Date of Award

Spring 2021

Degree Name

Master of Medical Science (Physician Assistant)

Department

Physician Assistant; College of Health Sciences

First Advisor

Allison Ermol

Abstract

Abstract:

Introduction: Postural orthostatic tachycardia syndrome (POTS) is a form of orthostatic intolerance prominent in young females, and can be difficult to diagnose and treat. POTS is defined as a clinical syndrome of orthostatic intolerance that has a heart rate (HR) increase of 30 beats per minute (BPM) or more, with a standing HR of >120 bpm in the context of a 10 minute standing orthostatic intolerance test, with the absence of orthostatic hypotension (a decrease in systolic blood pressure (BP) of ~20 or more mmHg with or without a decrease in diastolic BP of ~10 or more mmHg). There are common conditions/comorbidities that may occur which may not be physiologically explained by the orthostatic intolerance or tachycardia. These symptoms include chronic fatigue, dizziness, syncope, migraines, GI disorders, nausea, fibromyalgia, joint hypermobility, and cognitive disturbances. As a result of this uncertainty with treatment, and wanting what is best for the patient in the long run, this poses the following question: In adult women (18-45 years old) diagnosed with POTS who experience comorbidities of daily fatigue and “brain fog” [P], will stimulants be the most beneficial treatment for these symptoms [I], as opposed to the current standard of care (exercise) [C] for symptomatic relief [O]? This study will evaluate different clinical trials and studies that look at the effects of stimulants in POTS management versus exercise and the outcomes of these interventions.

Methods: A literature search was conducted on Pubmed, Google Scholar, and Ovid, with all of the articles found being from Pubmed. A randomized control trial, two longitudinal studies, a questionnaire, and two retroactive studies were chosen to be analyzed and compared. These studies were chosen based on which were most relevant to this analysis.

Results: The evidence collected yielded some confounding information. One study compared modafinil to a placebo, and this did not yield any statistically significant results of modafinil having better outcomes than a placebo. Two studies were longitudinal studies which followed POTS patients completing exercise programs. These showed statistically significant improvement in the symptoms of the patients that were able to complete these programs. Two retrospective studies aimed at studying if stimulants were helpful to patients with cognitive decline. These studies found that it did help these patients subjectively, however the collection and analysis of results in these studies were unreliable.

Discussion: Each of the studies had differing outcome measures, so comparing them was a difficult process. Only one study used blinding and it would have been ideal to have more of these studies available. There was lack of long term data/follow up, which is another area which needs to be researched more extensively. The use of an exercise program was statistically significant in improving the symptoms and quality of life of POTS patients. There were not any negative health outcomes reported for any of the interventions (exercise or stimulant therapy), but long term follow-ups were not completed. Further studies of these topics is necessary for clinical application of stimulant medications.

Conclusion: Stimulant therapy has been shown to help cognitive function in those with ADHD, but no studies have confirmed its benefit in those with POTS who experience cognitive impairment. It is important to use the least amount of medication for the maximum benefit in these patients because they often get prescribed multiple medications to treat symptoms because they can be very bothersome. Medications come with side effects, and when patients are on multiple medications, it may be difficult to know which symptoms are from the disease or from medication. More research needs to be done in the utilization of stimulant medication in the POTS population. Exercise has shown to be effective at improving the quality of life of those with this disease. Further research is necessary to find the most beneficial treatment for these patients that they will be compliant with.

Additional Files

PICO.mp4 (13011 kB)
Brief synopsis of poster

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Stimulant Vs. Exercise Use for Symptomatic Relief in Postural Orthostatic Tachycardia Syndrome

Abstract:

Introduction: Postural orthostatic tachycardia syndrome (POTS) is a form of orthostatic intolerance prominent in young females, and can be difficult to diagnose and treat. POTS is defined as a clinical syndrome of orthostatic intolerance that has a heart rate (HR) increase of 30 beats per minute (BPM) or more, with a standing HR of >120 bpm in the context of a 10 minute standing orthostatic intolerance test, with the absence of orthostatic hypotension (a decrease in systolic blood pressure (BP) of ~20 or more mmHg with or without a decrease in diastolic BP of ~10 or more mmHg). There are common conditions/comorbidities that may occur which may not be physiologically explained by the orthostatic intolerance or tachycardia. These symptoms include chronic fatigue, dizziness, syncope, migraines, GI disorders, nausea, fibromyalgia, joint hypermobility, and cognitive disturbances. As a result of this uncertainty with treatment, and wanting what is best for the patient in the long run, this poses the following question: In adult women (18-45 years old) diagnosed with POTS who experience comorbidities of daily fatigue and “brain fog” [P], will stimulants be the most beneficial treatment for these symptoms [I], as opposed to the current standard of care (exercise) [C] for symptomatic relief [O]? This study will evaluate different clinical trials and studies that look at the effects of stimulants in POTS management versus exercise and the outcomes of these interventions.

Methods: A literature search was conducted on Pubmed, Google Scholar, and Ovid, with all of the articles found being from Pubmed. A randomized control trial, two longitudinal studies, a questionnaire, and two retroactive studies were chosen to be analyzed and compared. These studies were chosen based on which were most relevant to this analysis.

Results: The evidence collected yielded some confounding information. One study compared modafinil to a placebo, and this did not yield any statistically significant results of modafinil having better outcomes than a placebo. Two studies were longitudinal studies which followed POTS patients completing exercise programs. These showed statistically significant improvement in the symptoms of the patients that were able to complete these programs. Two retrospective studies aimed at studying if stimulants were helpful to patients with cognitive decline. These studies found that it did help these patients subjectively, however the collection and analysis of results in these studies were unreliable.

Discussion: Each of the studies had differing outcome measures, so comparing them was a difficult process. Only one study used blinding and it would have been ideal to have more of these studies available. There was lack of long term data/follow up, which is another area which needs to be researched more extensively. The use of an exercise program was statistically significant in improving the symptoms and quality of life of POTS patients. There were not any negative health outcomes reported for any of the interventions (exercise or stimulant therapy), but long term follow-ups were not completed. Further studies of these topics is necessary for clinical application of stimulant medications.

Conclusion: Stimulant therapy has been shown to help cognitive function in those with ADHD, but no studies have confirmed its benefit in those with POTS who experience cognitive impairment. It is important to use the least amount of medication for the maximum benefit in these patients because they often get prescribed multiple medications to treat symptoms because they can be very bothersome. Medications come with side effects, and when patients are on multiple medications, it may be difficult to know which symptoms are from the disease or from medication. More research needs to be done in the utilization of stimulant medication in the POTS population. Exercise has shown to be effective at improving the quality of life of those with this disease. Further research is necessary to find the most beneficial treatment for these patients that they will be compliant with.