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Chronic fatigue syndrome symptoms common in patients with vasovagal syncope
Letters to the Editor
bone sites, but nevertheless, a lower rate of hip and vertebral fractures (1,3,4), suggesting that an ethnic-specific reference may be more appropriate. On the other hand, women living in Japan appear to have a higher rate of vertebral fractures than American women (4), suggesting that an ethnicspecific reference may underdiagnose women at risk of vertebral fractures. Although a more favorable hip geometry may protect Japanese women from hip fractures (5), their lower BMD may increase their risk of vertebral fractures and subsequent disability. Longitudinal research is needed to determine whether absolute or ethnic-matched T scores best predict future fractures, so that all people, regardless of ethnicity, can be diagnosed accurately and treated appropriately. This is especially important given the significant benefits and potential risks of drugs used to treat osteoporosis. Madeline Murguia Rice, PhD Eric B. Larson, MD, MPH University of Washington School of Medicine Seattle, Washington Andrea Z. LaCroix, PhD Fred Hutchinson Cancer Research Center Seattle, Washington Barbara L. Drinkwater, PhD Pacific Medical Center Seattle, Washington 1. Davis JW, Novotny R, Ross PD, Wasnich RD. The peak bone mass of Hawaiian, Filipino, Japanese, and white women living in Hawaii. Calcif Tissue Int. 1994;55:249 –252. 2. Graves AB, Larson EB, Edland SD, et al. Prevalence of dementia and its subtypes in the Japanese American population of King County, Washington State. The Kame Project. Am J Epidemiol. 1996;144:760 –771. 3. Ross PD, Norimatsu H, Davis JW, et al. A comparison of hip fracture incidence among Native Japanese, Japanese Americans, and American Caucasians. Am J Epidemiol. 1991;133:801– 809. 4. Ross PD, Fujiwara S, Huang C, et al. Vertebral fracture prevalence in women in Hiroshima compared to Caucasians or Japanese 242
February 15, 2001
in the US. Int J Epidemiol. 1995;24:1171– 1177. 5. Cummings SR, Cauley JA, Palmero L, et al. Racial differences in hip axis lengths might explain racial differences in rates of hip fracture. Osteo Int. 1994;4:226 –229.
CHRONIC FATIGUE SYNDROME SYMPTOMS COMMON IN PATIENTS WITH VASOVAGAL SYNCOPE 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 syn-
cope or light-headedness (5). A report of an abnormal response to tilttable 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.
Table 1. Symptoms of Chronic Fatigue Syndrome in Vasovagal Syncope Patients and Controls
Symptoms Fatigue ⬎6 months Sore throat Painful cervical/axillary lymphadenopathy Myalgia Arthralgia Postexercise fatigue Headache Cognitive disturbance† Sleep disturbance Criteria for chronic fatigue syndrome met
Patients with Vasovagal Syncope n ⫽ 62 (%)
Comparison Group n ⫽ 119 (%)
P Value*
18 (29) 18 (29) 2 (3)
2 (1) 26 (22) 3 (2)
⬍0.001 0.2 0.7
22 (35) 25 (41) 15 (24) 19 (31) 16 (26) 26 (42) 13 (21)
24 (20) 25 (21) 7 (6) 26 (22) 19 (16) 30 (25) 1 (1)
0.02 0.006 ⬍0.001 ⬍0.001 0.1 0.02 ⬍0.001
* According to chi-square test with Bonferroni correction. † Impairment of concentration or memory.
THE AMERICAN JOURNAL OF MEDICINE威
Volume 110
Letters to the Editor
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 [⫾ SD] age 50 ⫾ 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 ⫾ 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. 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
1. Kenny RA, Ingram A, Bayliss J, Sutton R. Head up tilt: a useful test for investigating unexplained syncope. Lancet. 1986;1: 1352–1354. 2. Parry SW, Kenny RA. The management of vasovagal syncope. Q J Med. 1999;92:697– 705. 3. Sheldon R. Pacing to prevent vasovagal syncope. Cardiology Clinics. 2000;18(1): 81–93. 4. Calkins H, Shyr Y, Frumin H, 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. 1995;98:365–373. 5. Bou-Holaigah I, Rowe PC, Kan JS, Calkins H. The relationship between neurally mediated hypotension and the chronic fatigue syndrome. JAMA. 1995;274:961– 967. 6. Rowe PC, Bou-Holaigah I, Kan JS, Calkins H. Is neurally mediated hypotension an unrecognised cause of chronic fatigue syndrome. Lancet. 1995;345:623– 624. 7. Fukuda K, Straus S, Hickie I, et al. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med. 1994;121:953–959.
LOUSY DIAGNOSTICS IN THE EMERGENCY ROOM To the Editor: During a night shift in a busy emergency room, several patients with acute coronary syndromes are admitted in rapid succession. A patient with suspected meningitis is admitted soon after. The resident on call is exhausted. Later at night, 3 more patients are brought to the emergency room. The first is a 20-year-old agitated psychotic woman with a history of ecstasy abuse who has overdosed on the neuroleptic chlorprothixen and the hypnotic zolpidem. Treatment is given at the intermediate care unit, and after her condition has stabilized, she is seen by the psychiatrist, who admits her to the psychiatry ward because of her persistent suicidality. The second patient is a 32-year-old man who has attempted suicide by trying to cut the arteries in his neck with a knife after his wife had inFebruary 15, 2001
formed him that she wanted a divorce. Once his condition has stabilized, he too is seen by the psychiatrist and is admitted to the psychiatric hospital nearby. The third patient, admitted to the emergency a few minutes later, is a 48-year-old woman who reports some sort of “electricity” on her head and in her hair and says that “animals” are eating and migrating on her head. The busy resident believes in the duplication (or triplication) of cases, and as the psychiatry consultant is still on the ward, asks him to examine this patient as well. The psychiatrist’s diagnosis is “head lice” and “stable mental condition,” and his report is not without an ironical undertone. Preconceived ideas in medicine are not always dangerous, but are often wrong and misleading. Juerg H. Beer, MD Fritz Kocher, MD Department of Medicine Kantonsspital Baden, Switzerland
PUBLIC KNOWLEDGE, ATTITUDES, AND EXPERIENCES WITH ANTIBIOTIC USE FOR ACUTE BRONCHITIS To the Editor: We read with great interest the article by Gonzales et al (1) concerning public knowledge, attitudes, and experiences with antibiotic use for acute bronchitis. This study certainly adds to the scanty literature about the attitudes of patients toward receiving medication for acute bronchitis and upper respiratory infection, but does not fully elucidate doctors’ attitudes about prescribing antibiotics. We surveyed antibiotic prescription rates for acute bronchitis and upper respiratory infection among 506 outpatients from three university hospitals and 764 outpatients from five private hospitals from 1999 to
THE AMERICAN JOURNAL OF MEDICINE威
Volume 110 243
bone sites, but nevertheless, a lower rate of hip and vertebral fractures (1,3,4), suggesting that an ethnic-specific reference may be more appropriate. On the other hand, women living in Japan appear to have a higher rate of vertebral fractures than American women (4), suggesting that an ethnicspecific reference may underdiagnose women at risk of vertebral fractures. Although a more favorable hip geometry may protect Japanese women from hip fractures (5), their lower BMD may increase their risk of vertebral fractures and subsequent disability. Longitudinal research is needed to determine whether absolute or ethnic-matched T scores best predict future fractures, so that all people, regardless of ethnicity, can be diagnosed accurately and treated appropriately. This is especially important given the significant benefits and potential risks of drugs used to treat osteoporosis. Madeline Murguia Rice, PhD Eric B. Larson, MD, MPH University of Washington School of Medicine Seattle, Washington Andrea Z. LaCroix, PhD Fred Hutchinson Cancer Research Center Seattle, Washington Barbara L. Drinkwater, PhD Pacific Medical Center Seattle, Washington 1. Davis JW, Novotny R, Ross PD, Wasnich RD. The peak bone mass of Hawaiian, Filipino, Japanese, and white women living in Hawaii. Calcif Tissue Int. 1994;55:249 –252. 2. Graves AB, Larson EB, Edland SD, et al. Prevalence of dementia and its subtypes in the Japanese American population of King County, Washington State. The Kame Project. Am J Epidemiol. 1996;144:760 –771. 3. Ross PD, Norimatsu H, Davis JW, et al. A comparison of hip fracture incidence among Native Japanese, Japanese Americans, and American Caucasians. Am J Epidemiol. 1991;133:801– 809. 4. Ross PD, Fujiwara S, Huang C, et al. Vertebral fracture prevalence in women in Hiroshima compared to Caucasians or Japanese 242
February 15, 2001
in the US. Int J Epidemiol. 1995;24:1171– 1177. 5. Cummings SR, Cauley JA, Palmero L, et al. Racial differences in hip axis lengths might explain racial differences in rates of hip fracture. Osteo Int. 1994;4:226 –229.
CHRONIC FATIGUE SYNDROME SYMPTOMS COMMON IN PATIENTS WITH VASOVAGAL SYNCOPE 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 syn-
cope or light-headedness (5). A report of an abnormal response to tilttable 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.
Table 1. Symptoms of Chronic Fatigue Syndrome in Vasovagal Syncope Patients and Controls
Symptoms Fatigue ⬎6 months Sore throat Painful cervical/axillary lymphadenopathy Myalgia Arthralgia Postexercise fatigue Headache Cognitive disturbance† Sleep disturbance Criteria for chronic fatigue syndrome met
Patients with Vasovagal Syncope n ⫽ 62 (%)
Comparison Group n ⫽ 119 (%)
P Value*
18 (29) 18 (29) 2 (3)
2 (1) 26 (22) 3 (2)
⬍0.001 0.2 0.7
22 (35) 25 (41) 15 (24) 19 (31) 16 (26) 26 (42) 13 (21)
24 (20) 25 (21) 7 (6) 26 (22) 19 (16) 30 (25) 1 (1)
0.02 0.006 ⬍0.001 ⬍0.001 0.1 0.02 ⬍0.001
* According to chi-square test with Bonferroni correction. † Impairment of concentration or memory.
THE AMERICAN JOURNAL OF MEDICINE威
Volume 110
Letters to the Editor
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 [⫾ SD] age 50 ⫾ 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 ⫾ 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. 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
1. Kenny RA, Ingram A, Bayliss J, Sutton R. Head up tilt: a useful test for investigating unexplained syncope. Lancet. 1986;1: 1352–1354. 2. Parry SW, Kenny RA. The management of vasovagal syncope. Q J Med. 1999;92:697– 705. 3. Sheldon R. Pacing to prevent vasovagal syncope. Cardiology Clinics. 2000;18(1): 81–93. 4. Calkins H, Shyr Y, Frumin H, 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. 1995;98:365–373. 5. Bou-Holaigah I, Rowe PC, Kan JS, Calkins H. The relationship between neurally mediated hypotension and the chronic fatigue syndrome. JAMA. 1995;274:961– 967. 6. Rowe PC, Bou-Holaigah I, Kan JS, Calkins H. Is neurally mediated hypotension an unrecognised cause of chronic fatigue syndrome. Lancet. 1995;345:623– 624. 7. Fukuda K, Straus S, Hickie I, et al. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med. 1994;121:953–959.
LOUSY DIAGNOSTICS IN THE EMERGENCY ROOM To the Editor: During a night shift in a busy emergency room, several patients with acute coronary syndromes are admitted in rapid succession. A patient with suspected meningitis is admitted soon after. The resident on call is exhausted. Later at night, 3 more patients are brought to the emergency room. The first is a 20-year-old agitated psychotic woman with a history of ecstasy abuse who has overdosed on the neuroleptic chlorprothixen and the hypnotic zolpidem. Treatment is given at the intermediate care unit, and after her condition has stabilized, she is seen by the psychiatrist, who admits her to the psychiatry ward because of her persistent suicidality. The second patient is a 32-year-old man who has attempted suicide by trying to cut the arteries in his neck with a knife after his wife had inFebruary 15, 2001
formed him that she wanted a divorce. Once his condition has stabilized, he too is seen by the psychiatrist and is admitted to the psychiatric hospital nearby. The third patient, admitted to the emergency a few minutes later, is a 48-year-old woman who reports some sort of “electricity” on her head and in her hair and says that “animals” are eating and migrating on her head. The busy resident believes in the duplication (or triplication) of cases, and as the psychiatry consultant is still on the ward, asks him to examine this patient as well. The psychiatrist’s diagnosis is “head lice” and “stable mental condition,” and his report is not without an ironical undertone. Preconceived ideas in medicine are not always dangerous, but are often wrong and misleading. Juerg H. Beer, MD Fritz Kocher, MD Department of Medicine Kantonsspital Baden, Switzerland
PUBLIC KNOWLEDGE, ATTITUDES, AND EXPERIENCES WITH ANTIBIOTIC USE FOR ACUTE BRONCHITIS To the Editor: We read with great interest the article by Gonzales et al (1) concerning public knowledge, attitudes, and experiences with antibiotic use for acute bronchitis. This study certainly adds to the scanty literature about the attitudes of patients toward receiving medication for acute bronchitis and upper respiratory infection, but does not fully elucidate doctors’ attitudes about prescribing antibiotics. We surveyed antibiotic prescription rates for acute bronchitis and upper respiratory infection among 506 outpatients from three university hospitals and 764 outpatients from five private hospitals from 1999 to
THE AMERICAN JOURNAL OF MEDICINE威
Volume 110 243