What are the diagnostic criteria and management options for neurocirculatory asthenia?

Neurocirculatory Asthenia: Diagnosis and Management

Diagnostic Approach

Neurocirculatory asthenia is a clinical diagnosis based on characteristic respiratory and cardiovascular symptoms in the absence of organic disease, requiring systematic exclusion of cardiac syncope, orthostatic hypotension, and psychiatric disorders before confirmation.

Core Diagnostic Criteria

The diagnosis requires the following constellation of symptoms with normal physical examination 1:

• Respiratory complaints (nearly universal): breathlessness at rest and with exertion, smothering sensations, sighing respirations 1
• Cardiovascular symptoms: palpitations, chest discomfort (non-ischemic pattern), awareness of heartbeat 1
• Neurological symptoms: dizziness, faintness (without true syncope), fatigue, weakness 1
• Normal physical examination is mandatory - any abnormal findings suggest alternative diagnosis 1

Essential Exclusions Before Diagnosis

You must systematically rule out conditions that present similarly but require different management:

1. Cardiac Syncope and Arrhythmias

• Obtain 12-lead ECG looking for conduction abnormalities, QT prolongation, signs of ischemia, or ventricular ectopy 2
• Consider arrhythmias (sick sinus syndrome, Mobitz II block, high-grade AV block) especially if true syncope occurred 3
• Cardiac catheterization is indicated if symptoms of angina, syncope, or dyspnea on exertion occur with concerning ECG findings 3

2. Orthostatic Hypotension

• Perform supine and upright blood pressure measurements (lying-to-standing test) 3, 2
• Classical orthostatic hypotension shows sustained decrease in systolic BP >20 mmHg or diastolic BP >10 mmHg within 3 minutes of standing 3
• Initial orthostatic hypotension occurs within 0-15 seconds and causes transient lightheadedness 3
• Review all medications, particularly antihypertensives, diuretics, tricyclic antidepressants, phenothiazines, and alpha-blockers 3

3. Psychiatric Disorders (Critical Distinction)

• Secondary neurocirculatory asthenia (59% of cases): psychiatric diagnosis (mainly anxiety disorder) precedes cardiorespiratory symptoms, which are part of the mental symptoms 4
• Primary neurocirculatory asthenia (41% of cases): cardiorespiratory symptoms occur first without preceding psychiatric illness 4
• Use structured psychiatric diagnostic interview and psychometric evaluation including depression scales, anxiety scales, and social phobia assessment 4
• Patients with secondary form have significantly higher anxiety, depression, social phobia, abnormal illness behavior, and impaired quality of life compared to primary form 4

Distinguishing Features from Similar Conditions

The European Heart Journal guidelines help differentiate neurocirculatory asthenia from reflex syncope and orthostatic intolerance syndromes 3:

• Unlike vasovagal syncope: no clear prodrome with autonomic activation (nausea, pallor, sweating) preceding loss of consciousness 3
• Unlike POTS: no inappropriate heart rate increase >30 bpm within 10 minutes of standing without BP fall 3
• Unlike autonomic failure: symptoms not consistently triggered by standing, no progressive worsening with prolonged upright posture 3

Management Strategy

Primary Neurocirculatory Asthenia

For patients without preceding psychiatric illness, reassurance and physical fitness improvement are the cornerstone of management 1:

• Provide detailed explanation that condition is benign with normal life span expected 1
• Implement graded exercise program to improve physical fitness 1
• No pharmacological treatment is typically required for primary form 4
• Prognosis is excellent at 1-year follow-up 4

Secondary Neurocirculatory Asthenia

When anxiety disorder precedes and drives symptoms, treat the underlying psychiatric condition 4:

• Address anxiety disorder as primary target (anxiolytic therapy may be considered) 4, 5
• In patients with hypertensive reactions and elevated anxiety, anxiolytic agents (such as Adaptol 1500 mg daily for 8 weeks) showed 74% improvement in clinical studies 5
• Prognosis is significantly worse than primary form without psychiatric treatment 4

Adjunctive Non-Pharmacological Approaches

For patients with enhanced meteosensitivity or autonomic imbalance 6:

• Interval hypoxic training combined with "dry" carbonic baths reduced severe meteopathic reactions from 14% to 3% 6
• These modalities are pathogenetically justified for treatment and prevention of weather-dependent exacerbations 6

Common Pitfalls to Avoid

• Do not dismiss as purely psychiatric without excluding cardiac and autonomic causes first - missing arrhythmias or orthostatic hypotension can be life-threatening 3, 2
• Do not use terms "neurocirculatory asthenia" or "effort syndrome" if fatigue is the predominant symptom (present in only 25% of cases) - consider chronic fatigue syndrome instead 4
• Do not assume all cases are benign - the 59% with secondary form require psychiatric intervention and have poor prognosis without treatment 4
• Do not overlook medication review - drug-induced orthostatic hypotension is the most frequent cause of similar symptoms and withdrawal can reduce recurrence 3, 2