Chronic Fatigue Syndrome and Neurally Mediated Hypotension
John Hopkins Study Shows Connection Between Irregular Blood Pressure & Chronic Fatigue Syndrome
HUGH CALKINS, MD
PETER C. ROWE, MD
Department of Medicine and Pediatrics, The Johns Hopkins University School of Medicine, Baltimore Maryland
Chronic fatigue syndrome is a chronic debilitating disease that afflicts 4/1000 of the general population. The pathophysiologic basis for this condition is unknown, and no known consistently effective therapy has been identified. Recent studies have reported a link between the chronic fatigue syndrome and neurally mediated hypotension, a common abnormality of blood pressure regulation.
In nonrandomized studies, treatment directed at neurally mediated hypotension has been effective in treating the symptoms of the chronic fatigue syndrome in two-thirds of patients. Prospective randomized trials are now in progress.
OBJECTIVE: To compare the clinical symptoms and response evoked by upright tilt-table testing in healthy individuals and in a sample of those satisfying strict criteria for chronic fatigue syndrome.
DESIGN: Case-comparison study with mean (SD) follow-up of 24 (5) weeks.
SETTING: Tertiary care hospital.
PATIENTS & OTHER PARTICIPANTS: A sample of 23 patients with chronic fatigue syndrome (five men and 18 women; mean age, 34 years), each of whom fulfilled the strict diagnostic criteria of the Centers for Disease Control and Prevention, was recruited from regional chronic fatigue support groups and from the investigators’ clinical practices. There were 14 healthy controls (four men and 10 women; mean age, 36 years).
INTERVENTIONS: Each subject completed a symptom questionnaire and underwent a three-stage upright tilt-table test (stage 1, 45 minutes at 70 degrees tilt; stage 2, 15 minutes at 70 degrees tilt with 1 to 2 micrograms/min of isoproterenol; and stage 3, 10 minutes at 70 degrees with 3 to 4 micrograms/min of isoproterenol). Patients were offered therapy with fludrocortisone, beta-adrenergic blocking agents, and disopyramide, alone or in combination, directed at neurally mediated hypotension.
MAIN OUTCOME MEASURES: Response to upright tilt and scores on symptom questionnaires prior to and during follow-up. RESULTS: An abnormal response to upright tilt was observed in 22 of 23 patients with chronic fatigue syndrome vs four of 14 controls (P < .001). Seventy percent of chronic fatigue syndrome patients, but no controls, had an abnormal response during stage 1 (P < .001). Nine patients reported complete or nearly complete resolution of chronic fatigue syndrome symptoms after therapy directed at neurally mediated hypotension. CONCLUSIONS: We conclude that chronic fatigue syndrome is associated with neurally mediated hypotension and that its symptoms may be improved in a subset of patients by therapy directed at this abnormal cardiovascular reflex.
Keywords: Neurally mediated hypotension, Vasodepressor syncope, Chronic fatigue syndrome, Fatigue