POTS and Inappropriate Sinus Tachycardia

Podcast Transcript

Announcer:

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Oussama Wazni, MD, MBA:

Hello, everyone. And welcome once more to Cleveland Clinic Electrophysiology podcast. I am Oussama Wazni, I'm the section head of EP here at the Cleveland Clinic. And today with me, I have Dr. Ken Mayuga, the Director of the Syncope Center. So welcome, Dr. Mayuga. Dr. Courson, welcome, and thank you for joining us. So could you tell us a little bit about your experience here at the Cleveland Clinic Syncope Center, and also, your interests that you take care of at the Clinic?

Jeffery Courson, DO:

Sure. I started here at main campus a little over a year ago. Before that, I had been involved with Cleveland Clinic, but through Akron General. Syncope has been a big part of my practice throughout my career. Although here, it's pretty much where all of my energy focuses on. So my interests are syncope, whether it's heart rhythm related or non-heart rhythm related. And in truth here, it's mostly the non-heart rhythm related patients that I'm dealing with. And then, I think of the tachycardia disorders, which are POTS and inappropriate sinus tachycardia, are probably the brunt of my non-syncope related practice.

Oussama Wazni, MD, MBA:

So we covered most of this, but you brought up a new one here, the inappropriate sinus tachycardia. Could you tell us a little bit more about inappropriate sinus tachycardia, how it's diagnosed, and what are the management challenges? And also, what are the management options?

Jeffery Courson, DO:

Sure. Inappropriate sinus tachycardia is a particular syndrome, that it is very similar to POTS. In fact, that it really affects largely, the same group, tends to be young, healthy women. For some reason, we don't really understand, there's a very high prevalence in nurses and healthcare workers. Just like with POTS, they have a lot of symptoms beyond just racing heartbeats and tachycardia. They tend to have a lot of orthostatic intolerance, like POTS patients do. So that if you do a tilt test on a POTS patient, you get a very exaggerated jump in their heart rate. You get the same response in a patient with inappropriate sinus tachycardia, that just usually, is not quite as exacerbated of a heart rate response. Both POTS patients and inappropriate sinus tachycardia patients have a lot of trouble doing activity. They get very fatigued, very short of breath pretty quickly, when they exert themselves doing physical exercise. The difference is, with POTS, that postural is a key component. If you have a POT's patient, and they lay flat, their heart rate's going to be normal. Whereas, an inappropriate sinus tachycardia patient, when they lay flat, their heart rate's actually still going to be fast. It might be in the 90s, but it's still faster than normal.

Jeffery Courson, DO:

So the same group that you think of POTS, is also the same group that's typically affected by inappropriate sinus tachycardia. And they tend to have a lot of the same key symptoms and features. One of the best ways to differentiate it, beyond the tilt test or an active stand test, is to do a heart monitor, and typically just even a 24 hour monitor. With a POTS patient, their average heart rate's going to be normal. They're actually at rest and recumbent much more than their up and active, so their overall average heart rate will be normal. With an inappropriate sinus tachycardia patient, their average heart rate's going to be fast. We classically think over 100 beats per minute, but even into the high 90s is pretty typical.

Oussama Wazni, MD, MBA:

So let me just here quickly summarize. So inappropriate sinus tachycardia is basically, sinus tachycardia means fast heart rate coming from the normal area of the heart where the heart generates a heartbeat. So sinus tachycardia just means, fast heart rate. But inappropriate sinus tachycardia means, that it's present all the time. And why is it called inappropriate? It's because it is appropriate for the heart rate to be fast, when a patient, for example, is excited or anxious, or in acute illness, or in pain, so that is appropriate. Or running, for example, jogging, that would increase the heart rate, and that's why we call that appropriate. Inappropriate means that it's happening at rest, when there is no explainable, or there is no reason, for this heart rate to be increased, but it is. And that's why it's called inappropriate sinus tachycardia. While it is mostly benign, it causes a lot of symptoms that are very difficult for patients to deal with. So Dr. Courson, how do we manage? We went through the diagnosis, now just tell us briefly, what are the treatment options of inappropriate sinus tachycardia?

Jeffery Courson, DO:

I would say, both inappropriate sinus tachycardia and POTS can be both very challenging to treat both. For inappropriate sinus tachycardia, lifestyle management is used very similar to what we do with POTS. And I emphasize, if they have orthostatic symptoms, a lot of the same type of lifestyle maneuvers, exercise, retraining the heart to accept that response with the tachycardia and improve functional status is very important. And I think, that for most patients with inappropriate sinus tachycardia, we use medicines to try to mitigate or lower the heart rate response. There is some centers that will focus on ablation, but really, ablation is not very effective, and it carries a fair amount of risk. So that should be used very carefully, as part of the treatment plan.

Oussama Wazni, MD, MBA:

Thank you, Dr. Courson. I want to thank you both for joining me today, regarding our Syncope Center. Just also for background, our syncope center, it probably sees more patients than any other syncope center in the world. We have patients from all over the world coming to seek your expertise in managing and diagnosing managing, and also, treating these conditions.

Oussama Wazni, MD, MBA:

We talked about syncope, and we said that, most syncope is really, what we call common fainting. In other cases, we have arrhythmia related syncope, meaning, it's because either the heart is too slow or too fast. And then, we talked about POTS, which means that, the heart rate increases when standing up. So it's normal when people are lying flat or sitting, and then it increases with standing up. But just by doing so, patients have a lot of symptoms, and we try to help them with that, and went over the options and the treatment challenges there. And then finally, we talked about inappropriate sinus tachycardia. And by that, I think we've covered the most of the spectrum. Do any of you have any final thoughts, or things to tell our patients when considering coming to the Cleveland Clinic for this range of problems?

Kenneth Mayuga, MD:

That's a wonderful summary, Dr. Wazni. I would like to add that, no matter where you're coming from, be it Ohio, or California, or another country, the Cleveland Clinic is always prepared to help you. We have many resources, a lot of support to help patients who travel a distance to come here, and more than happy to help you and your local care providers in helping you feel better.

Oussama Wazni, MD, MBA:

Thank you. Thank you so much. And thank you all very much for your attention, and I hope you found this helpful, and hopefully, we'll see you in the next podcast.

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