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Canadian Journal of Cardiology

Canadian Cardiovascular Society Position Statement on Postural Orthostatic Tachycardia Syndrome (POTS) and Related Disorders of Chronic Orthostatic Intolerance

      Abstract

      The current definition of postural orthostatic tachycardia syndrome (POTS) dates back to a small case series of patients with a subacute illness who presented with excessive orthostatic tachycardia and orthostatic intolerance, in the absence of another recognized disease. Conventional POTS criteria require an excessive orthostatic tachycardia in the absence of substantial orthostatic hypotension, and predominant symptoms of orthostatic intolerance, worse with upright posture and better with recumbence. POTS is a heterogeneous syndrome with likely several underlying pathophysiological processes, and not a specific disease. The primary panel for this Canadian Cardiovascular Society position statement sought to provide a contemporary update of the best evidence for the evaluation and treatment of POTS. We performed a systemic review of evidence for the evaluation of treatment of POTS using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology, and developed recommendations on the basis of the Canadian Cardiovascular Society approach to position statements. One identified problem was that numerous patients who did not meet criteria for POTS would still be given that diagnoses by providers to validate the illness even though this diagnosis is incorrect. This includes patients with postural symptoms without tachycardia, orthostatic tachycardia without symptoms, and those with orthostatic tachycardia but another overt cause for excessive tachycardia. We developed a novel nomenclature ecosystem for orthostatic intolerance syndromes to increase clarity. We also provide more clarity on how to interpret the orthostatic vital signs. These concepts will need to be prospectively assessed.

      Résumé

      La définition actuelle du syndrome de tachycardie orthostatique posturale (STOP) remonte à une petite série de cas de patients atteints d’une maladie subaiguë qui présentaient une tachycardie orthostatique excessive et une intolérance orthostatique, en l’absence d’une autre maladie reconnue. Selon les critères classiques, le STOP implique une tachycardie orthostatique excessive en l’absence d’hypotension orthostatique marquée, ainsi que des symptômes prédominants d’intolérance orthostatique, s’aggravant en position verticale et s’atténuant en position allongée. Le STOP est une entité hétérogène où interviennent probablement plusieurs processus physiopathologiques sous-jacents; il ne s’agit pas d’une maladie en tant que telle. Le principal groupe d’experts à l’origine de cet énoncé de position de la Société canadienne de cardiologie a cherché à présenter les données probantes les plus récentes et les meilleures en matière d’évaluation et de traitement du STOP. Nous avons effectué un examen systématique des données probantes aux fins d’évaluation du traitement du STOP conformément à la méthodologie GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) et formulé des recommandations fondées sur le cadre de référence relatif aux énoncés de position de la Société canadienne de cardiologie. Notre démarche a notamment fait ressortir une problématique, où un diagnostic de STOP avait été posé chez de nombreux patients malgré l’incongruence de leur état et des critères définissant le syndrome. Un tel diagnostic erroné avait notamment été prononcé chez des patients présentant des symptômes posturaux en l’absence de tachycardie, une tachycardie orthostatique asymptomatique ou encore une tachycardie orthostatique en présence d’une autre cause manifeste de tachycardie excessive. Par souci de clarté, nous avons élaboré un nouvel écosystème de classification des syndromes d’intolérance orthostatique. Dans la même optique, nous avons également précisé les critères d’interprétation des signes vitaux orthostatiques. Ces concepts devront être l’objet d’une évaluation prospective.
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