1
|
Criado JR, Kalafut MA. Physiological Targets for Orthostatic Hypotension: Improving Nonpharmacological Interventions in Patients with Orthostatic Cerebral Hypoperfusion. Appl Psychophysiol Biofeedback 2024:10.1007/s10484-024-09646-1. [PMID: 38809485 DOI: 10.1007/s10484-024-09646-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
Orthostatic hypotension (OH) is a form of orthostatic intolerance (OI) and a key physiological indicator of autonomic dysfunction that is associated with an increased risk of major cerebrocardiovascular events. Symptoms of cerebral hypoperfusion have been reported in patients with OH, which worsens symptoms and increases the risk of syncope. Since pharmacological interventions increase blood pressure (BP) independent of posture and do not restore normal baroreflex control, nonpharmacological treatments are considered the foundation of OH management. While reductions in cerebral blood flow velocity (CBFv) during orthostatic stress are associated with a decrease in end-tidal CO2 (EtCO2) and hypocapnia in patients with OI, their contribution to the severity of OH is not well understood. These measures have been physiological targets in a wide variety of biofeedback interventions. This study explored the relationship between cardiovascular autonomic control, EtCO2 and cerebral hypoperfusion in patients (N = 72) referred for OI. Patients with systolic OH were more likely to be male, older, demonstrate reduced adrenal and vagal baroreflex sensitivity, and reduced cardiovagal control during head-up tilt (HUT) than patients without systolic OH. Greater reduction in CBFv during HUT was associated with a larger reduction in ETCO2 and systolic BP during HUT. While deficits in cardiovascular autonomic control played a more important role in systolic OH, reduced EtCO2 was a major contributor to orthostatic cerebral hypoperfusion. These findings suggest that biofeedback treatments targeting both the autonomic nervous system and EtCO2 should be part of nonpharmacological interventions complementing the standard of care in OH patients with symptoms of cerebral hypoperfusion.
Collapse
Affiliation(s)
- José R Criado
- Division of Neurology, Autonomic Neuro Lab, Scripps Clinic, 9898 Genesee Ave., La Jolla, CA, 92037, USA
| | - Mary A Kalafut
- Division of Neurology, Autonomic Neuro Lab, Scripps Clinic, 9898 Genesee Ave., La Jolla, CA, 92037, USA.
| |
Collapse
|
2
|
Cheng Y, Lin L, Huang P, Zhang J, Wang Y, Pan X. Hypotension with neurovascular changes and cognitive dysfunction: An epidemiological, pathobiological, and treatment review. Chin Med J (Engl) 2024:00029330-990000000-01080. [PMID: 38785189 DOI: 10.1097/cm9.0000000000003103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Indexed: 05/25/2024] Open
Abstract
ABSTRACT Hypotension is a leading cause of age-related cognitive impairment. The available literature evidences that vascular factors are associated with dementia and that hypotension alters cerebral perfusion flow and can aggravate the neurodegeneration of Alzheimer's disease (AD). Despite the discovery of biomarkers and the recent progress made in neurovascular biology, epidemiology, and brain imaging, some key issues remain largely unresolved: the potential mechanisms underlying the neural deterioration observed in AD, the effect of cerebrovascular alterations on cognitive deficits, and the positive effects of hypotension treatment on cognition. Therefore, further well-designed studies are needed to unravel the potential association between hypotension and cognitive dysfunction and reveal the potential benefits of hypotension treatment for AD patients. Here, we review the current epidemiological, pathobiological, and treatment-related literature on neurovascular changes and hypotension-related cognitive dysfunction and highlight the unsettled but imminent issues that warrant future research endeavors.
Collapse
Affiliation(s)
- Yingzhe Cheng
- Department of Neurology, Center for Cognitive Neurology, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
- Fujian Institute of Geriatrics, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, Fujian 350001, China
- Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, Fujian 350001, China
| | - Lin Lin
- Department of Neurology, Center for Cognitive Neurology, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
- Fujian Institute of Geriatrics, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, Fujian 350001, China
- Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, Fujian 350001, China
| | - Peilin Huang
- Department of Neurology, Center for Cognitive Neurology, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
- Fujian Institute of Geriatrics, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, Fujian 350001, China
- Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, Fujian 350001, China
| | - Jiejun Zhang
- Department of Neurology, Center for Cognitive Neurology, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
- Fujian Institute of Geriatrics, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, Fujian 350001, China
- Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, Fujian 350001, China
- Center for Geriatrics, Hainan General Hospital, Haikou, Hainan 570311, China
| | - Yanping Wang
- Department of Endocrinology, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
| | - Xiaodong Pan
- Department of Neurology, Center for Cognitive Neurology, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
- Fujian Institute of Geriatrics, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, Fujian 350001, China
- Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, Fujian 350001, China
| |
Collapse
|
3
|
Hartmann JP, Lassen ML, Mohammad M, Iepsen UW, Mortensen J, Hasbak P, Berg RMG. Pulmonary blood volume measured by 82Rb-PET in patients with chronic obstructive pulmonary disease: a retrospective cohort study. J Appl Physiol (1985) 2024; 136:1276-1283. [PMID: 38602000 DOI: 10.1152/japplphysiol.00058.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 04/03/2024] [Accepted: 04/03/2024] [Indexed: 04/12/2024] Open
Abstract
In patients with chronic obstructive pulmonary disease (COPD), pulmonary vascular dysfunction and destruction are observable before the onset of detectable emphysema, but it is unknown whether this is associated with central hypovolemia. We investigated if patients with COPD have reduced pulmonary blood volume (PBV) evaluated by 82Rb-positron emission tomography (PET) at rest and during adenosine-induced hyperemia. This single-center retrospective cohort study assessed 6,301 82Rb-PET myocardial perfusion imaging (MPI) examinations performed over a 6-yr period. We compared 77 patients with COPD with 44 healthy kidney donors (controls). Cardiac output ([Formula: see text]) and mean 82Rb bolus transit time (MBTT) were used to calculate PBV. [Formula: see text] was similar at rest (COPD: 3,649 ± 120 mL vs. control: 3,891 ± 160 mL, P = 0.368) but lower in patients with COPD compared with controls during adenosine infusion (COPD: 5,432 ± 124 mL vs. control: 6,185 ± 161 mL, P < 0.050). MBTT was shorter in patients with COPD compared with controls at rest (COPD: 8.7 ± 0.28 s vs. control: 11.4 ± 0.37 s, P < 0.001) and during adenosine infusion (COPD: 9.2 ± 0.28 s vs. control: 10.2 ± 0.37 s, P < 0.014). PBV was lower in patients with COPD, even after adjustment for body surface area, sex, and age at rest [COPD: 530 (29) mL vs. 708 (38) mL, P < 0.001] and during adenosine infusion [COPD: 826 (29) mL vs. 1,044 (38) mL, P < 0.001]. In conclusion, patients with COPD show evidence of central hypovolemia, but it remains to be determined whether this has any diagnostic or prognostic impact.NEW & NOTEWORTHY The present study demonstrated that patients with chronic obstructive pulmonary disease (COPD) exhibit central hypovolemia compared with healthy controls. Pulmonary blood volume may thus be a relevant physiological and/or clinical outcome measure in future COPD studies.
Collapse
Affiliation(s)
- Jacob Peter Hartmann
- Centre for Physical Activity Research, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Martin Lyngby Lassen
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Milan Mohammad
- Centre for Physical Activity Research, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Ulrik Winning Iepsen
- Centre for Physical Activity Research, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital-Hvidovre, Copenhagen, Denmark
| | - Jann Mortensen
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Philip Hasbak
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Ronan M G Berg
- Centre for Physical Activity Research, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, United Kingdom
| |
Collapse
|
4
|
Pena C, Moustafa A, Mohamed AR, Grubb B. Autoimmunity in Syndromes of Orthostatic Intolerance: An Updated Review. J Pers Med 2024; 14:435. [PMID: 38673062 PMCID: PMC11051445 DOI: 10.3390/jpm14040435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
Orthostatic intolerance is a broad term that represents a spectrum of dysautonomic disorders, including postural orthostatic tachycardia syndrome (POTS) and orthostatic hypotension (OH), as manifestations of severe autonomic failure. While the etiology of orthostatic intolerance has not yet fully been uncovered, it has been associated with multiple underlying pathological processes, including peripheral neuropathy, altered renin-aldosterone levels, hypovolemia, and autoimmune processes. Studies have implicated adrenergic, cholinergic, and angiotensin II type I autoantibodies in the pathogenesis of orthostatic intolerance. Several case series have demonstrated that immunomodulation therapy resulted in favorable outcomes, improving autonomic symptoms in POTS and OH. In this review, we highlight the contemporary literature detailing the association of autoimmunity with POTS and OH.
Collapse
Affiliation(s)
- Clarissa Pena
- Department of Internal Medicine, University of Toledo, Toledo, OH 43614, USA;
| | - Abdelmoniem Moustafa
- Division of Cardiovascular Medicine, University of Toledo, Toledo, OH 43614, USA; (A.M.); (B.G.)
| | - Abdel-Rhman Mohamed
- Department of Internal Medicine, University of Toledo, Toledo, OH 43614, USA;
| | - Blair Grubb
- Division of Cardiovascular Medicine, University of Toledo, Toledo, OH 43614, USA; (A.M.); (B.G.)
| |
Collapse
|
5
|
Iwański MA, Sokołowska A, Sokołowski A, Wojdyła R, Styczkiewicz K. The Prevalence of Orthostatic Hypotension in Cancer Patients. Cancers (Basel) 2024; 16:1541. [PMID: 38672623 PMCID: PMC11049507 DOI: 10.3390/cancers16081541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/13/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Orthostatic hypotension (OH) is associated with a higher risk of mortality in the general population; however, it has not been studied in the cancer population. This study aimed to assess the prevalence of OH in cancer patients compared to that in the noncancer population. METHODS A total of 411 patients (mean age 63.5 ± 10.6 years) were recruited: patients with active cancer (n = 223) and patients hospitalised for other reasons, but without a cancer diagnosis (n = 188). Medical histories were collected and an orthostatic challenge test was performed. OH was defined as a blood pressure (BP) decrease upon standing of ≥20 mmHg for the systolic or ≥10 mmHg for the diastolic BP after 1 or 3 min; or a systolic BP decrease <90 mmHg. RESULTS The prevalence of OH in the subjects with cancer was significantly higher than in the subjects without cancer (28.7% vs. 16.5%, respectively, p = 0.003). OH was the most common in the lung cancer patients (57.5%). In a single-variable analysis, the predictors of OH were cancer presence, age ≥ 65 years, and body mass index (BMI) ≥ 30 kg/m2. In the multivariable model, the strongest independent predictor of OH was cancer status, which doubled the risk of OH, and BMI ≥ 30 kg/m2 and diabetes. CONCLUSIONS Cancer patients are characterised by a high prevalence of OH. In this population, the recommendation of routine orthostatic challenge tests should be considered.
Collapse
Affiliation(s)
- Mateusz A. Iwański
- Institute of Medical Sciences, College of Medical Sciences, University of Rzeszow, 1a Warzywna St., 35-310 Rzeszow, Poland; (M.A.I.); (A.S.)
| | - Aldona Sokołowska
- Institute of Medical Sciences, College of Medical Sciences, University of Rzeszow, 1a Warzywna St., 35-310 Rzeszow, Poland; (M.A.I.); (A.S.)
| | - Andrzej Sokołowski
- Collegium Humanum, Warsaw Management University, 133A Aleje Jerozolimskie St., 02-304 Warsaw, Poland;
| | - Roman Wojdyła
- New Medical Techniques Specialist Hospital of the Holy Family, Rudna Mała 600, 36-060 Rzeszow, Poland;
- 2nd Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego St., 30-688 Krakow, Poland
| | - Katarzyna Styczkiewicz
- Institute of Medical Sciences, College of Medical Sciences, University of Rzeszow, 1a Warzywna St., 35-310 Rzeszow, Poland; (M.A.I.); (A.S.)
- Subcarpathian Oncological Centre, Frederic Chopin University Clinical Hospital, 2 Fryderyka Szopena St., 35-055 Rzeszow, Poland
| |
Collapse
|
6
|
Conway AE, Verdi M, Shaker MS, Bernstein JA, Beamish CC, Morse R, Madan J, Lee MW, Sussman G, Al-Nimr A, Hand M, Albert DA. Beyond Confirmed Mast Cell Activation Syndrome: Approaching Patients With Dysautonomia and Related Conditions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00281-2. [PMID: 38499084 DOI: 10.1016/j.jaip.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/23/2024] [Accepted: 03/09/2024] [Indexed: 03/20/2024]
Abstract
Allergist-immunologists face significant challenges as experts in an ever-evolving field of neuroimmunology. Among these challenges is the increasingly frequent need to counsel patients with suspected mast cell activation disorders about perceived comorbidities, which may include hypermobile Ehlers-Danlos syndrome, amplified pain syndrome, fibromyalgia, burning sensation syndromes, migraines, irritable bowel syndrome, and postural orthostatic tachycardia syndrome. Patients may experience comorbid anxiety, panic disorder, and depression associated with disturbed sleep, fatigue, and cognitive impairment that often worsen when their physical symptoms increase in severity. These conditions may mimic mast cell activation disorders and are emotionally taxing for patients and clinicians because they are often accompanied by vague diagnostic courses, perceived unmanageability, social stigma, and significant impairment in quality of life. Combined with relatively poorly researched therapies, it is no surprise that clinicians may feel overwhelmed or find it difficult to provide consistently compassionate care for this population. In this article, we review available therapies for these conditions, which run the gamut from physical therapy to antidepressants to multimodal pain control. We highlight the benefit of multidisciplinary care within the primary care home, which includes an important role by the allergist-immunologist. By outlining simple approaches to initial treatment, we hope to empower clinicians with the tools needed to curb emotional burnout and embrace this patient population with compassion.
Collapse
Affiliation(s)
| | | | - Marcus S Shaker
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Rheumatology, Allergy, and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Claire C Beamish
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Richard Morse
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Pediatric Neurology, Children's Hospital at Dartmouth, Lebanon, NH
| | - Juliette Madan
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Pediatrics, Division of Child Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Psychiatry, Division of Child Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Michael W Lee
- Department of Medical Education, Dartmouth Geisel School of Medicine, Hanover, NH
| | - Gordon Sussman
- Division of Immunology, University of Toronto, St Michael's Hospital, Toronto, Ontario, Canada
| | - Amer Al-Nimr
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Pediatric Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Matthew Hand
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Pediatric Nephrology and Integrative Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Daniel A Albert
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Rheumatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| |
Collapse
|
7
|
Juraschek SP, Cortez MM, Flack JM, Ghazi L, Kenny RA, Rahman M, Spikes T, Shibao CA, Biaggioni I. Orthostatic Hypotension in Adults With Hypertension: A Scientific Statement From the American Heart Association. Hypertension 2024; 81:e16-e30. [PMID: 38205630 PMCID: PMC11067441 DOI: 10.1161/hyp.0000000000000236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Although orthostatic hypotension (OH) has long been recognized as a manifestation of autonomic dysfunction, a growing body of literature has identified OH as a common comorbidity of hypertension. This connection is complex, related to pathophysiology in blood pressure regulation and the manner by which OH is derived as the difference between 2 blood pressure measurements. While traditional therapeutic approaches to OH among patients with neurodegenerative disorders focus on increasing upright blood pressure to prevent cerebral hypoperfusion, the management of OH among patients with hypertension is more nuanced; resting hypertension is itself associated with adverse outcomes among these patients. Although there is substantial evidence that intensive blood pressure treatment does not cause OH in the majority of patients with essential hypertension, some classes of antihypertensive agents may unmask OH in patients with an underlying autonomic impairment. Practical steps to manage OH among adults with hypertension start with (1) a thorough characterization of its patterns, triggers, and cause; (2) review and removal of aggravating factors (often pharmacological agents not related to hypertension treatment); (3) optimization of an antihypertensive regimen; and (4) adoption of a tailored treatment strategy that avoids exacerbating hypertension. These strategies include countermaneuvers and short-acting vasoactive agents (midodrine, droxidopa). Ultimately, further research is needed on the epidemiology of OH, the impact of hypertension treatment on OH, approaches to the screening and diagnosis of OH, and OH treatment among adults with hypertension to improve the care of these patients and their complex blood pressure pathophysiology.
Collapse
|
8
|
Longrois D, de Tymowski C. PRO: The hypotension prediction index is clinically relevant: A physiologic/pathophysiologic approach opposed to a purely computational debate. Eur J Anaesthesiol 2024; 41:115-117. [PMID: 38085023 DOI: 10.1097/eja.0000000000001927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Affiliation(s)
- Dan Longrois
- From the Department of Anaesthesia and Intensive Care, Bichat-Claude Bernard and Louis Mourier Hospitals, DMU PARABOL, Université Paris Cité, INSERM U1148, Paris, France (DL, CdT)
| | | |
Collapse
|
9
|
Zeng J, Song H, Liu P, Xue X, Mei S, Xu B, Xing Y, Qu D, Xu E. Effect of acute levodopa challenge test on cerebral blood flow in Parkinson's disease with the supine-to-standing transcranial Doppler test. J Neurol Sci 2024; 456:122811. [PMID: 38070315 DOI: 10.1016/j.jns.2023.122811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 11/07/2023] [Accepted: 11/26/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Levodopa, a common drug that improves symptoms of Parkinson's disease (PD), can induce a reduction in blood pressure (BP); however, the effect of levodopa on cerebral blood flow (CBF) remains unclear. OBJECTIVES To observe the changes in BP and CBF during active standing before and after the acute levodopa challenge test (ALCT) and analyse the influencing factors of CBF in patients with PD. METHODS BP and CBF velocity were simultaneously recorded by continuous beat-to-beat non-invasive BP monitoring and transcranial Doppler at supine and orthostatic positions twice, before and after ALCT. The patients were divided into two groups according to those with increased and decreased CBF at baseline after ALCT to analyse the influencing factors. RESULTS We examined 64 patients with PD (59.2 ± 11.6 years, 33 males). BP decreased at all timepoints after ALCT, while there was no significant change in the magnitude of the drop in BP induced by standing. CBF was reduced after ALCT, especially within 15 s to 1 min of standing (15 s: 48.95 ± 13.50 vs. 44.93 ± 13.26, p < 0.001; 30 s: 52.46 ± 12.06 vs. 50.11 ± 12.56, p = 0.033; 1 min: 52.19 ± 11.83 vs. 50.17 ± 13.21, p = 0.044). Lower body mass index (β = -0.280, p = 0.027) was an independent factor associated with CBF reduction after ALCT. CONCLUSIONS Additional attention should be paid to changes in CBF and BP within 1 min after standing in patients with PD taking levodopa, especially in those with low bodyweight.
Collapse
Affiliation(s)
- Jingrong Zeng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Haixia Song
- Department of Neurology, Shijiazhuang People's Hospital, Shijiazhuang, China
| | - Peng Liu
- Department of Vascular and Endovascular Surgery, First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaofan Xue
- Department of Neurology, Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Shanshan Mei
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Baolei Xu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yingqi Xing
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Dian Qu
- Department of Neurology, Harbin 242 Hospital, Harbin, China
| | - Erhe Xu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
10
|
Xue C, Dou X, Yu C, Zhong Y, Wang J, Zhang X, Xue L, Hu D, Wu S, Zhang H, Tian M. In vivo cerebral metabolic and dopaminergic characteristics in multiple system atrophy with orthostatic hypotension. Eur J Nucl Med Mol Imaging 2024; 51:468-480. [PMID: 37807003 DOI: 10.1007/s00259-023-06443-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/15/2023] [Indexed: 10/10/2023]
Abstract
PURPOSE Multiple system atrophy (MSA) is a rare neurodegenerative disease, often presented with orthostatic hypotension (OH), which is a disabling symptom but has not been very explored. Here, we investigated MSA patients with OH by using positron emission tomography (PET) with 18F-fluorodeoxyglucose (18F-FDG) and 11C-N-2-carbomethoxy-3-(4-fluorophenyl)-tropane (11C-CFT) for in vivo evaluation of the glucose metabolism and dopaminergic function of the brain. METHODS Totally, 51 patients with MSA and 20 healthy controls (HC) who underwent 18F-FDG PET/CT were retrospectively enrolled, among which 24 patients also underwent 11C-CFT PET/CT. All patients were divided into MSA-OH(+) and MSA-OH(-) groups. Then, statistical parametric mapping (SPM) method was used to reveal the regional metabolic and dopaminergic characteristics of MSA-OH(+) compared with MSA-OH(-). Moreover, the metabolic networks of MSA-OH(+), MSA-OH(-) and HC groups were also constructed and analyzed based on graph theory to find possible network-level changes in MSA patients with OH. RESULTS The SPM results showed significant hypometabolism in the pons and right cerebellar tonsil, as well as hypermetabolism in the left parahippocampal gyrus and left superior temporal gyrus in MSA-OH(+) compared with MSA-OH(-). A reduced 11C-CFT uptake in the left caudate was also shown in MSA-OH(+) compared with MSA-OH(-). In the network analysis, significantly reduced local efficiency and clustering coefficient were shown in MSA-OH(+) compared with HC, and decreased nodal centrality in the frontal gyrus was found in MSA-OH(+) compared with MSA-OH(-). CONCLUSION In this study, the changes in glucose metabolism in the pons, right cerebellar tonsil, left parahippocampal gyrus and left superior temporal gyrus were found closely related to OH in MSA patients. And the decreased presynaptic dopaminergic function in the left caudate may contribute to OH in MSA. Taken together, this study provided in vivo pathophysiologic information on MSA with OH from neuroimaging approach, which is essential for a better understanding of MSA with OH.
Collapse
Affiliation(s)
- Chenxi Xue
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China
- Institute of Nuclear Medicine and Molecular Imaging of Zhejiang University, Hangzhou, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, China
| | - Xiaofeng Dou
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China
- Institute of Nuclear Medicine and Molecular Imaging of Zhejiang University, Hangzhou, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, China
| | - Congcong Yu
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China
- Institute of Nuclear Medicine and Molecular Imaging of Zhejiang University, Hangzhou, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, China
| | - Yan Zhong
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China
- Institute of Nuclear Medicine and Molecular Imaging of Zhejiang University, Hangzhou, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, China
| | - Jing Wang
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China
- Institute of Nuclear Medicine and Molecular Imaging of Zhejiang University, Hangzhou, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, China
| | - Xiang Zhang
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China
- Institute of Nuclear Medicine and Molecular Imaging of Zhejiang University, Hangzhou, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, China
| | - Le Xue
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China
- Institute of Nuclear Medicine and Molecular Imaging of Zhejiang University, Hangzhou, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, China
| | - Daoyan Hu
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China
- Institute of Nuclear Medicine and Molecular Imaging of Zhejiang University, Hangzhou, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, China
- College of Biomedical Engineering and Instrument Science of Zhejiang University, Hangzhou, China
| | - Shuang Wu
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China
- Institute of Nuclear Medicine and Molecular Imaging of Zhejiang University, Hangzhou, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, China
| | - Hong Zhang
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China.
- Institute of Nuclear Medicine and Molecular Imaging of Zhejiang University, Hangzhou, China.
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, China.
- College of Biomedical Engineering and Instrument Science of Zhejiang University, Hangzhou, China.
- Key Laboratory for Biomedical Engineering of Ministry of Education Zhejiang University, Hangzhou, China.
| | - Mei Tian
- Department of Nuclear Medicine and PET Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China.
- Institute of Nuclear Medicine and Molecular Imaging of Zhejiang University, Hangzhou, China.
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou, China.
- Human Phenome Institute, Fudan University, Shanghai, China.
| |
Collapse
|
11
|
Bhanu C, Petersen I, Orlu M, Davis D, Sofat R, Bazo-Alvarez JC, Walters K. Drug-induced orthostatic hypotension: Cluster analysis of co-prescription patterns in older people in UK primary care. Pharmacoepidemiol Drug Saf 2024; 33:e5730. [PMID: 37974394 DOI: 10.1002/pds.5730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE Over 250 medications are reported to cause orthostatic hypotension, associated with serious adverse outcomes in older adults. Studies suggest a harmful cumulative risk of orthostatic hypotension with multiple medication use. However, there is limited evidence on the potential for harm in practice, particularly which drugs is co-prescribed and may increase risk of orthostatic hypotension. METHODS Retrospective cohort study and cluster analysis using general practice data from IQVIA Medical Research Data (IMRD) in patients aged ≥50 contributing data between 1 January 2018 and 31 December 2018. Thirteen drug groups known to be associated with orthostatic hypotension by mechanism, were analyzed and clusters generated by sex and age-band. RESULTS A total of 602 713 individuals aged ≥50 with 283 912 (47%) men and 318 801 (53%) women were included. The most prevalent prescriptions that might contribute to orthostatic hypotension were ACE inhibitors, calcium-channel blockers, beta-blockers, selective serotonin reuptake inhibitors and uroselective alpha-blockers. We identified distinct clusters of cardiovascular system (cardiovascular system) drugs in men and women at all ages. cardiovascular system plus psychoactive drug clusters were common in women at all ages, and in men aged ≤70. cardiovascular system plus uroselective alpha-blockers were identified in men aged ≥70. CONCLUSIONS Distinct clusters of drugs associated with orthostatic hypotension exist in practice, which change over the life course. Our findings highlight potentially harmful drug combinations that may cause cumulative risk of orthostatic hypotension in older people. This may guide clinicians about the potential of synergistic harm and to monitor for orthostatic hypotension if using combinations of cardiovascular system drugs, cardiovascular system plus psychoactive drugs and/or alpha-blockers-particularly in patients aged ≥70 or at high-risk due to comorbidity. Future research should consider quantifying the risk of drug-induced orthostatic hypotension with such drug combinations.
Collapse
Affiliation(s)
- Cini Bhanu
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Irene Petersen
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Mine Orlu
- University College London (UCL) School of Pharmacy, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health & Ageing, University College London, London, UK
| | - Reecha Sofat
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
- British Heart Foundation, Data Science Centre, UK
| | - Juan Carlos Bazo-Alvarez
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Kate Walters
- Research Department of Primary Care and Population Health, University College London, London, UK
| |
Collapse
|
12
|
Ma Y, Zhang Y, Coresh J, Viswanathan A, Sullivan KJ, Walker KA, Liu C, Lipsitz LA, Selvin E, Sharrett AR, Gottesman RF, Blacker D, Hofman A, Windham BG, Juraschek SP. Orthostatic Blood Pressure Change, Dizziness, and Risk of Dementia in the ARIC Study. Hypertension 2024; 81:96-106. [PMID: 37869909 PMCID: PMC10843561 DOI: 10.1161/hypertensionaha.123.21438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/14/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Abnormal orthostatic blood pressure (BP) regulation may result in cerebral hypoperfusion and brain ischemia and contribute to dementia. It may also manifest as early symptoms of the neurodegenerative process associated with dementia. The relationship between the magnitude and timing of orthostatic BP responses and dementia risk is not fully understood. METHODS We conducted a prospective cohort analysis of the associations of orthostatic BP changes and self-reported orthostatic dizziness with the risk of dementia in the Atherosclerosis Risk in Communities study (ARIC). We calculated changes in BP from the supine to the standing position at 5 measurements taken within 2 minutes after standing during the baseline visit (1987-1989). The primary outcome was adjudicated dementia ascertained through 2019. RESULTS Among 11 644 participants (mean [SD] age, 54.5 [5.7] years; 54.1% women; 25.9% Black), 2303 dementia cases were identified during a median follow-up of 25.9 years. Large decreases in systolic BP from the supine to standing position measured at the first 2 measurements ≈30 and 50 seconds after standing, but not afterward, were associated with orthostatic dizziness and a higher risk of dementia. Comparing a decrease in systolic BP of ≤-20 or >-20 to -10 mm Hg to stable systolic BP (>-10 to 10 mm Hg) at the first measurement, the adjusted hazard ratios were 1.22 (95% CI, 1.01-1.47) and 1.10 (95% CI, 0.97-1.25), respectively. CONCLUSIONS Abnormal orthostatic BP regulation, especially abrupt drops in BP within the first minute, might be early risk markers for the development of dementia. Transient early orthostatic hypotension warrants more attention in clinical settings.
Collapse
Affiliation(s)
- Yuan Ma
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Yiwen Zhang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Josef Coresh
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Anand Viswanathan
- Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, USA
| | - Kevin J. Sullivan
- Memory Impairment and Neurogenerative Dementia Center, University of Mississippi Medical Center, Jackson, MS USA
| | - Keenan A. Walker
- Intramural Research Program of the National Institute on Aging, NIH, Baltimore, Maryland, USA
| | - Chelsea Liu
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Lewis A. Lipsitz
- Beth Israel Deaconess Medical Center, Harvard Medical School, and Hebrew Senior Life Hinda and Arthur Marcus Institute for Aging Research, Boston, USA
| | - Elizabeth Selvin
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - A. Richey Sharrett
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rebecca F. Gottesman
- National Institute of Neurological Disorders and Stroke Intramural Research Program, Bethesda, Maryland, USA
| | - Deborah Blacker
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Albert Hofman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - B. Gwen Windham
- Memory Impairment and Neurogenerative Dementia Center, University of Mississippi Medical Center, Jackson, MS USA
| | - Stephen P Juraschek
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| |
Collapse
|
13
|
Chou YT, Sun ZJ, Shao SC, Yang YC, Lu FH, Chang CJ, Liao TC, Li CY, Chen THH, Wu JS, Lai ECC. Autonomic modulation and the risk of dementia in a middle-aged cohort: A 17-year follow-up study. Biomed J 2023; 46:100576. [PMID: 36581249 PMCID: PMC10749883 DOI: 10.1016/j.bj.2022.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/20/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Altered autonomic modulation, measured by heart rate variability (HRV), has been found to be associated with dementia risk in the elderly. However, long-term follow-up study evaluating the association between autonomic modulation from middle-age and the incidence of dementia has been limited. METHODS This retrospective cohort analyzed data from Taiwan's National Health Insurance Database covering the period from 2001 to 2017, with a linkage to citywide health examinations conducted by Tainan Metropolitan City, Taiwan. We included subjects aged 45-64 years. The mean follow-up period was 15.75 ± 3.40 years. The measurements of HRV included resting heart rate, high frequency (HF), low frequency (LF), standard deviation of normal-to-normal R-R intervals (SDNN), ratio between the 30th and 15th R-R interval after standing up from the supine position (30/15 ratio), ratio between the R-R intervals during expiration and inspiration, and the ratio between the high- and low-frequency components (LF/HF). The main study outcome was the incidence of dementia. We performed multivariable Cox proportional hazard regression models to compare the risk of dementia among different HRV subgroups. RESULTS We included 565 participants with a mean age of 53 (SD: 6) years, of whom 44% were male. The risk of dementia was significantly increased in association with lower parasympathetic HRV modulation, including SDNN (HR: 3.23, 95% CI: 1.55-6.73) and 30/15 ratio (HR: 3.52, 95%CI: 1.67-7.42). Moreover, the risk of dementia was increased in subjects with higher LF/HF ratios (HR: 2.05, 95% CI: 1.12-3.72). CONCLUSIONS Lower parasympathetic activity and higher sympathetic-vagal imbalance in middle-age were associated with dementia risk.
Collapse
Affiliation(s)
- Yu-Tsung Chou
- Department of Health Management Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Zih-Jie Sun
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Family Medicine, National Cheng Kung University Hospital Dou-Liou Branch, College of Medicine, National Cheng Kung University, Yunlin, Taiwan
| | - Shih-Chieh Shao
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Pharmacy, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
| | - Yi-Ching Yang
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Feng-Hwa Lu
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Jen Chang
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Family Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Tzu-Chi Liao
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
| | - Tony Hsiu-Hsi Chen
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Jin-Shang Wu
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Family Medicine, National Cheng Kung University Hospital Dou-Liou Branch, College of Medicine, National Cheng Kung University, Yunlin, Taiwan; Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| |
Collapse
|
14
|
Luchian ML, Higny J, Benoit M, Robaye B, Berners Y, Henry JP, Colle B, Xhaët O, Blommaert D, Droogmans S, Motoc AI, Cosyns B, Gabriel L, Guedes A, Demeure F. Unmasking Pandemic Echoes: An In-Depth Review of Long COVID's Unabated Cardiovascular Consequences beyond 2020. Diagnostics (Basel) 2023; 13:3368. [PMID: 37958264 PMCID: PMC10647305 DOI: 10.3390/diagnostics13213368] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/23/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023] Open
Abstract
At the beginning of 2020, coronavirus disease 2019 (COVID-19) emerged as a new pandemic, leading to a worldwide health crisis and overwhelming healthcare systems due to high numbers of hospital admissions, insufficient resources, and a lack of standardized therapeutic protocols. Multiple genetic variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been detected since its first public declaration in 2020, some of them being considered variants of concern (VOCs) corresponding to several pandemic waves. Nevertheless, a growing number of COVID-19 patients are continuously discharged from hospitals, remaining symptomatic even months after their first episode of COVID-19 infection. Long COVID-19 or 'post-acute COVID-19 syndrome' emerged as the new pandemic, being characterized by a high variability of clinical manifestations ranging from cardiorespiratory and neurological symptoms such as chest pain, exertional dyspnoea or cognitive disturbance to psychological disturbances, e.g., depression, anxiety or sleep disturbance with a crucial impact on patients' quality of life. Moreover, Long COVID is viewed as a new cardiovascular risk factor capable of modifying the trajectory of current and future cardiovascular diseases, altering the patients' prognosis. Therefore, in this review we address the current definitions of Long COVID and its pathophysiology, with a focus on cardiovascular manifestations. Furthermore, we aim to review the mechanisms of acute and chronic cardiac injury and the variety of cardiovascular sequelae observed in recovered COVID-19 patients, in addition to the potential role of Long COVID clinics in the medical management of this new condition. We will further address the role of future research for a better understanding of the actual impact of Long COVID and future therapeutic directions.
Collapse
Affiliation(s)
- Maria-Luiza Luchian
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Julien Higny
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Martin Benoit
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Benoit Robaye
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Yannick Berners
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Jean-Philippe Henry
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Benjamin Colle
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Olivier Xhaët
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Dominique Blommaert
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Steven Droogmans
- Department of Cardiology, Centrum voor Hart-en Vaatziekten, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Andreea Iulia Motoc
- Department of Cardiology, Centrum voor Hart-en Vaatziekten, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Bernard Cosyns
- Department of Cardiology, Centrum voor Hart-en Vaatziekten, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Laurence Gabriel
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Antoine Guedes
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Fabian Demeure
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| |
Collapse
|
15
|
Tephilla E, Elizabeth T, Shalini J, Vinod A. Orthostatic hypotension in the elderly: Prevalence and its management by simple isometric limb tensing exercises. J Family Med Prim Care 2023; 12:2661-2666. [PMID: 38186782 PMCID: PMC10771198 DOI: 10.4103/jfmpc.jfmpc_1009_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 07/18/2023] [Accepted: 08/09/2023] [Indexed: 01/09/2024] Open
Abstract
Objective Orthostatic hypotension (OH), an important cause of falls in the elderly, is grossly underdiagnosed. Our study aimed to determine the prevalence and associated factors of OH among the elderly attending a secondary care hospital. Furthermore, we assessed and compared the effectiveness of simple arm and leg tensing exercises, performed just prior to standing, to mitigate the orthostatic fall in blood pressure (BP) in elderly OH patients. Materials and Methods A cross-sectional study screened elderly patients (≥65 years) for OH and recruited them into a randomized controlled trial (CTRI/2020/08/027182) of two parallel groups performing either arm tensing or leg tensing exercises just before standing up. We performed an interim analysis of the ongoing trial using paired t-test for within-group comparisons. Patients identified to have OH based on systolic or diastolic fall in BP were analyzed separately. Chi-square analysis compared the improvement in OH status between the two groups. Results Nineteen out of 186 screened elderly patients were diagnosed with OH (10.21%, 95% CI: 7.99-12.43). Arm exercise significantly reduced the orthostatic-induced fall in systolic and diastolic BP, while leg exercise effectively reduced only the systolic fall in BP among patients with OH. The proportion of patients with OH after arm exercise (20%) was significantly lower than after leg exercise (77.8%) (P = 0.023, Fischer's exact test). Conclusion We found a 10.21% prevalence of OH in our elderly population. Furthermore, we found that simple isometric arm tensing exercise ameliorates the fall in BP on standing up in OH patients.
Collapse
Affiliation(s)
- Epsibha Tephilla
- Department of Physiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Tharion Elizabeth
- Department of Physiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Jeyapaul Shalini
- Department of Community Health, Christian Medical College, Vellore, Tamil Nadu, India
| | - Abraham Vinod
- Department of Community Health, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
16
|
Chen B, Yang W, Luo Y, Tan EK, Wang Q. Non-pharmacological and drug treatment of autonomic dysfunction in multiple system atrophy: current status and future directions. J Neurol 2023; 270:5251-5273. [PMID: 37477834 DOI: 10.1007/s00415-023-11876-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/11/2023] [Accepted: 07/11/2023] [Indexed: 07/22/2023]
Abstract
Multiple system atrophy (MSA) is a sporadic, fatal, and rapidly progressive neurodegenerative disease of unknown etiology that is clinically characterized by autonomic failure, parkinsonism, cerebellar ataxia, and pyramidal signs in any combination. Early onset and extensive autonomic dysfunction, including cardiovascular dysfunction characterized by orthostatic hypotension (OH) and supine hypertension, urinary dysfunction characterized by overactive bladder and incomplete bladder emptying, sexual dysfunction characterized by sexual desire deficiency and erectile dysfunction, and gastrointestinal dysfunction characterized by delayed gastric emptying and constipation, are the main features of MSA. Autonomic dysfunction greatly reduces quality of life and increases mortality. Therefore, early diagnosis and intervention are urgently needed to benefit MSA patients. In this review, we aim to discuss the systematic treatment of autonomic dysfunction in MSA, and focus on the current methods, starting from non-pharmacological methods, such as patient education, psychotherapy, diet change, surgery, and neuromodulation, to various drug treatments targeting autonomic nerve and its projection fibers. In addition, we also draw attention to the interactions among various treatments, and introduce novel methods proposed in recent years, such as gene therapy, stem cell therapy, and neural prosthesis implantation. Furthermore, we elaborate on the specific targets and mechanisms of action of various drugs. We would like to call for large-scale research to determine the efficacy of these methods in the future. Finally, we point out that studies on the pathogenesis of MSA and pathophysiological mechanisms of various autonomic dysfunction would also contribute to the development of new promising treatments and concepts.
Collapse
Affiliation(s)
- BaoLing Chen
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of China
| | - Wanlin Yang
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of China
| | - Yuqi Luo
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of China
| | - Eng-King Tan
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
| | - Qing Wang
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of China.
| |
Collapse
|
17
|
Byrd JB, Bisognano JD, Brook RD. Treating Hypertension in Patients With Orthostatic Hypotension: Benefits vs Harms in the Era of Aggressive Blood Pressure Lowering. JAMA 2023; 330:1435-1436. [PMID: 37847283 DOI: 10.1001/jama.2023.19096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Affiliation(s)
- James Brian Byrd
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor
| | - John D Bisognano
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor
| | - Robert D Brook
- Division of Cardiovascular Diseases, Department of Internal Medicine, Wayne State University, Detroit, Michigan
| |
Collapse
|
18
|
Wei ZYD, Liang K, Shetty AK. Complications of COVID-19 on the Central Nervous System: Mechanisms and Potential Treatment for Easing Long COVID. Aging Dis 2023; 14:1492-1510. [PMID: 37163427 PMCID: PMC10529748 DOI: 10.14336/ad.2023.0312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/12/2023] [Indexed: 05/12/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) invades human cells by binding to the angiotensin-converting-enzyme-2 (ACE-2) using a spike protein and leads to Coronavirus disease-2019 (COVID-19). COVID-19 primarily causes a respiratory infection that can lead to severe systemic inflammation. It is also common for some patients to develop significant neurological and psychiatric symptoms. The spread of SARS-CoV-2 to the CNS likely occurs through several pathways. Once spread in the CNS, many acute symptoms emerge, and such infections could also transpire into severe neurological complications, including encephalitis or ischemic stroke. After recovery from the acute infection, a significant percentage of patients develop "long COVID," a condition in which several symptoms of COVID-19 persist for prolonged periods. This review aims to discuss acute and chronic neurological problems after SARS-CoV-2 infection. The potential mechanisms by which SARS-CoV-2 enters the CNS and causes neuroinflammation, neuropathological changes observed in post-mortem brains of COVID-19 patients, and cognitive and mood problems in COVID-19 survivors are discussed in the initial part. The later part of the review deliberates the causes of long COVID, approaches for noninvasive tracking of neuroinflammation in long COVID patients, and the potential therapeutic strategies that could ease enduring CNS symptoms observed in long COVID.
Collapse
Affiliation(s)
- Zhuang-Yao D Wei
- Institute for Regenerative Medicine, Department of Cell Biology and Genetics, Texas A&M University Health Science Center School of Medicine, College Station, TX, USA
| | - Ketty Liang
- Sam Houston State University College of Osteopathic Medicine, Conroe, TX, USA
| | - Ashok K Shetty
- Institute for Regenerative Medicine, Department of Cell Biology and Genetics, Texas A&M University Health Science Center School of Medicine, College Station, TX, USA
| |
Collapse
|
19
|
Han J, Park J, Kang H, Lee H, Kim N. The Effect of a Biofeedback-Based Integrated Program on Improving Orthostatic Hypotension in Community-Dwelling Older Adults: A Pilot Study. J Cardiovasc Nurs 2023:00005082-990000000-00120. [PMID: 37615610 DOI: 10.1097/jcn.0000000000001026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
BACKGROUND Orthostatic hypotension (OH) is prevalent among community-dwelling older adults and is associated with multiple negative health outcomes. Older adults are susceptible to developing OH because aging alters autonomic nervous system function. Biofeedback is a noninvasive, nonpharmacological intervention that can modulate autonomic nervous system dysfunction in older adults. OBJECTIVES Our aim in this study was to examine the effect of a biofeedback-based integrated program on community-dwelling older adults with OH. METHODS We conducted a controlled pilot study. Community-dwelling older adults 65 years or older who had nonneurogenic OH were eligible. Data from 51 participants, comprising 27 in the intervention group and 24 in the control group, were analyzed. Weekly biofeedback-based integrated program consisting of biofeedback training along with group education about behavioral modification, physical activities, and telephone counseling was provided for 12 weeks. Orthostatic hypotension was evaluated by measuring the drop in systolic and diastolic blood pressure after postural changes. Autonomic nervous system function was measured using heart rate variability. RESULTS Among the indicators of heart rate variability, total power (P = .037) and low frequency (P = .017) increased significantly, suggesting that autonomic function improved. Severity of orthostatic symptoms (P < .001) and drops in systolic (P = .003) and diastolic (P = .012) blood pressure after postural changes decreased significantly in the intervention group. CONCLUSION Biofeedback-based integrated program was effective in improving autonomic nervous system function and alleviated OH. Therefore, biofeedback-based integrated program should be tested in a larger randomized controlled study with long-term follow-up.
Collapse
|
20
|
Wang L, Pronk AC, van Poelgeest EP, Briggs R, Claassen JAHR, Jansen S, Klop M, de Lange FJ, Meskers CCGM, Odekerken VJJ, Payne SJ, Trappenburg MC, Thijs RD, Uleman JF, Hoekstra AG, van der Velde N. Applying systems thinking to unravel the mechanisms underlying orthostatic hypotension related fall risk. GeroScience 2023; 45:2743-2755. [PMID: 37115348 PMCID: PMC10651607 DOI: 10.1007/s11357-023-00802-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
Orthostatic hypotension (OH) is an established and common cardiovascular risk factor for falls. An in-depth understanding of the various interacting pathophysiological pathways contributing to OH-related falls is essential to guide improvements in diagnostic and treatment opportunities. We applied systems thinking to multidisciplinary map out causal mechanisms and risk factors. For this, we used group model building (GMB) to develop a causal loop diagram (CLD). The GMB was based on the input of experts from multiple domains related to OH and falls and all proposed mechanisms were supported by scientific literature. Our CLD is a conceptual representation of factors involved in OH-related falls, and their interrelatedness. Network analysis and feedback loops were applied to analyze and interpret the CLD, and quantitatively summarize the function and relative importance of the variables. Our CLD contains 50 variables distributed over three intrinsic domains (cerebral, cardiovascular, and musculoskeletal), and an extrinsic domain (e.g., medications). Between the variables, 181 connections and 65 feedback loops were identified. Decreased cerebral blood flow, low blood pressure, impaired baroreflex activity, and physical inactivity were identified as key factors involved in OH-related falls, based on their high centralities. Our CLD reflects the multifactorial pathophysiology of OH-related falls. It enables us to identify key elements, suggesting their potential for new diagnostic and treatment approaches in fall prevention. The interactive online CLD renders it suitable for both research and educational purposes and this CLD is the first step in the development of a computational model for simulating the effects of risk factors on falls.
Collapse
Affiliation(s)
- Liping Wang
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Geriatrics, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health, Aging and Later Life, Amsterdam, The Netherlands
| | - Anouschka C Pronk
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Geriatrics, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health, Aging and Later Life, Amsterdam, The Netherlands
| | - Eveline P van Poelgeest
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Geriatrics, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam Public Health, Aging and Later Life, Amsterdam, The Netherlands.
| | - Robert Briggs
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
| | - Jurgen A H R Claassen
- Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
| | - Sofie Jansen
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Geriatrics, Meibergdreef 9, Amsterdam, The Netherlands
| | - Marjolein Klop
- Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
| | - Frederik J de Lange
- Amsterdam UMC location University of Amsterdam, Cardiology and Cardiothoracic Surgery, Meibergdreef 9, Amsterdam, The Netherlands
| | - Carel C G M Meskers
- Amsterdam UMC location Vrije Universiteit Amsterdam, Rehabilitation Medicine, De Boelelaan, 1117, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Vincent J J Odekerken
- Amsterdam UMC location University of Amsterdam, Neurology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Stephen J Payne
- Institute of Applied Mechanics, National Taiwan University, Taipei, Taiwan
| | | | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
| | - Jeroen F Uleman
- Department of Geriatric Medicine, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
- Institute for Advanced Study, Amsterdam, The Netherlands
| | - Alfons G Hoekstra
- Computational Science Lab, Informatics Institute, Faculty of Science, University of Amsterdam, Amsterdam, The Netherlands
| | - Nathalie van der Velde
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Geriatrics, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health, Aging and Later Life, Amsterdam, The Netherlands
| |
Collapse
|
21
|
Yoo SW, Oh YS, Ryu DW, Ha S, Kim Y, Yoo JY, Kim JS. A 3-year natural history of orthostatic blood pressure dysregulation in early Parkinson's disease. NPJ Parkinsons Dis 2023; 9:96. [PMID: 37344481 DOI: 10.1038/s41531-023-00546-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 06/09/2023] [Indexed: 06/23/2023] Open
Abstract
In Parkinson's disease (PD), cardiovascular dysautonomia accumulates with disease progression, but studies are lacking on the natural history behind each subtype except orthostatic hypotension. This study investigated the early natural history of orthostatic blood pressure (BP) subtypes in PD. Two hundred sixty-seven early PD patients were included. Their cardiovascular functions were assessed by head-up tilt-test and 123I-metaiodobenzylguanidine scintigraphy. All patients were classified as having supine hypertension (SH), orthostatic hypertension (OHT), delayed orthostatic hypotension (dOH), or orthostatic hypotension (OH) according to consensus criteria. The patients were assigned to one of three groups: extreme BP dysregulation (BPextreme), mild BP dysregulation (BPmild), and no BP dysregulation (BPnone) according to their orthostatic BP subtypes. The autonomic functions of 237 patients were re-assessed after approximately 3 years. Among initially enrolled subjects, 61.8% of the patients showed orthostatic BP dysregulation: 29.6% in the BPextreme group and 32.2% in the BPmild group. At follow-up, the BPextreme group increased in number, while the BPmild group diminished. Two-thirds of the initial BPextreme patients maintained their initial subtype at follow-up. In comparison, 40.7% of the initial BPmild patients progressed to the BPextreme group, and 32.4% and 14.7% of the initial BPnone group progressed to BPextreme and BPmild groups, respectively. Cardiac denervation was most severe in the BPextreme group, and a linear gradient of impairment was observed across the subtypes. In conclusion, various forms of positional BP dysregulation were observed during the early disease stage. SH and OH increased with disease progression, while OHT and dOH decreased, converting primarily to SH and/or OH.
Collapse
Affiliation(s)
- Sang-Won Yoo
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoon-Sang Oh
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong-Woo Ryu
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seunggyun Ha
- Division of Nuclear Medicine, Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yuna Kim
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji-Yeon Yoo
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joong-Seok Kim
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| |
Collapse
|
22
|
De León AM, Garcia-Santibanez R, Harrison TB. Article Topic: Neuropathies Due to Infections and Antimicrobial Treatments. Curr Treat Options Neurol 2023; 25:1-17. [PMID: 37360749 PMCID: PMC10256960 DOI: 10.1007/s11940-023-00756-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/28/2023]
Abstract
Purpose of eview The aim of this review is to discuss the presentation, diagnosis, and management of polyneuropathy (PN) in selected infections. Overall, most infection related PNs are an indirect consequence of immune activation rather than a direct result of peripheral nerve infection, Schwann cell infection, or toxin production, though note this review will describe infections that cause PN through all these mechanisms. Rather than dividing them by each infectious agent separately, we have grouped the infectious neuropathies according to their presenting phenotype, to serve as a guide to clinicians. Finally, toxic neuropathies related to antimicrobials are briefly summarized. Recent findings While PN from many infections is decreasing, increasing evidence links infections to variants of GBS. Incidence of neuropathies secondary to use of HIV therapy has decreased over the last few years. Summary In this manuscript, a general overview of the more common infectious causes of PN will be discussed, dividing them across clinical phenotypes: large- and small-fiber polyneuropathy, Guillain-Barré syndrome (GBS), mononeuritis multiplex, and autonomic neuropathy. Rare but important infectious causes are also discussed.
Collapse
Affiliation(s)
- Andrés M. De León
- Neuromuscular Division Department of Neurology, Emory University, Executive Park 12 NE, GA 30329 Atlanta, USA
| | - Rocio Garcia-Santibanez
- Neuromuscular Division Department of Neurology, Emory University, Executive Park 12 NE, GA 30329 Atlanta, USA
| | - Taylor B. Harrison
- Division of Neuromuscular Medicine, Department of Neurology, Emory University School of Medicine, 83 Jessie Junior Drive Box 039, Atlanta, GA 30303 USA
| |
Collapse
|
23
|
Hoxhaj P, Shah S, Muyolema Arce VE, Khan W, Sadeghzadegan A, Singh S, Collado GF, Goyal A, Khawaja I, Botlaguduru D, Razzaq W, Abdin ZU, Gupta I. Ampreloxetine Versus Droxidopa in Neurogenic Orthostatic Hypotension: A Comparative Review. Cureus 2023; 15:e38907. [PMID: 37303338 PMCID: PMC10257554 DOI: 10.7759/cureus.38907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/13/2023] Open
Abstract
Neurogenic orthostatic hypotension (nOH) is a disabling problem of autonomic dysfunction in patients with Parkinson's disease, which is associated with poor quality of life and higher mortality rates. The purpose of this literature review was to explore and compare the efficacy and safety of droxidopa (an existing treatment) and ampreloxetine (a newer medication) in the treatment of nOH. We used a mixed-method literature review that addresses the epidemiology, pathophysiology, and pharmacological and non-pharmacological management of nOH in Parkinson's disease in a general way, with a more exploratory approach to droxidopa- and ampreloxetine-controlled trial studies. We included a total of 10 studies of randomized controlled trials with eight studies focused on droxidopa and two studies focused on ampreloxetine. These two drugs were analyzed and compared based on the collected individual study results. Treatment of nOH in Parkinson's disease patients with droxidopa or ampreloxetine showed clinically meaningful and statistically significant improvements relative to placebo on the components of the OHSA (Orthostatic Hypotension Symptom Assessment) composite score and OHDAS (Orthostatic Hypotension Daily Activity Scale composite scores) composite score. Droxidopa had an improved effect on daily activities, with an associated increase in standing systolic blood pressure (BP), but the long-term efficacy of droxidopa has not been documented. Standing systolic BP was maintained by ampreloxetine and worsened after the withdrawal phase. This highlights the importance of conducting further research which will help us to improve the therapeutic approach for patients with nOH and Parkinson's disease.
Collapse
Affiliation(s)
| | - Shruti Shah
- Internal Medicine, Byramjee Jeejeeboy (BJ) Medical College, Pune, IND
| | | | | | | | - Saumya Singh
- Internal Medicine, Gujarat Medical Education & Research Society (GMERS) Medical College and Hospital, Gujarat, IND
| | - Gaudy F Collado
- Internal Medicine, Fleet Medical Unit, Philippine Fleet, Philippine Navy, Cavite City, PHL
| | - Abhishek Goyal
- Internal Medicine, Kasturba Medical College, Manipal, Manipal, IND
| | - Imran Khawaja
- Internal Medicine, Ayub Medical Institute, Abbottabad, PAK
| | | | - Waleed Razzaq
- Internal Medicine, Services Hospital Lahore, Lahore, PAK
| | - Zain U Abdin
- Medicine, District Head Quarters Hospital, Faisalabad, PAK
| | - Ishita Gupta
- Medicine, Dr. Rajendra Prasad Government Medical College, Tanda, IND
| |
Collapse
|
24
|
Stumpf MAM, Pinheiro FMM, Silva GO, Cescato VAS, Musolino NRC, Cunha-Neto MBC, Glezer A. How to manage intolerance to dopamine agonist in patients with prolactinoma. Pituitary 2023:10.1007/s11102-023-01313-8. [PMID: 37027090 DOI: 10.1007/s11102-023-01313-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 04/08/2023]
Abstract
PURPOSE Dopamine agonists (DA) are the gold-standard for prolactinoma and hyperprolactinemia treatment. Intolerance to DA leading to drug drop out occurs in 3 to 12% of cases. We provide here a review of published data about DA intolerance and present a case report concerning the use of intravaginal cabergoline. METHODS We review the literature on the definition, the pathogenesis, frequency and management of DA intolerance. In addition, the review provides strategies to enhance tolerability and avoid precocious clinical treatment withdrawal. RESULTS Cabergoline is often cited as the most tolerable DA and its side effects tend to ameliorate within days to weeks. Restarting the same drug at a lower dose or switching to another DA can be used in cases of intolerance. The vaginal route can be tried specifically if there are gastrointestinal side effects in the oral administration. Symptomatic treatment could be attempted, although mainly based on a strategy used in other diseases. CONCLUSIONS Due to limited data, no guidelines have been developed for the management of intolerance in DA treatment. The most frequent management is to perform transsphenoidal surgery. Nevertheless, this manuscript provides data derived from published literature and expert opinion, suggesting new approaches to this clinical issue.
Collapse
Affiliation(s)
- Matheo Augusto Morandi Stumpf
- Unidade de Neuroendocrinologia, Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Ovídio Pires de Campos, 225 - Cerqueira César, São Paulo, 05403- 010, SP, Brazil.
| | - Felipe Moura Maia Pinheiro
- Unidade de Neuroendocrinologia, Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Ovídio Pires de Campos, 225 - Cerqueira César, São Paulo, 05403- 010, SP, Brazil
| | - Gilberto Ochman Silva
- Grupo de Neuroendocrinologia, Divisão de Neurocirurgia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brasil
| | - Valter Angelo Sperling Cescato
- Grupo de Neuroendocrinologia, Divisão de Neurocirurgia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brasil
| | - Nina Rosa Castro Musolino
- Grupo de Neuroendocrinologia, Divisão de Neurocirurgia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brasil
| | - Malebranche Berardo Carneiro Cunha-Neto
- Grupo de Neuroendocrinologia, Divisão de Neurocirurgia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brasil
| | - Andrea Glezer
- Unidade de Neuroendocrinologia, Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Ovídio Pires de Campos, 225 - Cerqueira César, São Paulo, 05403- 010, SP, Brazil
| |
Collapse
|
25
|
Grobman B, Turkson-Ocran RA, Staessen JA, Yu YL, Lipsitz LA, Mukamal KJ, Juraschek SP. Body Position and Orthostatic Hypotension in Hypertensive Adults: Results from the Syst-Eur Trial. Hypertension 2023; 80:820-827. [PMID: 36744469 PMCID: PMC10448480 DOI: 10.1161/hypertensionaha.122.20602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/19/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND We recently demonstrated that more intensive blood pressure (BP) treatment lowered risk of orthostatic hypotension (OH) measured with a seated-to-standing protocol. However, seated-to-standing OH assessments are less sensitive than supine-to-standing and could miss clinically relevant OH. OBJECTIVES Using data from the Syst-Eur trial (Systolic Hypertension in Europe), we examined the effect of hypertension treatment on incidence of OH based on the difference in BP from 3 body positions. METHODS Syst-Eur was a multi-center, randomized trial that enrolled adults with isolated systolic hypertension to investigate whether active hypertension treatment could reduce cardiovascular events. Participants underwent BP measurement in supine, seated, and standing positions. Using differences in BP between the 3 body positions (seated minus supine, standing minus seated, and standing minus supine), we defined OH as a drop in systolic BP ≥20 mm Hg or diastolic BP ≥10 mm Hg. We included measurements from baseline and follow-up visits. RESULTS Among 4695 participants (mean age, 70.2±6.7 years; 66.9% female) with 42 636 BP measurements, OH was present in 4.9% of measures with supine-to-seated, 7.9% with seated-to-standing, and 11.4% with supine-to-standing protocols, respectively. Compared with placebo, BP treatment did not increase OH with any set of maneuvers, OR, 0.79 (95% CI, 0.65-0.95) with seated-to standing, 1.03 (95% CI, 0.86-1.24) with supine-to-seated, and 0.99 (95% CI, 0.86-1.15) with supine-to-standing. CONCLUSIONS Regardless of protocol, active hypertension treatment did not increase the risk of OH, reinforcing evidence that OH should not be viewed as a complication of hypertension treatment. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02088450.
Collapse
Affiliation(s)
- Ben Grobman
- Harvard Medical School, Boston, Massachusetts
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston Massachusetts
| | | | - Jan A Staessen
- Non-Profit Research Alliance for the Promotion of Preventive Medicine, Belgium; Biomedical Science Group, Faculty of Medicine, University of Leuven, Leuven, Belgium
| | - Yu-Ling Yu
- Research Unit Environment and Health, KU Leuven Department of Public Health and Primary Care, University of Leuven, Leuven, Belgium
| | - Lewis A Lipsitz
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston Massachusetts
| | - Kenneth J Mukamal
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston Massachusetts
| | - Stephen P Juraschek
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston Massachusetts
| |
Collapse
|
26
|
Kittleson MM, Ruberg FL, Ambardekar AV, Brannagan TH, Cheng RK, Clarke JO, Dember LM, Frantz JG, Hershberger RE, Maurer MS, Nativi-Nicolau J, Sanchorawala V, Sheikh FH. 2023 ACC Expert Consensus Decision Pathway on Comprehensive Multidisciplinary Care for the Patient With Cardiac Amyloidosis: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2023; 81:1076-1126. [PMID: 36697326 DOI: 10.1016/j.jacc.2022.11.022] [Citation(s) in RCA: 92] [Impact Index Per Article: 92.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
|
27
|
Beretta MV, Milan VB, Hoffmeister MC, Rodrigues TC. Orthostatic hypotension, falls and in-hospital mortality among elderly patients with and without type 2 diabetes. J Hypertens 2023; 41:388-392. [PMID: 36728920 DOI: 10.1097/hjh.0000000000003338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To evaluate the association of falls and in-hospital mortality with the presence of orthostatic hypotension and type 2 diabetes mellitus (T2D). The study also aims to identify whether the orthostatic hypotension assessed at 1 min or at 3 min can predict falls and mortality, as a secondary objective to identify the predictors of fall during hospitalization. METHODS We performed a prospective study with patients admitted to a university hospital. The risk of falls was assessed using the Morse questionnaire and the presence of falls was verified by the patient's medical records during hospitalization. The orthostatic hypotension was determined by measuring blood pressure at three times, considering as orthostatic hypotension the reduction of at least 20 mmHg in SBP or 10 mmHg in DBP. In-hospital mortality was consulted in the medical records. RESULTS Patients with orthostatic hypotension were slower on Timed Up and Go test (TUG) (12.26 ± 3.16 vs. 16.08 ± 5.96 s, P = 20 s) and presence of orthostatic hypotension. After adjustments, patients with T2D and orthostatic hypotension had a 2.7 times greater risk of in-hospital falls and 1.54 times greater odds of in-hospital mortality when compared with patients without T2D and orthostatic hypotension. CONCLUSION In this sample, sedentary patients and those with lower TUG had a higher risk of falls. The prevalence of falls was higher in patients with T2D. The association of T2D with orthostatic hypotension significantly increased both the risk of falls and the risk of in-hospital mortality.
Collapse
Affiliation(s)
- Mileni V Beretta
- Internal Medicine Department, Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul
- Endocrine Division, Hospital de Clínicas de Porto Alegre
| | - Victoria B Milan
- Endocrine Division, Hospital de Clínicas de Porto Alegre
- Federal University of Medical Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Mariana C Hoffmeister
- Internal Medicine Department, Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul
| | - Ticiana C Rodrigues
- Internal Medicine Department, Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul
- Endocrine Division, Hospital de Clínicas de Porto Alegre
| |
Collapse
|
28
|
Kim HL, Lee EM, Ahn SY, Kim KI, Kim HC, Kim JH, Lee HY, Lee JH, Park JM, Cho EJ, Park S, Shin J, Kim YK. The 2022 focused update of the 2018 Korean Hypertension Society Guidelines for the management of hypertension. Clin Hypertens 2023; 29:11. [PMID: 36788612 PMCID: PMC9930285 DOI: 10.1186/s40885-023-00234-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/25/2023] [Indexed: 02/16/2023] Open
Abstract
Hypertension is the leading cause of death in human being, which shows high prevalence and associated complications that increase the mortality and morbidity. Controlling blood pressure (BP) is very important because it is well known that lowering high BP effectively improves patients' prognosis. This review aims to provide a focused update of the 2018 Korean Hypertension Society Guidelines for the management of hypertension. The importance of ambulatory BP and home BP monitoring was further emphasized not only for the diagnosis but also for treatment target. By adopting corresponding BPs, the updated guideline recommended out-of-office BP targets for both standard and intensive treatment. Based on the consensus on corresponding BPs and Systolic Blood Pressure Intervention Trial (SPRINT) revisit, the updated guidelines recommended target BP in high-risk patients below 130/80 mmHg and it applies to hypertensive patients with three or more additional cardiovascular risk factors, one or more risk factors with diabetes, or hypertensive patients with subclinical organ damages, coronary or vascular diseases, heart failure, chronic kidney disease with proteinuria, and cerebral lacunar infarction. Cerebral infarction and chronic kidney disease are also high-risk factors for cardiovascular disease. However, due to lack of evidence, the target BP was generally determined at < 140/90 mmHg in patients with those conditions as well as in the elderly. Updated contents regarding the management of hypertension in special situations are also discussed.
Collapse
Affiliation(s)
- Hack-Lyoung Kim
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun Mi Lee
- grid.410899.d0000 0004 0533 4755Department of Internal Medicine, Wonkwang University Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, Republic of Korea
| | - Shin Young Ahn
- grid.411134.20000 0004 0474 0479Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kwang-il Kim
- grid.412480.b0000 0004 0647 3378Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Hyeon Chang Kim
- grid.15444.300000 0004 0470 5454Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ju Han Kim
- grid.411597.f0000 0004 0647 2471Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Hae-Young Lee
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jang Hoon Lee
- grid.258803.40000 0001 0661 1556Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Republic of Korea
| | - Jong-Moo Park
- grid.255588.70000 0004 1798 4296Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, Republic of Korea
| | - Eun Joo Cho
- grid.488414.50000 0004 0621 6849Department of Internal Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sungha Park
- grid.15444.300000 0004 0470 5454Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jinho Shin
- grid.49606.3d0000 0001 1364 9317Department of Internal Medicine, Hanyang University Medical Center, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Young-Kwon Kim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University School of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
29
|
Donnell DO, Romero-Ortuno R, Kennelly SP, O’Neill D, Donoghue PO, Lavan A, Cunningham C, McElwaine P, Kenny RA, Briggs R. The 'Bermuda Triangle' of orthostatic hypotension, cognitive impairment and reduced mobility: prospective associations with falls and fractures in The Irish Longitudinal Study on Ageing. Age Ageing 2023; 52:7024511. [PMID: 36735845 PMCID: PMC9897301 DOI: 10.1093/ageing/afad005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Orthostatic hypotension (OH), cognitive impairment (Cog) and mobility impairment (MI) frequently co-occur in older adults who fall. This study examines clustering of these three geriatric syndromes and ascertains their relationship with future falls/fractures in a large cohort of community-dwelling people ≥ 65 years during 8-year follow-up. METHODS OH was defined as an orthostatic drop ≥ 20 mmHg in systolic blood pressure (from seated to standing) and/or reporting orthostatic unsteadiness. CI was defined as Mini Mental State Examination ≤ 24 and/or self-reporting memory as fair/poor. MI was defined as Timed Up and Go ≥12 s. Logistic regression models, including three-way interactions, assessed the longitudinal association with future falls (explained and unexplained) and fractures. RESULTS Almost 10% (88/2,108) of participants had all three Bermuda syndromes. One-fifth of participants had an unexplained fall during follow-up, whereas 1/10 had a fracture. There was a graded relationship with incident unexplained falls and fracture as the number of Bermuda syndromes accumulated. In fully adjusted models, the cluster of OH, CI and MI was most strongly associated with unexplained falls (odds ratios (OR) 4.33 (2.59-7.24); P < 0.001) and incident fracture (OR 2.51 (1.26-4.98); P = 0.045). Other clusters significantly associated with unexplained falls included OH; CI and MI; MI and OH; CI and OH. No other clusters were associated with fracture. DISCUSSION The 'Bermuda Triangle' of OH, CI and MI was independently associated with future unexplained falls and fractures amongst community-dwelling older people. This simple risk identification scheme may represent an ideal target for multifaceted falls prevention strategies in community-dwelling older adults.
Collapse
Affiliation(s)
- Desmond O Donnell
- Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin 8, Ireland,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
| | - Roman Romero-Ortuno
- Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin 8, Ireland,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
| | - Sean P Kennelly
- Age-Related Health Care, Tallaght University Hospital, Dublin 24, Ireland,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
| | - Desmond O’Neill
- Age-Related Health Care, Tallaght University Hospital, Dublin 24, Ireland,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
| | - Patrick O Donoghue
- Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin 8, Ireland,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
| | - Amanda Lavan
- Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin 8, Ireland,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
| | - Conal Cunningham
- Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin 8, Ireland,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
| | - Paul McElwaine
- Age-Related Health Care, Tallaght University Hospital, Dublin 24, Ireland,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
| | - Rose Anne Kenny
- Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin 8, Ireland,Discipline of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
| | - Robert Briggs
- Address correspondence to: Robert Briggs. Tel: (+35) 314284105.
| |
Collapse
|
30
|
Brignole M, Rivasi G, Fedorowski A, Ståhlberg M, Groppelli A, Ungar A. Tests for the identification of reflex syncope mechanism. Expert Rev Med Devices 2023; 20:109-119. [PMID: 36814102 DOI: 10.1080/17434440.2023.2174428] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
INTRODUCTION Treatment efficacy of reflex syncope is mainly related to the mechanism underlying syncope rather than its etiology or clinical presentation. The predominant mechanism underlying reflex syncope can be assigned to hypotensive or to bradycardic phenotypes. AREAS COVERED Methodology and diagnostic criteria of the most useful tests for the identification of hypotensive and bradycardic phenotypes are discussed. Diagnostic tests for the hypotensive phenotype include office blood pressure measurement with active standing test, home, and wearable blood pressure monitoring, 24-h ambulatory blood pressure monitoring and tilt table test. Diagnostic tests for the bradycardic phenotype include carotid sinus massage, tilt table test and prolonged ECG monitoring. EXPERT OPINION In reflex syncope, the documentation of bradycardia/asystole during a syncopal episode does not rule out the possibility that a preceding or parallel hypotensive reflex plays an important role. Similarly, even when a hypotensive mechanism is established, the possibility of an associated cardioinhibitory reflex should be investigated. Investigating the mechanism of reflex syncope is mandatory in patients with severe recurrent episodes, with the final aim to develop a personalized treatment strategy. Recent trials have demonstrated the benefits of personalized mechanism-based therapy, thus highlighting the importance of a comprehensive assessment of the mechanisms underlying syncope.
Collapse
Affiliation(s)
- Michele Brignole
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Sweden
| | - Marcus Ståhlberg
- Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Sweden
| | - Antonella Groppelli
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| |
Collapse
|
31
|
Lutchmansingh DD, Higuero Sevilla JP, Possick JD, Gulati M. "Long Haulers". Semin Respir Crit Care Med 2023; 44:130-142. [PMID: 36646091 DOI: 10.1055/s-0042-1759568] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Post-COVID conditions continue to afflict patients long after acute severe acute respiratory syndrome-coronavirus-2 (SARS CoV-2) infection. Over 50 symptoms across multiple organ systems have been reported, with pulmonary, cardiovascular, and neuropsychiatric sequelae occurring most frequently. Multiple terms have been used to describe post-COVID conditions including long COVID, long-haul COVID, postacute coronavirus disease 2019 (COVID-19), postacute sequelae of SARS-CoV-2 infection, long-term effects of COVID, and chronic COVID-19; however, standardized assessments and treatment algorithms for patients have generally been lacking. This review discusses the epidemiology and risk factors for post-COVID conditions and provides a general overview of the diagnostic assessment and treatment of specific manifestations. Data derived from the multitude of observational studies and scientific investigations into pathogenesis are providing a clearer understanding of the distinct phenotypes of post-COVID conditions. Insight gained from these studies and ongoing interventional trials continues to lead to the development of clinical protocols directed toward improving COVID-19 survivors' quality of life and preventing or reducing long-term morbidity.
Collapse
Affiliation(s)
- Denyse D Lutchmansingh
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jean Paul Higuero Sevilla
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jennifer D Possick
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Mridu Gulati
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
32
|
Jordan J, Biaggioni I, Kotsis V, Nilsson P, Grassi G, Fedorowski A, Kario K. Consensus statement on the definition of orthostatic hypertension endorsed by the American Autonomic Society and the Japanese Society of Hypertension. Clin Auton Res 2023; 33:69-73. [PMID: 36173501 PMCID: PMC9984343 DOI: 10.1007/s10286-022-00897-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 09/13/2022] [Indexed: 12/25/2022]
Abstract
We propose a consensus definition of "an exaggerated orthostatic pressor response" in subjects in whom systolic blood pressure increases ≥ 20 mmHg when going from supine to standing posture. This definition can be extended for seated to standing measurements. We reserve the term "orthostatic hypertension" for when this pressor response leads to an upright systolic blood pressure ≥ 140 mmHg. We believe this consensus definition will help in the study of the pathophysiology, clinical impact, and potential treatment of these entities, and identification of patients who are at greater cardiovascular risk.
Collapse
Affiliation(s)
- Jens Jordan
- Institute of Aerospace Medicine, German Aerospace Center (DLR), Linder Hoehe, 51147, Cologne, Germany.
- Medical Faculty, University of Cologne, Cologne, Germany.
| | - Italo Biaggioni
- Autonomic Dysfunction Center and Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Vasilios Kotsis
- 3rd Department of Internal Medicine, Hypertension-24-h ABPM ESH Center of Excellence, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Peter Nilsson
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Guido Grassi
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Monza, Italy
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Karolinska University Hospital, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Kazuomi Kario
- Department of Cardiology, Jichi University School of Medicine, Tochigi, Japan.
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine (JMU), 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
| |
Collapse
|
33
|
Awosika A, Adabanya U, Millis RM, Omole AE, Moon JH. Postprandial Hypotension: An Underreported Silent Killer in the Aged. Cureus 2023; 15:e35411. [PMID: 36851946 PMCID: PMC9964048 DOI: 10.7759/cureus.35411] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2023] [Indexed: 03/01/2023] Open
Abstract
Orthostatic hypotension (OH) is one of the most common autonomic dysfunctions, with high prevalence in populations of elderly, hypertensive, diabetic, or Parkinson's patients. Evidence is emerging that OH co-occurs with postprandial hypotension (PPH); a greater prevalence of PPH than of OH is reported for Parkinson's disease patients. OH is diagnosed by measuring the blood pressure changes associated with postural changes and often produces alterations in consciousness or other such bothersome symptoms as fainting. PPH is diagnosed by measuring the blood pressure changes associated with ingesting high carbohydrate test meals. Because of the time lag between food ingestion and absorption, PPH is often not reported as symptomatic and, therefore, not diagnosed as PPH. OH and PPH are independent predictors for all causes of mortality. Relative underdiagnosis may qualify PPH as a "silent killer" disease. This review is aimed at providing updates on the epidemiology, pathophysiology, and clinical aspects associated with the diagnosis and treatment of PPH. Highlighting the current gaps in knowledge and research about PPH is expected to make medical practitioners more cognizant of the dangers of underdiagnosis and motivate future research to identify individuals and populations at high risk for PPH and its sequelae.
Collapse
Affiliation(s)
- Ayoola Awosika
- College of Medicine, University of Illinois, Chicago, USA.,College of Health Sciences and Professions, Ohio University, Athens, USA
| | | | - Richard M Millis
- Pathophysiology, American University of Antigua, St. John's, ATG
| | - Adekunle E Omole
- Anatomical Sciences, American University of Antigua, St. John's, ATG
| | - Jin Hyung Moon
- General Medicine, Mercer University School of Medicine, Columbus, USA
| |
Collapse
|
34
|
Short-term Outcomes of Hypertensive Crises in Patients with Orthostatic Hypotension. Curr Probl Cardiol 2023; 48:101455. [PMID: 36280124 DOI: 10.1016/j.cpcardiol.2022.101455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/13/2022] [Indexed: 01/04/2023]
Abstract
Supine hypertension-orthostatic hypotension disease poses a management challenge to clinicians. Data on short term outcomes of patients with orthostatic hypotension (OH) who are hospitalized with hypertensive (HTN) crises is lacking. The Nationwide Readmission Database 2016-2019 was queried for all hospitalizations of HTN crises. Hospitalizations were stratified according to whether OH was present or not. We employed propensity score to match hospitalizations for patients with OH to those without, at 1:1 ratio. Outcomes evaluated were 30-days readmission with HTN crises or falls, as well as hospital outcomes of in-hospital mortality, acute kidney injury, acute congestive heart failure, acute coronary syndrome, type 2 myocardial infarction, aortic dissection, stroke, length of stay (LOS), discharge to nursing home and hospitalization costs. We included a total of 9451 hospitalization (4735 in the OH group vs 4716 in the control group). OH group was more likely to be readmitted with falls (Odds ratio [OR]:3.27, P < 0.01) but not with HTN crises (P = 0.05). Both groups had similar likelihood of developing acute kidney injury (P = 0.08), stroke/transient ischemic attack (P = 0.52), and aortic dissection (P = 0.66). Alternatively, OH group were less likely to develop acute heart failure (OR:0.54, P < 0.01) or acute coronary syndrome (OR:0.39, P < 0.01) in the setting of HTN crises than non-OH group. OH group were more likely to have longer LOS and have higher hospitalization costs. Patients with OH who are admitted with HTN crises tend to have similar or lower HTN-related complications to non-OH group while having higher likelihood of readmission with falls, LOS and hospitalization costs. Further studies are needed to confirm such findings.
Collapse
|
35
|
Zeng J, Xing Y, Mei S, Xu B, Xue X, Song H, Xu E. The differences of orthostatic hypotension in patients with Parkinson's disease and multiple system atrophy. Front Neurol 2023; 14:1070943. [PMID: 36779052 PMCID: PMC9909276 DOI: 10.3389/fneur.2023.1070943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/09/2023] [Indexed: 01/27/2023] Open
Abstract
Background Multiple system atrophy (MSA) and Parkinson's disease (PD) have similar clinical presentations in their early stages. Orthostatic hypotension (OH) is a common autonomic dysfunction associated with MSA and PD. Heart rate (HR) and systolic blood pressure (SBP) changes are measured in response to the active standing test, which is widely used to screen for cardiovascular autonomic function. Objectives and methods Overall, 255 patients (67 MSA, 188 PD) underwent continuous beat-to-beat non-invasive BP monitoring and active standing test. The total standing time was 10 min, and the BP differences between both groups were compared to determine whether the ΔHR/ΔSBP can differentiate both conditions. Results Classical orthostatic hypotension (COH) (52%) and initial OH (19%) were most common in MSA and PD, respectively. MSA had a higher HR (75.0 ± 9.7 vs. 71.0 ± 10.7, P = 0.008) than PD in the supine position. SBP (135.70 ± 15.68 mmHg vs. 127.31 ± 15.14 mmHg, P = 0.106), diastolic BP (78.45 ± 12.36 mmHg vs. 67.15 ± 13.39 mmHg, P = 0.009) and HR (73.94 ± 8.39 bpm vs. 71.08 ± 13.52 bpm, P = 0.389) at baseline were higher in MSA-COH than in PD-COH. After adjusting for age and disease duration, the ΔHR/ΔSBP-10 min significantly discriminated MSA-COH from PD-COH (P = 0.031). An ΔHR/ΔSBP-10 min of 0.517 showed a sensitivity of 67% and specificity of 84% (AUC = 0.77, 95% CI: 0.63-0.91). Conclusion The SBP, diastolic BP, and HR were higher in the supine position; however, ΔHR and ΔSBP were lower after standing in MSA patients than in PD patients. The ΔHR/ΔSBP-10 min discriminated between MSA-COH and PD-COH with quiet acceptable accuracy.
Collapse
Affiliation(s)
- Jingrong Zeng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yingqi Xing
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shanshan Mei
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Baolei Xu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaofan Xue
- Department of Neurology, Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Haixia Song
- Department of Neurology, The People's Hospital of Shijiazhuang, Shijiazhuang, Hebei, China
| | - Erhe Xu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China,*Correspondence: Erhe Xu ✉
| |
Collapse
|
36
|
Na JH, Kim SR, Lee YJ. Effect of Orthostatic Hypotension on Kidney Function. Nephron Clin Pract 2023; 147:401-407. [PMID: 36649688 DOI: 10.1159/000528431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 11/08/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The association between orthostatic hypotension (OH) and long-term changes in kidney function in the general population is not yet well known. METHODS We performed a population-based cohort study based on data from the Korean Genome and Epidemiology Study (KoGES). The primary exposure was the presence of classic OH, defined as a postural drop in blood pressure (systolic blood pressure ≥20 mm Hg and/or diastolic blood pressure ≥10 mm Hg) at 2 min of standing after 5 min of supine rest. The primary outcome was a 12-year change in kidney function, assessed by subtracting the baseline estimated glomerular filtration rate (eGFR) from the eGFR at 12 years of follow-up. RESULTS Our study included 5,905 participants (median [interquartile range] age, 49 [44-58] years; 46% males) who met inclusion and exclusion criteria. Classic OH was detected in 268 (4.5%) of the total participants. In the regression analyses, participants with classic OH had a greater decline in eGFR over 12 years compared with those without classic OH; the fully adjusted beta coefficient and 95% confidence intervals (95% CIs) were -1.74 (-3.07, -0.40). Furthermore, classic OH was associated with 27% greater risk of a 30% decline in kidney function compared with those without classic OH; fully adjusted hazard ratio and 95% CIs were 1.27 (1.07, 1.49). CONCLUSIONS Classic OH can negatively affect long-term kidney function in the general population.
Collapse
Affiliation(s)
- Jin Hee Na
- Division of Nephrology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Sung Rok Kim
- Division of Nephrology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Yu-Ji Lee
- Division of Nephrology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| |
Collapse
|
37
|
Bhanu C, Petersen I, Orlu M, Davis D, Walters K. Incidence of postural hypotension recorded in UK general practice: an electronic health records study. Br J Gen Pract 2023; 73:e9-e15. [PMID: 36253110 PMCID: PMC9591019 DOI: 10.3399/bjgp.2022.0111] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 08/11/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Postural hypotension is a common condition associated with adverse outcomes in older adults. General practice plays an important role in identification of the condition. AIM To examine the incidence of postural hypotension between 2008 and 2018 in general practice and how trends vary by age, sex, year, and social deprivation. DESIGN AND SETTING Retrospective cohort study using electronic health records from the IQVIA Medical Research Data (IMRD) between 2008 and 2018. METHOD Patients were included if they were aged ≥50 years. Incident postural hypotension was identified as a new (first) recording of a postural hypotension code. Recording of incident postural hypotension was estimated per 10 000 person-years at risk (PYAR) according to age, sex, year, and social deprivation. Incident rate ratios were estimated by multivariable Poisson regression. RESULTS Of 2 911 260 patients, 24 973 had an electronic record indicating a new diagnosis of postural hypotension between 2008 and 2018. This was equivalent to 17.9 cases per 10 000 PYAR in males (95% confidence interval [CI] = 17.6 to 18.2) and 16.2 cases per 10 000 PYAR in females (95% CI = 15.9 to 16.5). A significant age-sex interaction was identified. Recorded postural hypotension rate increased with age and social deprivation, and reduced between 2008 and 2018. The rate was higher in males compared with females, particularly in older age groups (>80 years). CONCLUSION To the authors' knowledge, this is the first study to quantify incident recorded postural hypotension in general practice. The rate is lower than expected compared with studies in screened older populations. Potential barriers to identification include underreporting, underdetection owing to lack of time and/or poorly standardised methods of measurement, and poor coding. Future research should investigate current practice and approaches for increased detection such as education, practical methods of screening, and standardised measurement of postural blood pressure.
Collapse
Affiliation(s)
- Cini Bhanu
- Research Department of Primary Care and Population Health, University College London, London
| | - Irene Petersen
- Research Department of Primary Care and Population Health, University College London, London
| | - Mine Orlu
- UCL School of Pharmacy, University College London, London
| | - Daniel Davis
- MRC Unit for Lifelong Health & Ageing, University College London, London
| | - Kate Walters
- Research Department of Primary Care and Population Health, University College London, London
| |
Collapse
|
38
|
Consensus statement on the definition of orthostatic hypertension endorsed by the American Autonomic Society and the Japanese Society of Hypertension. Hypertens Res 2023; 46:291-294. [PMID: 36418529 PMCID: PMC9899687 DOI: 10.1038/s41440-022-01074-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 09/13/2022] [Indexed: 11/24/2022]
Abstract
We propose a consensus definition of "an exaggerated orthostatic pressor response" in subjects in whom systolic blood pressure increases ≥20 mmHg when going from the supine to standing posture. This definition can be extended for seated to standing measurements. We reserve the term "orthostatic hypertension" if this pressor response leads to an upright systolic blood pressure ≥140 mmHg. We believe this consensus definition will help in the study of the pathophysiology, clinical impact, and potential treatment of these entities, and the identification of patients that are at greater cardiovascular risk.
Collapse
|
39
|
Oyake K, Tateishi T, Murayama J, Shijima N, Sekizuka T, Otaka Y, Momose K. Blood pressure reduction cut-points for orthostatic hypotension in stroke survivors using a sit-up test: a multicentre cross-sectional study. J Hypertens 2023; 41:83-89. [PMID: 36205007 PMCID: PMC9794131 DOI: 10.1097/hjh.0000000000003305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 08/08/2022] [Accepted: 09/05/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The sit-up test is used to assess orthostatic hypotension in stroke survivors who cannot stand independently without using a tilt table. However, no study has identified the optimal cut-points for orthostatic hypotension using the test. Therefore, this study aimed to examine the decrease in SBP and DBP during the sit-up test to detect orthostatic hypotension in individuals with stroke. METHODS Thirty-eight individuals with stroke, recruited from three convalescent rehabilitation hospitals, underwent the sit-up and head-up tilt tests. Systolic and diastolic orthostatic hypotension was defined as a decrease of at least 20 and 10 mmHg in the SBP and DBP, respectively, during the head-up tilt test. The receiver operator characteristic curve with the Youden Index was used to identify the optimal cut-points. RESULTS Eight and three participants showed systolic and diastolic orthostatic hypotension, respectively. The optimal cut-points for orthostatic hypotension using the sit-up test were a decrease of 10 mmHg in SBP [sensitivity = 87.5% (95% confidence interval: 47.4-99.7), specificity = 96.7% (82.8-99.9)] and 5 mmHg in DBP [sensitivity = 100.0% (29.2-100.0), specificity = 88.6% (73.3-96.8)]. CONCLUSION Compared with the conventional cut-points, smaller cut-points of a decrease in SBP and DBP may be better to identify orthostatic hypotension in individuals with stroke using the sit-up test. The findings of this study may provide valuable information for the clinical application of the sit-up test.
Collapse
Affiliation(s)
- Kazuaki Oyake
- Department of Physical Therapy, School of Health Sciences, Shinshu University, Nagano
- Department of Rehabilitation Medicine, Tokyo Bay Rehabilitation Hospital, Chiba
| | - Takaki Tateishi
- Department of Rehabilitation Medicine, Tokyo Bay Rehabilitation Hospital, Chiba
| | - Jun Murayama
- Department of Rehabilitation Medicine, Tokyo Bay Rehabilitation Hospital, Chiba
| | - Naoki Shijima
- Department of Physical Therapy, Saku Central Hospital
| | - Tasuku Sekizuka
- Department of Rehabilitation, Kakeyu-Misayama Rehabilitation Center Kakeyu Hospital, Nagano
| | - Yohei Otaka
- Department of Rehabilitation Medicine, Tokyo Bay Rehabilitation Hospital, Chiba
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Aichi, Japan
| | - Kimito Momose
- Department of Physical Therapy, School of Health Sciences, Shinshu University, Nagano
| |
Collapse
|
40
|
de Matos DG, de Santana JL, Mendelson AA, Duhamel TA, Villar R. Integrated Dynamic Autonomic and Cardiovascular Regulation during Postural Transitions in Older Adults Living with Frailty: A Systematic Review Protocol. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:566. [PMID: 36612888 PMCID: PMC9819247 DOI: 10.3390/ijerph20010566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/25/2022] [Accepted: 12/24/2022] [Indexed: 06/17/2023]
Abstract
Older adults often experience episodes of a sudden drop in blood pressure when standing, known as orthostatic hypotension (OH). OH is associated with an increased risk of life-threatening health problems, falls, and death. Although OH has been studied in older adults, the integrated dynamic autonomic and cardiovascular regulation during postural transitions in older adults with frailty remains scarce and poorly understood. The primary aim of this systematic review is to determine the association between how active (e.g., lie-to-stand) and passive (head-up tilt) postural transitions affect the dynamic integrated autonomic and cardiovascular regulatory responses, comparing older adults with different levels of frailty (non-frail, pre-frail, or frail). A second aim is to perform a meta-analysis to compare autonomic and cardiovascular responses during active postural transitions in non-frail, pre-frail, and frail older adults. The systematic review will be outlined according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. The meta-analysis will generate estimates of the comparative autonomic and cardiovascular responses after active postural transitions in adults who are non-frail, pre-frail, and frail. This systematic review will provide critical information on how integrated dynamic autonomic and cardiovascular regulation occurs during postural transitions in older adults with different frailty statuses.
Collapse
Affiliation(s)
- Dihogo Gama de Matos
- Cardiorespiratory & Physiology of Exercise Research Laboratory, Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB R3T 2N2, Canada
| | - Jefferson Lima de Santana
- Cardiorespiratory & Physiology of Exercise Research Laboratory, Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB R3T 2N2, Canada
| | - Asher A. Mendelson
- Section of Critical Care, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0W2, Canada
| | - Todd A. Duhamel
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB R3T 2N2, Canada
- Institute of Cardiovascular Sciences, St. Boniface General Hospital Albrechtsen Research Centre, Winnipeg, MB R2H 2A6, Canada
| | - Rodrigo Villar
- Cardiorespiratory & Physiology of Exercise Research Laboratory, Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB R3T 2N2, Canada
| |
Collapse
|
41
|
Pei J, Zhang H, Li Y, Yan J, Zheng K, Wang X, Zheng XL, Hu X. Relationship between orthostatic blood pressure changes and intensive blood pressure management in patients with hypertension. HEART (BRITISH CARDIAC SOCIETY) 2022; 109:111-118. [PMID: 36007937 DOI: 10.1136/heartjnl-2022-321276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 08/08/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated that closely controlling blood pressure (BP) could decrease cardiovascular outcome risk without increasing the orthostatic hypotension rate. We aimed to evaluate the association between baseline orthostatic BP change and major adverse cardiovascular event (MACE) occurrence. METHODS We conducted a post hoc analysis using SPRINT data including 9329 patients with hypertension. The SPRINT trial was a two-arm, multicentre, randomised clinical trial designed to test whether an intensive treatment aimed at reducing systolic BP (SBP) to <120 mm Hg would reduce cardiovascular disease risk. Orthostatic BP change was defined as baseline standing systolic BP (SBP)-baseline mean seated SBP, or diastolic BP (DBP)-baseline mean seated DBP. RESULTS We found a U-shaped relationship between orthostatic BP changes and MACE occurrence. All lowest risk points were around 0 mm Hg. On the left side of the inflection point, MACE risk decreased with orthostatic BP change decrease (HR=0.99, 95% CI (0.98 to 1.00), p=0.04, SBP change) (HR=0.97, 95% CI (0.95 to 0.99), p<0.01, DBP change); on the right side, MACE risk increased with orthostatic BP change increase (HR=1.02, 95% CI (1.01 to 1.06), p<0.01, SBP change) (HR=1.01, 95% CI (1.00 to 1.03), p=0.16, DBP change). There was no significant interaction effect between orthostatic SBP (p for interaction=0.37) or DBP changes (p for interaction=0.33) and intensive BP management. CONCLUSIONS Orthostatic DBP increase and SBP decrease were associated with an increased MACE risk. The benefits of intensive BP management were also consistent across different orthostatic BP change ranges.
Collapse
Affiliation(s)
- Junyu Pei
- Department of Cardiovascular Medicine, Central South University, Changsha, Hunan, China.,Department of Biochemistry and Molecular Biology, The Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Hao Zhang
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Yanan Li
- School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Jiafu Yan
- Department of Cardiovascular Medicine, Capital Medical University, Beijing, China
| | - Keyang Zheng
- Department of Cardiovascular Medicine, Capital Medical University, Beijing, China
| | - Xiaopu Wang
- The Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Xi-Long Zheng
- Department of Biochemistry and Molecular Biology, The Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Xinqun Hu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| |
Collapse
|
42
|
Nomogram for Prediction of Postoperative Delirium after Deep Brain Stimulation of Subthalamic Nucleus in Parkinson’s Disease under General Anesthesia. PARKINSON'S DISEASE 2022; 2022:6915627. [DOI: 10.1155/2022/6915627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 09/04/2022] [Accepted: 09/07/2022] [Indexed: 12/05/2022]
Abstract
Introduction. Postoperative delirium can increase cognitive impairment and mortality in patients with Parkinson’s disease. The purpose of this study was to develop and internally validate a clinical prediction model of delirium after deep brain stimulation of the subthalamic nucleus in Parkinson’s disease under general anesthesia. Methods. We conducted a retrospective observational cohort study on the data of 240 patients with Parkinson’s disease who underwent deep brain stimulation of the subthalamic nucleus under general anesthesia. Demographic characteristics, clinical evaluation, imaging data, laboratory data, and surgical anesthesia information were collected. Multivariate logistic regression was used to develop the prediction model for postoperative delirium. Results. A total of 159 patients were included in the cohort, of which 38 (23.90%) had postoperative delirium. Smoking (OR 4.51, 95% CI 1.56–13.02,
) was the most important risk factor; other independent predictors were orthostatic hypotension (OR 3.42, 95% CI 0.90–13.06,
), inhibitors of type-B monoamine oxidase (OR 3.07, 95% CI 1.17–8.04,
), preoperative MRI with silent brain ischemia or infarction (OR 2.36, 95% CI 0.90–6.14,
), Hamilton anxiety scale score (OR 2.12, 95% CI 1.28–3.50,
), and apolipoprotein E level in plasma (OR 1.48, 95% CI 0.95–2.29,
). The area under the receiver operating characteristic curve (AUC) was 0.76 (95% CI 0.66–0.86). A nomogram was established and showed good calibration and clinical predictive capacity. After bootstrap for internal verification, the AUC was 0.74 (95% CI 0.66–0.83). Conclusion. This study provides evidence for the independent inducing factors of delirium after deep brain stimulation of the subthalamic nucleus in Parkinson’s disease under general anesthesia. By predicting the development of delirium, our model may identify high-risk groups that can benefit from early or preventive intervention.
Collapse
|
43
|
Chakrala T, Jain A, Xiang K, Kerensky R. Use of Multimodal Therapies to Treat Severe Orthostatic Hypotension From Autonomic Failure. Cureus 2022; 14:e31990. [DOI: 10.7759/cureus.31990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2022] [Indexed: 11/30/2022] Open
|
44
|
Raber I, Belanger MJ, Farahmand R, Aggarwal R, Chiu N, Al Rifai M, Jacobsen AP, Lipsitz LA, Juraschek SP. Orthostatic Hypotension in Hypertensive Adults: Harry Goldblatt Award for Early Career Investigators 2021. Hypertension 2022; 79:2388-2396. [PMID: 35924561 PMCID: PMC9669124 DOI: 10.1161/hypertensionaha.122.18557] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Orthostatic hypotension affects roughly 10% of individuals with hypertension and is associated with several adverse health outcomes, including dementia, cardiovascular disease, stroke, and death. Among adults with hypertension, orthostatic hypotension has also been shown to predict patterns of blood pressure dysregulation that may not be appreciated in the office setting, including nocturnal nondipping. Individuals with uncontrolled hypertension are at particular risk of orthostatic hypotension and may meet diagnostic criteria for the condition with a smaller relative reduction in blood pressure compared with normotensive individuals. Antihypertensive medications are commonly de-prescribed to address orthostatic hypotension; however, this approach may worsen supine or seated hypertension, which may be an important driver of adverse events in this population. There is significant variability between guidelines for the diagnosis of orthostatic hypotension with regards to timing and position of blood pressure measurements. Clinically relevant orthostatic hypotension may be missed when standing measurements are delayed or when taken after a seated rather than supine position. The treatment of orthostatic hypotension in patients with hypertension poses a significant management challenge for clinicians; however, recent evidence suggests that intensive blood pressure control may reduce the risk of orthostatic hypotension. A detailed characterization of blood pressure variability is essential to tailoring a treatment plan and can be accomplished using both in-office and out-of-office monitoring.
Collapse
Affiliation(s)
- Inbar Raber
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Matthew J Belanger
- Northeast Medical Group, Yale New Haven Hospital, New Haven, Connecticut
| | - Rosemary Farahmand
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Rahul Aggarwal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Nicholas Chiu
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mahmoud Al Rifai
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Alan P. Jacobsen
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Lewis A. Lipsitz
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Stephen P Juraschek
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
45
|
Hui G, Xiahuan C, Yanjun W, Wenyi L, Meilin L. Influencing factors and hemodynamic study of initial and sustained orthostatic hypotension in middle-aged and elderly patients. J Clin Hypertens (Greenwich) 2022; 24:1491-1497. [PMID: 36263516 DOI: 10.1111/jch.14588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/23/2022] [Accepted: 09/23/2022] [Indexed: 12/01/2022]
Abstract
Orthostatic hypotension (OH) is a common autonomic disorder. This study aimed to investigate the influencing factors and hemodynamic mechanisms of initial and sustained OH in middle-aged and elderly patients. The authors analyzed the clinical characteristics and hemodynamic variables of patients aged ≥ 50 years according to the various forms of OH, diagnosed by an active orthostatic test using the CNAP monitor. The study included 473 participants; 119 (25.2%) patients had initial (54, 45.4%) or sustained (65, 54.6%) OH. Age, comorbidities, or medications did not differ significantly between the initial OH and non-OH groups. Sustained OH was associated with age and diabetes (p = .003 and p = .015, respectively). Hemodynamic analysis revealed higher cardiac output (CO) in the sustained OH group within 15 s than in the non-OH and initial OH groups (both p < .001); no difference in CO was observed between the initial OH and non-OH groups. The systemic vascular resistance (SVR) in both initial OH and sustained OH groups within 15 s was lower than that in the non-OH group (both p < .001). No differences in SVR at 3 min were observed between the initial OH and non-OH groups. The SVR at 3 min in the sustained OH group was significantly lower than in non-OH and initial OH groups (both p < .001). Age and diabetes emerged as the independent risk factors associated with sustained OH. Initial OH is associated with a mismatch of increase in CO and decrease in SVR. Sustained OH is mainly associated with sustained inadequate adjustment in SVR.
Collapse
Affiliation(s)
- Geng Hui
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| | - Chen Xiahuan
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| | - Wang Yanjun
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| | - Liang Wenyi
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| | - Liu Meilin
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| |
Collapse
|
46
|
Tanaka R, Hattori N. Abnormal circadian blood pressure regulation and cognitive impairment in α-synucleinopathies. Hypertens Res 2022; 45:1908-1917. [PMID: 36123397 DOI: 10.1038/s41440-022-01032-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/08/2022] [Accepted: 08/25/2022] [Indexed: 11/09/2022]
Abstract
Circadian blood pressure (BP) rhythm is important for the maintenance of healthy daily life, and its disruption is associated with poor outcomes. Cardiovascular autonomic failure is often observed in older populations but has a greater impact on neurodegenerative disorders such as α-synucleinopathies. These BP abnormalities include orthostatic hypotension (OH), supine hypertension (SH), and a loss of nocturnal BP fall. OH not only causes falls or syncope but is also related to cognitive impairment in α-synucleinopathies. For example, OH doubles or triples the risk for the development of cognitive impairment in Parkinson's disease (PD). The diffuse central and peripheral neuropathology of α-synuclein may contribute to both OH and cognitive impairment. Moreover, repeated cerebral hypoperfusion in OH is thought to be related to cerebrovascular and neuronal damage, which may cause cognitive impairment. SH, which often coexists with OH, is also associated with cognitive impairment through cerebrovascular damage, such as white matter lesions and cerebral microbleeds. The reverse-dipping (riser) pattern on ambulatory BP monitoring is commonly observed in PD (∼56%), regardless of disease duration and severity. It is also related to cognitive impairment and more pronounced when coexisting with OH. These abnormal circadian BP profiles may be synergistically associated with cognitive impairment and poor outcomes in α-synucleinopathies. Although evidence for aggressive control of BP dysregulation improving cognitive impairment and outcomes is limited, regular BP monitoring appears to be important for total management of α-synucleinopathies.
Collapse
Affiliation(s)
- Ryota Tanaka
- Stroke Center and Division of Neurology, Department of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University School of Medicine, Hongo 3311-1, Bunkyo-ku, Tokyo, 113-0011, Japan
| |
Collapse
|
47
|
Chen H, Xu E, Zhou F, Li Q, Zeng J, Mei S, Xing Y. Impaired dynamic cerebral autoregulation: A potential mechanism of orthostatic hypotension and dementia in Parkinson’s disease. Front Aging Neurosci 2022; 14:927009. [PMID: 36158547 PMCID: PMC9492951 DOI: 10.3389/fnagi.2022.927009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 08/08/2022] [Indexed: 12/05/2022] Open
Abstract
Background Orthostatic hypotension (OH) and cognitive impairment are common non-motor symptoms of Parkinson’s disease (PD). This study aimed to investigate whether impaired dynamic cerebral autoregulation (dCA) is associated with OH and Parkinson’s disease dementia (PDD), and analyze the related risk factors in patients with PDD. Materials and methods We enrolled 89 patients with PD and 20 age- and sex-matched healthy controls (HCs). Cognition and different cognitive domains were assessed by the Montreal Cognitive Assessment scale. Non-invasive continuous beat-to-beat blood pressure and cerebral blood flow velocity were assessed using a servo-controlled finger plethysmograph and transcranial Doppler, respectively. dCA was examined using supine and orthostatic changes with transfer function analysis to derive the autoregulatory parameters of phase, gain, and coherence. Logistic regression analysis was performed to determine the risk factors for PDD. Results We found that 21 (23.6%) patients with PD had OH. These patients showed worse cognitive performance in specific cognitive tasks, such as language and orientation. The patients with OH also had poorer dCA; the very low frequency (VLF) phase in two different postures was lower than that in patients without OH as well as HCs (both P < 0.05). And the normalized gain in the VLF and low frequency (LF) in standing position was higher in PD patients with and without OH than in HCs. PDD patients also had significantly higher LF normalized gain when standing than patients without dementia (P = 0.015), indicating impaired dCA. LF normalized gain in standing (odds ratio: 3.756, 95% confidence interval: 1.241–11.367) and education were significantly associated with PDD. Conclusion Diminished dCA may represent a potential mechanism for OH and cognitive impairment and low educational level might be a significant factor contributing to the increased risk of PDD.
Collapse
Affiliation(s)
- Hongxiu Chen
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
- Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China
- Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Erhe Xu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Fubo Zhou
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
- Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China
- Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Qiuping Li
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
- Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China
- Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Jingrong Zeng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shanshan Mei
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yingqi Xing
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
- Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China
- Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
- *Correspondence: Yingqi Xing,
| |
Collapse
|
48
|
Nimmons D, Bhanu C, Orlu M, Schrag A, Walters K. Orthostatic Hypotension and Antiparkinsonian Drugs: A Systematic Review and Meta-analysis. J Geriatr Psychiatry Neurol 2022; 35:639-654. [PMID: 34964392 PMCID: PMC9386765 DOI: 10.1177/08919887211060017] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Orthostatic hypotension (OH) is multifactorial in Parkinson's disease (PD). Antiparkinsonian medication can contribute to OH, leading to increased risk of falls, weakness and fatigue. METHODS We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) of antiparkinsonian drugs associated with OH as an adverse effect, compared to placebo. We searched EMBASE, MEDLINE and Web of Science databases until November 2020. Analysis used fixed-effects models and the GRADE tool to rate quality of evidence. Meta-analysis was performed if 3 or more studies of a drug group were available. RESULTS Twenty-one RCTs including 3783 patients were included comparing 6 PD drug groups to placebo (MAO-B inhibitors, dopamine agonists, levodopa, COMT inhibitors, levodopa and adenosine receptor antagonists). OH was recorded as an adverse event or measurement of vital signs, without further specification on how this was defined or operationalised. Meta-analysis was performed for MAO-B inhibitors and dopamine agonists, as there were 3 or more studies for these drug groups. In this analysis, compared with placebo, neither MAO-B inhibitors or dopamine agonists were associated with increased risk of OH, (OR 2.28 [95% CI:0.81-6.46]), (OR 1.39 [95% CI:0.97-1.98]). CONCLUSIONS Most studies did not specifically report OH, or reporting of OH was limited, including how and when it was measured. Furthermore, studies specifically reporting OH included participants that were younger than typical PD populations without multimorbidity. Future trials should address this, for example,, by including individuals over the age of 75, to improve estimations of how antiparkinsonian medications affect risk of OH.
Collapse
Affiliation(s)
- Danielle Nimmons
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, UCL, UK,Danielle Nimmons, Research Department of Primary Care and Population Health, UCL, Rowland Hill Street, London NW3 2PF, UK.
| | - Cini Bhanu
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, UCL, UK
| | | | - Anette Schrag
- Department of Neurology, Institute of Neurology, UCL, UK
| | - Kate Walters
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, UCL, UK
| |
Collapse
|
49
|
Scala I, Bellavia S, Luigetti M, Brunetti V, Broccolini A, Gabrielli M, Zileri Dal Verme L, Calabresi P, Della Marca G, Frisullo G. Autonomic dysfunction in non-critically ill COVID-19 patients during the acute phase of disease: an observational, cross-sectional study. Neurol Sci 2022; 43:4635-4643. [PMID: 35608736 PMCID: PMC9127042 DOI: 10.1007/s10072-022-06136-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/09/2022] [Indexed: 01/05/2023]
Abstract
Introduction
Evidence is emerging about an extra-pulmonary involvement of SARS-CoV-2, including the nervous system. Autonomic dysfunction in patients recovering from acute coronavirus disease 2019 (COVID-19) has been recently described. Dysautonomic symptoms have been reported in the acute phase of the disease, but clear evidence is lacking, especially in the non-critical forms of the infection. Objective The aim of this study is to assess the prevalence of dysautonomia in acute, non-critically ill COVID-19 patients. Methods In this observational, cross-sectional study, we compared 38 non-critically ill patients with acute COVID-19 (COVID + group) to 38 healthy volunteers (COVID − group) in order to assess the prevalence of signs and symptoms of dysautonomia through the administration of the composite autonomic symptom score 31 (COMPASS-31) and an active standing test. Comparisons between groups were performed by means of both univariate and multivariate analyses. Results The prevalence of orthostatic hypotension was significantly higher in the COVID + group. Higher total scores of COMPASS-31 were observed in the COVID + group than controls. Significant differences between groups emerged in the secretomotor, orthostatic intolerance, and gastrointestinal COMPASS-31 domains. All these results maintained the statistical significance after the adjustment for concomitant drugs with a known effect on the autonomic nervous system assumed by the study participants, except for the differences in the gastrointestinal domain of COMPASS-31. Conclusion Our results suggest that an autonomic dysfunction could be an early manifestation of COVID-19, even in the contest of mild forms of the infection.
Collapse
Affiliation(s)
- Irene Scala
- Catholic University of Sacred Heart, Rome, Italy
| | | | - Marco Luigetti
- Dipartimento Di Scienze Dell'Invecchiamento, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Neurologiche, Rome, Italy.
| | - Valerio Brunetti
- Dipartimento Di Scienze Dell'Invecchiamento, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Neurologiche, Rome, Italy
| | - Aldobrando Broccolini
- Catholic University of Sacred Heart, Rome, Italy
- Dipartimento Di Scienze Dell'Invecchiamento, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Neurologiche, Rome, Italy
| | - Maurizio Gabrielli
- Department of Emergency, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo Gemelli 8, 00168, Rome, Italy
| | | | - Paolo Calabresi
- Catholic University of Sacred Heart, Rome, Italy
- Dipartimento Di Scienze Dell'Invecchiamento, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Neurologiche, Rome, Italy
| | - Giacomo Della Marca
- Catholic University of Sacred Heart, Rome, Italy
- Dipartimento Di Scienze Dell'Invecchiamento, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Neurologiche, Rome, Italy
| | - Giovanni Frisullo
- Dipartimento Di Scienze Dell'Invecchiamento, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Neurologiche, Rome, Italy
| |
Collapse
|
50
|
Ko HL, Min HK, Lee SW. Risk of Chronic Kidney Disease Associated With Orthostatic Hypotensive Stress: A Community-Based Korean Study. Am J Hypertens 2022; 35:656-663. [PMID: 35353880 DOI: 10.1093/ajh/hpac041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 03/14/2022] [Accepted: 03/23/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The relationship between orthostatic blood pressure (BP) changes and incident chronic kidney disease (CKD) has not been explored in Asian populations. METHODS We reviewed the data of 7,039 participants from the Ansung-Ansan cohort study. BP was measured in the supine position and 2 minutes after standing. The change in BP from the supine to upright position was defined as orthostatic BP change. Orthostatic systolic BP (SBP) decline was defined as an orthostatic SBP change of <-2 mm Hg. The primary outcome was the development of CKD, defined as the first event of an estimated glomerular filtration rate <60 ml/min/1.73 m2 at least twice during the follow-up period. RESULTS Of 7,039 participants, 949 (13.5 %) developed incident CKD over a mean of 11.9 years. Although orthostatic diastolic BP change was not associated with incident CKD, every 1 mm Hg increase in orthostatic SBP change was associated with a decreased risk of incident CKD (HR, 0.989; 95% CI, 0.982-0.995; P = 0.001). Orthostatic SBP decline was associated with an increased risk of incident CKD (HR, 1.337; 95% CI, 1.163-1.537; P < 0.001). Older age and diabetes were associated with increased odds of orthostatic SBP decline, whereas male sex and high body mass index were associated with decreased odds of orthostatic SBP decline. Subgroup analysis revealed that orthostatic SBP decline was associated with incident CKD only in non-diabetic participants. CONCLUSIONS Orthostatic SBP decline was independently associated with an increased risk of future incident CKD, whereas orthostatic DBP decline was not.
Collapse
Affiliation(s)
- Hyun-Lee Ko
- Department of Internal Medicine, Uijeongbu Eulji Medical Center, Eulji University, Gyeonggi-do, Korea
| | - Hyang-Ki Min
- Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Sung-Woo Lee
- Department of Internal Medicine, Uijeongbu Eulji Medical Center, Eulji University, Gyeonggi-do, Korea
| |
Collapse
|