Neurally Mediated Hypotension
An Interview with Johns Hopkins
University's Dr. Peter Rowe
By Rebecca C.
Originally published in Youth Allied By CFIDS, Fall
Dr. Peter Rowe is a pediatrician and
associate professor of pediatrics at Johns Hopkins University. He and his
colleagues in the departments of pediatrics and cardiology have been studying
adolescents with chronic fatigue syndrome (CFS) and neurally mediated
hypotension (NMH). NMH (also called vasodepressor syncope or neurocardiogenic
syncope) is a blood pressure abnormality brought on by a nervous system reflex.
It can cause symptoms such as chronic fatigue, light-headedness, recurrent
fainting, malaise, nausea, exercise intolerance and cognitive dysfunction. Dr.
Rowe and his colleagues at JHU have linked chronic fatigue syndrome and NMH
through their clinical observations and through tilt table testing. Their paper,
"Is neurally mediated hypotension an unrecognized cause of chronic fatigue?,"
was published in Lancet in March 1995. For more information on NMH, see:
- Burns RB: Johns Hopkins Research May
Hold Promise for PWCs. The CFIDS Chronicle 1995;2:4-8. *
- Brosius E: Patient's Perspective:
Pursuing Treatment for Neurally Mediated Hypotension. The CFIDS
Chronicle 1995;2:6-7. *
- Rowe P, Bou-Holaigah I, Kan J, Calkins
H: Is neurally mediated hypotension an unrecognized
cause of chronic fatigue?
Lancet 1995;345:623-624. *
- Rubin AM, et. al: The
head-up tilt table test and cardiovascular neurogenic syncope.
American Heart Journal 1993;125:476.
- Bou-Holaigah I, MD; Rowe PC, MD; Kan J,
MD; Calkins H, MD: The
relationship between neurally mediated hypotension and the chronic fatigue
syndrome. JAMA 1995
September 27; 274(12): 961-967.
- Stewart JM, Gewitz MH, Weldon A,
Arlievsky N, Li K, and Munoz J. Orthostatic Intolerance in Adolescent Chronic
Fatigue Syndrome ,
Pediatrics . 1999 January; 103(1): 116-121
- General Information Brochure on Neurally Mediated
Hypotension and its Treatment ,
Neurally Mediated Hypotension Working Group, Johns Hopkins Hospital
Q: What is your position
A : I run the diagnostic
referral clinic in the department of pediatrics. We evaluate children who do not
have a clear diagnosis and whose problems don't fit into any one classical
Q: What led you to study this
population and your conclusions?
A: There were two groups of
patients that helped stimulate my thinking about this problem. One was a group
of children, mostly adolescents, who had recurrent episodes of fainting or near
fainting. By talking to Drs. Kan and Calkins (my colleagues at JHU in pediatric
and adult cardiology), I learned a great deal about neurally mediated
hypotension (NMH). NMH has been known about for a long, long time. There was a
classic paper about it in 1932 in which, interestingly enough, people who
fainted had prolonged periods of fatigue after they fainted. But that
observation was largely ignored.
About 10 years ago, cardiologists
discovered that by using a tilt table test they could reproduce the abnormality
that caused these people to faint. So, instead of being told that they just had
to put up with their symptoms, people with recurrent fainting were diagnosed
with NMH and started treatment.
As I was looking at the children with
recurrent fainting, I was also seeing adolescents with chronic fatigue and
chronic fatigue syndrome. It looked to me like these two groups (NMH and CF/CFS)
had a lot in common. We observed that the kids with chronic fatigue and
post-exertional fatigue also had cognitive problems and were coming close to
syncope, or fainting, but were mainly just light-headed. Because of these
similarities, we decided to do tilt table tests on them and found that they all
had profound abnormalities in the regulation of blood pressure. This was a
surprise and a new finding.
Q: Every single one had
A: Yes. We studied 12 of them
in a row. Five of them had one or more prior episodes of fainting, and all five
of them, as might be expected, had abnormal tilt table tests. The seven whom we
wrote about in the Lancet paper had no evidence of previous syncope. They simply
had lightheadedness, chronic fatigue and worsening of their fatigue after
exertion. And, all seven of them had abnormal tilt tests.
Q: Can youth pursue this
testing and treatment now in most areas of the country?
A: Yes. Fortunately, the tilt
table test is something that most cardiologists who have trained recently have
some experience with. And, all cardiologists who are electrophysiologists
(specialists in heart rhythm abnormalities) can usually perform the test.
I would be very concerned about folks who
don't have cardiology training buying tilt tables and testing people. This test,
in the hands of people who are experienced, is quite safe. But one of the
reactions to being in an upright position, if you have an impressive test, can
be that the heart will stop for a brief period of time. We've seen it stop for
up to 12 seconds. It always restarts, but it restarts because we put the table
down flat. I would be worried if people were unattended or poorly monitored in a
tilt test. And, I think that would only occur when tilt tests were being done by
people with no training.
Q: In the youth with CFIDS
that you tested, what symptoms were most commonly present when their blood
A: As the tilt table went up,
they could maintain their blood pressure for a period of time, but during that
time they became gradually more symptomatic. Then their blood pressure tended to
drop very precipitously, and at that point they had a worsening of all of their
symptoms. The test was stopped if they really couldn't tolerate it any further
or if they fainted.
Q: Which symptoms are most
commonly helped by treatment of NMH?
A: In our patients in the
Lancet study, when we found an effective therapy, all of their symptoms were
improved, namely lightheadedness, fatigue, post-exertional fatigue and cognitive
dysfunction. A number who came in complaining of aches and pains in their
muscles and joints had a resolution of those aches and pains. When we found an
effective treatment for their recurrent lightheadedness, it seemed that all of
the other symptoms that people have associated with CFS also disappeared. And
that has made us hypothesize that this blood pressure reflex is responsible for
most, if not all, of the CFS symptoms.
Q: Do you think that the
adolescents you studied had NMH all of their lives?
A: No. A number of them had
their symptoms begin suddenly after what seemed to be a viral infection. Now,
there are others who, in addition to having a definite onset, had a history of
fainting once or twice before the infectious illness. They often were more tired
than their peers. People thought of them as lazy. Those kinds of symptoms are
occasionally present in the background history of some individuals, but for
many, some apparent infectious disease seemed to be associated with the
worsening of symptoms.
Q: Were adolescents more
likely to get this after puberty?
A Yes, girls getting NMH as
soon as they start to menstruate is something that I've seen time and time
again. In addition to that, there's often a worsening of fatigue in the day or
two prior to the onset of the period, at a time when we think blood volume is
probably being affected by hormones. This worsening of symptoms at puberty
hasn't been anywhere near as dramatic in male adolescent patients, in part,
because there are so many more females than males with this problem.
Q: In speaking with other
YPWCs, I have found that most are curious about how severely disabled these
adolescents were before they were treated.
A: Well, let me give you an
example of one of them who really has had a profound impact on our thinking. I
saw this girl in the spring, about a year after her symptoms started. She got a
little bit better in the summertime, but as soon as school started, her symptoms
returned. By November she was falling asleep in class, unable to concentrate and
had to read the same paragraph over 10 times just for it to sink in. She
couldn't walk more than 10 minutes without getting exhausted, couldn't do any
social activities and was home most of the time. She had to [go on home
teaching] and her relationships with her friends suffered. Her physicians told
her she was depressed and that she needed to get herself back in the swing of
things. But her aunt, who is a pediatrician, was convinced that this girl had
had a major physical change for which she wasn't to blame.
Q: How did her symptoms
change once she began treatment?
A: We put her on a beta
blocker and within a week she had an improvement in lightheadedness and fatigue,
and she was able to do more things, like riding her bike a mile to her friend's
house. About two weeks into treatment, she told us it was as if a fog had lifted
from her brain; she was able to read things properly.
By this time it was the beginning of May,
and the school decided that she ought to remain on home teaching in case her
symptoms returned. But instead of always being behind in her schoolwork, she
caught up, exceeded the reading load of the course and finished the year. This
past year (when she was on treatment) she was able to go to school and she
danced until five in the morning at her high school senior prom. She's got an
active, normal adolescent social life.
Now, she's not without symptoms and if she
skips her medications her symptoms come back, but she is able to cope with them
much better. There's a bit of a roller coaster still, but it's much more
manageable than before treatment.
Q: What did you learn about
CFIDS that you wish you had known sooner?
A: I think the thing that I
learned the most is how difficult the cognitive dysfunction is for people, how
much it bothers people who start off as bright, intelligent folks.
It was important to learn about the various
symptoms of CFS. In medical school, students are told if patients come in with
more than four or five complaints, they should assume that those people have
psychiatric or psychosomatic disease. That notion has to be exploded because of
the fact that NMH and CFIDS have a tremendous number of symptoms, but they are
* These articles are available from
The CFIDS Association of America. Please call 704/365-2343 for pricing and