Send to

Choose Destination
Circ Arrhythm Electrophysiol. 2020 Feb;13(2):e007744. doi: 10.1161/CIRCEP.119.007744. Epub 2020 Jan 15.

When Sinus Tachycardia Becomes Too Much: Negative Effects of Excessive Upright Tachycardia on Cardiac Output in Vasovagal Syncope, Postural Tachycardia Syndrome, and Inappropriate Sinus Tachycardia.

Author information

Department of Pediatrics and Physiology, New York Medical College, Valhalla (J.M.S., M.S.M.).
Department of Epidemiology and Biostatistics, Baystate Medical Center, Springfield, MA, (P.V.).
University of Massachusetts School of Medicine, Worcester (P.V.).
Department of Cardiology, National Heart and Lung Institute, Imperial College, London, United Kingdom (R.S.).



Upright posture reduces venous return, stroke volume, and cardiac output (CO) while causing reflex sinus rate (heart rate [HR]) increase. Yet, in inappropriate sinus tachycardia (IST), postural tachycardia syndrome (POTS), and vasovagal syncope (VVS), symptomatic excessive HR occurs. We hypothesized that CO reaches maximum as function of HR in all.


We recruited 12 healthy controls, 9 IST, 30 VVS, and 30 POTS patients (13-23years) selected randomly by disorder not by HR, each fulfilled appropriate diagnostic criteria. Subjects were instrumented for electrocardiography, beat-to-beat blood pressure, respiratory rate, CO-Modelflow algorithm, and central blood volume from impedance cardiography; 10-minute data were collected supine; subjects were tilted head-up for ≤10 minutes. We computed phase differences, ΔΦ, between fluctuations of HR (ΔHR) and CO (ΔCO) tabulating data when phases were synchronized, determined by a squared nonlinear phase synchronization index >0.5, describing extent/validity of CO/HR coupling. We graphed results supine, 1-minute post-tilt-up, mid-tilt, and pre-tilt-down using polar coordinates (HR-radius, ΔΦ-angle) plotting cos(ΔΦ) versus HR to determine if transition HR exists at which in-phase shifts to antiphase above which CO decreases when HR further increases.


At baseline HR, diastolic and mean arterial pressures in IST and POTS were higher versus controls. Upright HR increased most in POTS then IST and VVS, with diverse changes in CO, SVR, and central blood volume. Each patient grouping was separately and collectively analyzed for HR change showing transition from in-phase to anti-phase (ΔΦ) as HR increased: HRtransition=115±6 (IST), 123±8 (POTS), 124±7 (VVS), P=ns. Controls never reached transitional HR.


Excessive HR independently and equivalently reduces upright CO, in IST, POTS, and VVS.


blood pressure; blood volume; cardiac output; radius; tachycardia

[Available on 2021-02-01]

Supplemental Content

Full text links

Icon for Atypon
Loading ...
Support Center