Noninvasive Vagus Nerve Stimulation in Postural Tachycardia Syndrome A Randomized Clinical Trial

BACKGROUND Low-level transcutaneous stimulation of the auricular branch of the vagus nerve at the tragus is antiarrhythmic and anti-inflammatory in animals and humans. Preliminary studies show that transcutaneous vagus nerve stimulation (tVNS) is beneficial in animal models of postural tachycardia syndrome (POTS). OBJECTIVES In this study the authors conducted a sham -controlled, double-blind, randomized clinical trial to examine the effect of tVNS on POTS over a 2 -month period relative to sham stimulation. METHODS tVNS (20 Hz, 1 mA below discomfort threshold) was delivered using an ear clip attached to either the tragus (active; n = 12) or the ear lobe (sham; n = 14) for 1 hour daily over a 2 -month period. Postural tachycardia was assessed during the baseline and 2 -month visit. Heart rate variability based on 5 -minute electrocardiogram, serum cytokines, and antiautonomic autoantibodies were measured at the respective time points. RESULTS Mean age was 34 +/- 11 years (100% female; 81% Caucasian). Adherence to daily stimulation was 83% in the active arm and 86% in the sham arm (P > 0.05). Postural tachycardia was significantly less in the active arm compared with the sham arm at 2 months (mean postural increase in heart rate 17.6 +/- 9.9 beats/min vs 31.7 +/- 14.4 beats/min; P = 0.01). Antiadrenergic autoantibodies and inflammatory cytokines were lower in the active arm compared with the sham arm at 2 months (P < 0.05). Heart rate variability was better in the active arm. No device -related side effects were observed. CONCLUSIONS Our results support the emerging paradigm of noninvasive neuromodulation to treat POTS. Mechanistically, this effect appears to be related to reduction of antiautonomic autoantibodies and inflammatory cytokines, and improvement in autonomic tone. Further studies are warranted. (Autoimmune Basis for Postural Tachycardia Syndrome; NCT05043051). (J Am Coll Cardiol EP 2024;10:346-355) (c) 2024 by the American College of Cardiology Foundation.