This Article Free upon publication Full Text Full Text (PDF) CME: Take the course for this article: Circulation: September 1, 2009, Volume 120, Number 9 All Versions of this Article: 120/9/725    most recent CIRCULATIONAHA.108.846501v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Google Scholar Articles by Raj, S. R. Articles by Robertson, D. PubMed PubMed Citation Articles by Raj, S. R. Articles by Robertson, D. Pubmed/NCBI databases Compound via MeSH Substance via MeSH Hazardous Substances DB PROPRANOLOL HYDROCHLORIDE Related Collections Cardiovascular Pharmacology Arrhythmias, clinical electrophysiology, drugs Autonomic, reflex, and neurohumoral control of circulation Related Article

(Circulation. 2009;120:725-734.)
© 2009 American Heart Association, Inc.

Arrhythmia/Electrophysiology

Propranolol Decreases Tachycardia and Improves Symptoms in the Postural Tachycardia Syndrome

Less Is More

Satish R. Raj, MD, MSCI; Bonnie K. Black, RN, CNP; Italo Biaggioni, MD; Sachin Y. Paranjape, BS; Maricelle Ramirez; William D. Dupont, PhD; David Robertson, MD

From the Departments of Medicine (S.R.R., B.K.B., I.B., S.Y.P., M.R., D.R.), Pharmacology (S.R.R., I.B., D.R.), Neurology (D.R.), and Biostatistics (W.D.D.), Autonomic Dysfunction Center, Division of Clinical Pharmacology, Vanderbilt University, Nashville, Tenn.

Reprint requests to Satish R. Raj, MD, MSCI, AA3228 Medical Center North, Vanderbilt University, 1161 21st Ave S, Nashville, TN 37232-2195. E-mail satish.raj{at}vanderbilt.edu

Received December 23, 2008; accepted June 15, 2009.

Background— Postural tachycardia syndrome (POTS) induces disabling chronic orthostatic intolerance with an excessive increase in heart rate on standing. β-Blockade is an appealing treatment approach, but conflicting preliminary reports are conflicting. We tested the hypothesis that propranolol will attenuate the tachycardia and improve symptom burden in patients with POTS. In protocol 1, a low dose (20 mg) was compared with placebo, and the dose response was assessed in protocol 2.

Methods and Results— In protocol 1, patients with POTS (n=54) underwent acute drug trials of propranolol 20 mg orally and placebo, on separate mornings, in a randomized crossover design. Blood pressure, heart rate, and symptoms were assessed while the patients were seated and after standing for up to 10 minutes before and hourly after the study drug. Supine (P<0.001) and standing (P<0.001) heart rates were significantly lower after propranolol compared with placebo. The symptom burden improvement from baseline to 2 hours was greater with propranolol than placebo (median, –4.5 versus 0 arbitrary units; P=0.044). In protocol 2, 18 patients with POTS underwent similar trials of high-dose (80 mg) versus low-dose (20 mg) propranolol. Although the high dose elicited a greater decrease than the low dose in standing heart rate (P<0.001) and orthostatic tachycardia (P<0.001), the improvement in symptoms at 2 hours was greater with low-dose propranolol (–6 versus –2 arbitrary units; P=0.041).

Conclusions— Low-dose oral propranolol significantly attenuated tachycardia and improved symptoms in POTS. Higher-dose propranolol did not further improve, and may worsen, symptoms.

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CLINICAL PERSPECTIVE

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Clinical Summaries
Circulation 2009 120: 717. [Extract] [Full Text]