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Dysautonomia and pots
The document discusses dysautonomia and Postural Orthostatic Tachycardia Syndrome (POTS). It defines POTS as excessive increase in heart rate when upright, and describes its two main forms - neuropathic POTS caused by loss of vasoconstriction and hyperadrenergic POTS with increased norepinephrine. Treatment depends on the form but may include physical countermaneuvers, salt, water, medications and exercise. Postural vasovagal syncope, characterized by fainting, is the most common type of orthostatic intolerance.
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Dysautonomia and pots
- 1. Dysautonomia and POTS Presentedby Dr. Roy Maynard October 2, 2013
- 2. Objectives • Understand basicsrelated to the autonomic nervous system • Describe normal orthostatic response in transitioning from supine to upright position • Identify symptoms associated with POTS • Name the most common form of orthostatic intolerance 2 of 36
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- 4. Definitions • Dysautonomia:- malfunctionof the autonomic nervous system • POTS:- Postural Orthostatic Tachycardia Syndrome 4 of 36
- 5. Autonomic Nervous System •Two Components – Sympathetic • Fight or flight – Parasympathetic • Rest or digest 5 of 36
- 6. Autonomic Nervous System •Anatomy – Lower brainstem • Sympathetic T1- L3 • Parasympathetic S2-S4, Cranial Nerves 3, 7, 9, 10 • Function – – – – Subconscious level Visceral functions Heart rate, respiration, blood pressure Digestion, micturation, perspiration, salivation, pupillary dilatation – Dilatation and constriction of blood vessels (arteries and veins) 6 of 36
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- 8. Normal Orthostatic Response •Standing transfers more than 17 ounces of blood into the abdomen and legs • Initial period of instability (initial orthostatic hypotension) ensues and blood pressure may decrease by 30% for 10 to 20 seconds after standing • Reflex tachycardia happens • Blood pressure restored within 30 to 60 seconds 8 of 36
- 9. Normal Orthostatic Response •Mechanisms to restore hemodynamics – Arterial vasoconstriction – Elastic recoil of venous blood in dependent veins – Active venoconstriction in splanchnic veins 9 of 36
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- 11. Douglas Bader http://en.wikipedia.org/wiki/Supermarine_Spitfire http://en.wikipedia.org/wiki/Douglas_Bader Accessed on8/5/13 Accessed on 8/5/13 11 of 36
- 12. G-Forces and theFighter Pilot http://www.gforces.com/military.html Accessed on 8/5/13 12 of 36
- 13. Types of Orthostatic Hypotension •Initial Orthostatic Hypotension • Orthostatic Hypotension – Nonneurogenic orthostatic hypotension – Neurogenic orthostatic hypotension • POTS – Neuropathic POTS – Hyperadrenergic POTS • Vasovagal Syncope (VVS) 13 of 36
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- 15. Initial Orthostatic Hypotension PEDIATRIC Journal,Volume 131, Number 5, May 2013 – Page 969 15 of 36
- 16. Types of Orthostatic Hypotension •Initial Orthostatic Hypotension • Orthostatic Hypotension – Non-neurogenic orthostatic hypotension – Neurogenic orthostatic hypotension • POTS – Neuropathic POTS – Hyperadrenergic POTS • Postural Vasovagal syncope 16 of 36
- 17. Orthostatic Hypotension • Non-neurogenicorthostatic hypotension – Common in young – Cause – drugs, dehydration, hemorrhage – Mechanism- incomplete autonomic nervous system compensation for stressors – Treatment- stop medication, prevent dehydration 17 of 36
- 18. Orthostatic Hypotension • Neurogenicorthostatic hypotension – Rare in young people, no increase in heart rate – Associated with diabetes, amyloidosis, Parkinson’s disease – Cause- autonomic vasoconstrictor failure – Treatment- physical counter-maneuvers, • Medications- IV saline, corticosteroids, midodrine, droxidopa 18 of 36
- 19. Types of Orthostatic Hypotension •Initial Orthostatic Hypotension • Orthostatic Hypotension – Non-neurogenic orthostatic hypotension – Neurogenic orthostatic hypotension • POTS – Neuropathic POTS – Hyperadrenergic POTS • Postural Vasovagal syncope 19 of 36
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- 21. Postural Orthostatic Tachycardia Syndrome •Definition: chronic day-to-day symptoms of orthostatic intolerance plus excessive increase in heart rate when upright – HR>30 from baseline or >120 after 10 minutes during tilt test in adults – HR>40 from baseline in children and teens – Blood pressure usually not low • Cause: alterations in autonomic nervous system 21 of 36
- 22. Postural Orthostatic Tachycardia Syndrome •Clinical Presentation – Palpitations – Fatigue – Lightheadedness – Exercise intolerance – Nausea – Headache – Syncope/near syncope 22 of 36
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- 24. Epidemiology • Females >Males 3:1 to 5:1; > 500,000 in 1999 • Triggers: Onset often follows flulike illness, selflimited autoimmune disease, surgery or injury, pregnancy, rapid growth spurt • May be associated with joint hypermobility syndromes • Young women may be underweight; need to differentiate from eating disorders • Hot weather or hot showers worsens symptoms • Cognitive function may be affected 24 of 36
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- 26. POTS • Neuropathic POTS –Cause- loss of regional vasoconstrictive ability – Blood pooling in lower extremities – Heart rate increases to compensate for decreased circulating blood volume now pooling in lower extremities 26 of 36
- 27. Treatment • Neuropathic POTS-defect is loss of regional vasoconstrictive ability – Physical counter-manuevers – Salt and water loading – Midodrine – Mestinon – Exercise – Rapid water ingestion 27 of 36
- 28. POTS • Hyperadrenergic POTS –Increased circulating norepinephrine – May have increased orthostatic blood pressure – Less common than neuropathic form – Symptoms attributed- anxiety, tremor, cold sweaty extremities 28 of 36
- 29. Treatment • Hyperadrenergic POTS:-Defect adrenergic potentiation – Physical counter-manuevers – Beta-blockers – Angiotension receptor blocker – Fludrocortisone 29 of 36
- 30. OUTCOME for patientswith POTS • Adolescent-onset: 80% recover by mid 20’s • Adult-onset: large percentage recover within 2-5 years • Some patients will suffer from long term disability associated with POTS 30 of 36
- 31. Types of Orthostatic Hypotension •Initial Orthostatic Hypotension • Orthostatic Hypotension – Non-neurogenic orthostatic hypotension – Neurogenic orthostatic hypotension • POTS – Neuropathic POTS – Hyperadrenergic POTS • Postural Vasovagal syncope 31 of 36
- 32. Postural Vasovagal Syncope •Most common form of orthostatic intolerance • Onset age 15, 2/3 are female • 40% of the population has had at least one episode in their lifetime 32 of 36
- 33. Treatment • Postural vasovagalsyncope- defect ? Loss of regional vasoconstrictive ability, acute reversible baroreflex dysfunction – Physical counter manuevers – Salt and water – Acute water ingestion – Midodrine – Rapid water ingestion 33 of 36
- 34. Summary • Orthostatic Intolerancedefined by symptoms when upright that are relieved by lying down • Orthostatic hypotension is a form of orthostatic intolerance • Initial orthostatic hypotension is a common form of orthostatic intolerance in the young • Postural vasovagal syncope is the most common form of orthostatic intolerance 34 of 36
- 35. Summary • POTS isa form of chronic orthostatic intolerance results • (1) from a circulatory system not responding to autonomic inputs properly • (2) hyperadrenergic state • (3) chronic bed rest 35 of 36
- 36. The End • Thanksfor coming. • Questions? 36 of 36