Altered oscillatory cerebral blood flow velocity and autoregulation in postural tachycardia syndrome

Abstract

Decreased upright cerebral blood flow (CBF) with hyperpnea and hypocapnia is seen in a minority of patients with postural tachycardia syndrome (POTS). More often, CBF is not decreased despite upright neurocognitive dysfunction. This may result from time-dependent changes in CBF. We hypothesized that increased oscillations in CBF occurs in POTS (N = 12) compared to healthy controls (N = 9), and tested by measuring CBF velocity (CBFv) by transcranial Doppler ultrasound of the middle cerebral artery, mean arterial pressure (MAP) and related parameters, supine and during 70° upright tilt. Autospectra for mean CBFv and MAP, and transfer function analysis were obtained over the frequency range of 0.0078-0.4 Hz. Upright HR was increased in POTS (125 ± 8 vs. 86 ± 2 bpm), as was diastolic BP (74 ± 3 vs. 65 ± 3 mmHg) compared to control, while peripheral resistance, cardiac output, and mean CBFv increased similarly with tilt. Upright BP variability (BPV), low frequency (LF) power (0.04-0.13 Hz), and peak frequency of BPV were increased in POTS (24.3 ± 4.1, and 18.4 ± 4.1 mmHg(2)/Hz at 0.091 Hz vs. 11.8 ± 3.3, and 8.8 ± 2 mmHg(2)/Hz c at 0.071 Hz), as was upright overall CBFv variability, low frequency power and peak frequency of CBFv variability (29.3 ± 4.7, and 22.1 ± 2.7 [cm/s](2)/Hz at.092 Hz vs. 14.7 ± 2.6, and 6.7 ± 1.2 [cm/s](2)/Hz at 0.077Hz). Autospectra were sharply peaked in POTS. LF phase was decreased in POTS (-14 ± 4 vs. -25 ± 10 degrees) while upright. LF gain was increased (1.51 ± 0.09 vs. 0.86 ± 0.12 [cm/s]/ mmHg) while coherence was increased (0.96 ± 0.01 vs. 0.80 ± 0.04). Increased oscillatory BP in upright POTS patients is closely coupled to oscillatory CBFv over a narrow bandwidth corresponding to the Mayer wave frequency. Therefore combined increased oscillatory BP and increased LF gain markedly increases CBFv oscillations in a narrow bandwidth. This close coupling of CBF to MAP indicates impaired cerebral autoregulation that may underlie upright neurocognitive dysfunction in POTS.

Keywords: cerebral blood flow; mean arterial pressure autospectra; mean cerebral blood flow velocity autospectra; postural tachycardia syndrome; transfer function analysis; vasomotion.

Figure 1

Representative supine and upright control and POTS phasic arterial pressure (AP) and cerebral blood flow velocity (CBFv) in the time domain. With tilt, oscillations in arterial pressure intensify in POTS, less so in control and at a lower frequency. Oscillations in arterial pressure are synchronous with oscillations in CBFv in POTS.

Figure 2

Autospectral curves showing mean arterial pressure (BP) power and cerebral blood flow velocity (CBF_v) power, comparing control subjects to POTS patients while upright. There is a significant shift to higher frequencies in POTS patients (p < 0.01).

Figure 3

Comparison of blood pressure variability (left panel), low frequency gain (Middle Panel) and cerebral blood flow velocity variability (right panel comparing control subjects (■) to POTS patients (□) supine and upright during 70° head-up tilt. ^* p < 0.05 comparing POTS to control; ^‡ p < 0.05 comparing upright to supine.