small heart – American ME and CFS Society

Small heart and single coronary artery in a young patient with chronic fatigue syndrome: a case report

Abstract:

Aims: Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a clinically defined condition reported mostly in adults, characterized by fatigue and unexplained aspecifical symptoms. Patients with CFS/ME frequently have reduced stroke volume with an inverse relation between cardiac output and post-exertional malaise severity. We describe a rare case of a young man affected by CFS/ME, small heart, and anomalous anatomy of left main coronary artery (LMCA).

Methods and results: A 19-year-old Caucasian male referred to our clinic complaining weakness, lack of concentration, and sleepiness. He suffered by CFS/ME, D hypovitaminosis, inflammatory bowel disease, and exocrine pancreas insufficiency.

Blood tests revealed no pathological findings. Faecal exams documented intestinal dysbiosis and low pancreatic elastase.

He was treated with oxygen-ozone rectal insufflations and probiotics. Physical examination was unremarkable.

Electrocardiogram showed normal sinus rhythm. Echocardiogram revealed reduced diameters of the left ventricle (LV), normal aortic root dimensions and, in a five-chamber apical view, a binary structure that seemed to cross the aorta perpendicularly. Cardiac magnetic resonance (CMR) found reduced LV stroke volume (34 ml/m²) and end-diastolic volume (57 ml/m²) together with reduced end-diastolic wall mass (51 g/m²). Right ventricle volumes were reduced too.

In addition, the exam confirmed the anomalous origin of LMCA stemming from the proximal segment of right coronary artery and following a retro-aortic course.

Mechanism of CFS/ME remains unknown, although various factors have been implicated, including immune activation, chronic viral infection, and emotional disorders.

A considerable number of patients affected by CFS has an anatomically small heart. Small heart syndrome, in fact, may contribute to the onset of CFS/ME.

Previous studies hypothesized that clinical manifestations of CMS/ME were caused by reduced venous return, cardiac output, and heart mass, together with decreased arterial oxygen saturation. Single coronary artery is an uncommon congenital anatomic abnormality identified by a single coronary ostium giving rise to all arteries supplying the heart.

Thus, we reported a rare case of a very young man affected by chronic fatigue syndrome and small heart, investigated not only with echocardiogram but also with CMR, not often used in this clinical setting. More, we found an anomalous origin of LMCA. From literature, it’s not reported any cases of a patient including these three rare conditions (CFS/ME, small heart, and single coronary artery).

Conclusions: This case highlights that CFS/ME together with small heart is a condition possible also in young people. More studies and reports could be necessary to better define the association between cardiac congenital anomalies and CFS/ME.

Source: Cristina Poleggi, Silvia Perfetti, Davide Restelli, Alessia Perna, Rocco Donato, Gianluca Di Bella, 770 Small heart and single coronary artery in a young patient with chronic fatigue syndrome: a case report, European Heart Journal Supplements, Volume 23, Issue Supplement_G, December 2021, suab133.018, https://doi.org/10.1093/eurheartj/suab133.018

Chronic fatigue syndrome in women assessed with combined cardiac magnetic resonance imaging

Abstract:

OBJECTIVE: In chronic fatigue syndrome (CFS), only a few imaging and histopathological studies have previously assessed either cardiac dimensions/function or myocardial tissue, suggesting smaller left ventricular (LV) dimensions, LV wall motion abnormalities and occasionally viral persistence that may lead to cardiomyopathy. The present study with cardiac magnetic resonance (CMR) imaging is the first to use a contrast-enhanced approach to assess cardiac involvement, including tissue characterisation of the LV wall.

METHODS: CMR measurements of 12 female CFS patients were compared with data of 36 age-matched, healthy female controls. With cine imaging, LV volumes, ejection fraction (EF), mass, and wall motion abnormalities were assessed. T2-weighted images were analysed for increased signal intensity, reflecting oedema (i. e. inflammation). In addition, the presence of contrast enhancement, reflecting fibrosis (i. e. myocardial damage), was analysed.

RESULTS: When comparing CFS patients and healthy controls, LVEF (57.9 ± 4.3 % vs. 63.7 ± 3.7 %; p < 0.01), end-diastolic diameter (44 ± 3.7 mm vs. 49 ± 3.7 mm; p < 0.01), as well as body surface area corrected LV end-diastolic volume (77.5 ± 6.2 ml/m2 vs. 86.0 ± 9.3 ml/m2; p < 0.01), stroke volume (44.9 ± 4.5 ml/m2 vs. 54.9 ± 6.3 ml/m2; p < 0.001), and mass (39.8 ± 6.5 g/m2 vs. 49.6 ± 7.1 g/m2; p = 0.02) were significantly lower in patients. Wall motion abnormalities were observed in four patients and contrast enhancement (fibrosis) in three; none of the controls showed wall motion abnormalities or contrast enhancement. None of the patients or controls showed increased signal intensity on the T2-weighted images.

CONCLUSION: In patients with CFS, CMR demonstrated lower LV dimensions and a mildly reduced LV function. The presence of myocardial fibrosis in some CFS patients suggests that CMR assessment of cardiac involvement is warranted as part of the scientific exploration, which may imply serial non-invasive examinations.

Source: Olimulder MA, Galjee MA, Wagenaar LJ, van Es J, van der Palen J, Visser FC, Vermeulen RC, von Birgelen C. Chronic fatigue syndrome in women assessed with combined cardiac magnetic resonance imaging. Neth Heart J. 2016 Dec;24(12):709-716. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5120006/ (Full article)

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

Abstract:

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.

Source: Miwa K. Cardiac dysfunction and orthostatic intolerance in patients with myalgic encephalomyelitis and a small left ventricle. Heart Vessels. 2015 Jul;30(4):484-9. doi: 10.1007/s00380-014-0510-y. Epub 2014 Apr 16. https://www.ncbi.nlm.nih.gov/pubmed/24736946

Small heart with low cardiac output for orthostatic intolerance in patients with chronic fatigue syndrome

Abstract:

BACKGROUND: The etiology of chronic fatigue syndrome (CFS) is unknown. Orthostatic intolerance (OI) is common in CFS patients. Recently, small heart with low cardiac output has been postulated to be related to the genesis of both CFS and OI.

HYPOTHESIS: Small heart is associated with OI in patients with CFS.

METHODS: Study CFS patients were divided into groups of 26 (57%) CFSOI(+) and 20 (43%) CFSOI(-) according to the presence or absence of OI. In addition, 11 OI patients and 27 age- and sex-matched control subjects were studied. Left ventricular (LV) dimensions and function were determined echocardiographically.

RESULTS: The mean values of cardiothoracic ratio, systemic systolic and diastolic pressures, LV end-diastolic dimension, LV end-systolic dimension, stroke volume index, cardiac index, and LV mass index were all significantly smaller in CFSOI(+) patients than in CFSOI(-) patients and healthy controls, and also in OI patients than in controls. A smaller LV end-diastolic dimension (<40 mm) was significantly (P<0.05) more prevalently noted in CFSOI(+) (54%) and OI (45%) than in CFSOI(-) (5%) and controls (4%). A lower cardiac index (<2 L/min/mm(2)) was more prevalent in CFSOI(+) (65%) than in CFSOI(-) (5%, P<0.01), OI (27%), and controls (11%, P<0.01).

CONCLUSIONS: A small size of LV with low cardiac output was noted in OI, and its degree was more pronounced in CFSOI(+). A small heart appears to be related to the genesis of OI and CFS via both cerebral and systemic hypoperfusion. CFSOI(+) seems to constitute a well-defined and predominant subgroup of CFS.

Source: Miwa K, Fujita M. Small heart with low cardiac output for orthostatic intolerance in patients with chronic fatigue syndrome. Clin Cardiol. 2011 Dec;34(12):782-6. doi: 10.1002/clc.20962. Epub 2011 Nov 28. http://onlinelibrary.wiley.com/doi/10.1002/clc.20962/full (Full article)

Cardiovascular dysfunction with low cardiac output due to a small heart in patients with chronic fatigue syndrome

Abstract:

OBJECTIVE: Little attention has been paid to possible cardiovascular involvement in patients with chronic fatigue syndrome (CFS), although many of their symptoms and signs suggest cardiovascular dysfunction. Possible cardiovascular symptoms and cardiac function were investigated in CFS patients.

METHODS: Cardiovascular symptoms were intensively investigated and cardiac function was evaluated echocardiographically.

PATIENTS: Fifty-three patients (23 men and 30 women, mean age: 31+/-7 years) with CFS under 50 years were studied.

RESULTS: Slender build (body mass index <20 kg/m(2)) was common (47%). Possible cardiovascular symptoms including shortness of breath (32%), dyspnea on effort (28%), rapid heartbeat (38%), chest pain (43%), fainting (43%), orthostatic dizziness (45%) and coldness of feet (42%), were all frequent complaints. Hypotension (28%) was occasionally noted. Electrocardiograms frequently revealed right axis deviation (21%) and severe sinus arrhythmia (34%) suggesting accentuated parasympathetic nervous activity. Small heart shadow (cardiothoracic ratio <or=42%) was noted on the chest roentgenogram in 32 patients (60%). Echocardiographic examination demonstrated low cardiac indexes (<2 L/min/m(2)) with low stroke volume indexes (<30 mL/m(2)) due to a small left ventricular chamber in 19 (36%, p<0.05 vs. 8% in 36 controls). None had reduced left ventricular ejection fraction.

CONCLUSION: Cardiovascular symptoms are common in CFS patients. Cardiac dysfunction with low cardiac output due to small left ventricular chamber may contribute to the development of chronic fatigue as a constitutional factor in a considerable number of CFS patients.

Source: Miwa K, Fujita M. Cardiovascular dysfunction with low cardiac output due to a small heart in patients with chronic fatigue syndrome. Intern Med. 2009;48(21):1849-54. Epub 2009 Nov 2. https://www.ncbi.nlm.nih.gov/pubmed/19881233

Cardiac function fluctuates during exacerbation and remission in young adults with chronic fatigue syndrome and “small heart”

Abstract:

BACKGROUND: “Small heart syndrome”, previously referred to as so-called “neurocirculatory asthenia” associated with a small heart shadow on the chest roentgenogram, is characterized by weakness or fatigue even after mild exertion, palpitation, dyspnea, and fainting, many of which resemble symptoms in patients with chronic fatigue syndrome (CFS).

METHODS AND RESULTS: The study population comprised 42 patients with CFS younger than 40 years of age. Cardiothoracic ratio was determined on the chest roentgenogram and echocardiographic examination was performed to evaluate both the cardiac chamber size and function. “Small heart” (cardiothoracic ratio < or = 42%) on the chest X-ray photograph was noted in 26 (62%) of the study CFS patients. Echocardiographic examination demonstrated significantly smaller mean values of both the left ventricular (LV) end-diastolic and end-systolic dimensions, stroke volume indexes and cardiac indexes in CFS patients with “small heart” than in those without it and also in 20 control subjects. Thus, CFS patients with “small heart” had an actually small LV chamber and poor cardiac performance. During a long follow-up period of 10 CFS patients with “small heart”, all echocardiographic parameters mentioned above improved and cardiothoracic ratios increased significantly during the remission phase as compared with exacerbation phase.

CONCLUSIONS: “Small heart” on the chest X-ray photograph was prevalently noted in CFS patients. Echocardiographic examination revealed that CFS patients with “small heart” had an actually small LV chamber and poor cardiac performance. Cardiac functional changes evaluated by repeated examinations appeared to be directly associated with the severity of their symptoms. Small heart syndrome with impaired cardiac function may contribute to the development of CFS through low cardiac output as a constitutional factor.

Source: Miwa K, Fujita M. Cardiac function fluctuates during exacerbation and remission in young adults with chronic fatigue syndrome and “small heart”. J Cardiol. 2009 Aug;54(1):29-35. doi: 10.1016/j.jjcc.2009.02.008. Epub 2009 Mar 28. http://www.journal-of-cardiology.com/article/S0914-5087(09)00066-5/fulltext (Full article)

Small heart syndrome in patients with chronic fatigue syndrome

Abstract:

BACKGROUND: Small heart syndrome has previously been reported as neurocirculatory asthenia, associated with a small heart shadow on a chest roentgenogram. This is characterized as weakness or fatigue even after ordinary exertion, palpitation, dyspnea, and fainting, resembling patients with chronic fatigue syndrome (CFS).

HYPOTHESIS: Small heart syndrome may be prevalent in patients with CFS.

METHODS: The study population consisted of 56 patients (<50 y of age) with CFS, and 38 control subjects. Chest roentgenographic, echocardiographic, and physical examinations were performed.

RESULTS: Small heart syndrome (cardiothoracic ratio <or= 42%) was significantly more prevalent in the CFS group (61%) than in the control group (24%) (p < 0.01). In CFS patients with a small heart (n = 34), narrow chest (88%), orthostatic dizziness (44%), foot coldness (41%), pretibial pitting edema (32%), r-kidney palpability (47%), and mitral valve prolapse (29%), were all significantly more prevalent than in the control group, and also in the CFS patients without small heart syndrome. Echocardiographic examination demonstrated significantly smaller values of both the left ventricular (LV) end-diastolic dimensions and end-systolic, and stroke volume and cardiac indexes in CFS with a small heart, as compared with control subjects with a normal heart size (42% < cardiothoracic ratio < 50%).

CONCLUSIONS: A considerable number of CFS patients have a small heart. Small heart syndrome may contribute to the development of CFS as a constitutional factor predisposing to fatigue, and may be included in the genesis of CFS.

Source: Miwa K, Fujita M. Small heart syndrome in patients with chronic fatigue syndrome. Clin Cardiol. 2008 Jul;31(7):328-33. doi: 10.1002/clc.20227. http://onlinelibrary.wiley.com/doi/10.1002/clc.20227/epdf (Full article)