to hear you are unwell.
Headaches are commonly seen in patients with various autonomic disorders, and they can be difficult to manage. I do not think that these are due to the brain not getting enough oxygen. That can lead to loss of consciousness and not "pain".
I would suggest that it is important to make sure that your BP is adequately supported.  If you are dropping your BP or perfusion, that could certainly account for the shoulder pain on standing and maybe head/neck pain.
Another consideration is that there are some patients that can develop spontaneous leaks of their cerebrospinal fluid. The headaches are like "spinal headaches" that people can experience sometimes after epidurals that go poorly.  These can be hard to diagnose, but one can start by looking at an MRI of the brainstem and occasionally doing a myelogram (contrast into the spinal canal to look for leaks).  The treatment often starts with attempts at a "blood patch" (blood injection into the spinal canal to try to clot and "patch" the hole).  Unfortunately, they are often less effective in this condition with the spontaneous leaks than in patients where a needle caused the hole. Some patients also get better for several days and then get worse again.  However, some do get better.
Dr. Satish Raj
Dr. Satish R. Raj    MD, MSCI, FPCPC
Associate Professor of Cardiac Sciences
Libin Cardiovascular Institute of Alberta
University of Calgary | Vanderbilt University
 
Question from member Jan: 
My cardiologist said I have dysautonomia. My BP is both very low with passing out or very high eg 220/125. In the last 12 months, my high BP has caused some heart damage, left ventricular thickening, left atrial enlargement, mitral valve regurgitation.
A geneticist last year said I meet all the criteria for EDS hypermobility Syndrome with the exception of high as well as low bp. I also have chronic secretory diarrhea which appears to have some autonomic component. This does not match the criteria for EDS. Had a normal nerve conduction test.
My problem is how to treat labile bp so that treatment doesn’t worsen passing out. My treatment at present is to take a small amount of short-acting bp reducing medicine if bp over 180 sustained for 1 hour, max 3in one day. However, on the occasion, I took two in one day I was on the floor and bp extremely low for hours.
Most information on dysautonomia is about dropping bp. Are you aware of my problem and any advice on management?
Answer from Dr. Nicholas Tullo:
The term “dysautonomia” includes many different disturbances of the part of the nervous system that controls heart rate and blood pressure. However, many factors affect blood pressure other than the autonomic nervous system. These factors include the total amount of blood and fluid in your circulatory system, the strength of your heart’s contraction, and the health of your venous system. The veins become an important issue because a significant portion of a person’s circulating blood volume can wind up pooled in the veins of the legs and even the lower abdominal cavity. The body’s ability to maintain a normal blood pressure depends heavily on how much blood is getting back to the heart since the heart has to be able to fill properly (“what goes in must come out”).  When most of the blood is in the “wrong place” (stuck in the lower parts of the body) the blood pressure can drop dramatically. Chronic diarrhea represents an excessive amount of fluid loss that tips the scales towards being a little dehydrated, which just compounds the problem. Hypertension may be a manifestation of age (stiff blood vessels) and “essential hypertension,” which is probably a genetic abnormality in the hormonal control of blood vessel constriction.
Ultimately, maintaining an adequate fluid intake is key to avoiding hypotension. People with blood pressure instability should be taking in at least 2-3 liters of fluid per day (maybe more). Having EDS may affect the elasticity of the veins and exaggerate the pooling that goes on when a person stands up for more than a few minutes. External ways to reduce blood pooling includes thigh-high or waist-high compression hose or abdominal binders. They can make a big difference.
Hypertension needs to be treated with medications because of the potential organ damage that comes with excessively high blood pressures. Unfortunately, there is no one medication that solves the problem, and many patients with such an unstable blood pressure have to monitor it closely and make day-to-day adjustments in their meds (like you are doing).  It is very important to avoid hypertension at night during sleep, since that induces an increase in urine production at night, leading to very wide blood pressure changes in the early morning hours. Sleeping with the head of your bed elevated 4-6 inches may help reduce nighttime urine production as well. Sometimes it’s a juggling act to have to take medications like fludrocortisone and midodrine to prevent hypotension, but taking hypertension meds… usually something long-acting in the morning and perhaps short-acting like nifedipine or nitrates to take later on if the blood pressure gets too high. You need to find a doctor nearby who is willing to work with you and help you devise a medication strategy that will help you keep your blood pressure in an acceptable range. Generally, daytime blood pressures in the 140-160 mmHg range may be reasonable in patients who are prone to severe orthostatic drops in order to avoid symptoms such as fainting.
Best of luck!
Nicholas G. Tullo, MD, FACC, FHRS
New Jersey Center for Fainting
njfaint.com
 
 
 
Question from member Megan: 
Hello there!  I wanted to ask a question about Beta Blockers use and Dysautonomia. We have malfunctions of our Autonomic Nervous System and my understanding is that Beta Blockers may increase the amount of Beta-Adrenergic receptors.  It seems as though this would then make it more difficult to ever withdraw the Beta Blockers because withdrawal would cause a massive adrenergic response until the receptors down-regulated.
It would make it difficult to know when Beta Blockers were no longer needed. The Nervous System is already not functioning properly and then it is stressed even more when the medication is withdrawn.  What are your thoughts on that?
Answer from Dr. Svetlana Blitshteyn:
Beta-blockers may cause an indirect upregulation of the beta-adrenergic receptors in response to blocking of the beta receptors, but in our experience, beta blockers are excellent for many patients with POTS, chronic headache, anxiety, chest pain and intermittent tachycardia at rest.  We have not observed patients having difficulty weaning off or stopping beta blockers when their symptoms no longer necessitate the use of beta blockers. Dysautonomia is not a static disorder; it can change in the type and severity of symptoms over a period of months to years. Many patients may use beta blockers for extended periods of time, then wean off or switch to other medications if the use of beta blockers is no longer needed or preferred. We have not observed major deterioration in symptoms when a decision to stop or wean off beta blockers is made appropriately by the specialist and the patient.
Sincerely,
Dr. Blitshteyn
Svetlana Blitshteyn, MD
Director and Founder of Dysautonomia Clinic and Amherst Neurology
Clinical Assistant Professor of Neurology
University at Buffalo School of Medicine and Biomedical Sciences
Phone: 716-531-4598
Fax: 716-478-6917
http://www.dysautonomiaclinic.com
Return to 02/2019 Table of Contents

edriscoll
There are identifiable mechanisms that can be contributing to a patient's orthostatic intolerance. Many of these mechanisms may result in a lack of oxygen to the brain upon standing. Blood pooling in the veins of the lower body is a major factor in the vast majority of patients with orthostatic intolerance (Streeten, 1999).
The following is a partial list of proposed mechanisms that may be occurring in patients with orthostatic intolerance:
Alpha-receptor dysfunction may be occurring in some POTS patients (Gordon, Opfer-Gehrking, Novak & Low, 2000). Alpha-1 receptors cause peripheral vasoconstriction when stimulated. Alpha-1 receptor supersensitivity may be causing dysautonomia in some patients (Stewart & Erickson, 2002). Others with POTS may have an autonomic neuropathy that predominantly affects the lower extremities. This neuropathy may be resulting in alpha-1 adrenergic denervation hypersensitivity. Denervation hypersensitivity may be provoking the pooling of blood in a number of individuals with this disorder (Stewart & Erickson, 2002).
Beta-receptor supersensitivity may occur with hyperadrenergic states in some people with POTS (Low, 2000). The heart is responding to excessive catecholamine output in these patients. 
Brain-stem dysregulation may be occurring in some POTS patients (Novak, Novak, Opfer-Gehrking, O'Brien & Low, 1998). Researchers have identified a subset of patients with marked orthostatic hypertension, markedly labile blood pressure and troublesome orthostatic symptoms (Low, Schondorf, Novak, Sandroni, Opfer-Gehrking & Novak, 1997, pp. 686-687). These patients present as though they are suffering from baroreflex failure, although the baroreflexes are working. Excessive sympathetic activity is noted, which suggests the possibility of central (presumably brain-stem) dysregulation. One patient reportedly improved after microvascular decompression at the region of the left medulla (Low et al., 1997, p. 687).
Central autonomic regulation abnormalities leading to a hyperadrenergic state are a proposed cause of POTS. However, physicians have yet to determine whether a central abnormality of the autonomic nervous system is the primary mechanism or if the increase in sympathetic activity is an appropriate response to an underlying defect, such as a decreased blood volume or a circulating vasodilator (Jacob & Biaggioni, 1999). Circulating vasodilators are suspected of provoking dysautonomia in disorders such as hyperbradykininism, mast-cell activation and hyperdopaminergic states.
Delayed forms of orthostatic intolerance have been observed in POTS patients. Some physicians believe POTS symptoms should occur within 10 minutes of standing. However, studies on orthostatic intolerant patients prove that some display a delayed form of orthostatic intolerance in which orthostatic hypotension occurs after ten minutes of standing (Streeten & Anderson, 1992). One study showed that out of 23 chronic fatigue patients, 17 had orthostatic tachycardia alone during the initial period of head-up tilt. However, 22 eventually had obvious orthostatic hypotension after an extended period of time (Bou-Holaigah, Rowe, Kan & Calkins, 1995).
Hyperdopaminergic states maybe the underlying problem for some people with orthostatic intolerance. Some patients have been found to have a significant increase in upright (free + sulfconjugated) dopamine levels (Kuchel, Buu, Hamet, Larochelle, Gutkowska, Schiffrin, Bourque & Genest, 1985). Free plasma norepinephrine also tends to be higher in these patients. The excessive dopamine release might be causing natriuresis and vasodilatation, thus contributing to the pathophysiology of this disorder (Jacob & Biaggioni, 1999).
Orthostatic hypotension occurs in some patients with orthostatic intolerance. However, there are physicians who exclude orthostatic hypotension when defining POTS. Orthostatic hypotension is traditionally defined as a fall in systolic blood pressure of 20 mm Hg or more upon standing. Some physicians believe smaller drops in blood pressure associated with symptoms are also significant (Grubb & Karas, 1999). Orthostatic hypotension may become apparent only after prolonged standing. Baroreceptor-initiated reflex tachycardia is a potent physiological mechanism for correcting hypotension (Streeten, 1999). Hence, the standing tachycardia observed in POTS patients is sometimes occurring because the body is attempting to counteract falling blood pressure.
Some patients become more symptomatic than others when their blood pressure drops. Patients who experience few symptoms while hypotensive have a minimal decline in brain blood flow and good dilating blood vessels. Patients who become symptomatic when their blood pressure drops have a greater decline in blood flow to the brain (Coghlan, 2002).
Reduced cerebral blood flow has been noted in several studies of POTS patients.  However, one studydid not report this finding, and concluded that cerebral perfusion and autoregulation in many patients with POTS does not differ from that of normal control subjects (Schondorf, Benoit & Stein, 2005).
A reduction of cardiac output by arrhythmias, bradycardia, or intrinsic cardiac causes of pump failure can cause fainting, or other clinical manifestations of reduced cerebral blood flow (Streeten, 1999). Blood pooling in the lower body may also cause reduced blood flow to the brain. It has been reported that a person with POTS can have a 28% decrease in brain blood flow upon standing (Robertson, 2000). A normal person will have about a 9% decrease in blood flow to the brain upon standing. Transcranial Doppler ultrasonography is useful in detecting a reduction in cerebral blood flow (Fredman, Biermann, Patel, Uppstrom & Auer, 1995). Orthostatic symptoms have been attributed to impaired cerebral perfusion, even in the absence of a significant fall in blood pressure (Jacob & Biaggioni, 1999). 
Central nervous system abnormalities may be occurring in patients with reduced cerebral blood flow (Hermosillo, Jauregui-Renaud, Kostine, Marquez, Lara & Cardenas, 2002). One study reported that continuous observation of the Doppler recording in patients with postural tachycardia showed intermittent fluctuation of the cerebral blood flow velocity, with an oscillatory pattern (Hermosillo et al., 2002). This fluctuation in cerebral blood flow velocity occurred in spite of there being no systemic hypotension. This study also showed that when compared with neurocardiogenic syncope patients, those with postural tachycardia had larger variations of the pulsatility index (systolic velocity-diastolic velocity/mean velocity). The results suggest that patients with postural tachycardia, on standing up, could have an inefficient regulation of cerebral blood vessels (Hermosillo, et al., 2002). These findings led the researchers to conclude that central nervous system abnormalities may play a pivotal role in the pathogenesis of postural tachycardia syndrome (Hermosillo, et al., 2002).
Reduced venous return is one of the main mechanisms that results in POTS symptoms. Venous return can be reduced due to conditions such as low plasma volume (see hypovolemia), venous pooling and denervation (Low, 2000). A hyperadrenergic state may result as the body attempts to compensate for these abnormalities. Conditions resulting in reduced venous return often overlap or occur because of one another. The following are some abnormalities that can result in reduced venous return:
Sympathetic Overactivity is observed in many POTS patients. The sympathetic overactivity can be secondary to a number of factors, some of which may be peripheral denervation, venous pooling, or end-organ dysfunction (Low et al, 1998). Hyperadrenergic states with elevated norepinephrine levels are often found in patients with sympathetic overactivity. One study found that 29% of POTS patients had elevated norepinephrine levels upon standing, and the mean level was 531 pg/mL (Thieben, Sandroni, Sletten, Benrud-Larson, Fealey, Vernino, Lennon, Shen & Low, 2007). Norepinephrine is similar to adrenaline and is a natural vasoconstrictor. Genetic or acquired deficits in norepinephrine activation may result in hyperadrenergic states that lead to orthostatic intolerance (Shannon, Flattem, Jordan, Jacob, Black, Biaggioni, Blakely & Robertson, 2000). These deficits can cause patients to experience symptoms suggestive of not enough norepinephrine simultaneously with high norepinephrine levels. Many of the mechanisms listed here can result in states of chronic adrenergic activation that lead to orthostatic intolerance.
Sympathetic underactivty can also occur in some forms of orthostatic intolerance (Robertson, 2000), such as pure autonomic failure.
The above are some of the possible mechanisms that may be resulting in orthostatic intolerance. Physicians should attempt to discover the underlying mechanisms contributing to a patient's symptoms. This will ensure that treatment plans are tailored to target the specific mechanisms resulting in autonomic dysfunction, and that patients will receive the most effective care.
References
    1. Bou-Holaigah, I., Rowe, P. C.,  Kan, J., & Calkins, H. (1995). The   relationship between neurally mediated hypotension and the chronic fatigue     syndrome. Journal of the American Medical Association, 27, 961-967.     PMID: 7674527 [PubMed - indexed for MEDLINE]     2. Bush, V. E., Wight, V. L., Brown, C. M., & Hainsworth, R. (2000). Vascular     responses to orthostatic stress in patients with postural tachycardia   syndrome (POTS), in patients with low orthostatic tolerance, and in   asymptomatic controls. Clinical Autonomic Research 10, 279-284.   PMID: 11198483 [PubMed - indexed for MEDLINE]     3. Coghlan, H. C. (2002, July). Orthostatic Intolerance. National Dysautonomia   Research Foundation Patient Conference. Washington, DC.     4. Fredman, C. S., Biermann, K. M., Patel, V., Uppstrom, E. L., &  Auer, A. I.    (1995). Transcranial Doppler Ultrasonography during Head-Upright    Tilt-Table Testing. Annals of Internal Medicine 123, 848-849.         5. Gordon, V. M., Opfer-Gehrking, T. L., Novak, V., & Low, P. A. (2000).   Hemodynamic and symptomatic effects of acute interventions on tilt in   patients  with postural tachycardia syndrome. Clinical Autonomic   Research, 10(1), 29-33. PMID: 10750641     6. Grubb, B. P. (2000, July). Orthostatic intolerance. National Dysautonomia    Research Foundation Patient Conference. Minneapolis, Minnesota.     7. Grubb, B. P., & Karas, B. (1999) Clinical disorders of the autonomic nervous    system associated with orthostatic intolerance. Pacing and Clinical    Electrophysiology, 22, 798-810.    Full text: http://www.ndrf.org/PDF%20Files/disorders.PDF     8. Heitz, U. & Horne, M. M. (2005). Fluid, Electrolyte and Acid-Base Balance.   St. Louis, MO: Elsevier Mosby.     9.Hermosillo, A. G., Jauregui-Renaud, K., Kostine, A., Marquez, M. F., Lara,    J. L., Cardenas, M. (2002). Comparative study of cerebral blood flow   between postural tachycardia and neurocardiogenic syncope, during   head-up tilt test. Europace, 4, 369-74.   Full text: http://europace.oxfordjournals.org/cgi/reprint/4/4/369     .10.  Jacob, G., & Biaggioni I. (1999). Idiopathic orthostatic intolerance and   postural tachycardia syndromes. The American Journal of the     Medical Sciences, 317, 88-101. PMID: 10037112     11. Jacob, G., Robertson, D., Mosqueda-Garcia, R., Ertl, A. C., Robertson, R.   M., Biaggioni, I. (1997). Hypovolemia in syncope and orthostatic   intolerance: role of the renin-angiotensin system. American Journal of   Medicine, 103(2), 128-133. PMID: 9274896     12. Kuchel, O., Buu, N. T., Hamet, P., Larochelle, P., Gutkowska, J., Schiffrin,     E. L., Bourque, M., & Genest, J. (1985). Orthostatic hypotension: a    posture-induced hyperdopaminergic state. The American Journal of the     Medical Sciences, 289, 3-11. PMID: 3881951     13. Low, P. A. (2000, July). Orthostatic intolerance. National Dysautonomia    Research Foundation Patient Conference. Minneapolis, Minnesota.     14. Low, P. A., Schondorf, R., Novak, V., Sandroni, P., Opfer-Gehrking, T. L.,   & Novak, P. (1997). Postural Tachycardia Syndrome. In P.A. Low (Ed.),    Clinical Autonomic Disorders (pp. 681-697). Philadelphia:    Lippincott-Raven Publishers.     15. Novak, V., Novak, P., Opfer-Gehrking, T. L., O'Brien, P. C., & Low P. A.    (1998). Clinical and laboratory indices that enhance the diagnosis of    postural tachycardia syndrome. Mayo Clinic Proceedings, 73, 1141-50.   PMID: 9868411 [PubMed - indexed for MEDLINE]     16. Raj, S. R., Biaggioni, I., Yamhure, P. C., Black, B. K., Paranjape, S. Y.,   Byrne, D. W., & Robertson, D. (2005). Renin-aldosterone paradox   and perturbed blood volume regulation underlying postural tachycardia   syndrome. Circulation. 111(13), 1574-1582. Full Text     17. Robertson, D. (2000, July). General description of the autonomic nervous   system and orthostatic intolerance overview. National Dysautonomia   Research Foundation Patient Conference. Minneapolis, Minnesota.     18. Schondorf, R., Benoit, J., & Stein, R. (2005). Cerebral autoregulation is   preserved in postural tachycardia syndrome (POTS). Journal of   Applied Physiology, Apr 28; [Epub ahead of print] Full Text     19. Shannon, J. R., Flattem, N. L., Jordan, J., Jacob, G., Black, B. K.,   Biaggioni, I., Blakely, R. D., & Robertson, D. (2000). Orthostatic   intolerance and tachycardia associated with norepinephrine-transporter   deficiency. New England Journal of  Medicine, 24, 541-9.    http://content.nejm.org/cgi/content/abstract/342/8/541     20. Stewart, J. M. (2000, July). Pediatric and adolescent orthostatic intolerance   and CFIDS. National Dysautonomia Research Foundation Patient    Conference. Minneapolis, Minnesota.     21. Stewart, J. M., & Erickson, L.C., (2002). Orthostatic intolerance: an   overview. In Alejos, J. C., Konop, R., Chin, A. J., Herzberg, G., Neish, S.   (Eds.). emedicine Journal, 3, (1).   http://www.emedicine.com/ped/topic2860.htm     22. Stewart, J. M., & Weldon, A. (2001). Reflex vascular defects in the   orthostatic tachycardia syndrome of adolescents. Journal of Applied   Physiology, 90, 2025-2032.   Full text: http://jap.physiology.org/cgi/content/full/90/6/2025     23. Streeten, D. H. (1999). Orthostatic intolerance. A historical introduction to the   pathophysiological mechanisms. The American Journal of the Medical    Sciences, 317, 78-87. PMID: 10037111     24. Streeten, D. H., & Anderson, G. H. (1992). Delayed orthostatic intolerance.   Archives of  Internal Medicine, 152, 1066-72   PMID: 1580710 [PubMed - indexed for MEDLINE]     25. Thieben, M. J., Sandroni, P., Sletten, D. N., Benrud-Larson, L. M.,   Fealey, R. D., Vernino, S., Lennon, V. A., Shen, W. K.,  &   Low, P. A., (2007).  Postural orthostatic tachycardia syndrome: the   Mayo Clinic experience. Mayo Clin. Proc. 82, (3), 308-313.    

edriscoll
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Studies: Open recruiting studies for dysautonomia and related chronic illness
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Medical Q & A - Your questions answered by DINET's Medical Advisors
Updated Research Information for Dysautonomia and Related Chronic Illnesses
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edriscoll

How is POTS Diagnosed?

By edriscoll, in POTS,

POTS is a disorder that can easily be overlooked or misdiagnosed. Some patients have had to wait years before their condition was properly labeled. POTS is sometimes misdiagnosed because of the wide array of symptoms that accompany this syndrome. The symptoms of postural orthostatic tachycardia often mimic other illnesses. Entities such as thyroid disease, pheochromocytoma, hypoadrenalism, cardiac disease, autonomic neuropathies, medication side effects and anxiety disorders need to be ruled out before a patient is labeled with POTS (Low, 2000).

POTS is an easy disorder to overlook because physicians routinely take heart and blood pressure readings while the patient is sitting down. The POTS patient may have relatively normal vital signs while sitting down. Also, POTS symptoms can vary from day to day. Patients sometimes report good phases in which their symptoms are milder, followed by bad phases in which symptoms become more severe. This fluctuation in symptoms can also lead to difficulties in detecting POTS. Physicians that have experience in detecting and treating dysautonomia can be located on our Find a Physician database of dysautonomia specialists. 

There are a variety of tests that the POTS patient may undergo. Orthostatic symptoms are usually the most debilitating aspect of autonomic dysfunction readily amenable to therapy, and for this reason the blood pressure and heart rate response to upright posture should be the starting point of any autonomic laboratory evaluation (Robertson, 1996, p. 111).
To learn about the tests used to diagnose POTS and other forms of dysautonomia, please visit our Autonomic Testing page.
 

 

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Autonomic nerve disorders (dysautonomia) refer to disorders of the autonomic nervous system (ANS) function. Dysautonomia is a general term used to describe a breakdown or abnormal function of the ANS. The autonomic nervous system controls much of your involuntary functions. Symptoms are wide-ranging and can include problems with the regulation of heart rate, blood pressure, body temperature, perspiration, and bowel and bladder functions. Other symptoms include fatigue, lightheadedness, feeling faint or passing out (syncope), weakness, and cognitive impairment. (1. Mayo Clinic, Autonomic Nerve Disorders 2019)
Some forms of dysautonomia include; Postural Orthostatic Tachycardia Syndrome (POTS), Orthostatic Hypotension (OH),  Orthostatic Intolerance (OI), Neurocarciogenic Syncope (NCS), Pure Autonomic Failure (PAF), Multiple System Atrophy/Shy-Drager syndrome (MSA). 
There are many advanced tests used for further diagnosis once some form of dysautonomia is detected.  The most common tests used are as follows.
The tilt table test is often the standard method used for detecting types of dysautonomia. A patient is strapped to a mechanical table, which will tilt them upright at an angle of at least 60 degrees. Measurements of heart rate and blood pressure are taken while lying flat and then again at intervals while tilted upright. The optimal duration of tilt testing in patients suspected of Autonomic Dysfunction is 40 minutes or until they faint, at which point the test is concluded (Carew, Cooke, O'Connor, Donnelly, Costelloe, Sheehy & Lyons, 2009). Some patients are given a drug called isoproterenol through an intravenous line during this test. Isoproterenol is used to test the sensitivity of beta-receptors. People who have POTS with beta-receptor supersensitivity and a hyperadrenergic state will generally have an exacerbation of symptoms due to this drug. Other drugs that are sometimes used in place of isoproterenol include nitroglycerin, edrophonium, adenosine triphosphate, ephedrine and nitroprusside (Grubb & McMann, 2001).
The tilt table test may be combined with transcranial doppler ultrasonography. Transcranial doppler ultrasonography is useful in detecting a reduction in cerebral blood flow (Fredman, Biermann, Patel, Uppstrom & Auer, 1995). A number of  patients with orthostatic issues will have a decrease in blood flow to the brain upon standing (Low, 2000). This can occur even if the patient does not become hypotensive (Low, 2000).
Bowel motility studies are useful in ascertaining the degree of gastrointestinal involvement present (Grubb, Kanjwal & Kosinski, 2006).
A catecholamine test is sometimes given to patients suspected of having chemical abnormalities. Testing one's levels of catecholamines and their metabolites is also useful in detecting certain tumors, such as pheochromocytoma. Some  patients will have abnormal catecholamine levels, particularly norepinephrine levels. Norepinephrine is the main chemical messenger of the sympathetic nervous system, and is often elevated in certain types of dysautonomia patients. A physician can determine one's total catecholamine levels through analysis of their blood or urine. 
The blood test is quite simple. The patient will have to lie quietly for a period of time (usually around 30 minutes) before their blood is drawn. Some doctors believe a more accurate reading is gained if an intravenous line is placed in the patient's arm before the resting period. This is because the fear and pain associated with needles may induce a rise in catecholamines that could obscure results.
Other doctors will use the 24-hour urine catch method to determine catecholamine levels. The patient is given a container to collect their total urine volume over a 24-hour period. The container is then returned to the physician and catecholamine levels are assayed. 
The cold pressor test is used to activate the blood pressure control system. The patient places their hand in ice water during this test. The physician will monitor blood pressure changes. This test can be used to localize a sympathetic lesion in the afferent or efferent limb of the baroreceptor reflex arc (Engstrom &  Aminoff, 1997). 
Deep breathing/Paced respirations are tests that evaluate autonomic function by measuring heart rate responses to controlled breathing.
Electromyography (EMG) is sometimes used to test the electrical activity of nerves and muscles. A needle electrode(s) is inserted through the skin into the muscle. The measured muscle response to nervous stimulation can detect nerve or muscle disorders. A nerve conduction study may be given concurrently with electromyography. During this test, muscles and nerves are stimulated with small bursts of electricity to determine if they are functioning in a normal manner.
The Hand-grip test is a simple and non-invasive test of sympathetic function. Some physicians feel its sensitivity and specificity compare favorably with the tilt table test (Khurana & Setty, 1996). During this test, a patient squeezes a hand-grip until their arm is fatigued. Those with autonomic dysfunction may have an excessive diastolic blood pressure response to this test.
Magnetic resonance imaging (MRI)/(MRA) can be used to diagnose some conditions thought to be associated with autonomic dysfunction, such as tumors, Chiari, cervical stenosis or the nutcracker phenomenon. This test encompasses a powerful magnet, low-intensity radio waves, and computer technology. The patient lies still inside the magnet. The magnetic field and different radio frequencies allow a specialized computer to generate detailed images of the inside of the body. The Stand-Up MRI may lead to interesting findings in POTS patients.
Microneurography is sometimes used to record traffic from the peripheral nerves. A small needle is placed into a nerve in the leg. Physicians can then measure nerve signals traveling from the brain to the blood vessels. Some POTS patients have nerve damage in their legs (Low, 2000)..
Sweat tests such as the thermoregulatory, resting sweat output and the quantitative sudomotor axon reflex are sometimes given to patients to determine if they are sweating appropriately. Many people with forms of dysautonomia will have impaired sweating abilities. Some patients report inappropriate sweating, including night sweats. 
During the thermoregulatory sweat test, the patient wears a disposable bathing suit and an orange powder is applied to the skin. The patient is then placed in a hot environment to induce sweating. The orange powder will turn purple where the patient sweats. In this way, physicians can determine if the patient has abnormal sweating patterns.
A small battery operated current may be used to stimulate the sweat glands directly during the resting sweat output test. 
The quantitative sudomotor axon reflex test (QSART) is used to determine sweat volume and latency of response. It can also be used to test for postganglionic lesions (Fealey, 1996, p. 297). A reduced or absent sweat response indicates postganglionic sympathetic sudomotor failure. Used in conjunction with the thermoregulatory sweat test, QSART can differentiate a pre- from the postganglionic lesion (Low, 2003, 407-421).
Some patients may be given a 24-hour urinary sodium test. This test is useful in determining if one's plasma volume is normal (Low, 2000). One study performed by researchers at the Mayo Clinic showed that 28.9% of POTS patients excreted less than 100 mEq in 24 hours and 66.4% excreted less than 150 mEq in 24 hours. These researchers concluded that an important first step in the assessment and treatment of POTS is to determine the patient's volume status and institute salt and fluid replacement in those with hypovolemia (Thieben, Sandroni, Sletten, Benrud-Larson, Fealey, Vernino, Lennon, Shen & Low, 2007).
A study of neurocardiogenic patients noted that those with a urinary sodium excretion <170 mmol/24 hrs. were more likely to have reduced plasma volume (El-Sayed & Hainsworth, 1996). These patients responded well to salt loading. 
A patient may also be given a test to determine total red cell mass and plasma volume. Hypovolemia is sometimes found in conjunction with POTS. Plasma volume may be reduced or red cell mass may be reduced in the POTS patient (Low, 1993).
Another test that is sometimes used to determine autonomic dysfunction is the Valsalva maneuver. This is a test of baroreflex responsiveness. A physician will have the patient blow into a tube while observing heart rate and blood pressure changes. Impaired baroreflex appears to be characteristic of moderate to severe forms of dysautonomia (Stewart, 2002). Patients may have an excessive blood pressure increment after cessation of the maneuver that is sometimes associated with headache (Sandroni, Novak, Opfer-Gehrking, Huck & Low, 2000). Some researchers report normal heart rate responses during the maneuver and conclude that the assessment of heart rate responses during this test does not contribute to the diagnosis of POTS (Braune, Wrocklage, Schulte-Monting, Schnitzer & Lucking, 1999).
A Patient may be given various tests to determine how dysautonomia is affecting their heart. Sinus tachycardia commonly occurs in those with dysautonomia. A patient may be asked to wear a Holter monitor to determine if their heart is functioning correctly. This device allows physicians to record the heart's activity over an extended period of time (usually 24 hours). Electrodes are placed at various locations on the patient's chest. These electrodes are attached to a small portable recorder. A patient may be asked to keep a written journal of any symptoms they experience while wearing the Holter monitor. Irregular heart rhythms are recorded and then evaluated by a physician.
Endless-loop recorders or event recorders are sometimes used instead of Holter monitors. These recorders are smaller and can be worn for months at a time. Patients will press a button after experiencing symptoms such as tachycardia or fainting. An ECG of the event will be recorded and transmitted via telephone for a physician to access.  
A stress test can be used to determine how exercise might affect the dysautonomia patient. The patient walks on a treadmill until a target heart rate is reached. The test is ceased if the patient becomes exhausted or develops complications. The heart's electrical activity is recorded while the patient exercises. Sometimes an echocardiogram will be performed along with the stress test. An echocardiogram is an ultrasound of the heart. This test helps physicians identify abnormalities in the heart's structure and function. 
The above are only some of the tests that may be given to a  patient suspected of having autonomic dysregulation. It is important for patients to ask their physician if they should discontinue their medication before taking specific tests. Some medications that have been reported to significantly affect autonomic testing results include chlorpromazine, thioridazine, tricyclic antidepressants, bupropion, mirtazapine, venlafaxine, clonidine, alpha blockers, beta blockers, calcium channel blockers, opiates and topical capsaicin (Sandroni, 1998). A patient taking medication to lessen symptoms will present with decreased symptoms upon testing. A patient should always consult their physician before discontinuing any medication.
Resources
1. Mayo Clinic, Autonomic Nerve Disorders, Full Text Link
2. Braune, S., Wrocklage, C., Schulte-Monting, J., Schnitzer, R., & Lucking, C.   H. (1999). Diagnosis of tachycardia syndromes associated with orthostatic    symptoms. Clinical Autonomic Research, 9(2), 97-101   PMID: 10225614 [PubMed - indexed for MEDLINE]     3. Carew, S., Cooke, J., O'Connor, M., Donnelly, T., Costelloe, A., Sheehy, C.,   & Lyons, D. (2009). What is the optimal duration of tilt testing for the   assessment of patients with suspected postural tachycardia syndrome?   Europace. 11(5), 635-637. PubMed   4. El-Sayed, H., & Hainsworth, R. (1996). Salt supplement increases plasma    volume and orthostatic tolerance in patients with unexplained syncope.    Heart, 75,  134-140. Full Text     5.  Engstrom,  J. W., &  Aminoff, M. J. (1997). Evaluation and treatment of     orthostatic hypotension. American Family of Physicians, 56(5).   PubMed     6. Fealey, R. (1996). Disorders of sweating. In D. Robertson, P. A. Low, & R. J.    Polinsky (Eds.), Primer on the autonomic nervous system (p. 293-299).    San Diego, CA: Academic Press.     7. Grubb B. P., Kanjwal, Y., & Kosinski, D. J. (2006). The postural   tachycardia syndrome: A concise guide to diagnosis and management.   J Cardiovasc Electrophysiol., 17, 108-112.     8. Grubb, B. P., & McMann, M. C. (2001). The Fainting Phenomenon:    Understanding why people faint and what can be done about it.    New York: Futura Publishing Company.     9. Khurana, R.K., &  Setty, A. (1996). The value of the isometric hand-grip    test--studies in various autonomic disorders. Clinical Autonomic     Research, 6, 211-218.    PMID: 8902317 [PubMed - indexed for MEDLINE]     10. Low, P. A. (1993). Postural Orthostatic Tachycardia Syndrome.    Department of neurology, Mayo Clinic.     11. Low, P. A. (2000, July). Orthostatic intolerance. National Dysautonomia    Research Foundation Patient Conference. Minneapolis, Minnesota.     12. Low, P. A. (2003). Seminars in neurology. In K. L. Ross and R. Freeman   (Eds.), Testing the Autonomic Nervous System (pp. 407-421). New York,   NY: Thieme Medical Publishers, Inc.     13. Robertson, D. (1996). Clinical assessment of autonomic failure. In D.    Robertson, P. A. Low, & R. J. Polinsky (Eds.), Primer on the    autonomic nervous system (p. 111-115). San Diego, CA:   Academic Press.     14. Sandroni, P. (1998, November/December). Testing the autonomic nervous     system. In C. B. Berde, & M. C. Rowbotham (Eds.) International    Association for the Study of Pain: Technical Corner From IASP   Newsletter. http://www.iasp-pain.org/TC98NovDec.html     15. Sandroni, P., Novak, V., Opfer-Gehrking, T. L., Huck, C. A., & Low, P. A.    (2000). Mechanisms of blood pressure alterations in response to the     Valsalva maneuver in postural tachycardia syndrome. Clinical    Autonomic Research, 10(1), 1-5.     16. Stewart, J. M. Heart rate and blood pressure variability. Retrieved March 23,    2002, from Center for Pediatric Hypotension.    http://www.nymc.edu/fhp/centers/syncope/heart%20rate%20variability%2   C%20blood%20pressure%20variability%20and%20the%20baroreflex.htm     17. Thieben, M. J., Sandroni, P., Sletten, D. N., Benrud-Larson, L. M.,   Fealey, R. D., Vernino, S., Lennon, V. A., Shen, W. K.,  &   Low, P. A., (2007).  Postural orthostatic tachycardia syndrome: the   Mayo Clinic experience. Mayo Clin. Proc. 82, (3), 308-313.  
 

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Updated Info:  Dr. Raj and associate, Dr. Miller's updated article about the pharmacotherapy for POTS.  Pub. May 2018 in Science Direct, Autonomic Neuroscience. 
https://www.sciencedirect.com/science/article/pii/S1566070218300250
NEW:  An examination of whether the impairment of the Corticol Autonomic Network (CAN) of the brain is involved int he psysiology of Neurogenic Orthostatic Hypotension (NOH) Pub. Oct 2018  https://www.ncbi.nlm.nih.gov/pubmed/30332348
NEW RESULTS:  The need for specific diagnosis and treatment for patients labeled with CFS and Fibromyalgia.  Important research results from one of DINET's Medical Advisors, Dr. Svetlana Blitshteyn and her colleague, Pradeep Chopra, Pub date Oct 2018  Read full article:  2018CFS_Fibromyalgia_ChronicPain_PubKarger.pdf
Updated info from the CDC on HPV Vaccine safety for POTS patients  https://www.cdc.gov/vaccinesafety/vaccines/hpv/hpv-safety-faqs.html  Follow up to: HPV Vaccine and POTS - https://www.ncbi.nlm.nih.gov/pubmed/28689455
Complex Regional Pain Syndrome, Type 1 -  Diagnosis and management.  https://www.ncbi.nlm.nih.gov/pubmed/29409405?_ga=2.71311891.1204982470.1531704876-989465291.1526426607
Study results:  A presentation made by the American Association for Cancer Research at their annual meeting reported findings related to health risks in post-menopausal women using medication for high blood pressure.  The report claims an increased risk of pancreatic cancer in post-menopausal women using short-acting calcium channel blocking medications for their blood pressure treatment.  Read the information from the AACR.
Study results:  NE Journal of Medicine releasing study results for episodic migraine treatment using Erenunab.  The publication is reporting a 50% or greater reduction in the average number of migraine days per month.  Read more about this study
Study results:  Physical maneuvers are viewed as important and promising strategies for reducing recurring episodes of syncope in vasovagal syncope patients.  Read the result of the study published Jan. 2018
Study results:  University of Alberta & McGill University release their findings for a new therapeutic agent  that may hold the potential for the prevention of MS
Article synopsis:  https://bit.ly/2GhF5FK
Research Article:  https://insight.jci.org/articles/view/98410  
Study results:  Could gut bacteria be the key to preventing autoimmune disorders?  Researchers from Yale, New Haven, CT are reporting that discovery that bacteria in the small intestine can travel to other organs and induce an autoimmune response.  They also are reporting that antibiotic treatment or vaccine may be the key to combating this reaction.  The study results were originally published in the journal Science.  This article from Medical News Today gives a synopsis of the findings and links to the full study.   https://www.medicalnewstoday.com/articles/321157.php
Genomics and Health Impact Blog -  a discussion about gene testing from the CDC
There have been enormous contributions towards disease prevention in women's health, in particular, the development of consumer testing for the BRCA gene.  The benefits cannot be applauded enough. However, health protection & research organizations like the CDC, are increasingly warning consumers about the need for professional counsel when interpreting results.   This article, humorously entitled "Think before you spit"  tempers the amazing breakthroughs with the cautionary information we need to have to be able to put a perspective on the results testing may give us.  https://blogs.cdc.gov/genomics/2017/04/18/direct-to-consumer-2/
1st lab test to detect concussion approved by FDA
For any person who has fainted or fallen and hit their head, the blood test approved recently by the FDA could be a lifesaver.  The test detects concussion by looking for specific proteins released into the blood within 12 hours after the head trauma.  Known as the Banyan Brain Trauma Indicator it can reduce the need for CT Scans and radiation and will produce results within 3 - 4 hours following injury.  Read more about this important breakthrough
Neuroprotective diet having good results for people living with MSA
https://www.multiplesystematrophy.org/about-msa/neuroprotective-diet 
POTS & Ehlers-Danlos Syndrome 
"Postural tachycardia in hypermobile Ehlers-Danlos syndrome: A distinct subtype?" by Miglis MG, Schultz B, and Muppidi S, from the Departments of Neurology and Psychiatry at Stanford University Medical Center.
"It is not clear if patients with postural tachycardia syndrome (POTS) and Ehlers-Danlos syndrome (hEDS) differ from patients with POTS due to other etiologies. We compared the results of autonomic testing and healthcare utilization in POTS patients with and without hEDS."
https://www.ncbi.nlm.nih.gov/pubmed/28986003
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edriscoll

EDS Overview

By edriscoll, in EDS,

What is Ehler's Danlos Syndrome?
EDS is a connective tissue disorder caused by various defects in the synthesis of collagen.  Along with Hypermobility Spectrum Disorder (HSD), they are a class of genetic disorders, present at birth but unrecognized for years.  There are 13 different types of EDS. 
Studies have found that EDS is associated with dysautonomia, usually in the form of POTS and OI.  Recent findings report 80% of Hypermobility EDS patients have POTS and 33% OI.  
In addition to the symptoms associated with dysautonomia, some common symptoms of EDS are joint laxity, soft skin, easy bruising, widespread manifestations in the tissue, vascular system and organs.  
Strategic, customized exercise plans, a skilled medical team, and protection of joints and skin, and pain management are the essentials of a good treatment plan and management of the disorder. 
To learn more about the connection between EDS and POTS, visit our page "What causes POTS".  To learn more about Ehler's Danlos Syndrome, visit the Ehler's Danlos Society at https://ehlers-danlos.com   For information about POTS symptoms and treatment, visit https://www.dinet.org/content/information-resources/pots/
 
Source:  Ehler's Danlos Society

edriscoll

POTS Research

By edriscoll, in POTS,

The following are selected articles relating to POTS. These articles can be obtained at medical libraries or ordered online at Loansome Doc Ordering System.
Postural Orthostatic Tachycardia in a Patient with Type 2 Diabetes with Diabetic Neuropathy   Tomichi Y, Kawano H, Mukaino A, Chiba Ak Doi Y, Arakawa S, Ishimatsu T, Fukae S, Abiru N, Maemura K  2018 Oct  PubMed
Quantitative assessment of autonomic symptom burden in Postural tachycardia syndrome (POTS) Rea NA, Campbell CL, Cortez MM  2017 June   PubMed
Painful temporomandibular disorders are common in patients with POTS and impact significantly upon quality of life.    Durham J, McDonald C. Hutchinson L, Newton JL  2015 PubMed 
Neurocardiogenic syncope coexisting with postural orthostatic tachycardia syndrome in patients suffering from orthostatic intolerance: a combined form of autonomic dysfunction.  Kanjwal K, Sheikh M, Karabin B, Kanjwal Y, Grubb BP  2011 May  PubMed
Comorbidities in Pediatric Patients with Postural Orthostatic Tachycardia Syndrome. Ojha A, Chelimsky TC, Chelimsky G. J Pediatr. 2010 Aug 17. PubMed
New onset postural orthostatic tachycardia syndrome following ablation of AV node reentrant tachycardia. Kanjwal K, Karabin B, Sheikh M, Kanjwal Y, Grubb BP. J Interv Card Electrophysiol. 2010 Aug 14. PubMed
Flow-mediated vasodilation and endothelium function in children with postural orthostatic tachycardia syndrome. Liao Y, Chen S, Liu X, Zhang Q, Ai Y, Wang Y, Jin H, Tang C, Du J. Am J Cardiol. 2010 Aug 1;106(3):378-82. PubMed
Effect of pregnancy on postural tachycardia syndrome. Kimpinski K, Iodice V, Sandroni P, Low PA. Mayo Clin Proc. 2010 Jul;85(7):639-44. Epub 2010 Jun 1. PubMed
Orthostatic intolerance and the headache patient. Mack KJ, Johnson JN, Rowe PC. Semin Pediatr Neurol. 2010 Jun;17(2):109-16. PubMed
Use of Octreotide in the Treatment of Refractory Orthostatic Intolerance. Kanjwal K, Saeed B, Karabin B, Kanjwal Y, Grubb BP. Am J Ther. 2010 Jun 9. PubMed
Menstrual Cycle Affects Renal-Adrenal and Hemodynamic Responses During Prolonged Standing in the Postural Orthostatic Tachycardia Syndrome.  Fu Q, Vangundy TB, Shibata S, Auchus RJ, Williams GH, Levine BD.  Hypertension. 2010 May 17. PubMed
Use of Methylphenidate in the Treatment of Patients Suffering From Refractory Postural Tachycardia Syndrome.  Kanjwal K, Saeed B, Karabin B, Kanjwal Y, Grubb BP.  Am J Ther. 2010 May 10. PubMed
Acute fluid ingestion in the treatment of orthostatic intolerance - important implications for daily practice.  Z'graggen WJ, Hess CW, Humm AM.  Eur J Neurol. 2010 Apr 20. PubMed
Comparative clinical profile of postural orthostatic tachycardia patients with and without joint hypermobility syndrome.  Kanjwal K, Saeed B, Karabin B, Kanjwal Y, Grubb BP.  Indian Pacing Electrophysiol J. 2010 Apr 1;10(4):173-8. PubMed
Autonomic dysfunction presenting as postural orthostatic tachycardia syndrome in patients with multiple sclerosis.  Kanjwal K, Karabin B, Kanjwal Y, Grubb BP.  Int J Med Sci. 2010 Mar 11;7:62-7. PubMed
Orthostatic syndromes differ in syncope frequency.  Ojha A, McNeeley K, Heller E, Alshekhlee A, Chelimsky G, Chelimsky TC.  Am J Med. 2010 Mar;123(3):245-9. PubMed
Efficiency evaluation of autonomic heart control by using the principal component analysis of ECG P-wave.  Krisciukaitis A, Simoliuniene R, Tamosiunas M, Saferis V, Vainoras A, Gargasas L.  Methods Inf Med. 2010 Mar 16;49(2):161-7. Epub 2010 Feb 22. PubMed
Postural orthostatic tachycardia syndrome: a clinical review. Johnson JN, Mack KJ, Kuntz NL, Brands CK, Porter CJ, Fischer PR. Pediatr Neurol. 2010 Feb;42(2):77-85. PubMed
Perioperative care of an adolescent with postural orthostatic tachycardia syndrome. Kernan S, Tobias JD. Saudi J Anaesth. 2010 Jan;4(1):23-7. Full text
Distal sudomotor findings in postural tachycardia syndrome. Peltier AC, Garland E, Raj SR, Sato K, Black B, Song Y, Wang L, Biaggioni I, Diedrich A, Robertson D. Clin Auton Res. 2009 Dec 25. PubMed
Postural Orthostatic Tachycardia Syndrome: A Rare Complication Following Electrical Injury. Kanjwal K, Karabin B, Kanjwal Y, Grubb BP. Pacing Clin Electrophysiol. 2009 Dec 10. PubMed
Postpartum postural orthostatic tachycardia syndrome in a patient with the joint hypermobility syndrome. Kanjwal K, Karabin B, Kanjwal Y, Grubb BP. Cardiol Res Pract. 2009;2009:187543. Epub 2009 Oct 11. Full Text
Cardiac Neurotransmission Imaging with 123I-Meta-iodobenzylguanidine in Postural Tachycardia Syndrome.  Haensch CA, Lerch H, Schlemmer H, Jigalin A, Isenmann S. J Neurol Neurosurg Psychiatry. 2009 Aug 16. PubMed
Outcomes of pregnancy in patients with preexisting postural tachycardia syndrome. Kanjwal K, Karabin B, Kanjwal Y, Grubb BP. Pacing Clin Electrophysiol. 2009 Aug;32(8):1000-3. PubMed
Propranolol Decreases Tachycardia and Improves Symptoms in the Postural Tachycardia Syndrome. Less Is More. Raj SR, Black BK, Biaggioni I, Paranjape SY, Ramirez M, Dupont WD, Robertson D. Circulation. 2009 Aug 17. PubMed
Decreased Upright Cerebral Blood Flow and Cerebral Autoregulation in Normocapnic Postural Tachycardia Syndrome. Ocon AJ, Medow MS, Taneja I, Clark D, Stewart JM. Am J Physiol Heart Circ Physiol. 2009 Jun 5. PubMed
Autonomic Testing in Functional Gastrointestinal Disorders: Implications of Reproducible Gastrointestinal Complaints during Tilt Table Testing. Safder S, Chelimsky TC, O'Riordan MA, Chelimsky G. Gastroenterol Res Pract. 2009;2009:868496. Epub 2009 May 5. Full Text
Defects in cutaneous angiotensin-converting enzyme 2 and angiotensin-(1-7) production in postural tachycardia syndrome. Stewart JM, Ocon AJ, Clarke D, Taneja I, Medow MS. Hypertension. 2009 May;53(5):767-74. Full Text
What is the optimal duration of tilt testing for the assessment of patients with suspected postural tachycardia syndrome? Carew S, Cooke J, O'Connor M, Donnelly T, Costelloe A, Sheehy C, Lyons D. Europace. 2009 May;11(5):635-7. Epub 2009 Mar 4. PubMed
Quantitative study on cerebral blood volume determined by a near-infrared spectroscopy during postural change in children. Kim YT, Tanaka H, Takaya R, Kajiura M, Tamai H, Arita M. Acta Paediatr. 2009 Mar;98(3):466-71. PubMed
Antibody titers predict clinical features of autoimmune autonomic ganglionopathy. Gibbons CH, Freeman R. Auton Neurosci. 2009 Mar 12;146(1-2):8-12. PubMed
Japanese clinical guidelines for juvenile orthostatic dysregulation version 1. Tanaka H, Fujita Y, Takenaka Y, Kajiwara S, Masutani S, Ishizaki Y, Matsushima R, Shiokawa H, Shiota M, Ishitani N, Kajiura M, Honda K; Task Force of Clinical Guidelines for Child Orthostatic Dysregulation, Japanese Society of Psychosomatic Pediatrics. Pediatr Int. 2009 Feb;51(1):169-79. PubMed
Outcomes in adolescents with postural orthostatic tachycardia syndrome treated with midodrine and beta-blockers. Lai CC, Fischer PR, Brands CK, Fisher JL, Porter CB, Driscoll SW, Graner KK. Pacing Clin Electrophysiol. 2009 Feb;32(2):234-8. PubMed.
Postural tachycardia syndrome (POTS). Low PA, Sandroni P, Joyner M, Shen WK J Cardiovasc Electrophysiol. 2009 Mar;20(3):352-8. Epub 2009 Jan 16. Review. PubMed
Treatment of inappropriate sinus tachycardia with ivabradine in a patient with postural orthostatic tachycardia syndrome and a dual chamber pacemaker. Khan S, Hamid S, Rinaldi C. Pacing Clin Electrophysiol. 2009 Jan;32(1):131-3. PubMed
Effect of selective alpha1 receptor agonist in the treatment of children with postural orthostatic tachycardia syndrome. Chen L, DU JB, Jin HF, Zhang QY, Li WZ, Wang L, Wang YL. Zhonghua Er Ke Za Zhi. 2008 Sep;46(9):688-91. Chinese. PubMed
Postural orthostatic tachycardia in a teenager with Klinefelter syndrome. Hainstock MR, Gruchala NE, Fike N, Samson RA, Klewer SE, Barber BJ. Congenit Heart Dis. 2008 Nov-Dec;3(6):440-2. PubMed
Autonomic dysfunction in fibromyalgia syndrome: postural orthostatic tachycardia. Staud R. Curr Rheumatol Rep. 2008 Dec;10(6):463-6. PubMed
Postural orthostatic tachycardia syndrome is an under-recognized condition in chronic fatigue syndrome. Hoad A, Spickett G, Elliott J, Newton J. QJM. 2008 Dec;101(12):961-5. Epub 2008 Sep 19. PubMed
Postural orthostatic tachycardia in a teenager with Klinefelter syndrome. Hainstock MR, Gruchala NE, Fike N, Samson RA, Klewer SE, Barber BJ. Congenit Heart Dis. 2008 Nov;3(6):440-2. PubMed
Psychiatric Profile and Attention Deficits in Postural Tachycardia Syndrome. Raj V, Haman KL, Raj SR, Byrne D, Blakely RD, Biaggioni I, Robertson D, Shelton RC. J Neurol Neurosurg Psychiatry. 2008 Oct 31. PubMed
Reversible postural tachycardia syndrome due to inadvertent overuse of Red Bull((R)). Terlizzi R, Rocchi C, Serra M, Solieri L, Cortelli P. Clin Auton Res. 2008 Aug;18(4):221-3. Epub 2008 Aug 5. PubMed
Anesthesia for caesarean section in a patient with Ehlers-Danlos syndrome associated with postural orthostatic tachycardia syndrome. Jones TL, Ng C. Int J Obstet Anesth. 2008 Jul 8. PubMed
Cardiovascular autonomic reflexes on the postural orthostatic tachycardia syndrome. Benjelloun H, Benjelloun H, Aboudrar S, Coghlan L, Benomar M. Ann Cardiol Angeiol (Paris). 2008 Jun 10. PubMed
Postural tachycardia syndrome.Grubb BP. Circulation. 2008 May 27;117(21):2814-7. Full Text
Invited Article: Autonomic ganglia: target and novel therapeutic tool.Vernino S, Sandroni P, Singer W, Low PA. Neurology. 2008 May 13;70(20):1926-32. PubMed
Orthostatic intolerance and gastrointestinal motility in adolescents with nausea and abdominal pain. Antiel RM, Risma JM, Grothe RM, Brands CK, Fischer PR. J Pediatr Gastroenterol Nutr. 2008 Mar;46(3):285-8. PubMed
Postural tachycardia syndrome and coronary artery bridge. Abdelmoneim SS, Moustafa S, Mookadam F. Europace. 2008 Apr;10(4):482-5. Epub 2008 Mar 13. PubMed
A Matched Case Control Study of Orthostatic Intolerance in Children/Adolescents With Chronic Fatigue Syndrome. Galland BC, Jackson PM, Sayers RM, Taylor BJ. Pediatr Res. 2008 Feb;63(2):196-202. PubMed
Angiotensin II type 1 receptor blockade corrects cutaneous nitric oxide deficit in postural tachycardia syndrome. Stewart JM, Taneja I, Glover J, Medow MS. Am J Physiol Heart Circ Physiol. 2008 Jan;294(1):H466-73. PubMed
A multicenter study on treatment of autonomous nerve-mediated syncope in children with beta-receptor blocker. Chen L, DU JB, Zhang QY, Wang C, DU ZD, Wang HW, Tian H, Chen JJ, Wang YL, Hu XF, Li WZ, Han L. Zhonghua Er Ke Za Zhi. 2007 Dec;45(12):885-8. PubMed
Takotsubo cardiomyopathy in a patient with postural tachycardia syndrome.  Khurana RK. Clin Auton Res. 2007 Oct 19. PubMed
Postural tachycardia syndrome with asystole on head-up tilt. Alshekhlee A, Guerch M, Ridha F, McNeeley K, Chelimsky TC. Clin Auton Res. 2007 Oct 19 PubMed
Symptom improvement in postural orthostatic tachycardia syndrome with the sinus node blocker ivabradine. Ewan V, Norton M, Newton JL. Europace. 2007 Dec;9(12):1202. Epub 2007 Oct 19. PubMed
Sympathovagal balance analysis in idiopathic postural orthostatic tachycardia syndrome. Russo V, De Crescenzo I, Ammendola E, Santangelo L, Calabrò R. Acta Biomed. 2007 Aug;78(2):133-8. PubMed
Cardiac denervation in postural tachycardia syndrome.Haensch CA, Lerch H, Jigalin A, Schlemmer H, Isenmann S. Clin Auton Res. 2007 Sep 26. PubMed
Postural syncope: mechanisms and management.Vaddadi G, Lambert E, Corcoran SJ, Esler MD. Med J Aust. 2007 Sep 3;187(5):299-304. PubMed
Treatment of autonomic neuropathy, postural tachycardia and orthostatic syncope with octreotide LAR. Hoeldtke RD, Bryner KD, Hoeldtke ME, Hobbs G. Clin Auton Res. 2007 Aug 31. PubMed
Blood volume perturbations in the postural tachycardia syndrome. Raj SR, Robertson D. Am J Med Sci. 2007 Jul;334(1):57-60. PubMed
Reduced stroke volume during exercise in postural tachycardia syndrome. Masuki S, Eisenach JH, Schrage WG, Johnson CP, Dietz NM, Wilkins BW, Sandroni P, Low PA, Joyner MJ. J Appl Physiol. 2007 Jul 12; PubMed
Postural orthostatic tachycardia syndrome. Agarwal AK, Garg R, Ritch A, Sarkar P. Postgrad Med J. 2007 Jul;83(981):478-80. PubMed
Reduced Central Blood Volume and Cardiac Output, and Increased Vascular Resistance during Static Handgrip Exercise in Postural Tachycardia Syndrome. Stewart J, Taneja I, Medow MS. Am J Physiol Heart Circ Physiol. 2007 Jul 6; PubMed
Postural orthostatic tachycardia syndrome: an underrecognized disorder.PandianJD, Dalton K, Henderson RD, McCombe PA. Intern Med J. 2007 Jul 19;37(8):529-535. PubMed
Sympathetic neural activity, sex dimorphism, and postural tachycardia syndrome. Bonyhay I, Freeman R. Ann  Neurol. 2007 Mar 14. PubMed
Postural orthostatic tachycardia syndrome: the Mayo clinic experience. Thieben MJ, Sandroni P, Sletten DM, Benrud-Larson LM, Fealey RD, Vernino S, Lennon VA, Shen WK, Low PA. Mayo Clin Proc. 2007 Mar;82(3):308-13. Full Text

The postural tachycardia syndrome. Medow MS, Stewart JM. Cardiol Rev. 2007 Mar-Apr;15(2):67-75. PubMed
Pyridostigmine in the treatment of orthostatic intolerance. Gales BJ, Gales MA. Ann Pharmacother. 2007 Feb;41(2):314-8. Epub 2007 Feb 6. PubMed
Postural orthostatic tachycardia syndrome: anesthetic implications in the obstetric patient.McEvoy MD, Low PA, Hebbar L. Anesth Analg. 2007 Jan;104(1):166-7. PubMed
Episodic hypertension in postural orthostatic tachycardia syndrome. Carvajal Roca E, Torro Domenech I. Lurbe Ferrer E. An Pediatr (Barc). 2006 Nov;65(5):496-9. PubMed   
Excessive Heart Rate Response to Orthostatic Stress in Postural Tachycardia Syndrome is Not Caused by Anxiety. Masuki S, Eisenach JH, Johnson C, Dietz NM, Benrud-Larson L, Schrage WG, Curry TB, Sandroni P, Low PA, Joyner MJ. J Appl Physiol. 2006 Nov 16. PubMed
Treatment of postural tachycardia syndrome: a comparison of octreotide and midodrine. Hoeldtke RD, Bryner KD, Hoeldtke ME, Hobbs G. Clin Auton Res. 2006 Oct 11 PubMed
Pharmacokinetics of Pyridostigmine in a Child With Postural Tachycardia Syndrome. Filler G, Gow RM, Nadarajah R, Jacob P, Johnson G, Zhang YL, Christians U. Pediatrics. 2006 Oct 2; PubMed
The Postural Tachycardia Syndrome (POTS): Pathophysiology, Diagnosis & Management. Raj SR. Indian Pacing Electrophysiol J. 2006 Apr 1;6(2):84-99. PubMed
Experimental induction of panic-like symptoms in patients with postural tachycardia syndrome. Khurana RK. Clin Auton Res. 2006 Aug 16; PubMed
Anaesthetic management of a parturient with the postural orthostatic tachycardia syndrome: a case report. Corbett WL, Reiter CM, Schultz JR, Kanter RJ, Habib AS. Br J Anaesth. 2006 May 12; PubMed
Postural orthostatic tachycardia syndrome: Dental treatment considerations. Brooks JK, Francis LA. J Am Dent Assoc. 2006 Apr;137(4):488-93. PubMed
Familial orthostatic tachycardia. Keller NR, Robertson D. Curr Opin Cardiol. 2006 May;21(3):173-9. PubMed

Postural Hypocapnic Hyperventilation is Associated with Enhanced Peripheral Vasoconstriction in Postural Tachycardia Syndrome with Normal Supine Blood Flow. Stewart JM, Medow MS, Cherniack NS, Natelson BH. Am J Physiol Heart Circ Physiol. 2006 Mar 24. PubMed

Beta2-adrenoceptor genotype and function affect hemodynamic profile heterogeneity in postural tachycardia syndrome. Jacob G, Garland EM, Costa F, Stein CM, Xie HG, Robertson RM, Biaggioni I, Robertson D. Hypertension. 2006 Mar;47(3):421-7. Epub 2006 Feb 6. PubMed

The postural tachycardia syndrome: a concise guide to diagnosis and management. Grubb BP, Kanjwal Y, Kosinski DJ. J Cardiovasc Electrophysiol. 2006 Jan;17(1):108-12. No abstract available.
Characterizing Gulf War Illnesses: neurally mediated hypotension and postural tachycardia syndrome. Lucas KE, Armenian HK, Debusk K, Calkins HG, Rowe PC. Am J Med. 2005 Dec;118(12):1421-7. PubMed
Orthostatic instability in a population-based study of chronic fatigue syndrome. Jones JF, Nicholson A, Nisenbaum R, Papanicolaou DA, Solomon L, Boneva R, Heim C, Reeves WC. Am J Med. 2005 Dec;118(12):1415. PubMed

Increased plasma angiotensin II in postural tachycardia syndrome is related to reduced blood flow and blood volume. Stewart JM, Glover JL, Medow MS. Clin Sci (Lond).2005 Nov 1; PubMed
Decreased Microvascular Nitric Oxide-Dependent Vasodilation in Postural Tachycardia Syndrome. Medow MS, Minson CT, Stewart JM. Circulation. 2005 Oct 17; PubMed

Inappropriate sinus tachycardia, postural orthostatic tachycardia syndrome, and overlapping syndromes. Brady PA, Low PA, Shen WK.
Pacing Clin Electrophysiol. 2005 Oct;28(10):1112-21. PubMed

Endothelial NO Synthase Polymorphisms and Postural Tachycardia Syndrome. Garland EM, Winker R, Williams SM, Jiang L, Stanton K, Byrne DW, Biaggioni I, Cascorbi I, Phillips Iii JA, Harris PA, Rudiger H, Robertson D. Hypertension. 2005 Oct 3. Full Text
Continuous progression of orthostatic tachycardia as a further feature of the postural tachycardia syndrome. Diehl RR. Pacing Clin Electrophysiol. 2005 Sep;28(9):975-9. PubMed

Persistent Splanchnic Hyperemia during Upright tilt in Postural Tachycardia Syndrome. Stewart JM, Medow MS, Glover JL, Montgomery LD. Am J Physiol Heart Circ Physiol. 2005 Sep 2; PubMed
Cerebral blood flow during supine rest and the first minute of head-up tilt in patients with orthostatic intolerance. Jauregui-Renaud K, Hermosillo JA, Jardon JL, Marquez MF, Kostine A, Silva MA, Cardenas M. Europace. 2005 Sep;7(5):460-4. PubMed

Orthostatic intolerance and syncope associated with Chiari type I malformation. Prilipko O, Dehdashti AR, Zaim S, Seeck M.
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Splanchnic Hyperemia and Hypervolemia during the Valsalva Maneuver in Postural Tachycardia Syndrome. Stewart JM, Medow MS, Montgomery LD, Glover JL, Millonas MM. Am J Physiol Heart Circ Physiol. 2005 Jun 17. PubMed
Pregnancy in postural orthostatic tachycardia syndrome. Glatter KA, Tuteja D, Chiamvimonvat N, Hamdan M, Park JK. Pacing Clin Electrophysiol. 2005 Jun;28(6):591-3. PubMed
The value of autonomic testing in postural tachycardia syndrome. A screen of candidate genes and influence of beta(2)-adrenergic receptor genotypes in postural tachycardia syndrome. Auton Neurosci. 2005 Jun 15;120(1-2):97-103. PubMed
A screen of candidate genes and influence of beta(2)-adrenergic receptor genotypes in postural tachycardia syndrome. Nickander KK, Carlson PJ, Urrutia RA, Camilleri M, Low PA. Auton Neurosci. 2005 Jun 15;120(1-2):97-103. PubMed
Acetylcholinesterase inhibition improves tachycardia in postural tachycardia syndrome. Raj SR, Black BK, Biaggioni I, Harris PA, Robertson D. Circulation. 2005 May 31;111(21):2734-40. PubMed
Cerebral Autoregulation Is Preserved In Postural Tachycardia Syndrome (POTS). Schondorf R, Benoit J, Stein R. J Appl Physiol. 2005 Apr 28; PubMed
Baroreflex control of muscle sympathetic nerve activity in the postural orthostatic tachycardia syndrome. Muenter Swift N, Charkoudian N, Dotson RM, Suarez GA, Low PA. Am J Physiol Heart Circ Physiol. 2005 Apr 29. PubMed
Gastrointestinal symptoms associated with orthostatic intolerance. Sullivan SD, Hanauer J, Rowe PC, Barron DF, Darbari A, Oliva-Hemker M. J Pediatr Gastroenterol Nutr. 2005 Apr;40(4):425-8. PubMed
Renin-aldosterone paradox and perturbed blood volume regulation underlying postural tachycardia syndrome. Raj SR, Biaggioni I, Yamhure PC, Black BK, Paranjape SY, Byrne DW, Robertson D. Circulation. 2005 Apr 5;111(13):1574-82. PubMed
Postural tachycardia syndrome. Makai A, Tahin T, Simor T, Csanadi Z, Rudas L. Orv Hetil. 2005 Mar 13;146(11):515-20. Review. Hungarian. PubMed
Clinical analysis and follow-up study of postural orthostatic tachycardia syndrome in 28 pediatric cases. Zhang QY, Du JB, Li WZ. Zhonghua Er Ke Za Zhi. 2005 Mar;43(3):165-9. Chinese. PubMed
Hyperadrenergic Postural Tachycardia Syndrome in Mast Cell Activation Disorders. Shibao C, Arzubiaga C, Roberts Ii LJ, Raj S, Black B, Harris P, Biaggioni I. Hypertension. 2005 Feb 14. PubMed 
Chronic orthostatic intolerance and the postural tachycardia syndrome (POTS). Stewart JM. J Pediatr. 2004 Dec;145(6):725-30.  No Abstract Available.
Neurocirculatory Abnormalities in Chronic Orthostatic Intolerance.
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Postural Orthostatic Tachycardia Warrants Investigation of Chiari I Malformation as a Possible Cause. Pasupuleti DV, Vedre A. Cardiology. 2004 Nov 3;103(1):55-56. PubMed
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Lower limb compression bandaging is effective in preventing signs and symptoms of seating-induced postural hypotension. Gorelik O, Fishlev G, Almoznino-Sarafian D, Alon I, Weissgarten J, Shteinshnaider M, Chachashvily S, Modai D, Cohen N. Cardiology. 2004;102(4):177-83.
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Regional Blood Volume and Peripheral Blood Flow in the Postural Tachycardia Syndrome. Stewart JM, Montgomery LD. Am J Physiol Heart Circ Physiol. 2004 Apr 29. PubMed
Asymptomatic Brugada Syndrome Associated with Postural Orthostatic Tachycardia Syndrome: Morishima I, Sone T, Tsuboi H, Mukawa H, Satoda M, Uesugi M. Pacing Clin Electrophysiol. 2004 Apr;27(4):537-540. PubMed
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Prospective evaluation of somatic and autonomic small fibers in selected autonomic neuropathies. Singer W, Spies JM, McArthur J, Low J, Griffin JW, Nickander KK, Gordon V, Low PA. Neurology. 2004 Feb 24;62(4):612-8. PubMed
Case reports and review of Postural Orthostatic Tachycardia syndrome (POTS). Carothers B, Schmidt L, Puri V. J Ky Med Assoc. 2003 Dec;101(12):549-52. Review. PubMed
Correlates of functional disability in patients with postural tachycardia syndrome: preliminary cross-sectional findings. Benrud-Larson LM, Sandroni P, Haythornthwaite JA, Rummans TA, Low PA. Health Psychol. 2003 Nov;22(6):643-8. PubMed
Decreased Skeletal Muscle Pump Activity in Postural Tachycardia Syndrome Patients with Low Peripheral Blood Flow. Stewart JM, Medow MS, Montgomery LD, McLeod KD. Am J Physiol Heart Circ Physiol. 2003 Oct 23. PubMed
Orthostatic headaches without CSF leak in postural tachycardia syndrome. Mokri B, Low PA. Neurology. 2003 Oct 14;61(7):980-2. PubMed

Treatment of postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia. Kanjwal MY, Kosinski DJ, Grubb BP.
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Local Vascular Responses Affecting Blood Flow in Postural Tachycardia Syndrome. Stewart JM, Medow MA, Montgomery LD.
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Dysautonomia in the joint hypermobility syndrome. Gazit Y, Nahir AM, Grahame R, Jacob G. Am J Med. 2003 Jul;115(1):33-40. PubMed 
Microvascular filtration is increased in postural tachycardia syndrome. Stewart JM. Circulation. 2003 May 19. PMID: 12756156 PubMed
Diagnostic management of orthostatic intolerance in the workplace. Winker R, Barth A, Dorner W, Mayr O, Pilger A, Ivancsits S, Ponocny I, Heider A, Wolf C, Rudiger HW. Int Arch Occup Environ Health. 2003 Mar;76(2):143-50. PMID: 12733087 PubMed
Contrasting neurovascular findings in chronic orthostatic intolerance and neurocardiogenic syncope.Stewart JM, Weldon A.
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Heart rate-dependent electrocardiogram abnormalities in patients with postural tachycardia syndrome. Singer W, Shen WK, Opfer-Gehrking TL, McPhee BR, Hilz MJ, Low PA. Auton Neurosci. 2003 Jan 31;103(1-2):106-13. PMID: 12531404 [PubMed - in process]

Clinical and physiological effects of an acute alpha-1 adrenergic agonist and a beta-1 adrenergic antagonist in chronic orthostatic intolerance. Stewart JM, Munoz J, Weldon A. Circulation. 2002 Dec 3;106(23):2946-54. PMID: 12460877 [PubMed - in process]

Comparative study of cerebral blood flow between postural tachycardia and neurocardiogenic syncope, during head-up tilt test. Hermosillo AG, Jauregui-Renaud K, Kostine A, Marquez MF, Lara JL, Cardenas M.Europace. 2002 Oct;4(4):369-74. PMID: 12408256 [PubMed - in process]

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Polymorphisms of genes encoding components of the sympathetic nervous system but not the renin-angiotensin system as risk factors for orthostatic hypotension. Tabara Y, Kohara K, Miki T. J Hypertens. 2002 Apr;20(4):651-656. 
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Evidence of an intrinsic sinus node abnormality in patients with postural tachycardia syndrome. Singer W, Shen WK, Opfer-Gehrking TL, McPhee BR, Hilz MJ, Low PA. Mayo Clin Proc. 2002 Mar;77(3):246-52.  PMID: 11888028 [PubMed - indexed for MEDLINE] From PubMed
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The postural orthostatic tachycardia syndrome: a potentially treatable cause of chronic fatigue, exercise intolerance, and cognitive impairment in adolescents. Karas B,  Grubb BP,  Boehm K,  Kip K. Pacing Clin Electrophysiol. 2000 Mar;23(3):344-51.  PMID: 10750135 [PubMed - indexed for MEDLINE] From PubMed
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Mechanisms of blood pressure alterations in response to the Valsalva maneuver in postural tachycardia syndrome. Sandroni P,  Novak V,  Opfer-Gehrking TL,  Huck CA,  Low PA. Clin Auton Res. 2000 Feb;10(1):1-5.  PMID: 10750636 [PubMed - indexed for MEDLINE] From PubMed
Orthostatic intolerance and tachycardia associated with norepinephrine-transporter deficiency. Shannon JR,  Flattem NL,  Jordan J,  Jacob G,  Black BK,  Biaggioni I,  Blakely RD,  Robertson D. N Engl J Med. 2000 Feb 24;342(8):541-9.  PMID: 10684912 [PubMed - indexed for MEDLINE] From PubMed
Blood volume: importance and adaptations to exercise training, environmental stresses, and trauma/sickness. Sawka MN,  Convertino VA,  Eichner ER,  Schnieder SM,  Young AJ. Med Sci Sports Exerc. 2000 Feb;32(2):332-48.  PMID: 10694114 [PubMed - indexed for MEDLINE] From PubMed
[Idiopathic orthostatic tachycardia. Etiology, diagnosis and treatment]. Grubb BP,  Blanc JJ. Arch Mal Coeur Vaiss. 2000 Jan;93(1):79-85. French.  PMID: 11227722 [PubMed - indexed for MEDLINE] From PubMed
[Differential orthostatic dysregulation disorders diagnosis]. Diehl RR,  Linden D. Nervenarzt. 1999 Dec;70(12):1044-51. German.  PMID: 10637809 [PubMed - indexed for MEDLINE] From PubMed
Postural tachycardia syndrome: clinical features and follow-up study. Sandroni P,  Opfer-Gehrking TL,  McPhee BR,  Low PA. Mayo Clin Proc. 1999 Nov;74(11):1106-10.  PMID: 10560597 [PubMed - indexed for MEDLINE] From PubMed
Interaction of genetic predisposition and environmental factors in the pathogenesis of idiopathic orthostatic intolerance. Jordan J,  Shannon JR,  Jacob G,  Pohar B,  Robertson D. Am J Med Sci. 1999 Nov;318(5):298-303.  PMID: 10555091 [PubMed - indexed for MEDLINE] From PubMed
Putting it together: a new treatment algorithm for vasovagal syncope and related disorders. Bloomfield DM,  Sheldon R,  Grubb BP,  Calkins H,  Sutton R. Am J Cardiol. 1999 Oct 21;84(8A):33Q-39Q.  PMID: 10568559 [PubMed - indexed for MEDLINE] From PubMed
Orthostatic intolerance and chronic fatigue syndrome associated with Ehlers-Danlos syndrome. Rowe PC,  Barron DF,  Calkins H,  Maumenee IH,  Tong PY,  Geraghty MT. J Pediatr. 1999 Oct;135(4):494-9.  PMID: 10518084 [PubMed - indexed for MEDLINE] From PubMed
[Syndromes of autonomic insufficiency associated with orthostatic intolerance: classification, diagnostic and therapeutic approach]. Grubb BP,  Klingenheben T. Z Kardiol. 1999 Aug;88(8):541-9. German.  PMID: 10506389 [PubMed - indexed for MEDLINE] From PubMed
Analysis of heart rate variability during head-up tilt testing in a patient with idiopathic postural orthostatic tachycardia syndrome (POTS). Sumiyoshi M,  Nakata Y,  Mineda Y,  Yasuda M,  Nakazato Y,  Yamaguchi H. Jpn Circ J. 1999 Jun;63(6):496-8.  PMID: 10406593 [PubMed - indexed for MEDLINE] From PubMed
Cerebrovascular mechanisms in neurocardiogenic syncope with and without postural tachycardia syndrome. Diehl RR,  Linden D,  Chalkiadaki A,  Diehl A. J Auton Nerv Syst. 1999 May 28;76(2-3):159-66.  PMID: 10412840 [PubMed - indexed for MEDLINE] From PubMed
Diagnosis of tachycardia syndromes associated with orthostatic symptoms. Braune S,  Wrocklage C,  Schulte-Monting J,  Schnitzer R,  Lucking CH. Clin Auton Res. 1999 Apr;9(2):97-101.  PMID: 10225614 [PubMed - indexed for MEDLINE] From PubMed
Cerebrovascular regulation in the postural orthostatic tachycardia syndrome (POTS). Low PA,  Novak V,  Spies JM,  Novak P,  Petty GW. Am J Med Sci. 1999 Feb;317(2):124-33.  PMID: 10037116 [PubMed - indexed for MEDLINE] From PubMed
Clinical and laboratory indices that enhance the diagnosis of postural tachycardia syndrome. Novak V,  Novak P,  Opfer-Gehrking TL,  O'Brien PC,  Low PA. Mayo Clin Proc. 1998 Dec;73(12):1141-50.  PMID: 9868411 [PubMed - indexed for MEDLINE] From PubMed
Autonomic neuropathies. Low PA. Curr Opin Neurol. 1998 Oct;11(5):531-7.  PMID: 9848003 [PubMed - indexed for MEDLINE] From PubMed
[Orthostatic intolerance. A review and clinical case]. Freitas J,  Almeida J,  Azevedo E,  Carvalho MJ,  Costa O,  de Freitas AF. Rev Port Cardiol. 1998 Sep;17(9):715-20. Portuguese.  PMID: 9834642 [PubMed - indexed for MEDLINE] From PubMed
[Orthostatic postural tachycardia: study of 8 patients]. Santiago Perez S,  Ferrer Gila T. Med Clin (Barc). 1998 Feb 7;110(4):138-41. Spanish.  PMID: 9541904 [PubMed - indexed for MEDLINE] From PubMed
The postural orthostatic tachycardia syndrome: a neurocardiogenic variant identified during head-up tilt table testing. Grubb BP,  Kosinski DJ,  Boehm K,  Kip K. Pacing Clin Electrophysiol. 1997 Sep;20(9 Pt 1):2205-12.  PMID: 9309745 [PubMed - indexed for MEDLINE] From PubMed
Postural tachycardia syndrome: time frequency mapping. Novak V,  Novak P,  Opfer-Gehrking TL,  Low PA. J Auton Nerv Syst. 1996 Dec 14;61(3):313-20.  PMID: 8988490 [PubMed - indexed for MEDLINE] From PubMed
Certain cardiovascular indices predict syncope in the postural tachycardia syndrome. Sandroni P,  Opfer-Gehrking TL,  Benarroch EE,  Shen WK,  Low PA. Clin Auton Res. 1996 Aug;6(4):225-31.  PMID: 8902319 [PubMed - indexed for MEDLINE] From PubMed
Postural tachycardia syndrome (POTS). Low PA,  Opfer-Gehrking TL,  Textor SC,  Benarroch EE,  Shen WK,  Schondorf R,  Suarez GA,  Rummans TA. Neurology. 1995 Apr;45(4 Suppl 5):S19-25.  
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Comparison of the postural tachycardia syndrome (POTS) with orthostatic hypotension due to autonomic failure. Low PA,  Opfer-Gehrking TL,  Textor SC,  Schondorf R,  Suarez GA,  Fealey RD,  Camilleri M. J Auton Nerv Syst. 1994 Dec 15;50(2):181-8.  PMID: 7884158 [PubMed - indexed for MEDLINE] From PubMed
Autonomic neuropathies. Low PA. Curr Opin Neurol. 1994 Oct;7(5):402-6.  PMID: 7804460 [PubMed - indexed for MEDLINE] From PubMed
Autonomic nervous system function. Low PA. J Clin Neurophysiol. 1993 Jan;10(1):14-27.  PMID: 8458992 [PubMed - indexed for MEDLINE] From PubMed
Idiopathic postural orthostatic tachycardia syndrome: an attenuated form of acute pandysautonomia? Schondorf R,  Low PA. Neurology. 1993 Jan;43(1):132-7.  PMID: 8423877 [PubMed - indexed for MEDLINE] From PubMed

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