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Orthostatic Intolerance Symptoms Are Associated with Depression And Moon et al. Health and Quality of Life Outcomes (2016) 14:144 DOI 10.1186/s12955-016-0548-x RESEARCH Open Access Orthostatic intolerance symptoms are associated with depression and diminished quality of life in patients with postural tachycardia syndrome Jangsup Moon1,3, Do-Yong Kim1, Jung-Ick Byun1,4, Jun-Sang Sunwoo1,5, Jung-Ah Lim1,3, Tae-Joon Kim1,3, Jung-Won Shin6, Woo-Jin Lee1,3, Han Sang Lee1,3, Jin-Sun Jun1,3, Kyung-Il Park2, Keun-Hwa Jung1,3, Soon-Tae Lee1,3, Ki-Young Jung1,3, Kon Chu1,3* and Sang Kun Lee1,3* Abstract Background: Patients with postural tachycardia syndrome often appear depressive and report diminished quality of life (QOL). In the current study, we first evaluated if the maximal heart rate (HR) increment after standing is associated with the clinical symptoms in patients with excessive orthostatic tachycardia (OT). Next, we investigated the correlations among the symptoms of orthostatic intolerance (OI), depression, and health-related QOL in these patients. Finally we assessed if patients with minimal OI symptoms suffer from depression or diminished QOL. Methods: We performed a comprehensive questionnaire-based assessment of symptoms in 107 patients with excessive OT with a ≥ 30 beats/min heart rate increment (or ≥ 40 beats/min in individuals aged between 12 and 19) within 10 min after standing up. An existing orthostatic intolerance questionnaire (OIQ), the Beck depression inventory-II (BDI-II), and the 36 Item Short-Form Health Survey were completed prior to any treatment. Correlation analyses among the items of the questionnaires and other parameters were performed. Additionally, patients with minimal OI symptoms were analysed separately. Results: The maximal orthostatic HR increment was not associated with the clinical symptoms. The OI symptoms were significantly correlated with depression and diminished QOL. The BDI-II score demonstrated a positive linear relationship with total OIQ score (r = 0.516), and both physical and mental component summary scales of SF-36 showed a negative linear relationship with total OIQ score (r = -0.542 and r = -0.440, respectively; all p <0.001). Some OI symptoms were more strongly associated with depression, and others were more strongly related to QOL. Chest discomfort and concentration difficulties were the most influential OI symptoms for depression, while nausea and concentration difficulties were the most influential symptoms for physical and mental QOL, respectively. Dizziness and headache were the two most common complaints in patients with mild to moderate OI symptoms. In addition, subjects with minimal OI symptoms also had considerable deterioration in QOL. Conclusion: The OI symptoms, but not the maximal HR increment, are significantly correlated with depression and diminished QOL in patients with excessive OT. Therefore, pervasive history taking is important when encountering patients with excessive OT. Keywords: Orthostatic intolerance, Depression, Quality of life, Correlation, Postural tachycardia syndrome * Correspondence: [email protected]; [email protected] 1Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea Full list of author information is available at the end of the article © 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Moon et al. Health and Quality of Life Outcomes (2016) 14:144 Page 2 of 9 Background Methods Postural tachycardia syndrome (POTS) is a clinical Participants syndrome usually characterized by an excessive incre- Patient with excessive OT were recruited from either ment of heart rate (HR) upon standing with frequent neurology outpatient clinics or the Center for Epi- symptoms of orthostatic intolerance (OI). A diagnosis lepsy and Autonomic Disorders of the Seoul National of POTS requires a HR increment ≥ 30 beats/min University Hospital. The main causes of admission (bpm) (or ≥ 40 bpm in individuals aged between 12 were recurrent dizziness, headaches, loss of con- and 19) within 10 min after standing from a recum- sciousness, convulsive movements, or other paroxys- bent position, in the absence of orthostatic mal symptoms requiring the exclusion of syncope or hypotension [1]. However, some reports have shown seizure disorders for accurate diagnosis. Orthostatic that a certain portion of healthy individuals experi- vital sign (OVS) tests were performed twice in every ence a HR increment of ≥ 30 bpm after standing (up patient except for one patient who had one OVS test to ~30 %), especially in the morning [2]. Therefore, and one head-up tilt test. The OVS test was per- symptoms of OI may be crucial for making a diagno- formed as described before.[19] The patients were in sis of POTS. a supine position for ≥ 10 min before the baseline Some studies define POTS as when patients have a > blood pressure (BP) and HR were measured. After the 6-month history of OI symptoms [2–4] while other stud- baseline measurement, patients stood upright without ies require only a > 3-month history of symptoms [5–7], support and remained still right beside the bed. The and some studies even do not have criteria for a minimal BP and HR were checked immediately and at 1, 3, 5, disease duration [8–11]. Both 3- and 6-month periods and 10 min after standing. Maximal HR increment are fairly arbitrary criterion to indicate a chronic condi- observed in each patient was calculated from the two tion. Moreover, symptoms of POTS range from well- OVS tests. recognized orthostatic dizziness and palpitation, to less Patients were included when at least one of the tests recognized symptoms, such as fatigue, gastrointestinal met the following criteria: (1) HR increment ≥ 30 bpm dysfunction, and increased sweating. [12, 13] These less (or ≥ 40 bpm in patients aged between 12 and 19) within recognized non-orthostatic symptoms could be 10 min after standing up; (2) absence of orthostatic unnoticeable without clinical suspicion. hypotension leading to compensatory orthostatic tachy- TheprevalenceofPOTSisestimatedat0.2%in cardia; and (3) no overt cause for tachycardia, such as the general population [1]; however, the exact preva- acute blood loss, hyperthyroidism, prolonged bed rest, lence remains unknown. POTS is still considered to or tachycardia-promoting medications. This study was be an under-recognized disorder [12], and its clinical approved by the Institutional Review Board of Seoul significance is increasing, as it has been reported to National University Hospital (IRB No. H-1401-091-550) be frequently accompanied by depression [11, 14], and informed consent was obtained from all individual sleep problems [15], chronic fatigue syndrome [16, participants included in the study. 17], and diminished quality of life (QOL) [15, 18]. However, it is not known if depression or deterior- Questionnaire ation of QOL occurs frequently in patients with min- All subjects performed three sets of self-report ques- imal OI symptoms despite excessive orthostatic tionnaires prior to the treatment. The symptoms of tachycardia (OT). OI were evaluated using a questionnaire (Orthostatic In this study, we hypothesized that each specific Intolerance Questionnaire, OIQ) which has been symptom of POTS may have a different clinical sig- widely used to assess the symptoms of POTS patients nificance for the assessment of POTS or comorbid in previous studies [20–24]. The subjects specified the conditions, and patients with minimal OI symptoms presence and frequency of nausea, tremor in hands, might have depression or deteriorated QOL. There- dizziness, palpitation, headache, profuse perspiration, fore, we performed a comprehensive questionnaire- blurred vision, chest discomfort, lightheadedness, and based assessment of OI symptoms, depression and concentration difficulties. The frequency of specific QOL in patients with excessive OT, including those symptoms was marked with a score ranging from 0 with minimal OI symptoms. First, we evaluated if the to 4, with 0 for never, 1 for once a month, 2 for 2–4 maximal HR increment is associated with the severity times per month, 3 for 2–7 times per week, and 4 for of symptoms. Second, we analysed the correlations more often than once daily. The total symptom score among the symptoms of OI, depression, and the was calculated by summing the scores of 10 physical and mental components of QOL. Finally, we symptoms. assessed if patients with minimal OI symptoms suffer Depression was assessed using the Beck depression from depression or deterioration of QOL. inventory-II (BDI-II), which is a widely used self-report Moon et al. Health and Quality of Life Outcomes (2016) 14:144 Page 3 of 9 inventory with 21 multiple-choice questions (score of 0 (BMI), maximal HR increment) and OIQ items were per- to 3 for each question). A total score of 0–13 indicates formed using T-test. The OIQ variables of p <0.1and/or minimal depression, 14–19 mild depression, 20–28 basic demographic factors were included in the multivari- moderate depression, and 29–63 severe depression [25]. ate analysis. Data were collected and analysed using SPSS The 36 Item Short-Form Health Survey (SF-36) was 22.0.0 for Windows, and values of p < 0.05 were considered used to assess the health related QOL [26]. The ques- significant. tionnaire contains 36 items that yield 8 category scales: physical functioning, role limitation caused by physical Results problems, bodily pain, general health, vitality, social The maximal orthostatic heart rate increment is not functioning, role limitations caused by emotional prob- associated with clinical symptoms lems, and mental health.
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