Heart and Vessels

, Volume 30, Issue 4, pp 484–489 | Cite as

Cardiac dysfunction and orthostatic intolerance in patients with myalgic encephalomyelitis and a small left ventricle

  • Kunihisa Miwa
Original Article


The etiology of chronic fatigue syndrome (CFS) is unknown. Myalgic encephalomyelitis (ME) has been recently postulated to be the cause of CFS. Orthostatic intolerance (OI) has been known as an important symptom in predicting quality of life in CFS patients. Cardiac function may be impaired in patients with ME. The presence or absence of OI was determined both symptomatically and by using a 10-min stand-up test in 40 ME patients. Left ventricular (LV) dimensions and function were determined echocardiographically in the ME patients compared to 40 control subjects. OI was noted in 35 (97 %) of the 36 ME patients who could stand up quickly. The mean values for the cardiothoracic ratio, systemic systolic and diastolic pressures, LV end-diastolic diameter (EDD), LV end-systolic diameter, stroke volume index, cardiac index and LV mass index were all significantly smaller in the ME group than in the controls. Both a small LVEDD (<40 mm, 45 vs. 3 %) and a low cardiac index (<2 l/min/mm2, 53 vs. 8 %) were significantly more common in the ME group than in the controls. Both heart rate and LV ejection fraction were similar between the groups. In conclusion, a small LV size with a low cardiac output was common in ME patients, in whom OI was extremely common. Cardiac dysfunction with a small heart appears to be related to the symptoms of ME.


Chronic fatigue syndrome Myalgic encephalomyelitis Orthostatic intolerance Small heart Low cardiac output 



I thank Ms. Kakuko Fukuda and Takako Miwa for technical help.

Conflict of interest

The author has no conflict of interest to report.


  1. 1.
    Shafran SD (1991) The chronic fatigue syndrome. Am J Med 90:730–739PubMedCrossRefGoogle Scholar
  2. 2.
    Fukuda K, Straus SE, Hickle I, Sharpe Mc, Dobbins JG, Komaroff A, International Chronic Fatigue Syndrome Study Group (1994) The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Int Med 121:953–959PubMedCrossRefGoogle Scholar
  3. 3.
    Afari N, Buchwald D (2003) Chronic fatigue syndrome: a review. Am J Psychiatry 160:221–236PubMedCrossRefGoogle Scholar
  4. 4.
    Carruthers BM, van de Sande MI, De Meirleir KL, Klimas NG, Broderick G, Mitchell T, Staines D, Powles ACP, Speight N, Vallings R, Bateman L, Baumgarten-Austrheim B, Bell DS, Carlo-Stella N, Chia J, Darragh A, Jo D, Lewis D, Light AR, Marshall-Gradisbik S, Mena I, Mikovits JA, Miwa K, Murovska M, Pall ML, Stevens S (2011) Myalgic encephalomyelitis: international Consensus Criteria. J Int Med 270:327–338CrossRefGoogle Scholar
  5. 5.
    Schondorf R, Freeman R (1999) The importance of orthostatic intolerance in the chronic fatigue syndrome. Am J Med Sci 317:117–123PubMedCrossRefGoogle Scholar
  6. 6.
    Schondorf R, Benoit J, Wein T, Phaneuf D (1999) Orthostatic intolerance in the chronic fatigue syndrome. J Auton Nerv Syst 75:192–201PubMedCrossRefGoogle Scholar
  7. 7.
    Streeten DHP, Thomas D, Bell DS (2000) The roles of orthostatic hypotension, orthostatic tachycardia, and subnormal erythrocyte volume in the pathogenesis of the chronic fatigue syndrome. Am J Med Sci 320:1–8PubMedCrossRefGoogle Scholar
  8. 8.
    Costigan A, Elliott C, McDonaldo C, Newton JL (2010) Orthostatic symptoms predict functional capacity in chronic fatigue syndrome: implications for management. Q J Med 103:589–595CrossRefGoogle Scholar
  9. 9.
    Miwa K, Fujita M (2008) “Small heart syndrome” in patients with chronic fatigue syndrome. Clin Cardiol 31:328–333PubMedCrossRefGoogle Scholar
  10. 10.
    Miwa K, Fujita M (2009) Cardiac function fluctuates during exacerbation and remission in young adults with chronic fatigue syndrome and “small heart”. J Cardiol 54:29–35PubMedCrossRefGoogle Scholar
  11. 11.
    Miwa K, Fujita M (2009) Cardiovascular dysfunction with low cardiac output due to small heart in patients with chronic fatigue syndrome. Inter Med 48:1849–1854CrossRefGoogle Scholar
  12. 12.
    Miwa K, Fujita M (2011) Small heart with low cardiac output for orthostatic intolerance in patients with chronic fatigue syndrome. Clin Cardiol 34:782–786PubMedCrossRefGoogle Scholar
  13. 13.
    Fu Q, VanGundy TB, Galbreath M, Shibata S, Jain M, Hastings JL, Bhella PS, Levine BD (2010) Cardiac origins of the postural orthostatic tachycardia syndrome. J Am Coll Cardiol 55:2858–2868PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Schiller NB, Shah PM, Crawford M, DeMaria A, Devereux R, Feigenbaum H, Gutgeseaell H, Reichek N, Sahn D, Schnittinger I, Silverman N, Tajik J, the American Society of Echocardiography, Committee on Standards, Subcommittee on Quantification of Two-Dimensional Echocardiograms (1989) Recommendations for the quantification of the left ventricle by two-dimensional echocardiography. J Am Soc Echocardiogr 2:358–367PubMedCrossRefGoogle Scholar
  15. 15.
    Teichholz LE, Kreulen T, Herman MV, Gorlin R (1976) Problems in echocardiographic volume determinations: echocardiographic-angiographic correlations in the presence or absence of asynergy. Am J Cardiol 37:7–11PubMedCrossRefGoogle Scholar
  16. 16.
    Peckerman A, Lamanca JJ, Dahl KA, Chemitiganti R, Qureishi B, Natelson BH (2003) Abnormal impedance cardiography predicts symptom severity in chronic fatigue syndrome. Am J Med Sci 326:55–60PubMedCrossRefGoogle Scholar
  17. 17.
    Hurwitz BE, Coryell VT, Parker M, Martin P, LaPerriere A, Kilmas NG, Sfakianakis GN, Bilsker MS (2010) Chronic fatigue syndrome: illness severity, sedentary lifestyle, blood volume and evidence of diminished cardiac function. Clin Sci 118:125–135CrossRefGoogle Scholar
  18. 18.
    Hattori H, Minami Y, Mizuno M, Yumino D, Hoshi H, Arashi H, Nuki T, Sashida Y, Higashitani M, Serizawa N (2013) Differences in hemodynamic responses between intravenous carperitide and nicorandil in patients with acute heart failure syndromes. Heart Vessels 28:345–351PubMedCrossRefGoogle Scholar
  19. 19.
    Ehara H, Nakamura Y, Matsumoto K, Hasegawa T, Shimada K, Takagi M, Hanatani A, Izumi Y, Terashima M, Yoshiyama M (2013) Effects of intravenous atrial natriuretic peptide and nitroglycerin on coronary vasodilation and flow velocity determined using 3 T magnetic resonance imaging in patients with nonischemic heart failure. Heart Vessels 28:596–605PubMedCrossRefGoogle Scholar
  20. 20.
    Furlan R, Jacob G, Snell M, Robertson D, Porta A, Harris P, Mosqueda-Garcia R (1998) Chronic orthostatic intolerance: a disorder with discordant cardiac and vascular sympathetic control. Circulation 98:2154–2159PubMedCrossRefGoogle Scholar
  21. 21.
    Stewart J (2002) Pooling in chronic orthostatic intolerance. Arterial vasoconstrictive but not venous compliance defects. Circulation 105:2274–2281PubMedCrossRefGoogle Scholar
  22. 22.
    Stewart J (2004) Chronic orthostatic intolerance and the postural tachycardia syndrome (POTS). J Pediatr 145:725–730PubMedCentralPubMedCrossRefGoogle Scholar
  23. 23.
    Robertson D (1999) The epidemic of orthostatic tachycardia and orthostatic intolerance. Am J Med Sci 317:75–77PubMedCrossRefGoogle Scholar
  24. 24.
    Rowe PC, Bou-Holaigah I, Kan JS, Calkins H (1995) Is neurally mediated hypotension an unrecognised cause of chronic fatigue? Lancet 345:623–624PubMedCrossRefGoogle Scholar
  25. 25.
    Jacobs G, Costa F, Shannon JR, Robertson RM, Wathen M, Stein M, Biaggioni I, Ertl A, Black B, Robertson D (2000) The neuropathic postural tachycardia syndrome. N Engl J Med 343:1008–1014CrossRefGoogle Scholar
  26. 26.
    Yoshiuchi K, Farkas J, Natelson B (2006) Patients with chronic fatigue syndrome have reduced absolute cortical blood flow. Clin Physiol Funct Imaging 26:83–86PubMedCrossRefGoogle Scholar
  27. 27.
    Tanaka H, Matsushima R, Tamai H, Kajimoto Y (2002) Impaired postural cerebral hemodynamics in young patients with chronic fatigue with and without orthostatic intolerance. J Pediatr 140:412–417PubMedCrossRefGoogle Scholar
  28. 28.
    Newton JL, Sheth A, Shin J, Pairman J, Wilton K, Burt JA, Jones DE (2009) Lower ambulatory blood pressure in chronic fatigue syndrome. Psychosom Med 71:361–365PubMedCrossRefGoogle Scholar
  29. 29.
    Raj SR, Biaggioni I, Yamhure PC, Black BK, Paranjape SY, Byrne DW, Robertson D (2005) Renin-aldosterone paradox and perturbed blood volume regulation underlying postural tachycardia syndrome. Circulation 111:1574–1578PubMedCrossRefGoogle Scholar
  30. 30.
    Miwa K, Fujita M (2014) Renin–aldosterone paradox in patients with myalgic encephalomyelitis and orthostatic intolerance. Int J Cardiol 172:514–515PubMedCrossRefGoogle Scholar
  31. 31.
    Scott LV, Dinam TG (1998) Urinary free cortisol excretion in chronic fatigue syndrome, major depression and in healthy volunteers. J of Affect Disord 47:49–53CrossRefGoogle Scholar
  32. 32.
    Demitrack MA, Crofford LJ (1998) Evidence for and pathologic implication of hypothalamic-pituitary-adrenal axis dysregulation in fibromyalgia and chronic fatigue syndrome. Ann NY Acad Sci 840:684–697PubMedCrossRefGoogle Scholar
  33. 33.
    Pagani M, Lucini D (1999) Chronic fatigue syndrome: a hypothesis focusing on the autonomic nervous system. Clin Sci 96:117–125PubMedCrossRefGoogle Scholar
  34. 34.
    Curtis AM, Cheng Y, Kapoor S, Reilly D, Price TS, FitzGerald GA (2007) Circadian variation of blood pressure and the vascular response to asynchronous stress. Proc Natl Acad Sci USA 104:3450–3455PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Springer Japan 2014

Authors and Affiliations

  1. 1.Department of Internal MedicineMiwa Naika ClinicToyamaJapan

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