TOTAL INVERSIÓN 80.752,
5.1.3 PRESUPUESTO DE COSTOS Y GASTOS
without POTS, in agreement with some (16) but not all previously reported studies (14). Several pathophysiological mechanisms have previously been described that could be responsible for the development of POTS. Such mechanisms include hypovolaemia (17, 36), increased sympathetic activity (37) and cardiovascular deconditioning (18), although it is not clear whether the latter is the cause of POTS or rather a consequence. However, given the fact that CFS patients are usually less active than healthy control subjects (22), we assumed deconditioning to be a contributing factor. Although maximum oxygen uptake during exercise is the gold standard to measure deconditioning, actometer scores give an indication of a patient’s activity pattern, and both of these methods have not been used previously in POTS-CFS patients. We did not find differences in the level of physical activity between POTS-CFS and non-POTS-CFS patients, which makes it less likely that deconditioning is the cause of POTS in these patients.
The influence of POTS on CFS treatment outcome has not been investigated previously. For adults, no differences could be found in the response to CBT. However, adolescents with POTS did have a higher fatigue score after treatment, although these patients did not report more POTS-related symptoms. Despite this significant difference, 58% of POTS-CFS adolescents were no longer severely fatigued after treatment, which indicates that treatment is still effective in the majority of patients. We propose the use of a stepped-care approach in adolescents, with evaluation for the presence of POTS in those who do not respond to CBT treatment or those who report vasovagal symptoms. Fortunately, treatment of POTS patients is remarkably successful, which means a combined approach could be effective (38). Treatment of POTS mainly includes lifestyle interventions, such as preventing dehydration and avoiding extreme heat; in addition, regular exercise should be promoted (13). There is limited evidence to support pharmacological treatment, for example using aldosterone analogues or beta-adrenergic blockers (36).
This study has several limitations. First, blood pressure measurement was resumed after a standing period of 5–8 min. This means that the reported values could be slightly underestimating the true prevalence of POTS. Nevertheless, patients with POTS had persistent tachycardia at least until 18 min in the standing position, which is consistent with the findings of others (39). In previous studies, POTS prevalence was most often based on heart rate after 2 min in the upright position, without taking into account the remaining 8 min. In that situation it should be realized that a transient tachycardia directly after standing is normal (40). Thus in daily practice, difficulties are encountered in differentiating those patients with a tachycardia upon standing from those with a normal physiological response, particularly among adolescents. Another limitation of the present study is the fact
that POTS-related symptoms were not recorded during the active standing test. However, these symptoms were recorded in the diary kept by all participants for 12 days.
9
Conclusion
In conclusion, in adult CFS patients the prevalence of POTS was low and not different from that in the non-CFS fatigued population. In addition, POTS in adult CFS patients was not related to disease severity, physical activity or treatment outcome. POTS-CFS adolescent patients showed a smaller reduction in fatigue after CBT. However, as most patients still benefit from CBT, there is no reason to withhold such treatment. Based on the results of this study, evaluation for POTS appears to be of limited additional value for the diagnosis of CFS; our findings do not support the addition of POTS to a new CFS case definition as proposed by the IOM. With the new SEID criteria, we are concerned that a subset of patients will not be diagnosed with CFS, although they are not different from other patients with respect to fatigue severity or mental and physical disabilities. This eventually could lead to a delay in starting effective treatment, which is in contrast to the goal of the IOM to accelerate the diagnostic process.
Acknowledgements
We would like to thank Tiny Fasotti-Dumont, Carel Kruip and Liesbeth Nieboer for performing the blood pressure measurements. We would also like to thank Remco Oomen and Betty Roerink-Raaijmakers for their help with structuring the data.
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