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Consensus statement collects recommendations on three disorders affecting CV, nervous systems
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BOSTON — The Heart Rhythm Society released a first-of-its kind expert consensus statement on the treatment of three CV disorders that affect the autonomic nervous system: postural tachycardia syndrome, inappropriate sinus tachycardia and vasovagal syncope.
“As many people get admitted through [the ED] with these disorders as with atrial fibrillation,” writing committee chair Robert S. Sheldon, MD, PhD, FHRS, from Libin Cardiovascular Institute of Alberta, Canada, told Cardiology Today. “Data are emerging, but [health care professionals] need help with how to manage these patients. It is not as visible a literature as for AF or sudden death. The evidence for almost all of what we do [with these three disorders] is average. There is a lot of work to be done.”
Postural tachycardia syndrome
When assessing patients for postural tachycardia syndrome, clinicians should perform a complete history and physical exam with orthostatic vital signs and 12-lead ECG. Complete blood count and thyroid function studies may be useful and 24-hour Holter monitoring, detailed autonomic testing, transthoracic echocardiogram tilt-table testing and exercise stress testing may be considered, according to the statement.
Treatment of postural tachycardia syndrome should be coordinated through a multidisciplinary team and inclusion of a structured exercise program is likely to be beneficial, the authors wrote. Recommended treatments that may be useful or may be considered include saline infusion (for those with short-term clinical decompensations, but not for those without), daily consumption of water and sodium chloride, fludrocortisone, pyridostigmine, midodrine, low-dose propranolol and chlonine or alpha-methyldopa (for those with hyperandregenic features). Drugs that block the norepinephrine reuptake inhibitor should be avoided, while radiofrequency sinus node modification, surgical correction of a Chiari malformation type I, and balloon dilation or stenting of the jugular vein are potentially harmful and should not be done routinely, according to the statement.
Inappropriate sinus tachycardia
The experts recommended a complete history, physical exam and 12-lead ECG for diagnosis of inappropriate sinus tachycardia. Complete blood counts, thyroid function studies, 24-hour Holter monitoring, urine/serum drug screening, autonomic testing and treadmill exercise testing could be useful, they wrote.
Clinicians should seek and treat reversible causes of the condition, and may find ivabradine (Corlanor, Amgen/Servier) useful, but sinus node modification, surgical ablation, and sympathetic denervation are not recommended for patients with it inappropriate sinus tachycardia.
Vasovagal syncope
If a clinician is uncertain about a diagnosis of vasovagal syncope, tilt-table testing can be useful, but is not recommended for predicting responses to therapies, Spencer and colleagues wrote. Implantable loop recorders can help in the diagnosis of older patients who lack a clear diagnosis and are at low risk for a fatal outcome, according to the statement.
The writing group strongly recommended education, reassurance and promoting salt and fluid intake as part of a treatment program. Reducing or withdrawing medications that can cause hypotension can also be beneficial.
In some patients with vasovagal syncope, physical counterpressure measures, fludrocortisone, beta-blockers and mitodrine are reasonable options.
The statement was created to give health care professionals “a framework to work with,” rather than making blanket pronouncements, Sheldon said. “What we are hoping to do is give people a comfort zone.”
The statement was published in Heart Rhythm and discussed at the Heart Rhythm Society Annual Scientific Sessions. – by Erik Swain
References:
Sheldon RS, et al. Special Session 15. Presented at: Heart Rhythm Society Annual Scientific Sessions; May 13-16, 2015; Boston.
Sheldon RS, et al. Heart Rhythm. 2015;doi:10.1016/j.hrthm.2015.03.029.
Disclosure: Sheldon reports no relevant financial disclosures. See the full statement for the relevant financial disclosures of the other authors and reviewers.