Da Costa's syndrome

Da Costa's Syndrome is a type of anxiety disorder named for the surgeon Jacob Mendes Da Costa who first observed it in soldiers during the American Civil War. It has also been called effort syndrome, neurocirculatory asthenia,^[1] or "soldier's heart".^[2] It causes symptoms similar to heart disease - such as fatigue upon exertion, shortness of breath, palpitations, sweating and chest pain - but upon examination, nothing is found to be physically wrong with the patient.^[3] The term is infrequently used in modern texts, and the syndrome is now usually interpreted as one of a number of imprecisely characterized "postwar syndromes".^{[4] [5]}

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History

Overview

The syndrome was first described among soldiers in 1869 by Arthur Bowen Richards Myers, who called it neurocirculatory asthenia or cardiovascular neurosis,^[6] but acquired its more usual name from the 1871 Da Costa study, which reported the latter's observations made during the American Civil War.^[7] Use of the term "Da Costa's syndrome" peaked in the early 20th century. Towards the mid-century, the condition was generally re-characterized as a form of neurosis.^[8] It was initially classified as "F45.30" (under somatoform disorder of the heart and cardiovascular system) in ICD-10, ^[9] and is now classified under "somatoform autonomic dysfunction".

1861-1950

Da Costa's Syndrome was named after physician Jacob Mendez Da Costa who identified a set of symptoms occurring amongst soldier’s during the American Civil War.^[10] Two hundred patients in the study reported chest pains, palpitations, breathlessness, dizziness and fatigue, typically brought on by strenuous exertion, such as hard field service, and long marches, or marching at double-quick pace. He also observed that the symptoms could follow wounds, scurvy, or viral infections, and tended to persist after the fever had passed.

The pulse was always greatly and rapidly influenced by position and could be aggravated by stooping, or by lying on the left or right side in some cases, and on the back in others.

He reported that the waist belt and the knapsack seemed to have something to do with it, and recommended that the soldiers did not wear restrictive clothing because it was liable to retard or prevent recovery.

In 1919 Sir Thomas Lewis commented “ it is because these symptoms and signs are largely, and sometimes wholly, the exaggerated physiological response to exercise . . . that I term the whole the ‘effort syndrome’.”^[11]

In 1941 Paul Wood studied the respiratory function of 150 cases of DaCosta's syndrome,^[12] and found that although the cause of the left sided chest pain was elusive it was located in the muscular and fibrous structures in the anterior chest wall, and although "very few patients had pain while these measurements were being made" it was associated with poor upward movement of the diaphragm, and poor expansion of the chest, particularly the lower chest. Similar pains occurred in the right side of the chest, and in other parts of the chest wall, but less commonly. A more severe chest pain could be brought on by cranking a lorry engine, or lifting a heavy weight.

In 1950 Edwin Wheeler and his colleagues from the Massachusetts General Hospital and the Harvard Medical School presented their report of a 20 year follow-up study of 173 patients with the Effort Syndrome in J.A.M.A.^[13] They found that the condition generally takes a variable course, and also varies from person to person. Most subjects completed questionnaires and of the 60 who attended medical examinations, 11.7% were well, 35% had symptoms, 38.3% had mild disability, and 15% had severe disability, and there are notes where the subjects led quiet or moderate lifestyles, and when changing to more strenuous and sustained activities their health deteriorated, so they returned to the quiet life and recovered. The periods of recuperation from the severe episodes varied from several days, and up to six weeks, and in one case for a year. In some cases this occurred two or three times in their life before they recognised the necessity and value of limiting their activities. Co-morbidity and life expectancy were better than average. An abstract attached to the article referred to the typical features of thin physiques, and long, narrow chests, and the vasomotor responses were below normal with delayed blood pressure and pulse in response to standard exertion, and there was high blood lactate concentration and low oxygen consumption associated with strenuous exercise.

After 1950

In 1956 Paul Wood’s 2nd edition of Diseases of the Heart and Circulation included a chapter on the effort syndrome . He described how "The syndrome is characterised by a group of symptoms which unduly limit the subject's capacity for effort" and recorded that " The cardinal symptoms" of effort syndrome, neurocirculatory asthenia, irritable heart, soldier's heart, disordered action of the heart (D.A.H.), etc. are "breathlessness (93%), palpitations (89%), fatigue (88%), left inframammary pain (78%), and dizziness (78%), or syncope (fainting) (35%)". He also suggested a variety of methods for diagnosing the difference between the symptoms and those of heart disease. For example (the) “Left inframammary pain (in the lower rib area) is commonly described as aching or as sharp and stabbing in quality” and “It may be initiated” “by fatigue or strain of respiratory muscles” caused by such things as “incessant minimum trauma from” “faulty posture" and there is "Dyspnoea instead of apnoea after forced breathing". Orthostatic dizziness is related to orthostatic hypotension and "The effort-tolerance test (for effort-intolerance) consists of stepping on and off a chair ten times, and counting the pulse rate before, immediately after, and subsequently at minute intervals until the resting speed is regained. The deceleration time is abnormal (over 2 minutes) in 33% of these patients." and "Physical signs of autonomic dysfunction are helpful in” “assessing the severity of the case." The photo of a painting of a typical round shouldered, thin chested, kyphotic patient is included on page 941.

In 1980 Soviet researcher V.S.Volkov presented his report on a comparative study of the exertional capacity of 228 patients which distinguished three stages of the effort syndrome (which he referred to as neurocirculatory dystony - NCD).^[14] For healthy men the average was 1176 kgm/min, and the three stages of NCD were 1161, 940 & 591 respectively, and for healthy women was 834, and the stages of NCD were 854, 621 & 420 kgm/min, indicating that the severity of the condition was related to circulatory efficiency and exertional capacity. 87.2% tolerated levels of 600 kgm/min or more, and 14 of the others had to stop because of overwhelming radiating chest pain, fatigue, and “fear for their hearts”, and another 14 stopped their test prematurely because of changes in their heart rates which reached sub-maximal levels.

Related conditions

Some researchers have described similarities between orthostatic intolerance, chronic fatigue syndrome, mitral valve prolapse syndrome, and the observations of Da Costa.^[15]

Treatment

The reports of DaCosta, and Wheeler show that patients recovered from the more severe symptoms when removed from the strenuous activity or sustained lifestyle that caused them. In many cases relapses were prevented by determining the limits of exertion and lifestyle and keeping within them. The limits were related to abnormalities in respiration and circulation. Other treatments evident from the previous studies were improving physique and posture, appropriate levels of exercise where possible, wearing loose clothing about the waist, and avoiding postural changes such as stooping, or lying on the left or right side, or the back in some cases, which relieved some of the palpitations and chest pains, and standing up slowly can prevent the faintness associated with postural or orthostatic hypotension in some cases.

See also

• Exercise intolerance
• Orthostatic intolerance
• Hyperventilation syndrome
• Chronic fatigue syndrome
• Soldier's Heart (novel)

References