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Europace Advance Access originally published online on October 19, 2007
Europace 2007 9(12):1202; doi:10.1093/europace/eum235
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org

SYNCOPE

Symptom improvement in postural orthostatic tachycardia syndrome with the sinus node blocker ivabradine

Victoria Ewan1, Michael Norton1 and Julia L. Newton1,2,*

1 Falls and Syncope Service, Institute for Cellular Medicine, Newcastle University, Newcastle NE2 4HH, UK; 2 Fatigue Interest Group, Institute for Cellular Medicine, Newcastle University, Newcastle NE2 4HH, UK

* Corresponding author. Tel: +44 191 2824128; fax: +44 191 222 5638.E-mail address: julia.newton{at}nuth.nhs.uk


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Here, we present a patient diagnosed with chronic fatigue syndrome/myalgic encephalomyelitis at the age of 15. She presented at that age with sudden onset of symptomatic palpitations after a viral illness. Over a period of days, she subsequently developed debilitating fatigue. Thyroid function tests and catecholamines were normal. Twelve lead ECG confirmed sinus tachycardia.

She was referred to our Tertiary referral Cardiovascular Investigation unit at the age of 21. At that time, her fatigue score (measured by Fatigue Impact Score (FIS) (range 0–160)) was 102 and orthostatic grading scale (OGS) 19 (range 0–20). Active stand confirmed the diagnosis of postural orthostatic tachycardia syndrome (POTS) (increase of >30 bpm from baseline or greater than 120 bpm within 10 min of standing in the absence of postural hypotension and demonstrable autonomic neuropathy) (Figure 1A). She was unable to tolerate beta-blockers (asthma) and verapamil (nausea). Despite conservative, non-pharmacologic treatment including volume expansion her symptoms persisted. Use of the sinus node blocker ivabradine at a dose of 2.5 mg twice daily and subsequently 5 mg twice daily led to dramatic improvements in subjective and objective symptomatology (FIS 52, OGS 9) in line with a reduction in heart rate on standing (Figure 1B). In conclusion: This case highlights the potential for the sinus node blocker ivabradine in the treatment of resistant POTS. Use of this medication appears to not only improve tachycardia but also symptomatology, including fatigue. A randomised controlled trial is needed.


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  		Figure 1 Continuous heart rate (25 mm/s) and blood pressure (Taskforce;CNSystems, Austria) in a patient with POTS and fatigue before (A) and after (B) treatment with 5 mg b.d of ivabradine. Standing is shown by red arrow. The patient has given consent for the use of these images, this can be provided on request.

 

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All authors participated in writing of this article.

Conflict of interest: none declared.


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This Article
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