Impaired Blood Pressure Variability as Potential Biomarker for CFS

Impaired blood pressure variability in chronic fatigue syndrome—a potential biomarker

1. J. Frith1,2,
2. P. Zalewski3,
3. J. J. Klawe3,
4. J. Pairman1,2,
5. A. Bitner3,
6. M. Tafil-Klawe4 and
7. J. L. Newton1,2

+Author Affiliations

1. From the 1UK NIHR Biomedical Research Centre in Ageing, Newcastle, UK, 2Institute for Ageing and Health, Newcastle University, Newcastle, UK and 3Department of Hygiene and Epidemiology and 4Department of Physiology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland

1. Address correspondence to Professor J. L. Newton, Institute for Ageing and Health, Medical School, Framlington Place, Newcastle-upon-Tyne, NE2 4HH, UK. email: julia.newton@nuth.nhs.uk

• Received April 4, 2012.
• Revision received April 13, 2012.

Abstract

Introduction: Autonomic dysfunction is common in chronic fatigue syndrome (CFS). This study set out to derive an autonomic biomarker using a comprehensive assessment of heart rate and blood pressure variability.
Methods: Heart rate and non-invasive continuous blood pressure measurements (task force monitor) at rest and on standing were performed in CFS (Fukuda n = 68) and matched controls (n  = 68) to derive high frequency (HF; parasympathetic) and low frequency (LF; sympathetic) heart rate variability (HRV), systolic (SBPV) and diastolic (DBPV) blood pressure variability. Variables of significance were combined using receiver operator curves to explore the diagnostic utility of parameters particularly at rest.
Results: At rest, LF-HRV (sympathetic) was significantly increased in CFS compared to controls, while parasympathetic markers were significantly reduced (P = 0.006). Total DBP spectral power was increased (P = 0.0003) across all domains, with a shift towards sympathetic and away from parasympathetic SBPV (P = 0.05). On standing, overall SBPV response was significantly reduced with reductions in both sympathetic and parasympathetic components of SBPV (all P < 0.0001). Change in LF-DBP and relative balance of LF/HF DBP on standing differed between CFS and controls (P  < 0.0001). Using the 85% sensitivity levels, we determined a threshold for three chosen resting BPV parameters of LF DBP >3.185, rest HF DBP >0.86, rest total DBP >7.05. Achieving all of these differentiated between CFS and controls with 77% sensitivity and 53% specificity.
Conclusion: This study has shown that there are objectively measured abnormalities of blood pressure variability in CFS and that these abnormalities have the potential to be a bedside diagnostic tool.

• © The Author 2012. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oup.com

This is an article from QJM- Oxford Journals. It was released online June 4, 2012.

I should have put the site: http://qjmed.oxfordjournals.org/content/early/2012/06/04/qjmed.hcs085.short?rss=1

About time there was a blood pressure study. . My variable BP is one of my worst ME symptoms with both high BP and low BP giving me sudden shifts in symptoms.

I cant thou understand this one thou, wish I could

Sorry I can't help you. I don't understand it either. It sounds good, though. I'm happy with any study that shows there is a measurable, physiological difference between healthy people and those with CFS.

This is so interesting. My systolic reading has been in the 40s a couple of times in the last year and I got some pretty funny looks. At the dentist office, they decided there was something wrong with the BP cuff and at the hospital, the nurse was stunned and I said, "I have CFS", and she said, "well, the body does adjust, doesn't it? - we'll get you on some IV fluids" and I felt so much better. I wonder if this has something to do with blood volume but have read it's the HPA axis that's screwed up. Don't know, but wish I could get a bag of fluid every morning - IV, please.

Gamboa, thanks for posting this abstact. I can't make much sense out of it either, but it looks interesting. The real question is, how to get doctors to actually read it and pay attention to it?

For many years the doctors have been telling me I have hypertension, then they launch into a lecture about how I'm gonna get a stroke, or kidney disease, or a heart attack, or some other horrible disease, as if I don't have one now. I fail to understand how they can be so concerned about something that might happen in the future while ignoring what is right in front of them.

I tell the doctors my BP and heart rate are all over the place, and they ignore that too. It's the only reliable objective medical evidence I have of a real problem. I have pages of HR and BP readings over the years, but since I'm a nutter and a malingerer, I've just made them up. I finally figured out to just bring the BP monitor with me to every appointment, like some doddering illiterate person who can't figure out how to get the numbers out of the machine.

I frequently wonder why I keep going to the doctors. The travel and the actual appointment almost always trigger a crash, and they almost never tell me anything useful, or offer a helpful treatment. If I didn't need to get Imitrex for the horrible migraines, I'd probably tell them to take a hike.

What I wouldn't give to find a real CFS doctor in Maine....

@jimells -- fwiw, I've found it much easier on my system to travel a long distance to see an ME/CFS specialist twice a year than to battle with any local ME/CFS-clueless doctors. Ultimately, it's less stress, less travel (because I don't have to go in for every blessed symptom), and way less annoyance and aggravation. And I get treatments and advice that actually improve my symptoms. Might be worth a try.

@SOC I know this sounds like 'yes, but,' -- I actually travelled to see an autonomic specialist at UMass Worcester as a charity case about three years ago. It was a total disaster. I crashed badly, got no help, and had to fight with the UMass bill collectors for a year before they finally gave up.

I have to depend on Medicaid to cover medical bills. They won't pay for doctors outside the state. They pay so little to doctors in state that I am extremely limited in who I can see. Meanwhile our idiotic Tea Party Governor is taking a meat axe to the Medicaid budget and throwing about FORTY THOUSAND people out of the program. That is supposed to teach us to stand on our own two feet - even if we can barely stand at all.

If a person has no money and no income besides food stamps, they have damn few options. If I had a dollar for every time a so-called social service agency told me "We'd like to help but there's nothing we can do" I could cover a trip to see someone like Dr Klimas. And if wishes were horses beggars could ride...

@jimells -- Wow. That really sucks. How do they expect people to get well if they don't allow them to see specialists in the field? Yeah, I know, they're not about helping people get well, they're about cutting the budget regardless of the consequences to the seriously ill.

You have my utmost sympathy.

jimellis, I was in your position nearly exactly and still am in terms of doctors and medical care, but I could travel out of state at this point. Only I don't know who I would go to. I feel it may be best to wait another year or so until some more of the recent research is in. What I can't put up with anymore is lots of very expensive rigamarole, a very demanding regime, etc., with it all being still a shot in the dark, a gamble with little hope of paying off. I can't put up with another huge disappointment. However, if they establish, finally, biomarkers for treatment, and establish the efficacy of Rituximab, for example, I will do it. My tolerance is gone for the decades of ineffective and irresponsible medical treatment.

Why they can't work out even to identify, acknowledge and treat simple disautonomic symptoms like extremely low blood pressure, or wildly varying blood pressure--how this could even be news after all these years--is inexcusable.

I gave up keeping records of my blood pressures when after months of painstaking monitoring, I presented this to a Cardiologist. He just brushed my record aside, dismissing it, and said, "What I want to know is how you FEEL (when your blood pressure is 58 over 40 something)". I told him as politely as possible that it was all I could do to remain standing to take the measurement, that my vision was graying out to nothing, I had chest pain, was struggling to breathe, my hands were fumbling and I was resisting an overwhelming urge to lie down asap. He dismissed that too, smugly content with his measurements taken when I was sitting down in a state of anger, which brought my bp up to supposed normal. This all seemed like a cruel game to me as, if I had gone in with no record, he would have said, "I don't want to hear how you FEEL, I want to see DATA." Other doctors have given me the runaround from this other direction too. Having waited months for this appointment, just as you may have done with your doctors, my reaction was extreme discouragement.

I know I sound like a broken record (we need new a 21st century simile for this that the kiddies will understand ), but if you can travel at this point, wouldn't it help to see an ME/CFS specialist? I fully understand that our local doctors (including cardiologists, endocrinologists, neurologists, etc) are completely ME/CFS-clueless and seeing them is worse than not seeing a doctor at all. But our best ME/CFS specialists are providing a lot of symptom relief, including for some dysautonomia symptoms. I've seen 3 different ME/CFS specialists over time and each one gave me no rigamarole or demanding regimes and each one helped me improve my symptoms and functionality in some way. None are promising a cure, of course, or even a full remission, but relief from some of the worst symptoms, like dysautonomia, could make a huge quality of life difference.

The research coming out in the next year is not going to shake down to our local docs for 5-10 (or even more) years, so they're going to remain worthless as far as ME/CFS is concerned. My thinking is that I want to have a good working relationship with an ME/CFS specialist when any big news comes out of the research. First, they'll know best whether the new info suits my condition. Second, if anything really big happens -- like Rituximab looks like The Thing -- the specialists are going to be swamped and new patients may have to wait years to see any of them.

Just my thinking, though. I know we all have to make our own decisions about these things, and no one else really knows what's best for us but ourselves.

When Im hospital and they get abnormal heart rate or BP results there.. they either
1/ Blame the monitor
2/ The one time it was way way low when I was laying, they keep taking it over and over, hurting my arm each time till it came good and then write in the normal result at that point. *Note ..they never write in my in my abnormal findings, only do if/when they get a normal result
3/ Blamed my tachycardia on the reason why I was in hospital at the time (which it wasnt to do with that as my heart was being its normal tachy self, rather then believing in POTS.

I have had the same kind of experience--nurses not reporting the abnormal findings but only the normal ones. Once, however, I had a nurse in rehab who insisted that my blood pressure was not at all normal but dangerously low, and she insisted on calling my doctor twice. He worked elsewhere. The first time she heard nothing back from him and the second time, he reportedly said, "Oh, I know about that." Period. Another time my bp shot up to 300, if my brain recorded this right. It was some astonishing high number. This was on the table before a small surgery requiring anesthesia, which I was frightened about. The doctor exclaimed, but then brushed it off. It never went into any report.

Well said, Sing! At the advice of my cardiologist, and after years of carrying my BP records to my doctor, I now take my blood pressure cuff to the doctor visit. In that way, I can compare the two readings. We have a good digital cuff, and much to my astonishment, after the nurse got a low normal BP reading, I was still struggling to get my cuff to read at all. I take this to imply that maybe many of the erratic readings in the past are to be blamed on my BP cuff. I have a "soft" BP and sometimes the nurse has to try a couple of times. She's used to it now.

I agree that we need to watch what BP readings we are getting from our monitors. Recently I was trying to take mine while walking about but at the time wasnt aware that really screws the actual reading up. (I only realised that after I tested it like that on my boyfriend).

I know thou my BP monitor if Im still, is quite accurately reading. (I like to test it on another who knows their readings after I've used it on me).

Interesting but old news in many ways. Certainly it is established that their are abnormalities on blood flow that appear mediated by autonomic disfunction characterised as a move towards sympathetic dominance over vagal or parasympathetic function.
Blood volume status could also offer a viable biomarker accoridng to Dr Bell in the early 90s. Similarly QSART abnormalities seem prevalent.
Or just NCS, NMH or POTS in many but not all. And these can be easily assessed through comparisons of standing heart rate and BP v supine readings.
Sympathetic excess might be the result of CNS outflow, NET inhibition, parasympthetic withdrawal as a primary problem or in response to reduced stroke volume, denervation hypersensitivity or in response to increased circulating vasodilators.

Wish I had your scientific background, ramakentesh, so I could bat the ball around with you (better). Even with little knowledge, years back, my intuition focussed on the vagus nerve--because it is also involved with digestive abnormalities, which many of us have, such as nausea and vomiting from incomplete emptying of the stomach--one extreme--or other GI tract problems. Something has impaired the neurological management of body systems. I want the research to go after the "something" rather than focus too much on the end results--to look, not for the initial cause, but the present drivers of these imbalances, deficits, etc..

But most of the medical industry only cares about covering up symptoms. If the root cause is fixed, then the illness quits generating profits. Repeat business is the ticket to wealth.

ramakentesh, could you explain this statement a bit more? The information I've seen since my own NMH diagnosis (back in 1995) has said that Neurally Mediated Hypotension (also known as NeuroCardiogenic Syncope, Vasovagal Syncope, Delayed Orthostatic Hypotension, Chronic Orthostatic Intolerance, and so on...I wish experts could agree on the terminology!) cannot be easily diagnosed by the simple comparison of standing vs. supine heart rate or blood pressure.

Here's a quote from a Johns Hopkins document on this subject:

I might have misunderstood your point, though. Maybe by "easily assessed" you meant that it's relatively easy to diagnose NMH or POTS by doing a tilt table test? (assuming the doctor doing the test understands how to read the data)

Thanks for posting, Gamboa. I don't understand all the details but the concept that the variability is one of the problems is something that has come up in a couple of studies. Looking at these fluctuations makes sense to me. Blood pressure variability has been studied in patients with high blood pressure, I think, but not so much in ME/CFS patients.

Dr. Julian Stewart's web pages (see http://www.nymc.edu/fhp/centers/syncope/index.htm) do talk about this somewhere.... Oh, I just found the link:

http://www.nymc.edu/fhp/centers/syn...d pressure variability and the baroreflex.htm