Cerebral Blood Flow and Cognitive Performance in Postural Tachycardia Syndrome: Insights from Sustained Cognitive Stress Test

J Am Heart Assoc. 2020 Dec 15;9(24):e017861. doi: 10.1161/JAHA.120.017861. Epub 2020 Dec 5.


Background The physiology underlying "brain fog" in the absence of orthostatic stress in postural tachycardia syndrome (POTS) remains poorly understood. Methods and Results We evaluated cognitive and hemodynamic responses (cardiovascular and cerebral: heart rate, blood pressure, end-tidal carbon dioxide, and cerebral blood flow velocity (CBFv) in the middle cerebral artery at baseline, after initial cognitive testing, and after (30-minutes duration) prolonged cognitive stress test (PCST) whilst seated; as well as after 5-minute standing in consecutively enrolled participants with POTS (n=22) and healthy controls (n=18). Symptom severity was quantified with orthostatic hypotensive questionnaire at baseline and end of study. Subjects in POTS and control groups were frequency age- and sex-matched (29±11 versus 28±13 years; 86 versus 72% women, respectively; both P≥0.4). The CBFv decreased in both groups (condition, P=0.04) following PCST, but a greater reduction in CBFv was observed in the POTS versus control group (-7.8% versus -1.8%; interaction, P=0.038). Notably, the reduced CBFv following PCST in the POTS group was similar to that seen during orthostatic stress (60.0±14.9 versus 60.4±14.8 cm/s). Further, PCST resulted in greater slowing in psychomotor speed (6.1% versus 1.4%, interaction, P=0.027) and a greater increase in symptom scores at study completion (interaction, P<0.001) in the patients with POTS, including increased difficulty with concentration. All other physiologic responses (blood pressure and end-tidal carbon dioxide) did not differ between groups after PCST (all P>0.05). Conclusions Reduced CBFv and cognitive dysfunction were evident in patients with POTS following prolonged cognitive stress even in the absence of orthostatic stress.

Keywords: cerebral blood flow; cognitive dysfunction; orthostatic intolerance; postural tachycardia syndrome; transcranial doppler.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Blood Pressure / physiology
  • Carbon Dioxide / physiology
  • Case-Control Studies
  • Cerebrovascular Circulation / physiology
  • Cognitive Dysfunction / physiopathology*
  • Female
  • Heart Rate / physiology
  • Hemodynamics / physiology
  • Humans
  • Male
  • Middle Cerebral Artery / diagnostic imaging
  • Middle Cerebral Artery / physiopathology*
  • Neuropsychological Tests / standards
  • Orthostatic Intolerance / physiopathology
  • Postural Orthostatic Tachycardia Syndrome / physiopathology*
  • Postural Orthostatic Tachycardia Syndrome / psychology*
  • Severity of Illness Index
  • Ultrasonography, Doppler, Transcranial / methods
  • Young Adult


  • Carbon Dioxide