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May 21, 2013; 80 (21) Article

Low-dose propranolol and exercise capacity in postural tachycardia syndrome

A randomized study

Amy C. Arnold, Luis E. Okamoto, André Diedrich, Sachin Y. Paranjape, Satish R. Raj, Italo Biaggioni, Alfredo Gamboa
First published April 24, 2013, DOI: https://doi.org/10.1212/WNL.0b013e318293e310
Amy C. Arnold
From the Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University, Nashville, TN.
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Luis E. Okamoto
From the Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University, Nashville, TN.
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André Diedrich
From the Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University, Nashville, TN.
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Sachin Y. Paranjape
From the Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University, Nashville, TN.
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Satish R. Raj
From the Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University, Nashville, TN.
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Italo Biaggioni
From the Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University, Nashville, TN.
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Alfredo Gamboa
From the Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University, Nashville, TN.
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Citation
Low-dose propranolol and exercise capacity in postural tachycardia syndrome
A randomized study
Amy C. Arnold, Luis E. Okamoto, André Diedrich, Sachin Y. Paranjape, Satish R. Raj, Italo Biaggioni, Alfredo Gamboa
Neurology May 2013, 80 (21) 1927-1933; DOI: 10.1212/WNL.0b013e318293e310

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Abstract

Objective: To determine the effect of low-dose propranolol on maximal exercise capacity in patients with postural tachycardia syndrome (POTS).

Methods: We compared the effect of placebo vs a single low dose of propranolol (20 mg) on peak oxygen consumption (VO2max), an established measure of exercise capacity, in 11 patients with POTS and 7 healthy subjects in a randomized, double-blind study. Subjects exercised on a semirecumbent bicycle, with increasing intervals of resistance to maximal effort.

Results: Maximal exercise capacity was similar between groups following placebo. Low-dose propranolol improved VO2max in patients with POTS (24.5 ± 0.7 placebo vs 27.6 ± 1.0 mL/min/kg propranolol; p = 0.024), but not healthy subjects. The increase in VO2max in POTS was associated with attenuated peak heart rate responses (142 ± 8 propranolol vs 165 ± 4 bpm placebo; p = 0.005) and improved stroke volume (81 ± 4 propranolol vs 67 ± 3 mL placebo; p = 0.013). In a separate cohort of POTS patients, neither high-dose propranolol (80 mg) nor metoprolol (100 mg) improved VO2max, despite similar lowering of heart rate.

Conclusions: These findings suggest that nonselective β-blockade with propranolol, when used at the low doses frequently used for treatment of POTS, may provide a modest beneficial effect to improve heart rate control and exercise capacity.

Classification of evidence: This study provides Class II evidence that a single low dose of propranolol (20 mg) as compared with placebo is useful in increasing maximum exercise capacity measured 1 hour after medication.

GLOSSARY

BP=
blood pressure;
CI=
confidence interval;
CO=
cardiac output;
HFRRI=
high-frequency R-R interval;
HR=
heat rate;
LFRRI=
low-frequency R-R interval;
MAP=
mean arterial pressure;
POTS=
postural tachycardia syndrome;
SV=
stroke volume;
SVR=
systemic vascular resistance;
VO2max=
peak oxygen consumption

Footnotes

  • Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Received October 13, 2012.
  • Accepted in final form January 29, 2013.
  • © 2013 American Academy of Neurology
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