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Autonomic Disorders (Dr Jaeger 9 30 09)

Wednesday, September 30, 2009

Fredrick Jaeger, DO
Miller Family Heart & Vascular Institute, Staff Physician,
Director, Cardiac Arrhythmia Monitoring Lab, Medical Director, Center for Syncope and Autonomic Disorders


Autonomic disorders are neurological diseases which can affect the cardiovascular system, in which the autonomic nervous system ceases to function properly. Syncope, Dysautonomia and POTs or Postural Tachycardia Syndrome are different forms of this disorder and are the most common. Over one million Americans are impacted with a primary autonomic system disorder and symptoms can include problems with the heart rate, blood pressure, body temperature and perspiration. Dr. Jaeger has a special interest in syncope and provides answers to your questions about autonomic disorders.

More Information

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Fredrick Jaeger, DO a Cleveland Clinic staff cardiologist and Medical Director of the Syncope Center. Dr. Jaeger, thank you for being here with us today.

Speaker-_Dr__Fredrick_Jaeger: Thank you for having me.


Dysautonomia Symptoms

ConcernedDad: Dr. Jaeger, Since may 2009, my 16 YO son is presenting with dysautonomia. Among other problems (persistent headaches, dizziness, joint pain), he suffers with severe memory loss/amnesia symptoms. He can forget memorable events that happened minutes earlier, hours earlier, the day before etc. Major problems retaining and following schoolwork. Through last year, a solid student. All neurological work-ups (MRIs, EEGs, LP etc.) are clean/normal. Is the severe memory loss/amnesia described above consistent with the "brain fog" and "concentration" symptoms that are described in various dysautonomia brochures and websites? Can it be that severe? Thanking you in advance for any assistance you can bring on this particular symptom of dysautonomia. --Concerned Dad

Speaker-_Dr__Fredrick_Jaeger: Sorry about your son. In general, the cognitive impairment in patients with dysautonomia is usually described as moderate although occasionally I will see someone with severe impairment. I assume he has had neuro-cognitive testing. Our neurologists frequently perform a comprehensive evaluation to look for any structural neurologic disease and as a cardiologist I will attempt to treat the other blood pressure and heart rate components of the dysautonomia. If you are interested in further evaluation - we would be happy to see your son.

smartN: My question follows: have been evaluated and tested by many neurologists in the year after my left total hip replacement (April 2008)--with no resulting diagnosis for blurred vision and poor balance. Only daily vigorous physical exercise has helped to alleviate these symptoms temporarily. After my second total hip replacement (June, 2009) my periods of blurry vision and poor balance have increased from early in the day and I experience these symptoms throughout the entire day. I have continued with my exercise program, which lessens the symptoms. Here is my question--what, besides daily exercise, should I be doing next? I've done some recent reading on dysautonomia and some of the symptoms sound like what I have, and am, experiencing.

Speaker-_Dr__Fredrick_Jaeger: You should have comprehensive dysautonomia testing

Broken_shell: I experience symptoms of dysautonomia but do not have large fluctuations in heart rate or blood pressure. Is this common? I have heard that the symptoms are related more to distribution of blood flow that is not readily analogous to peripheral BP measurements. What is a good target BP for patients with orthostatic intolerance but not orthostatic hypotension? Why are the symptoms of dysautonomia so pronounced during the first half of the day and usually less severe in the late afternoon and evening? Why do the symptoms of dysautonomia and the body systems they affect vary so much from day to day and throughout each day?

Speaker-_Dr__Fredrick_Jaeger: The hallmark of POTS is an over-activity of heart rate in response to exercise or common daily activities. This may or may not be accompanied by abnormalities in blood pressure. There is no target blood pressure other than to try to keep it in the normal range. Symptoms of dysautonomia can affect people at any time during the day.

LRHays: Is it true that POTS can go away?

Speaker-_Dr__Fredrick_Jaeger: It has been estimated that up to 80 percent of patients with dysautonomia such as POTS can have spontaneous resolution of their symptoms. However, the interval to elimination of symptoms is extremely variable and can be as short as months or as long as years - or rarely decades.

Dmeri6: I have had POTS for three and a half years with severe fatigue. However, recently I have been have energy level swings. Either I'm exhausted or have an overabundance of energy. When I'm tired I have a very strong appetite and when I'm full of energy it's hard for me to anything down, and eating certain things just make my energy burst worse. I believe this is my body producing adrenaline to increase blood flow. I was wondering if you had another theory or any suggestions. Also, my hands and feet can get red/purple and splotchy. Is this a sign of blood pooling? I don't notice it anywhere else.

Speaker-_Dr__Fredrick_Jaeger: The discoloration or mottling of the extremities is a common symptom of dysautonomia. It could reflect lack of appropriate blood vessel constriction leading to venous pooling. The fluctuation of your energy levels certainly could be related to over activity of the adrenaline system - and if you have not had blood tests or urinary tests for adrenaline - they should be performed.

LRHays: I woke up with a headache, 2 years ago, that has yet to go away. I do have many minor symptoms, but the headache is the worst and most debilitating. I was diagnosed with POTS last October and was told the headache would go away as I got the POTS under control. However the headache hasn't changed, and has even been getting worse. I've tried everything (drugs, alternative medicine, etc). Is this common for POTS patients? Could I be misdiagnosed?

Speaker-_Dr__Fredrick_Jaeger: Headache is extremely common with POTS patients. Many times the treatment of headache requires a different protocol than the POTS treatment. Here at the Cleveland Clinic I work closely with the headache neurologists who have an extremely high success rate in treating the headache component of the dysautonomia. Occasionally but not always drugs like beta blockers and the serotonin re-uptake inhibitors can be helpful for both.

Sorkvild: I am a recovering POTs patient and while most of my symptoms have improved, one that shows no sign of improvement is my altered vision. Since having POTs, images I see in the foreground and background of what I’m focusing on are doubled, with the distance between the two images being dependent on how close they are to me (closer to me, farther apart the objects are). I also have faint double vertical vision which is mostly apparent while looking at small bright lights in dark areas. I also have what appear to be permanent floaters in each eye, each having the exact same shape and size since having POTs. Finally, I have "visual snow", which is probably the most frustrating problem right now. Thank you so much for taking the time to look at my question and I hope you can offer some suggestions.

Speaker-_Dr__Fredrick_Jaeger: visual disturbances are frequently reported. Although by your description they may be separate from your POTS symptoms and you should see a neuro-opthamologist. Certainly get appropriate imaging of the eye and the part of the brain that controls vision. There are many disorders that affect the eye besides POTS - including a long list of neuromuscular diseases - you certainly should be evaluated.

primitivesplayer: Hello, I am a 61 year old female with multiple health problems , cabag done i 07, kidney stents in 07, and left carotid artery cleaned out 6 months ago , my meds are as follows atenelol 50 mg 2xdaily avaprp 150 1 daily lopid 600 mg 2 daily zocor 80 mg 1 daily plavix 1 daily 81 mg baby asprin daily nexium 2 daily lexapro 10mg 1 daily 4 fish oil daily 1000mg estrogen patch 0.025 one weekly xanax .25 mg 2 daily. My problem is that I have alot of erratic blood pressure reading when it gets to like 95 over 33 i am very sick passed out once about 2 weeks ago going up stairs is wicked after a large meal same . I walk 7 days a week and no symptoms odd I think . Sometimes it feels just horrible takes about 5 or so minutes to go away . Any input would be very helpful. Thank you so much for this forum sorry I am not much of a typer. God bless.

Speaker-_Dr__Fredrick_Jaeger: Post parandial hypotension - or hypotension that occurs after eating is very common in dysautonomia and with the conditions that you mentioned. Obviously small frequent meals to prevent pooling of blood in the intestines can help - frequently support stockings can also be helpful. We actually do testing that I mentioned previously that look at changes in blood pressure with changes in posture - there for testing would be helpful for you.

ken870: Is there a medicine that can help with blood pooling and if not what can be done for blood pooling in your stomach and legs and feet?

Speaker-_Dr__Fredrick_Jaeger: The best treatment for blood pooling or what we call venous pooling is daily regular exercise and compression stockings. Medical options include blood volume expanders such as Florinef which can improve blood vessel constriction, reflex responses - also beta blockers and Midodrine are helpful in this regard.

Dysautonomia Medications

anniekins: I have read that using opiates and some other medications can cause or make dysautonomia symptoms worse. If this is true would it be likely to make symptoms better if these drugs were stopped?

Speaker-_Dr__Fredrick_Jaeger: Narcotics, pain medicine, sleeping medications all may worsen the autonomic system including causing low blood pressure and affecting bowel and bladder activity and are best avoided.

Dysautonomia Diagnostic Testing

Broken_Shell: What type of monitoring and tests should someone with dysautonomia have on a regular basis (specific to their having dysautonomia)?

Speaker-_Dr__Fredrick_Jaeger: There are no specific regular tests other than postural blood pressure and heart rate checks that we do at every visit.

If we have patients on medications we may monitor blood work, renal function, electrolytes periodically. If patients symptoms are not responding we will routinely restage them with further autonomic testing such as tilt test and blood volume test to assess the effect of medication changes


POTS Symptoms

Rpap: I have POTS (undiagnosed for 33 years) and debilitating fatigue. Are there any new treatments or meds that could help me keep from lying down on and off all day? By about 7 PM I'm in bed for the night. I do walk/elliptical 3-6 days/week. I've tried adderall xr,wellbutrin, various antidepressents, flurinef, provigil (in excess of the max dosage), etc. Nothing helps with the unrelenting fatigue.

Speaker-_Dr__Fredrick_Jaeger: The medications you listed are certainly common ones prescribed by our group and neurologists who treat POTS. The drugs like metinon have also been used in patients with POTS who have evidence of small fiber neuropathy.

The exercise that you mention is probably as important if not more important than any pharmacologic regimen. You should continue daily if possible - it does not have to be extreme or to the point of exhaustion.

MomofDan: Please explain why low blood volume, or hypovolemia, is a common symptom of POTS. In what way does the ANS regulate blood volume?

Speaker-_Dr__Fredrick_Jaeger: The reasons for low blood volume in patients with dysautonomia are many. Young patients in particular may have inadequate salt intake or have extremely efficient kidneys that eliminate sodium resulting in hypovolemia. Persistent tachycardia is also frequently associated with hypovolemia because of its effect on renal hormones that control blood volume.

Elizabeth: Dr. Jaeger, My 20 year daughter was diagnosed recently with POTS. She is having convulsions and epilepsy was ruled out by videography. Many tests confirmed POTS. Since starting salt and water, convulsive episodes have decreased to 1-2 week. However when she has them, she loses consciousness, has posturing, closing of throat and very impaired breathing, with jaw clenching. These last 30-60 minutes. Is this common to POTS and is she at risk for stroke or death? What should we do? Is something else going on?

Speaker-_Dr__Fredrick_Jaeger: It sounds that her form of dysautonomia also has concomitant syncope which can reflect vasovagal being the most common. We always do an assessment of the heart in our syncopal patients and in our POTs patients. In the absence of heart disease or arrhythmias, stroke and heart attack - death from fainting spells is very rare. If this has not been done - she should have a comprehensive cardiovascular exam to address your concerns

StacyRN: If a person has POTS for years, does the tachycardia shorten your lifespan? I am an RN trying to cope with 12 hour shifts and POTS. Am I making the POTS worse by pushing myself so hard?

Speaker-_Dr__Fredrick_Jaeger: Since our understanding of the importance of dysautonomia such as POTS is relatively recent, there are no long term studies on survival. However - as I indicated in a previous question there is a high incidence of normalization of heart rate or resolution. My suspicion is that there is probably no reduction in survival assuming that the rest of the cardiovascular system and structure is normal. Frequently patients need to accommodate their work schedule around their symptoms.

paula_l: My questions are as follows: 1. Does POTS usually cause neurological symptoms like head pressure? 2. I know that most people grow out of POTS, but since her cancer was so rare do you think it's more unlikely for her to grow out of it?3. Is it okay to push her to do more? She should be in college (locally), but does not feel consistently well enough to go. What are your thoughts on this?4. Have you seen other cases like ours, and is there anywhere you can direct me to help her return to a normal life?5. My daughter has this weird feeling in her heart where it feels very heavy, like it's being squeezed. It only lasts for a few seconds and then it goes away. Is this due to POTS or is it something we should get checked?

Speaker-_Dr__Fredrick_Jaeger: Your daughter's case is certainly unusual and from your description would be consistent with one of the secondary types of POTS syndromes not the usual garden variety.

The treatment with plasmapheresis has helped many patients with these types of dysautonomias as well as IV IG injections and some patients with immunologically mediated POTS. There are several excellent centers in the NY area including Columbia and others that deal with autonomic dysfunction. Regarding with getting on with her life - this is a complex decision best made by her and her treating physicians.

fabracey: My 17 year old daughter has been struggling with every symptom of POTS for almost 2 years. one of the worst problems besides fainting is her constipation, what can be don’t for this?

Speaker-_Dr__Fredrick_Jaeger: Please refer to your family doctor or a GI specialist for this symptom.

POTS and Pregnancy

alange3: Are there any risks or problems a woman with POTs should be aware of during pregnancy?

Speaker-_Dr__Fredrick_Jaeger: Sure - frequently POTS symptoms transiently improve during pregnancy due to hormonal affects in blood volume expansion. However, the opposite can also occur and may certainly lead to worsening symptoms during pregnancy and delivery. The medication choices are very limited during the first trimester but there are some medications we can use safely during the second and third trimester. I frequently work closely with obstetricians who have experience with POTS patients and can get them successfully through delivery.

POTS Diagnostic Testing

love4kids: What tests should be done to see if I really have POTS??

Speaker-_Dr__Fredrick_Jaeger: The tilt test is the gold standard test.

fabracey: How did my daughter all of a sudden got POTS 2 years ago?-- she is 17 now. Is it genetic?

Speaker-_Dr__Fredrick_Jaeger: It is known to run in some families occasionally. There is a rare enzyme deficiency that can run in families that gives a POTS type syndrome.

POTS Treatment

kristeen11: How well do you think the epogen injection works for POTS Patients?

Speaker-_Dr__Fredrick_Jaeger: There are no controlled studies using epogen in patients with dysautonomia. However - I have occasionally seen it utilized with variable effects. It is very expensive and has some potential risks associated with its use. It also requires careful monitoring. It is certainly not a first line medication.

alange3: I was diagnosed with POTs a few years ago when my symptoms were at their worse and my blood pressure was dropping drastically while my heart rate increased rapidly. (The episodes had my resting heart rate of 65ish increase to 160 and blood pressure dropping from 110/80ish to 70/50ish bottoming out around 55/40.) I have never lost consciousness as a result from an episode but would frequently go through fainting symptoms slowly, almost always resulting in vision loss. The symptoms have dulled dramatically in the past few years, but recently my heart rate is rising during episodes but my blood pressure is only having mild changes. Do you have any suggestions of medications or treatments to keep my heart rate from increasing so dramatically?

Speaker-_Dr__Fredrick_Jaeger: In cases such as yours - we perform extensive autonomic testing to look at the underlying mechanisms - blood pressure and heart rate instability - including actually measuring your blood volume, the degree of blood volume distribution and pooling, the interaction of the autonomic nervous system and the brain and heart as well as the various components of the adrenaline and vagal side of the autonomic nervous system. We can then tailor a pharmacologic regimen based upon those results.

kristeen11: What do you think the best line of treatment is for pots patients that seem to be intolerant to medications such as midodrine, beta blockers, calcium channel blockers, ssri's etc.????

Speaker-_Dr__Fredrick_Jaeger: I will refer to the previous question - where we do extensive testing and evaluation to determine the best treatment.

POTS and other Conditions

Jewel: Hello Dr Jaegar. Thank you for your time. I have a diagnosis of severe POTS with Neurocardiogenic Syncope and NMH. I have read on occasion that having NCS , NMH and other blood pressure issues on standing precludes a diagnosis of classical POTS. Is this true ?

Speaker-_Dr__Fredrick_Jaeger: No - I don't think they are mutually exclusive.

Roseannecl: My daughter has very severe POTS and NMH.She also has severe CFS. All these issues started on the same day 8 years ago. She has tried many meds but has tolerated none. She is very worried about how deconditioning might affect her POTS and NMH yet finds due to her CFS that exercise can makes her problems much worse and the backlash she experiences after it is severe and can last months. Are there any tips on how to handle avoiding deconditioning while being very ill and unable to exercise?

Speaker-_Dr__Fredrick_Jaeger: We frequently utilize the expertise of physiatrists and rehab specialists to improve the cardiovascular adaptations in patients with POTS and chronic fatigue. An exercise prescription is tailored to the individual. Consult a supervised cardiac rehabilitation program.

AJS: I was wondering if it's common for a person with an autonomic disorder to have a positive ANA blood test. I tested positive for the SS-A antibody but was assured I do not have Lupus. Can this be connected at all? (I also had a positive tilt table test) Your guidance would be appreciated. Thanks!

Speaker-_Dr__Fredrick_Jaeger: Connective tissue diseases have been associated with dysautonomia, such as POTS. The relationship of positive ANA titers to possible POTS is unknown. It would make sense that they could be related given that one of the theories of POTS is that it is an autoimmune disease - but certainly much more research is needed to confirm the association.

Msaw: Should people with POTS & Ehlers-Danlos Syndrome (joint hypermobility syndrome) be checked for Chiari malformation?

Speaker-_Dr__Fredrick_Jaeger: We will screen people for our genetics center for Ehlers Danlos in particular what type as there are many people who are misdiagnosed. We also screen for chiari malformation through our neurosurgical colleagues through MRI.


ggnclinic: What is the importance of Head Tilt Table Testing in evaluation of syncope?

Speaker-_Dr__Fredrick_Jaeger: If a patient has recurrent syncope and their cardiovascular structure is normal and their electrical structure is normal then the most likely cause of the syncope is most likely vasovagal syncope - which is the exaggerated form of the common faint.

Tilt table is very helpful in confirming the diagnosis by testing susceptibility in the common faint - in addition - the tilt table is the standard test to look for the POTS form of dysautonomia - which may or may not have tendency toward fainting.

General Information and Resources

anlaki: I have an appointment with Dr. Shields on November 23, 2009. I have already had the tilt test, QSART test, and EMG. I was diagnosed with Ehler Danlos and know that when I am standing I do not get enough blood flow to the brain. Will Dr. Shields be able to do the blood flow test and transdoppler test that you would perform? I tried to get in to see you on the same date, but you are out of town. Tilt test showed excessive heart rate QSART test showed no response at all sites, and emg was borderline.

Speaker-_Dr__Fredrick_Jaeger: Dr. Shields is my colleague in our center for syncope and autonomic disorders and has considerable expertise in the evaluation of patients who have the problems that you are describing. He routinely orders the blood volume test and other cerebral flow tests. I would suggest that you submit your records to his office and perhaps touch base with him or his nurse to preschedule any additional testing that may be required.

Cleveland_Clinic_Host: Dr Jaeger, earlier in the chat you mentioned Cleveland Clinic's Center for Syncope and Autonomic Disorders. Can you please provide more information on the center and how to make appointments if need be?

Speaker-_Dr__Fredrick_Jaeger: The Center for Syncope and Autonomic Disorders has evolved over the last two years to incorporate diverse specialists and subspecialists devoted to the treatment of autonomic disorders.

We currently have two cardiologists who focus on the blood pressure and heart rhythm aspects of dysautonomia and have four autonomic neurologists, three adult and one pediatric - that work with us closely. We offer extensive testing of the autonomic nervous system which is currently centralized in the Heart and Vascular Institute of the Cleveland Clinic. The tilt table test was developed and introduced by the Clinic in the early 80s but our center has certainly grown to offer all the above diagnostic and therapeutic modalities.

We have the resources of the entire Cleveland Clinic including gastroenterologists, headache and epilepsy neurologists to assist us with our patients.

ykthomas: How can I explain this disorder to my family doctor and other medical personnel? It seems no one has heard of it.

Speaker-_Dr__Fredrick_Jaeger: Dysautonomia is becoming frequently recognized as a significant health issue but unfortunately has not been routinely emphasized in the training of young doctors in the past. Many medical centers now are establishing autonomic treatment centers. There are also many web resources available for your family doctor. I will post these at the end of the chat.

Cleveland_Clinic_Host: Thank you again Dr. Jaeger for taking the time to answer our questions about Autonomic Disorders today.

Speaker-_Dr__Fredrick_Jaeger: Thank you for having me - our website has more information for you - here are additional resources:

Technology for webchats paid in part by an educational grant from AT&T Ohio and the AT&T Foundation (formerly SBC).

Reviewed: 09/09

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