We asked our Medical Advisory Board, which includes many of the leading dysautonomia experts, to answer some questions from our patient community for Heart Month.

What is cardiac arrest?
A cardiac arrest is a condition in which the heart is not able to deliver blood to the brain and body. This can be due to multiple causes, but is most often due to an irregular heart beat (an arrhythmia that is either very fast or very slow) that makes it impossible for the brain to get enough blood and the patient becomes unconscious. When it is due to an extremely fast rhythm called ventricular fibrillation, this is often referred to as “sudden cardiac death” since the patient will die unless they get out of this rhythm within a few minutes. This is what is depicted in many medical TV shows when everyone rushes into a room and shocks a patient. The actors are pretending to shock someone out of ventricular fibrillation and return them to a heart rhythm that can deliver blood to the brain and body. It’s important to know that the fast heart rate seen in POTS is not considered an arrhythmia.

What is a heart attack?
A “heart attack” is colloquial term that refers to a myocardial infarction. This usually occurs when a clot forms around a cholesterol “plaque” that ruptures in one of the blood vessels that supplies the heart muscle its blood. This leads to heart muscle damage. When this is first happening, it can also lead to the abnormal rhythm of ventricular fibrillation, which causes the cardiac arrest. If a cardiac arrest happens, the patient will be unresponsive. If there is no pulse, then CPR should be started immediately, emergency services should be called (9-1-1 in North America) and an “automated external defibrillator” (or AED) used if it is available.

Does orthostatic intolerance (OI) or postural orthostatic tachycardia syndrome (POTS) cause cardiac arrest or heart attacks?
No. These are unrelated.

How common is cardiac arrest in the general population?
It is estimated that there are about 600,000 cardiac arrests in the USA annually, so the incidence is about 0.2% per year. In some people with structural heart diseases (e.g. cardiomyopathy or after myocardial infarctions, or in people with some inherited heart rhythm disorders), this may be a lot more common.

How common are heart attacks in the general population?
It is estimated that about  805,000 Americans have a heart attack every year, which is an incidence of about 0.24% per year.  Heart attacks are quite uncommon in the young, but it become more common in both men and women from middle age and the frequency increases with increasing age.

Where can people do to reduce their risk of heart attacks and cardiac arrest?
Exercise regularly, eat healthy, stop smoking, and manage conditions like diabetes or hypertension closely with your doctors. For more information, visit the sites below.
Dysautonomia International: dysautonomia-friendly exercise tips
American Heart Association: heart attack prevention
Heart Rhythm Society: sudden cardiac arrest prevention

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Meet Zack Orban, the focus of Dysautonomia International’s Volunteer Spotlight for December 2019! Zack has been a great volunteer for Dysautonomia International for the past several years.

Zack was instrumental in carrying out our 2019 conference study earlier this year. He processed hundreds of blood, serum and genetic specimens using the laboratory skills he acquired as a Neuroscience major at North Central College and as a Research Study Coordinator at Northwestern University, where he currently works on T cell immunity and the role of viruses in neurological disorders and neuroinfectious disease. “I was thrilled I was able to use my skill set and education to assist with a study to set the foundation for POTS research in terms of immunology.”

Zack has helped out at prior conferences too, and he raises funds to support Dysautonomia International’s research, physician education, public awareness, advocacy and patient empowerment programs. He’s also put his research skills to good use serving as a grant reviewer for Dysautonomia International’s highly competitive POTS Research Fund grant program.

“The organization means a lot to me and inspires me, as I want to become a researcher myself. Since I have POTS, I know first hand how badly we need the resources that Dysautonomia International provides.”

Zack was diagnosed with POTS 6 years ago and like many of us, he’s been through a lot, but he remains optimistic. “I struggled when I was first diagnosed, but once I had more experience on how to handle the condition I was able to see how much I was still able to do. Never give up and don’t be afraid to try new things that may help.”

If you’d like to volunteer for Dysautonomia International, get involved with our support groups to find out what’s going on in  your area (dysautonomiainternational.org/support), sign up for our email list (bit.ly/email_DI), or contact us at volunteer@dysautonomiainternational.org.

Zach (blue shirt, back row) was part of the international research team that conducted the POTS Immune-Phenotyping study during Dysautonomia International’s 2019 Conference.

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The holidays can be tough for someone with dysautonomia, but these affordable gifts are sure to being a smile to your favorite dysautonomia warrior’s face.

Donating in Honor of Someone Special
Donating to Dysautonomia International in honor someone who has dysautonomia or a family struggling with dysautonomia shows that you care. The individual or family the donation has been made in honor of will receive a nice letter notifying them that you have donated in their honor. The amount of the donation is not disclosed. All donations will be doubled during our Holiday Matching Grant Challenge, up to $150K, until December 31, 2019. Your donation will support Dysautonomia International’s research, physician education, public awareness, legislative advocacy and patient empowerment programs.

FighterWear
Nurture your loved one’s fighting spirit as they fight dysautonomia everyday! FighterWear was designed by fellow dysautonomia warrior Morgan McCastor, who donates the profits to Dysautonomia International. The hoodies are super soft and comfy. Turquoise is the color of dysautonomia awareness.

LiquidIV
Tasty flavors in single-serving sticks like lemon lime and passion fruit dissolve in water to help you get your sodium and hydration. Options to help with sleep and energy too! Liquid IV is a Diamond Sponsor of Dysautonomia International’s research, education, and patient empowerment programs.

SaltStick
SaltStick Vitassium is an oral salt pill with added potassium that is designed not to upset your tummy like many salt pills do. SaltStick FastChews are tasty little chewable tablets to help you get a quick fix of electrolytes. SaltStick is a Platinum Sponsor of Dysautonomia International’s research, education, and patient empowerment programs.

NormaLyte
NormaLyte PURE is a flavorless electrolyte powder you dissolve in water. PURE is formulated to provide maximum hydration and was developed with the input of over 1000 dysautonomia patients. NormaLyte also comes in flavors like green apple and grape. NormaLyte is a Gold Sponsor of Dysautonomia International’s research, education, and patient empowerment programs.

POTS: Together We Stand, Riding the Waves of Dysautonomia
This book was written by one of our founding board members, Jodi Epstein Rhum.  After raising kids with POTS and EDS, Jodi took everything she learned, reached out to experts like Dr. Svetlana Blitshteyn, and put it into an easy to understand book for patients and family members. Jodi founded the large POTS group on Facebook and is one of the founding board member of Dysautonomia International. She donates a portion of book sales to support Dysautonomia International.

Food That Cares: A Restorative Approach to Health, Living with POTS, Dysautonomia and Chronic Illness
This beautiful cookbook filled with delicious, easy to prepare, nutritious meals will get your taste buds excited. Author Wendy Baruchowitz became an Integrative Nutritionist after she was diagnosed with celiac disease and POTS. Wendy volunteers on Dysautonomia International’s Patient Advisory Board and donates a portion of book sales to support Dysautonomia International.

Peace, Love & Dysautonomia Awareness Tote
This Peace, Love & Dysautonomia Awareness tote is eco-friendly and a great conversation starer to help raise awareness. A portion of the sales benefits Dysautonomia International.  Shirts and other items with the same design are available through our Dysautonomia Gear Shop.

Compression Gear
Doctors often recommend 30-40mmHg full-length medical compression stockings to help dysautonomia patients avoid blood pooling and get more blood flowing back up to the heart and brain. While full-length stockings work best, some patients prefer thigh high or sock length compression gear.  They come in nude, black, many colors, and prints too! Compression socks aren’t as effective at preventing blood pooling, but may be fun to wear on days you’re dysautonomia warrior is chillin’ out on the couch. Abdominal compression can help too.  Abdominal binders are available, but women often prefer Spanx and similar compression undergarments. Compressing the lower abdominal area is key, so don’t get something that only cinches the smallest part of the waist.

Grocery or Meal Delivery Services
Some people who have dysautonomia have a really hard time finding the energy to go food shopping and cook healthy meals. This is extra challenging for adult patients who have families to care for.  Meal delivery services like Daily Harvest, Blue Apron or Freshly can give your loved one a healthy eating boost. A lot of people with dysautonomia have food allergies, so if you’re not sure if your loved one has a specific diet, a gift certificate for grocery delivery service like Amazon Fresh or Peapod may be helpful.

Cooling Devices
People with dysautonomia can feel much worse in the summer heat, because some of us don’t regulate our temperature properly, or we can’t sweat. Heat can also dilate our blood vessels more than normal, which can drop blood pressure. Cooling vests, neck wraps, wrist wraps, and personal spritzer fans may make us more comfortable in the heat of summer.

Glass Water Bottle Infuser
Dysautonomia experts jokingly refer to “the water bottle sign” as a sign that someone has dysautonomia. People with dysautonomia usually are advised by doctors to drink 2-3L of hydrating fluids per day, so it’s common for us to always have a water bottle with us.  It can get boring drinking plain water, so some patients like to infuse their water with melon, berries, mint, cucumber, pomegranate, citrus, herbal teas, and other flavor infusions. Look for glass bottles if you want a bottle that can hold hot and cold beverages, and something with a slip proof grip case, like this one. There are many sizes and options available.

Happy Holidays to all!

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For this week’s #SillySaturday humor, let’s find out what would happen if Simon & Garfunkel had dysautonomia.

Hello darkness my old friend
I’ve stood up too fast again
I lose my vision while standing
Bursts of tachy when I am sleeping
And the blood flow is not getting to my brain
So much pain
That’s the sound of my stomach

In restless dreams I never sleep
Can barely walk right down the street
Beneath the halo of an ER bay lamp
My body aches when it’s cold and damp
I’m gonna faint from the flash of a neon light
Don’t feel alright
And that’s the sound of my stomach

On the Dysautonomia International site I saw
We’re 70 million strong maybe more
Doctors interrupting when I’m speaking
Doctors judging without listening
Giving misdiagnoses that they’ve pulled right out of thin air
Some don’t care
Disturbed by the sound of my stomach

Fools I said you do not know
Dysautonomia really blows
Hear my words that I might teach you
Take my pulse so that I might reach you
But my limbs like spaghetti noodles fell
And echoed through the halls of your clinic

And the patients begged and prayed
Please give us NIH funding someday
Dysautonomia International flashed out a warning
That a huge patient movement was forming
And the sign said
The struggles we all have
are written on Facebook walls
And Instagram
And whispered over the sound of my stomach
————————————————————

Sing along to the original Simon & Garfunkel song, the Sound of Silence. Even better, send us a video of yourself singing these lyrics! Email your video to info@dysautonomiainternational.org.

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In 2019, Dysautonomia International’s POTS Research Fund received applications from researchers in nine countries seeking over $6.1M in research grants. Thanks to our amazing fundraising volunteers and donors, we are able to fund over $800,000 in POTS research grants this year! You can help support these grants and future research by making a contribution at CurePOTS.org.

It’s very difficult choosing the studies to fund, as we received so many great applications and we want to fund everything that will help advance our understanding of POTS and find better treatments for patients. We use a rigorous two-step peer-reviewed scoring system to help identify the most promising applications. All applications are reviewed by four independent scientists, two patients or caregivers, and our Board of Directors, prior to funding.

Our 2019 grant recipients are…

Dr. Artur Fedorowski, Lund University (Sweden)
Head-to-head comparison of cell-based functional assay vs. epitope-based ELISA method for detection of GPCR-autoantibodies in postural orthostatic tachycardia syndrome

Dr. Raffaello Furlan, Humanitas University (Italy)
Long-term effects of transcutaneous vagal nerve stimulation on symptoms and cardiovascular autonomic profile of patients with postural orthostatic tachycardia syndrome (POTS)

Dr. Katja Kovacic, The Medical College of Wisconsin (United States)
Optimizing Vagal Efficiency to Improve Gastrointestinal Function in POTS: Effects of Auricular Neurostimulation

Dr. Laura Pace, University of Utah (United States)
Altered Nitric Oxide Metabolism in POTS

Dr. Satish Raj, University of Calgary (Canada)
Cardiac Structure and Function in Postural Orthostatic Tachycardia Syndrome: A Cardiac Magnetic Resonance Study

Dr. Robert Sheldon, University of Calgary (Canada)
A Randomized Cross-Over Study of Propranolol Versus Ivabradine in Postural Orthostatic Tachycardia Syndrome

We also funded a study earlier in 2019…

Prof. Lauren Stiles, Stony Brook University (United States)
Dr. Jonas Axelsson, Karolinska Institutet (Sweden)
Dr. Artur Fedorwoski, Lund University (Sweden)
Immune-Phenotyping in Individuals with Postural Orthostatic Tachycardia Syndrome (read more about it)

We’ll be sharing more information on each of these studies in the coming weeks and we’ll share info on how you can volunteer as a study participant for some of the studies. In the meanwhile, please contribute to the POTS Research Fund if you can and ask your friends and family to do the same at CurePOTS.org. By pooling our donations together, small and large, we can advance the pace of research and get us closer to finding better treatments for millions of people around the world living with POTS.

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Each October I find myself inspired and empowered by the amazing work Dysautonomia International and the entire dysautonomia community does to raise the profile of illnesses of the autonomic nervous system. Awareness Month is an incredible tool to gather the collective power of this movement and elevate our stories in service of change. It’s encouraging to see others learn about dysautonomia and the impact it has on the lives of patients, caregivers, family, friends, and doctors. 

With each passing Awareness Month I feel more seen and understood, but I also wrestle with the pain of reflecting on life with POTS. Overall, I’ve gotten better at sharing my personal story without feeling the weight of it each time. But something about Awareness Month – the intensity of it and the many stories I hear of others suffering from the same senseless illness – brings a surge of sadness into the fore. Adding to that, October 1st is my “sickiversary” – the date in 2007 when I sustained a concussion triggering the onset of POTS. Each October, I find myself making a tally of the years I’ve been sick with POTS, 12, and of the years I’ve been diagnosed, 5. Those numbers stare at me and I stare back, knowing the pain, loneliness, and desperation that filled them. I reflect on those years not from the security of distance, but while feeling their presence. I remain consumed by the daily battle of life with POTS along with many co-morbid conditions. 

When I fall into this negative reflective spiral, I buoy myself by thinking about all the progress Dysautonomia International and this movement have made in a few short years. The diagnostic delay is down from 6 years 5 months to 4 years 2 months, and still improving. Fundraising is increasing and research is gaining speed. Volunteers have organized POTS walks around the country – from Boston and Philadelphia to Milwaukee and Greensboro. Lobbying and media efforts have started elevating dysautonomia in the public consciousness. Buildings have lit up across Australia, Malaysia, Japan, Canada, the United States, and beyond to #MakeNoiseForTurquoise. All of this signals a better future for the 70 million of us with dysautonomia.

Generally, thinking about this progress is enough to lift me up and propel me forward with renewed energy. But this year I found myself stuck. I began searching for a way to get out of the rut. I came to see that while my sadness is valid, it is not the complete picture. At the front of my mind there is a list of things POTS has taken from me, but hidden away there is also a list of things POTS has given me. I tend not to focus on the positives because it feels counterintuitive – why would I celebrate any outcome of being sick? But I realized I could acknowledge that good things have come from being sick without being happy that I got sick. So I started compiling positives and the weight began to lift. 

Creating this list helped me see that things aren’t as black and white or as good and bad as my mind likes to tell me they are when I’m down. Knowing I’m not alone in trying to make sense of life with dysautonomia, and discovering that this list helped me find some solace, I thought I’d share it. I’m hoping it may help others see bits of good that in their own dysautonomia and chronic illness experiences.

POTS has given me: 

• Resilience: Living life with a chronic illness has absolutely made me stronger. Surrendering to the daily uncertainty of POTS has equipped me with the tools I need to respond to adversity. I now see my abilities to endure and adapt as two of my greatest strengths.
• Mental health: I began therapy because of the impact being sick had on my mental health, but therapy has helped me cope with far more than my illness. It has enriched my life by teaching me how better to confront and unpack things. It’s made me more emotionally intelligent and strengthened my relationship with myself and others.
• Purpose: It took seven years for me to get diagnosed with POTS and I know my story is not unique. Knowing that millions of others were also struggling with this common but little known illness made me angry. That anger fueled a drive to speak out and fight for change. So I became an advocate and found the power that flows from vulnerability and the energy that comes from joining a movement.
• Authenticity: As a kid I struggled to be myself and often felt uncomfortable and uncertain. But the past 12 years of being sick have helped me shed that layer of insecurity. Speaking out about my experience and publicly sharing intensely personal and sometimes unflattering aspects of my life has numbed the feeling of self-consciousness. In its place I’ve found self-assurance, which has freed me of so many trappings.
• Community: POTS has given me a reason and a means to connect with others. I’ve met many incredible POTS and chronic illness warriors who have enriched my life. I’ve also received so much support and kindness from friends, family, and strangers. The fight against POTS is truly a movement, and this movement fills me with love and strength.
• Family time: I am lucky to have the unwavering support of my family. They’ve battled this shared enemy with me, and have shown me the meaning of devotion, selflessness, and love. Being sick has given us time together that we wouldn’t have otherwise gotten. Though that time is often spent in doctor’s offices, at my bedside, over SCIG infusions, or trips to the pharmacy, I’m grateful for it. 

What would be on your list? I’d love for this to be the start of an ongoing conversation that helps us inspire and lift each other up. This process won’t make the bad go away, but maybe it’ll make us all feel the good just a little bit more. And I think we’ve earned any happiness we can find, right?

Guest blogger Hanna Rutter Gully is a proud member of Dysautonomia International’s Patient Advisory Board and a self-proclaimed hair dye addict. She’s tried to live life to the fullest despite the presence of many unwelcome companions, including POTS, gastroparesis, MCAS, chronic migraine, joint hypermobility, post concussive syndrome, and an autoimmune disorder. Her favorite part of managing these conditions is her morning coffee, and her least favorite part is everything else. 

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Next weekend Dysautonomia International will launch one of the most in-depth immunological studies in POTS to date during our 7th Annual Conference in Philadelphia! Titled “Immune-Phenotyping in Postural Orthostatic Tachycardia Syndrome,” the study takes a deep dive into possible immune mechanisms in POTS. You can support this important research by making a contribution to our POTS Research Fund at CurePOTS.org.

We’ve put together some FAQs about this year’s study.

Who is running this year’s study?
After helping researchers from Vanderbilt University, Mayo Clinic, UT Southwestern and other universities organize the annual Dysautonomia International Conference research study for the past five years, Dysautonomia International founder and President, Lauren Stiles, will lead this year’s study. Lauren was recruited to serve as a Research Assistant Professor of Neurology at Stony Brook University’s School of Medicine last year to help the university expand its autonomic disorders research, education and clinical care. She will be joined by co-investigators from Sweden, Dr. Jonas Axelsson, Medical Director of the Center for Apheresis and Stem Cell Handling at the Karolinska Institutet Hospital, and Dr. Artur Fedorowski, Senior Consultant for the Department of Cardiology and Head of the Syncope Unit at Skåne University Hospital. Drs. Axellson and Fedorowski have teamed up on several prior POTS studies that found interesting immunological results, and they have set up the leading POTS research program in Europe. The study team also includes incredible young researchers from Penn State Hershey, Rush University, University of Calgary, and Columbia University who are forging a career in medicine and academic research after their own experiences with POTS.

What are they studying?
During the conference, the research team will screen 100 POTS patient volunteers for the following:

• HLA genetic markers: these are genetic markers that regulate the immune system;
• immune cell phenotyping:  B-cells, T-cells and NK-cells from collected peripheral blood mononuclear cells will be assayed with flow-cytometry with labelling according to the Freiburg (CD19, CD21, CD27, IgM, and IgD), FITMAN (CD45, CD4, CD8, CD45RA, CD27, CD69 and HLA-DR) or NK-panel (CD16, CD45 and CD56,), respectively;
  
• whole-tissue reactivity analysis: serum will be assessed for potential reactivity in routine clinical immunofluorescence assays for neuronal, pemphigoid and adrenal gland antibodies;
• novel calcium-mobilization assay: serum samples will also be tested using a novel, proprietary ELISA assay to quantify the amount of IgG reactive to calcium-binding protein;
• antibodies & immune markers associated with Sjögren’s syndrome: nRNP/Sm, Sm, SS-A, Ro-52, SS-B, Scl-70, PM-Scl, Jo-1, centromere protein B, PCNA, dsDNA, nucleosomes, histones, ribosomal P-proteins, AMA and M2;
• antibodies associated with autoimmune encephalitis: NMDAR, AMPAR, GABAR, LGI1, CASPR2;
• antibodies associated with neuromyelitis optica: NMO, AQP4;
• antibodies associated with polyneuropathy: GM, GM1, GM2, GM3, GD1b, GQ1b;
• antibodies associated with myasthenia gravis: muscle AChR; and,
• urine screening for albuminuria, hematuria, leukocyturia, nitrate, sodium, potassium, magnesium, chloride, creatinine, urea and pH.

Thankfully, the researchers only need two tubes of blood and a small urine sample to run all of these tests. They will also conduct 10-minute bedside orthostatic vitals, a Beighton exam to screen for joint hypermobility, a medical history interview, and a survey to capture other information about the patient’s health and family history.

After the conference study is done, any remaining blood, serum and urine specimens will be stored in a biobank at the Karolinska Institutet for future studies analyzing other biomarkers of interest in POTS. Dysautonomia International has already been contacted by other researchers seeking access to this biobank material. Biobank specimens will be stored in a de-identified manner, meaning that the identify of the individual who provided the specimen remains anonymous. This is designed to protect patient privacy.

Why are the researchers studying these biomarkers?
Prior research suggests that a majority of people diagnosed with POTS have an autoimmune problem that may be causing or contributing to their symptoms. Almost every autoantibody that has been studied in POTS has been found in a higher percentage of POTS patients than it is found in the general population, but we really don’t know why that is and what other antibodies may be involved. The conference study is designed to dig a little deeper and search a little broader for immunological biomarkers in POTS, to get a bigger, and hopefully clearer, picture of what’s going on.

This review article provides a good summary of what has been found to date regarding autoimmunity in POTS, although even more research on autoimmunity in POTS has published since that review article came out in December 2018. There are two recent articles of note.

The first, a study finding that a subset of Korean POTS patients have HLA genetic markers highly associated with the development of autoimmune disease, also finding beta2 adrenergic receptor antibodies in these patients, and noting that two of these patients who received immunotherapy responded well to it. HLA markers can vary by race and ethnicity, so it’s important to search for these markers in other races and ethnicities to see if it’s a common finding amongst POTS patients of all backgrounds.

The second, a study from Dr. David Kem’s lab at the University of Oklahoma confirming a much higher rate of adrenergic receptor antibody activity in POTS patients compared to healthy people (the samples were collected during our 2014 Conference).

Inside scoop for our blog readers… we expect to see another important autoimmune POTS paper coming out in the next month or two.

How can I participate in the conference study?
Study enrollment will be open to the first 100 registered conference guests who volunteer to participate in the study and meet the enrollment criteria below. Please note, the conference is sold out and there are no volunteer or scholarship passes remaining. Study enrollment will begin at 6pm on Friday evening in the main hotel ballroom. The research team will be available to answer your questions and sign you up if you’re interested in participating. The actual study procedures will take place on Saturday and Sunday during the conference. Registered conference guests will receive an email this week with a detailed schedule.

Inclusion Criteria
· Individuals previously diagnosed with POTS by a physician
· Ages 12-80 years
· Male and female subjects are eligible
· Able and willing to provide informed consent (if ≥18 years) or assent with parental consent if age 12-17 years

Exclusion Criteria
· Inability to give, or withdrawal of, informed consent
· Use of immune modulating treatments within the prior 6 months
· Women who are or may be pregnant
· Other factors which in the investigator’s opinion would prevent the subject from completing the protocol

Study volunteers do not need to stop any of their medications, nor do they have to bring medical records to the conference. The study will be performed while the participants are dressed in their normal clothing, but the researchers will ask volunteers to remove any compression garments they wear before they arrive in the study room, because these garments can impact orthostatic vitals.

Will study participants get their lab results?
The researchers can share results from HLA marker and antibody analyses if study participants choose to receive them. However, they cannot provide clinical interpretation of any of the results.

When will the results of the study be publicly available?
The researchers will move as quickly as possible to complete the study and publish the results, but it can take more than a year to published a detailed research paper like this. We will share the eventual journal article through Dysautonomia International’s social media channels and email list as soon as it’s available.

How is this research being funded?
This research is being funded through Dysautonomia International’s POTS Research Fund as well as some grants from the Swedish government. You can support this work and other critically-needed POTS research by making a contribution at CurePOTS.org.

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“If we want an answer from nature, we must put our questions in acts, not words, and the acts may take us to curious places. Some questions were answered in the laboratory, others in mines, others in a hospital where a surgeon pushed tubes in my arteries to get blood samples, others on top of Pike’s Peak in the Rocky Mountains, or in a diving dress on the bottom of the sea. That is one of the things I like about scientific research. You never know where it will take you next.”  — J.B.S. Haldane
From essay ‘Some Adventures of a Biologist’, as quoted in Ruth Moore, Man, Time, And Fossils (1953), 174

While not dressed as suggested by Dr. Haldane, I recently joined a massive expedition
intent on making new scientific discoveries. Working with an international group of
colleagues, I screened blood samples from 113 Swedish individuals with POTS and 283
people who don’t have POTS (controls) in search of one or more biomarkers.
Biomarkers are molecules present in a biological sample at concentrations that are
clearly different between patients and healthy people. Ideally, a biomarker would also
be more abnormal in more severe disease states, and closer to normal as a patient’s
symptoms improved or went in remission. In this particular case, we were hoping to
identify a biomarker that is as reliable and specific as the tilt test for identifying POTS,
so that someday, perhaps, POTS can be diagnosed by a blood test rather than the tilt
test. We used a new testing approach called Proximity Extension Assay, which allows
us to measure concentrations of 57 human protein biomarkers in a single sample
thanks to new DNA technology.

So, did we catch anything? The answer is yes, although we are still trying to puzzle out
the implications. We found one protein that was significantly less common in the blood
of POTS patients than in the blood of controls – furin. This protein was found in much
lower concentrations in POTS patients than in controls, but was also less abundant in
the blood of POTS patients with more severe POTS on tilt testing than in those with
milder POTS.

Furin promotes the maturation of secreted chemical messengers at the cell surface.
Furin is found throughout the body and has been reported to process a large number of
cytokines and chemokines, including anti-inflammatory transforming growth factor
(TGF)-β1 and pro-inflammatory secreted TNF-family members. Cytokines and
chemokines play important roles in the immune system.

Interestingly, previous evidence has suggested that inhibition of furin may result in a
breakdown of peripheral immune tolerance (Pesu et al., 2008) and development of
systemic autoimmune disease (Lisi et al., 2010). Recent findings report low furin levels
correlate to worsening systemic disease activity in Sjögren’s syndrome (Ranta et al.,
2018). It is important to note that only one POTS patient in our series had a confirmed
autoimmune disease, so there is much we still have to learn about the immune system
in POTS.

So how does this help us diagnose and treat POTS? Well, if our findings are replicated
in other populations, a furin blood test may assist in diagnosing POTS in the future. It
may also be that POTS patients with a very low furin may respond in a different way to
certain treatments than do those with more normal levels of furin. There is much
research to be done exploring why POTS patients have low furin levels, and how this
impacts their immune system.

As said so well by Dr. Haldane, “If we want an answer from nature, we must put our
questions in acts, not words…”! This is what I intend to do, continuing now from the
bottom of the sea to the next curious place. Stay tuned!

Guest blogger Jonas Axelsson, MD, PhD is the Director of the Center for Apheresis and Stem Cell Handling and an Associate Professor of Renal Medicine at the Karolinska Institutet in Sweden. He is interested in studying the immune system in POTS, ME/CFS and other conditions. He will be a guest speaker at the Dysautonomia International 7th Annual Conference this summer, where he will also be conducting a research study exploring even more immune and genetic biomarkers in POTS. When he’s not trying to figure out complicated diseases in the lab, he enjoys sailing, diving and photography.

REFERENCES
Spahic, J., Ricci, F., Aung, N., Axelsson, J., Melander, O., Sutton, R., Hamrefors, V., and Fedorowski, A. Proconvertase Furin Is Downregulated in Postural Orthostatic Tachycardia Syndrome. Front. Neurosci., 29 March 2019. doi.org/10.3389/fnins.2019.00301
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Compression garments are a common treatment for individuals with POTS, but why are they recommended, and how exactly do they work?

What happens when you stand up?

When a person stands up, gravity pulls blood from the upper chest down into the abdomen and legs.  As a result, there is less blood getting back to the heart.  This is a problem because the heart is not able to pump blood as effectively to the body.  The body detects these changes and activates the “fight or flight” response, or sympathetic branch of the autonomic nervous system, to increase heart rate and squeeze the blood vessels in the body to help blood get back to the heart.

When a healthy person stands up, they may experience a brief increase in heart rate, or decrease in blood pressure, but this usually isn’t noticeable because the body quickly adapts to the positional change.  However, in a person with POTS, the body’s ability to regulate this response to standing is disrupted.  An abnormal amount of blood collects, or pools, in the abdomen and legs, and blood does not get back to the heart very efficiently.  This leads to unpleasant and common POTS symptoms including lightheadedness, dizziness, shaking, chest pain and nausea.

How can compression garments help?

The body’s response to standing is where the theory of compression garments comes into play.  In a healthy person, when the sympathetic nervous system is activated, blood vessels in the body squeeze to get blood back to the heart.  However, in individuals with POTS we think there is still too much blood that is collecting in the abdomen and legs and not getting back to the heart.  What if we could intervene and mimic the squeezing of blood vessels with an external garment?  If we can provide mechanical squeezing to the abdomen and lower body, helping blood get back to the heart, then the heart doesn’t have to work as hard.  Compression garments do just this.  When applied to the body, they exert a force which pumps the pooled blood in the legs and abdomen back up to the heart.  Once the heart is getting enough blood, it doesn’t have to beat as fast to try and keep up with the body’s demands. The sympathetic nervous system reduces its activity and heart rate slows down.

POTS and Compression Garment Research :

Although compression garments are commonly prescribed for people with POTS, there is no research in an adult POTS population demonstrating how they work, and as well, which type of garment is best to manage POTS symptoms and lower heart rate.  Compression garments vary in terms of the strength of compression (measured in mmHg) and style, including socks, shorts and waist high tights.

I am currently conducting a clinical trial to understand more about how compression garments work.  This research is studying the use of compression garments in POTS to help minimize blood pooling, and in turn lower heart rate and symptoms.   I am using a non-inflatable lower body compression garment made of neoprene and Velcro, like a wetsuit.  This garment can be done up in different segments compressing all or part of the lower body. This garment serves as a good model compression garment for research because of the segments, and because multiple people of different sizes can wear the same garment.  However, it isn’t something a POTS patient would wear in real life.  Instead, we can translate the research findings from this garment to actual commercial garments like socks, shorts or waist-high tights.

In this study, I use a head up tilt table test to simulate standing.   When held upright on a tilt-table, the leg muscles that would normally help blood get back to their heart, are not engaged.  With this, we are measuring the body’s ability to manage standing without the leg muscle pump, as well as the action of the compression garments on the body.  During my study, the participants wear the compression garment done up in 4 different configurations for 10 minutes each, for a total of 4 tilt table tests.  The 4 configurations are: no garment, lower leg only (like a compression sock), upper leg/abdomen only (like compression shorts) and full lower body compression (like waist-high tights).

During the tilt table tests, I measure participants’ blood pressure, heart rate and symptom scores both lying down and upright.  From this data we can calculate how blood is flowing through the heart and blood vessels, which helps us understand how the body is responding to standing.   I am also measuring blood flow to the brain using ultrasound to determine whether or not compression garments affect blood flow to the brain, in addition to their possible heart rate and symptom effects.

Once this study is complete, we will be able to demonstrate whether or not compression garments are effective at lowering heart rate and improving symptoms in individuals with POTS and as well, if effective, which style/type of garment is best.  These findings can be used to help doctors recommend the best type of compression for management of POTS symptoms.  It may also provide evidence to aid in receiving insurance coverage for these garments.

Guest author, Kate Bourne, B.Sc., is a Cardiac Science Graduate student in Dr. Satish Raj’s Lab at the University of Calgary in Alberta, Canada.

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