title: Neurocardiogenic syncope coexisting with postural orthostatic tachycardia syndrome in patients suffering from orthostatic intolerance: a combined form of autonomic dysfunction.
abstract: BACKGROUND
  There is anecdotal evidence that one or more forms of orthostatic intolerance (OI) subgroups may coexist in the same patients. However, there is a paucity of published data on the clinical features and management of patients who suffer from coexisting features of postural tachycardia syndrome (POTS) and neurocardiogenic syncope (NCS). We herein present our experience of 18 patients who we found displayed evidence of coexisting NCS and POTS.
  
  
  METHODS
  We reviewed charts of 300 POTS patients seen at the University of Toledo Syncope and Autonomic Disorders Center from 2003 to 2010 and found 18 patients eligible for inclusion in this study. Patients were included in this study if they reported clinical symptoms consistent with both POTS and NCS and then demonstrated a typical POTS pattern (a rise in heart rate without change in blood pressure [BP]) on head up tilt table (HUTT) within the first 10 minutes of upright posture followed by a neurocardiogenic pattern (a sudden fall in heart rate and/or fall in blood pressure) reproducing symptoms that were similar to the patients spontaneous episodes.
  
  
  RESULTS
  We found 18 patients, mean age (30 ± 12), with 15 (84%) women and three (16%) men, who met the inclusion criterion for this study. Each of these 18 patients demonstrated a typical POTS pattern within the first 10 minutes on initial physical exam and on a HUTT. Continued tilting beyond 10 minutes resulted in a sudden decline in heart rate (which in some patients manifested as an asystole that lasted anywhere between 10 and 32 seconds [mean of 18 seconds]) and/or a fall in BP in each of these patients demonstrating a pattern consistent with neurocardiogenic subtype of OI. The mean time to the NCS pattern of a fall in BP and heart was 15 minutes with a range of 13-20 minutes. This group of patients was highly symptomatic and reported frequent clinical symptoms that were suggestive of OI. Recurrent presyncope, syncope, orthostatic palpitations, exercise intolerance, and fatigue were the principal symptoms reported.
  
  
  CONCLUSIONS
  NCS may coexist with POTS in a subgroup of patients suffering from OI.
authors.affiliation: Section of Electrophysiology, Division of Cardiology, Department of Medicine, The University of Toledo Medical Center, Toledo, Ohio 43614, USA. blair.grubb@utoledo.edu
authors.forename: Khalil
authors.initials: K
authors.lastname: Kanjwal
authors.forename: Mujeeb
authors.initials: M
authors.lastname: Sheikh
authors.forename: Beverly
authors.initials: B
authors.lastname: Karabin
authors.forename: Yousuf
authors.initials: Y
authors.lastname: Kanjwal
authors.forename: Blair P
authors.initials: BP
authors.lastname: Grubb
mesh_terms: D000328:Adult; D001341:Autonomic Nervous System / Q000503:physiopathology*; D001794:Blood Pressure / Q000502:physiology; D005260:Female; D006339:Heart Rate / Q000502:physiology; D006439:Hemodynamics; D006801:Humans; D008297:Male; D054971:Orthostatic Intolerance / Q000175:diagnosis / Q000503:physiopathology* / Q000628:therapy; D054972:Postural Orthostatic Tachycardia Syndrome / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D019462:Syncope, Vasovagal / Q000175:diagnosis / Q000503:physiopathology* / Q000628:therapy; D018667:Tilt-Table Test