Increased atrial fibrillation risk in Parkinson's disease: A nationwide population-based study

Amantadine Reduces Adverse Cardiovascular Outcomes in Patients With Parkinsonism or Parkinson Disease: A Global Propensity Score Matched Analysis

OBJECTIVE

N-methyl-d-aspartate (NMDA) receptor antagonism in the central nervous system has been described. More data are needed regarding its clinical impact on the cardiovascular system. In this study, we assess the cardiovascular impact of NMDA receptor antagonism with amantadine on patients with primary or secondary parkinsonism.

METHODS

To conduct this retrospective cohort analysis, we queried the TriNetX Global database on January 13, 2024 to identify patients 18 years old or older with Parkinsonism between January 2003 and December 2023 and divided them into 2 groups based on amantadine use. We conducted propensity score matched (PSM) analysis for sociodemographics, cardiovascular comorbidities and medications, and antiparkinsonian agents.

RESULTS

After PSM, relative risks (RRs) were used to compare outcomes over a 5-year follow-up period. After PSM, both groups had 28,461 patients each. Amantadine use in patients with parkinsonism was associated with a 13% reduction in 3-point major adverse cardiovascular and cerebrovascular events (RR: 0.867, 95% confidence interval [CI]: 0.836-0.900, P < 0.0001), as well as a significantly lower risk of all-cause mortality (RR: 0.877, 95% CI: 0.844-0.912, P < 0.0001), AMI (RR: 0.790, 95% CI: 0.709-0.881, P < 0.0001), and cerebral infarction (RR: 0.868, 95% CI: 0.791-0.952, P = 0.0026). It was also associated with lower rates of heart failure, atrial arrhythmias, bradycardia, atrioventricular blocks, ventricular tachycardia, syncope and collapse, and peripheral edema. Amantadine use was however associated with a higher risk of orthostatic hypotension.

CONCLUSIONS

NMDA antagonism with amantadine in patients with primary or secondary parkinsonism is associated with a significantly reduced risk of all-cause mortality, AMI, cerebral infarction, heart failure, and arrhythmias.

Establishing a robust triangulation framework to explore the relationship between hearing loss and Parkinson's disease

The relationship between hearing loss (HL) and Parkinson's disease (PD) remains unclear. Using individual-level and summary-level data from the UK Biobank and the largest genome-wide association studies, we examined this link through observational, Mendelian randomization and genetic pleiotropy analyses. Among 158,229 participants, PD risk rose with HL severity especially in elder and males, and hearing aids significantly reduced PD risk in males. Although our results did not support a causal association, genetic correlation analysis suggested a localized genetic overlap (17q21.31). We identified 1545 SNPs and 63 genes with pleiotropic effects on HL and PD, including 79 novel SNPs across 6 loci, with 3 showing strong co-localization. These loci were enriched in key tissues like brain, heart, liver and pancreas, linked to the dihydrolipoyl dehydrogenase complex pathway, and targeted by drugs such as Warfarin and Phenprocoumon. Overall, this study reveals the risk association, genetic basis, and pleiotropic loci connecting HL and PD.

Atrial Fibrillation and Cognitive Disorders

The prevalence of atrial fibrillation among older adults is increasing. Research has indicated that atrial fibrillation is linked to cognitive impairment disorders such as Alzheimer and vascular dementia, as well as Parkinson disease. Various mechanisms are believed to be shared between atrial fibrillation and cognitive impairment disorders. The specific pathologies and mechanisms of different cognitive disorders are still being studied. Potential mechanisms include cerebral hypoperfusion, ischemic or hemorrhagic infarction, and cerebrovascular reactivity to carbon dioxide. Additionally, circulatory biomarkers and certain infectious organisms appear to be involved. This review offers an examination of the overlapping epidemiology between atrial fibrillation and cognitive disorders, explores different cognitive disorders and their connections with this arrhythmia, and discusses trials and guidelines for preventing and treating atrial fibrillation in patients with cognitive disorders. It synthesizes existing knowledge on the management of atrial fibrillation and identifies areas that require further investigation to bridge the gap in understanding the complex relationship between dementia and atrial fibrillation.

Fibrinaloid Microclots and Atrial Fibrillation

Atrial fibrillation (AF) is a comorbidity of a variety of other chronic, inflammatory diseases for which fibrinaloid microclots are a known accompaniment (and in some cases, a cause, with a mechanistic basis). Clots are, of course, a well-known consequence of atrial fibrillation. We here ask the question whether the fibrinaloid microclots seen in plasma or serum may in fact also be a cause of (or contributor to) the development of AF. We consider known 'risk factors' for AF, and in particular, exogenous stimuli such as infection and air pollution by particulates, both of which are known to cause AF. The external accompaniments of both bacterial (lipopolysaccharide and lipoteichoic acids) and viral (SARS-CoV-2 spike protein) infections are known to stimulate fibrinaloid microclots when added in vitro, and fibrinaloid microclots, as with other amyloid proteins, can be cytotoxic, both by inducing hypoxia/reperfusion and by other means. Strokes and thromboembolisms are also common consequences of AF. Consequently, taking a systems approach, we review the considerable evidence in detail, which leads us to suggest that it is likely that microclots may well have an aetiological role in the development of AF. This has significant mechanistic and therapeutic implications.

Parkinson´s disease cardiovascular symptoms: A new complex functional and structural insight

BACKGROUND

The known impairments of the cardiovascular system in Parkinson´s disease (PD) are caused by autonomic dysfunction and manifested mainly in postural hypotension, chronotropic insufficiency, and reduced heart rate variability. Other dysfunctions, mainly stress response, arrhythmia occurrence, and heart morphology changes, are still the subject of research.

OBJECTIVES

To assess the heart rate and blood pressure reaction during exercise, advanced measurements of heart volumes and mass using cardiac magnetic resonance (CMR), and occurrence of arrhythmias in PD patients.

METHODS

Thirty PD patients (19 men, mean age 57.5 years) without known cardiac comorbidities underwent bicycle ergometry, electrocardiogram Holter monitoring and CMR. Exercise and CMR parameters were compared with controls (24 subjects for ergometry, 20 for CMR).

RESULTS

PD patients had lower baseline systolic blood pressure (SBP) (117.8 vs. 128.3 mmHg, p < 0.01), peak SBP (155.8 vs. 170.8 mmHg, p < 0.05), and lower heart rate increase (49.7 vs. 64.3 beats per minute, p < 0.01). PD patients had higher indexed left and right ventricular end-diastolic volumes (68.5 vs. 57.3, p = 0.003 and 73.5 vs. 61.0 mL/m2 , respectively) and also indexed left and right ventricular end-systolic volumes (44.1 vs. 39.0, p = 0.013 and 29.0 vs. 22.0 mL/m2 , p = 0.013, respectively). A high prevalence of atrial fibrillation (8 subjects, 26.7%) was found.

CONCLUSIONS

This novel study combining functional and structural approaches showed that PD is linked with weaker blood pressure and heart rate reaction during exercise, increased myocardial mass and heart volumes compared to controls, and a high prevalence of atrial fibrillation.

Quivering hand and heart: Parkinson's disease is not associated with increased in-hospital mortality in atrial fibrillation hospitalizations: A nationwide analysis

Background

Autonomic dysfunction in Parkinson's disease (PD) includes cardiovascular dysregulations which may manifest as an increased risk of atrial fibrillation (AF). However, data on the impact of PD in AF patients is lacking. Our study aimed to investigate the differences in in-hospital mortality of patients admitted for AF with underlying PD versus those without PD.

Methods

We examined the National Inpatient Sample (NIS) database from 2016 to 2019 for hospitalizations of AF as a principal diagnosis with and without PD as a secondary diagnosis. The primary outcome was inpatient mortality. The secondary endpoints were ventricular tachycardia (VT), ventricular fibrillation (VF), acute heart failure (AHF), cardiogenic shock (CS), cardiac arrest (CA), total hospital charge (THC), and length of stay (LOS).

Results

Of 1,861,859 A F hospitalizations, 0.01% (19,490) had coexisting PD. Cohorts of PD vs No-PD had a mean age of 78.1 years [CI 77.9-78.4] vs 70.5 years [CI 70.4-70.5]; male (56.3% vs 50.7%), female (43.7% vs 49.3%). The PD category had similar in-hospital mortality with the no-PD category (OR_Adj = 1.18 [0.89-1.57] P = 0.240). The PD group had a lesser incidence of AHF (OR_Adj = 0.79 [0.72-0.86] P < 0.001) and VT (OR_Adj = 0.77 [0.62-0.95] P = 0.015).

Conclusion

Co-existing PD in patients admitted for AF was not associated with increased in-hospital mortality; however, there were lower odds of AHF and VT. The diminished arrhythmogenic neurohormonal axis may explain these cardiovascular benefits. Notwithstanding, to better understand the outcomes of AF in patients with PD, additional studies are required.

Atrial fibrillation risk on Parkinson's disease - a systematic review and meta-analysis

The association of Parkinson's Disease (PD) with atrial fibrillation (AF) is not well established and previous studies' results were heterogeneous. This review aimed to evaluate if patients with PD are at increased risk of having AF. MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science, were searched from inception May 2021. Two reviewers independently selected observational studies with data allowing to estimate the risk of atrial fibrillation in PD patients compared with no-PD controls. Pooled estimates Odds Ratio (OR) and 95% confidence intervals (CIs) were derived through meta-analysis. Heterogeneity was assessed using I² test. The risk of bias of individual studies was evaluated using the ROBINS-I tool. The study protocol was registered at PROSPERO: CRD42020216572. Seven studies were included: five case-control studies and two cohort studies. Three of the studies included were a population-based study. No significant difference was detected between PD and controls regarding atrial fibrillation (OR 1.10, 95% CI 0.81 to 1.49). Early PD present a significant higher risk of AF (OR 1.55, 95% CI 1.00 to 2.40, I² 98%). The overall risk of bias was serious, with only two studies being considered as having moderate risk. The best evidence available do not support that there is an increased risk of AF in PD patients. Further studies are needed to better conclude if there is a relation between AF and PD.

Stroke in Parkinson's disease: a review of epidemiological studies and potential pathophysiological mechanisms

Parkinson's disease (PD) is the fastest growing neurological disorder and one of the leading neurological causes of disability worldwide following stroke. An overall aging global population, as well as general changes in lifestyle associated with mass industrialization in the last century, may be linked to both increased incidence rates of PD and an increase in cumulative cardiovascular risk. Recent epidemiological studies show an increased risk of stroke, post-stroke complications, and subclinical ischemic insults in PD. PD patients have a host of characteristics that might contribute to increasing the risk of developing ischemic stroke including motor impairment, dysautonomia, and sleep disorders. This increases the urgency to study the interplay between PD and other neurological disorders, and their combined effect on mortality, morbidity, and quality of life. In this review, we provide a comprehensive overview of the studied etiological factors and pathological processes involved in PD, specifically with regard to their relationship to stroke. We hope that this review offers an insight into the relationship between PD and ischemic stroke and motivates further studies in this regard.

Prevalence of Cardio-Embolic Brain Complications in Permanent and Paroxysmal Atrial Fibrillation Patients

Background: Atrial fibrillation (AF) is the most frequent of all cardiac arrhythmias, with an increasing prevalence in the last 20 years. Cardio-embolic brain complications (CEBC) related to AF often occur or recur, even following appropriate treatment. Method: We conducted a retrospective study and analyzed the presence of stroke, dementia, and Parkinson’s disease (PD) in both paroxysmal and permanent AF patients. The records of 1111 consecutive admitted patients with primary diagnosis of AF at the Municipal Emergency University Hospital, Timisoara, between 2015 and 2016 were examined. Statistical analysis was performed on the patients included in the study based on the inclusion and exclusion criteria. Results: A significant statistical difference was noted among the permanent AF group for stroke (48.75% vs. 26.74%, p < 0.001) and dementia (10.25% vs. 3.86%, p < 0.001) compared to paroxysmal AF patients. Permanent AF patients presented a higher risk of developing stroke, dementia, and PD compared to patients with paroxysmal AF. Meanwhile, male gender and an increase in age showed an increase in the odds of having cardio-embolic brain complications in patients with paroxysmal AF. Conclusion: Based on the results obtained, it can be concluded that the risk of cardio-cerebral embolic complications is greater in permanent AF patients compared to paroxysmal AF cases. Ischemic stroke and dementia are more frequent in the permanent AF group, but analyzing the data regarding the age of onset paroxysmal AF is critical due to the fact that it involves a younger population. Prompt diagnosis and treatment can help significantly in saving stroke patients.

Machine Learning Identifies Six Genetic Variants and Alterations in the Heart Atrial Appendage as Key Contributors to PD Risk Predictivity

Parkinson's disease (PD) is a complex neurodegenerative disease with a range of causes and clinical presentations. Over 76 genetic loci (comprising 90 SNPs) have been associated with PD by the most recent GWAS meta-analysis. Most of these PD-associated variants are located in non-coding regions of the genome and it is difficult to understand what they are doing and how they contribute to the aetiology of PD. We hypothesised that PD-associated genetic variants modulate disease risk through tissue-specific expression quantitative trait loci (eQTL) effects. We developed and validated a machine learning approach that integrated tissue-specific eQTL data on known PD-associated genetic variants with PD case and control genotypes from the Wellcome Trust Case Control Consortium. In so doing, our analysis ranked the tissue-specific transcription effects for PD-associated genetic variants and estimated their relative contributions to PD risk. We identified roles for SNPs that are connected with INPP5P, CNTN1, GBA and SNCA in PD. Ranking the variants and tissue-specific eQTL effects contributing most to the machine learning model suggested a key role in the risk of developing PD for two variants (rs7617877 and rs6808178) and eQTL associated transcriptional changes of EAF1-AS1 within the heart atrial appendage. Similarly, effects associated with eQTLs located within the Brain Cerebellum were also recognized to confer major PD risk. These findings were replicated in two additional, independent cohorts (the UK Biobank, and NeuroX) and thus warrant further mechanistic investigations to determine if these transcriptional changes could act as early contributors to PD risk and disease development.

Genetic predisposition to Parkinson's disease and risk of cardio and cerebrovascular disease: a Mendelian randomization study

BACKGROUND

Observational studies suggest that Parkinson's disease (PD) is related with the risk of cardio and cerebrovascular disease. However, the causality is not yet fully established. Therefore, we employed Mendelian randomization to assess whether PD is related to risk of ischemic stroke (IS), IS subtypes, coronary artery disease (CAD) and myocardial infarction (MI).

METHODS

Eighty-eight and eleven single nucleotide polymorphisms associated with PD at the genome-wide significance level, were used as instrumental variables for PD in European and East Asian population respectively. Using a 2-sample MR, we examined associations with IS, IS related subtypes, CAD and MI in European population. We also assessed the causal association of PD with IS and CAD in East Asian population. The primary MR analyses were performed by using the random-effects inverse variance weighted approach.

RESULTS

In European population, genetic predisposition to PD was related to higher risk of IS (odds ratio [OR], 1.03 per doubling in odds of PD; 95% confidence interval [CI], 1.01-1.05; P = 0.002) and cardioembolic stroke (OR, 1.08 per doubling in odds of PD; 95% CI, 1.04-1.12; P = 1.29 × 10^-4), but not large artery stroke, small vessel stroke, CAD and MI. In East Asian population, we found no evidence of causal effect of PD on the risk of IS and CAD.

CONCLUSIONS

This study found that genetic predisposition to PD is related to higher risk of IS and cardioembolic stroke in European population.

Parkinsonism and cerebrovascular disease

The relationship between cerebrovascular disease and parkinsonism is commonly seen in everyday clinical practice but remains ill-defined and under-recognised with little guidance for the practising neurologist. We attempt to define this association and to illustrate key clinical, radiological and pathological features of the syndrome of Vascular Parkinsonism (VaP). VaP is a major cause of morbidity in the elderly associated with falls, hip fractures and cognitive impairment. Although acute parkinsonism is reported in the context of an acute cerebrovascular event, the vast majority of VaP presents as an insidious syndrome usually in the context of vascular risk factors and radiological evidence of small vessel disease. There may be an anatomic impact on basal ganglia neuronal networks, however the effect of small vessel disease (SVD) on these pathways is not clear. There are now established reporting standards for radiological features of SVD on MRI. White matter hyperintensities and lacunes have been thought to be the representative radiological features of SVD but other features such as the perivascular space are gaining more importance, especially in context of the glymphatic system. It is important to consider VaP in the differential diagnosis of Parkinson disease (PD) and in these situations, neuroimaging may offer diagnostic benefit especially in those patients with atypical presentations or refractoriness to levodopa. Proactive management of vascular risk factors, monitoring of bone density and an exercise program may offer easily attainable therapeutic targets in PD and VaP. Levodopa therapy should be considered in patients with VaP, however the dose and effect may be different from use in PD. This article is part of the Special Issue "Parkinsonism across the spectrum of movement disorders and beyond" edited by Joseph Jankovic, Daniel D. Truong and Matteo Bologna.