Efficacy of β-Blockers on Postural Tachycardia Syndrome in Children and Adolescents: A Systematic Review and Meta-Analysis

Xinwei Deng, Yuyang Zhang, Ying Liao, Junbao Du, Xinwei Deng, Yuyang Zhang, Ying Liao, Junbao Du

Abstract

Background: Postural tachycardia syndrome (POTS) is a severe health problem in children. Short-term β-blockers are recommended for pharmaceutical treatment. However, there have been contradictory data about its efficacy among pediatric patients. Methods and Results: Eight studies comparing β-blockers to conventional treatments for children with POTS were selected, where 497 cases of pediatric POTS were included. The efficacy of β-blockers was evaluated using the effective rate, the change of symptom score, the change of heart rate difference and adverse events. The results were stated as relative ratio (RR) and mean difference (MD) with a 95% confidence interval (95% CI). A random-effects meta-analysis for the effective rate indicated that β-blockers were more effective in treating pediatric POTS than controlled treatment (79.5 vs. 57.3%, RR = 1.50, 95%CI: 1.15-1.96, P < 0.05). A fixed-effects model analysis showed that β-blockers were more effective in lowering the symptom score and the heart rate increment during standing test than controlled treatment with a mean difference of 0.81 (95% CI: 0.44-1.18, P < 0.05) and 3.78 (95% CI: 2.10-5.46, P < 0.05), respectively. There were no reported severe adverse events in included studies. Conclusion: β-blockers are effective in treating POTS in children and adolescents, alleviating orthostatic intolerance, and improving hemodynamic abnormalities.

Keywords: POTS; children; efficacy; metoprolol; β-blockers.

Copyright © 2019 Deng, Zhang, Liao and Du.

Figures

Figure 1
Figure 1
Study selection flow chart: Flow chart of the literature selection process for studies enrolled in this systematic review and meta-analysis. POTS, postural tachycardia syndrome.
Figure 2
Figure 2
Risk of bias summary: Review author's judgments about each risk of bias item for each included study. “+” indicates certain criterion has been met and therefore suggests a low risk of bias; “–” indicates certain criterion has not been met and therefore suggests a high risk of bias; “?” indicates unclear risk of bias for lack of relative information.
Figure 3
Figure 3
Risk of bias graph: Review author's judgments about each risk of bias item presented as percentages across all included studies.
Figure 4
Figure 4
Funnel plot of eight studies: Each dot stood for one study. The distance between each dot and the upright line indicated the bias in each study. (A) Funnel plot of comparison between metoprolol with controls in therapeutic effect. (B) Funnel plot of comparison between metoprolol with controls in Δ symptom score. (C) Funnel plot of comparison between metoprolol with controls in Δ heart rate difference. As the funnel plots of three outcomes were visually symmetric implying that publication bias may not exist.
Figure 5
Figure 5
Forest plot of eight studies in efficacy rate for metoprolol vs. comparator: Heterogeneity analysis showed statistical heterogeneity among the studies (p < 0.05). A random-effects model was conducted. The analysis of total effects presented in the bottom. Risk ratio of efficacy rate analyzed by Mantel-Haensze test was summarized on the right. Each little square represented the RR value of each study along with a transverse line representing 95% CI. The rhombus below stood for the overall result of meta-analysis.
Figure 6
Figure 6
Forest plot for sub-group analysis: (A) Five studies, comparing Δ heart rate difference between β-blockers and comparator. (B) Six studies, comparing Δ symptom score for two groups. The analysis of total effects were presented in the bottom. Mean difference analyzed by inverse variance method was summarized on the right. Each little square represented the mean difference of each study along with a transverse line representing 95% CI. The rhombus below stood for the overall result of meta-analysis.

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