Date sent: Fri, 2 Mar 2001 Source: The American Journal of Medicine Volume 110, Issue 3, Pages 242-243 Datum: February 15, 2001 URL: http://www.sciencedirect.com/science/journal/00029343 [Correspondence] Chronic fatigue syndrome symptoms common in patients with vasovagal syncope --------------------------------------------------------------------------- Rose Anne Kenny MD(a) and Laura A. Graham, MRCP(a) a Cardiovascular Investigation Unit, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom Available online 13 February 2001. To the Editor: Head-up tilt-table testing [1] to reproduce hemodynamic symptoms has considerably advanced the diagnosis and management of vasovagal syndrome. Symptoms include dizziness, presyncope, and syncope. Effective treatment includes manipulation of dietary salt and fluids, vasoconstrictor medications, beta-blockers, and other neurohumoral medications [2]. Some patients benefit from cardiac pacing [3]. Severe fatigue has been noted after vasovagal syncope [4]. Chronic fatigue syndrome, which is often protracted and disabling, is characterized by unexplained and disabling fatigue. Forty percent to 90% of patients reportedly suffer syncope or light-headedness [5]. A report of an abnormal response to tilt-table testing in 7 adolescents with chronic fatigue syndrome, 4 of whom responded to treatment for vasovagal syncope [6], and a study revealing abnormal hemodynamic responses in 22 of 23 chronic fatigue syndrome patients [5] suggest overlap of these syndromes. No studies have determined the prevalence of chronic fatigue syndrome features in patients with vasovagal syncope. We hypothesized that patients with vasovagal syncope share symptoms with chronic fatigue sufferers. To test this, we determined the prevalence of symptom criteria for chronic fatigue syndrome [7] in consecutive patients with a primary diagnosis of vasovagal syncope confirmed by symptom reproduction and diagnostic changes during head-up tilt-table testing [2]. All studies were carried out in the Cardiovascular Investigation Unit, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom, between September 1996 and October 1997. Patients had had at least two syncopal episodes in the previous year and no other attributable cause of syncope after routine cardiovascular testing. No subjects had a diagnosis of chronic fatigue syndrome. Patients completed a semistructured questionnaire for chronic fatigue symptoms [7]. Age-matched (to within 5 years) and sex-matched control subjects in good health who had not experienced syncope in the past 5 years were recruited through poster advertisements. Questionnaires were completed by 62 patients (63% women, mean [p/m SD] age 50 p/m 21 years [range 16 to 83]). Median symptom duration was 5 years. Median syncopal frequency was 12 episodes per year (range 2 per year to daily episodes). Comparison data were obtained from 119 controls (75% women, aged 44 p/m 22 years [range 16 to 85]). Five uncompleted surveys from controls were excluded. The symptom criteria for chronic fatigue syndrome [7] were fulfilled in 21% of the patients and zero controls (P <0.001). Prevalence of all symptoms was higher in the vasovagal group (Table 1). Twelve (92%) of 13 vasovagal patients with symptoms of chronic fatigue syndrome were women, compared with 13 (55%) of 49 without chronic fatigue symptoms (P=0.01). There were no differences between the two groups for baseline hemodynamic values, time to syncope, or syncopal frequency. Table 1. Symptoms of Chronic Fatigue Syndrome in Vasovagal Syncope Patients and Controls --------------------------------------------------------------------------- Symptoms Patients with Comparison P Value* Vasovagal Syncope Group n=62 (%) n=119 (%) --------------------------------------------------------------------------- Fatigue >6 months 18 (29) 2 (1) <0.001 Sore throat 18 (29) 26 (22) 0.2 Painful cervical/ 2 (3) 3 (2) 0.7 axillary lymphadenopathy Myalgia 22 (35) 24 (20) 0.02 Arthralgia 25 (41) 25 (21) 0.006 Postexercise fatigue 15 (24) 7 (6) <0.001 Headache 19 (31) 26 (22) <0.001 Cognitive disturbance** 16 (26) 19 (16) 0.1 Sleep disturbance 26 (42) 30 (25) 0.02 Criteria for 13 (21) 1 (1) <0.001 chronic fatigue syndrome met --------------------------------------------------------------------------- * According to chi-square test with Bonferroni correction. ** Impairment of concentration or memory. In this series, almost one fourth of the patients with vasovagal syncope had a high prevalence of symptoms of chronic fatigue syndrome, a finding that raises the question of a possible common pathophysiology. Successful treatments for vasovagal syncope are available, although recent evidence suggests that therapy with fludrocortisone may not be beneficial. Patients with chronic fatigue syndrome who have syncopal symptoms should be investigated for vasovagal syncope. Further studies of common mechanisms are warranted. Rose Anne Kenny, MD Laura A. Graham, MRCP Cardiovascular Investigation Unit Royal Victoria Infirmary Newcastle upon Tyne, United Kingdom References 1. R.A. Kenny, A. Ingram, J. Bayliss and R. Sutton, Head up tilt: a useful test for investigating unexplained syncope. Lancet 1 (1986), pp. 1352-1354. 2. S.W. Parry and R.A. Kenny, The management of vasovagal syncope. Q J Med 92 (1999), pp. 697-705. 3. Sheldon R. Pacing to prevent vasovagal syncope. Cardiology Clinics. 2000;18(1):81-93. 4. H. Calkins, Y. Shyr, H. Frumin et al., The value of the clinical history in the differentiation of syncope due to ventricular tachycardia, atrioventricular block, and neurocardiogenic syncope. Am J Med 98 (1995), pp. 365-373. 5. I. Bou-Holaigah, P.C. Rowe, J.S. Kan and H. Calkins, The relationship between neurally mediated hypotension and the chronic fatigue syndrome. JAMA 274 (1995), pp. 961-967. 6. P.C. Rowe, I. Bou-Holaigah, J.S. Kan and H. Calkins, Is neurally mediated hypotension an unrecognised cause of chronic fatigue syndrome. Lancet 345 (1995), pp. 623-624. 7. K. Fukuda, S. Straus, I. Hickie et al., The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med 121 (1994), pp. 953-959. -------- (c) 2001 ScienceDirect / Elsevier Science B.V.