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Badihian N, Savica R, Adler CH, Wszolek ZK, Jackson LM, Benarroch EE, Sandroni P, Low PA, Singer W, Coon EA. Clinical Characteristics and Outcomes in Young-Onset Multiple System Atrophy. Mov Disord Clin Pract 2024; 11:220-226. [PMID: 38468536 PMCID: PMC10928343 DOI: 10.1002/mdc3.13925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 09/22/2023] [Accepted: 10/29/2023] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Young-onset multiple system atrophy (YOMSA) is defined as the onset of multiple system atrophy (MSA) before the age of 40 years old. YOMSA is rare and there is much uncertainty of the phenotype and natural history in patients with YOMSA. OBJECTIVE The objective is to evaluate the characteristics and disease course of patients with YOMSA. METHODS We retrospectively reviewed medical records of patients with MSA who were evaluated at all Mayo Clinic sites from 1998 to 2021. We identified patients with YOMSA and evaluated clinical characteristics, autonomic function testing results, and disease course. RESULTS Of 1496 patients with a diagnosis of clinically probable or clinically established MSA, 20 patients had YOMSA. The median age of onset was 39.1 (interquartile range [IQR] = 37.1, 40.1) years; 13 patients (65%) were male. MSA-parkinsonism was the most common subtype (65%). The median duration of symptom onset to YOMSA diagnosis was 4.9 (IQR = 3.7, 9) years. At the time of medical record review, 17 patients were deceased with a median survival of 8.3 (IQR = 7, 10.9) years. Univariate analysis showed that initial onset of autonomic failure predicted unfavorable survival (hazard ratio = 2.89, P = 0.04) compared to those who presented with motor impairment only at onset. At the time of YOMSA diagnosis, composite autonomic severity score was available in 19 patients with a median of 5 (IQR = 4, 6.5). CONCLUSIONS YOMSA resembles MSA in most aspects including phenotype and prognosis, although the diagnosis is usually delayed. The presence of autonomic failure at symptom onset may be a poor predictor for survival.
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Affiliation(s)
- Negin Badihian
- Department of Neurology, Mayo ClinicRochesterMinnesotaUSA
| | - Rodolfo Savica
- Department of Neurology, Mayo ClinicRochesterMinnesotaUSA
| | - Charles H. Adler
- Department of Neurology, Mayo Clinic College of MedicineScottsdaleArizonaUSA
| | | | | | | | - Paola Sandroni
- Department of Neurology, Mayo ClinicRochesterMinnesotaUSA
| | - Phillip A. Low
- Department of Neurology, Mayo ClinicRochesterMinnesotaUSA
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Millar Vernetti P, Norcliffe-Kaufmann L, Palma JA, Biaggioni I, Shibao CA, Peltier A, Freeman R, Gibbons C, Goldstein DS, Low PA, Singer W, Coon EA, Miglis MG, Wenning GK, Fanciulli A, Vernino S, Betensky RA, Kaufmann H. Phenoconversion in pure autonomic failure: a multicentre prospective longitudinal cohort study. Brain 2024:awae033. [PMID: 38366572 DOI: 10.1093/brain/awae033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 12/20/2023] [Accepted: 01/09/2024] [Indexed: 02/18/2024] Open
Abstract
We aimed to describe the clinical features of patients with pure autonomic failure (PAF) preceding phenoconversion that could be useful as predictive markers for advancing α-synuclein-associated neurodegeneration of the brain. Patients diagnosed with PAF were evaluated at 8 Centers (7-US based and 1 European) and enrolled in a longitudinal observational cohort study (NCT01799915). Subjects underwent detailed assessments of motor, sleep, olfactory, cognitive, and autonomic function and were followed prospectively to determine whether they developed parkinsonism or dementia for up to 10 years. We identified incident cases of Parkinson disease (PD), dementia with Lewy bodies (DLB), or multiple system atrophy (MSA) and computed hazard ratios for phenoconversion as functions of clinical features. A total of 209 participants with PAF with a median disease duration of 6 years (IQR: 3-10) were enrolled. Of those, 149 provided follow-up information at an office or telemedicine visit. After a mean follow-up duration of 3 years, 48 (33%) participants phenoconverted (42% to PD, 35% to DLB, and 23% to MSA). Faster phenoconversion from study enrollment to any diagnosis was associated with urinary and sexual dysfunction [HR 5.9, 95%CI: 1.6-22, and HR: 3.6, 95%CI: 1.1-12] followed by subtle motor signs [HR: 2.7, 95%CI: 1.2-6], trouble swallowing [HR 2.5, 95%CI: 1.4-4.5], and changes in speech [HR:2.4, 95%CI:1.1-4.8] at enrollment. Subjects reporting deterioration of handwriting were more likely to phenoconvert to PD (HR: 2.6, 95%CI: 1.1-5.9, ) and those reporting difficulty handling utensils were more likely to phenoconvert to DLB (HR: 6.8, 95%CI: 1.2-38). Patients with a younger age of PAF onset [HR: 11, 95%CI: 2.6-46], preserved olfaction [HR: 8.7, 95%CI: 1.7-45], anhidrosis [HR: 1.8, 95%CI: 1-3.1, p=0.042], and severe urinary problems [HR 1.6, 95%CI: 1-2.5, p=0.033] were more likely to phenoconvert to MSA. The best autonomic predictor of PD was a blunted heart rate increase during the tilt-table test (HR: 6.1, 95%CI: 1.4-26). Patients with PAF have an estimated 12% (95% CI: 9%-15%) per year annual risk following study entry of phenoconverting to a manifest CNS synucleinopathy.
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Affiliation(s)
- Patricio Millar Vernetti
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Jose-Alberto Palma
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Italo Biaggioni
- Department of Pharmacology, Vanderbilt University, Nashville, TN 37232, USA
| | - Cyndya A Shibao
- Department of Pharmacology, Vanderbilt University, Nashville, TN 37232, USA
| | - Amanda Peltier
- Department of Pharmacology, Vanderbilt University, Nashville, TN 37232, USA
| | - Roy Freeman
- Department of Medicine, Boston, MA 02215, USA
| | | | - David S Goldstein
- Autonomic Medicine Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Phillip A Low
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
| | - Wolfgang Singer
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Mitchell G Miglis
- Department of Neurology and Neurological Sciences, Stanford University, A 94304, USA
| | - Gregor K Wenning
- Department of Neurology, Medical University of Innsbruck, Austria
| | | | - Steven Vernino
- Department of Neurology, University of Texas Southwestern, Dallas, TX 75390, USA
| | - Rebecca A Betensky
- Department of Biostatistics, School of Global Public Health, New York University, New York, NY 10003, USA
| | - Horacio Kaufmann
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10016, USA
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3
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van der Stam AH, Shmuely S, de Vries NM, Bloem BR, Thijs RD. The Impact of Head-Up Tilt Sleeping on Orthostatic Tolerance: A Scoping Review. Biology (Basel) 2023; 12:1108. [PMID: 37626994 PMCID: PMC10452159 DOI: 10.3390/biology12081108] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023]
Abstract
To systematically summarize the evidence of head-up tilt sleeping (HUTS) on orthostatic tolerance, we conducted a systematic, predefined search in PubMed, OVID Embase, Cochrane and Web of Science. We included studies assessing the effect of HUTS on orthostatic tolerance and other cardiovascular measures and rated the quality with the American Academy of Neurology risk of bias tool. We included 10 studies (n = 185) in four groups: orthostatic hypotension (OH; 6 studies, n = 103), vasovagal syncope (1 study, n = 12), nocturnal angina pectoris (1 study, n = 10) and healthy subjects (2 studies, n = 58). HUTS duration varied (1 day-4 months) with variable inclinations (5°-15°). In two of six OH studies, HUTS significantly improved standing systolic blood pressure. Orthostatic tolerance was consistently enhanced in OH studies with higher angles (≥12°), in 2 out of 3 with smaller angles (5°) but also in one studying horizontal sleeping. In vasovagal syncope, HUTS significantly augmented resilience to extreme orthostatic stress. One study was rated as a class II risk of bias, one of Class II/III and eight of Class IV. The evidence favouring HUTS to improve orthostatic tolerance is weak due to variable interventions, populations, small samples and a high risk of bias. Despite this, we found some physiological signs suggesting a beneficial effect.
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Affiliation(s)
- Amber H. van der Stam
- Department of Neurology, Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; (A.H.v.d.S.); (S.S.); (N.M.d.V.); (B.R.B.)
| | - Sharon Shmuely
- Department of Neurology, Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; (A.H.v.d.S.); (S.S.); (N.M.d.V.); (B.R.B.)
| | - Nienke M. de Vries
- Department of Neurology, Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; (A.H.v.d.S.); (S.S.); (N.M.d.V.); (B.R.B.)
| | - Bastiaan R. Bloem
- Department of Neurology, Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; (A.H.v.d.S.); (S.S.); (N.M.d.V.); (B.R.B.)
| | - Roland D. Thijs
- Department of Neurology, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands
- Stichting Epilepsie Instellingen Nederland, 2130 AM Hoofddorp, The Netherlands
- UCL Queen Square Institute of Neurology, University College London, London WC1N 1PJ, UK
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Heusser K, Erger F, Ebner U, Namer B, Eisenhofer G, Haensch CA, Weis H, Schmidt M, Drzezga A, Tank J, Netzer C, Jordan J. Disconnected Cardiac Autonomic Nerves in Genetic Ganglionic Acetylcholine Receptor Alpha-3 Subunit Deficiency. Hypertension 2023. [PMID: 37161764 DOI: 10.1161/hypertensionaha.123.21172] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Affiliation(s)
- Karsten Heusser
- Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, Germany (K.H., H.W., J.T., J.J.)
| | - Florian Erger
- Institute of Human Genetics, Medical Faculty, University of Cologne, Germany (F.E., C.N.)
| | - Ulrich Ebner
- Internal Medicine Practice, Regensburg, Germany (U.E.)
| | - Barbara Namer
- Institute of Physiology and Pathophysiology, Friedrich Alexander University Erlangen-Nuremberg, Germany (B.N.)
- Research Group Neuroscience, Interdisciplinary Centre for Clinical Research within the Faculty of Medicine at the RWTH Aachen University, Germany (B.N.)
- Department for Physiology, Faculty of Medicine at the RWTH Aachen University, Germany (B.N.)
| | - Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty, Technical University Dresden, Germany. (G.E.)
- University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus and Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty, Technical University Dresden, Germany. (G.E.)
| | - Carl-Albrecht Haensch
- Kliniken Maria Hilf Mönchengladbach, Autonomic Laboratory, Department of Neurology, Faculty of Health, University of Witten/Herdecke, Mönchengladbach, Germany (C.-A.H.)
| | - Henning Weis
- Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, Germany (K.H., H.W., J.T., J.J.)
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany (H.W., M.S., A.D.)
| | - Matthias Schmidt
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany (H.W., M.S., A.D.)
| | - Alexander Drzezga
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany (H.W., M.S., A.D.)
| | - Jens Tank
- Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, Germany (K.H., H.W., J.T., J.J.)
| | - Christian Netzer
- Institute of Human Genetics, Medical Faculty, University of Cologne, Germany (F.E., C.N.)
| | - Jens Jordan
- Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, Germany (K.H., H.W., J.T., J.J.)
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5
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Pechlivanidou M, Ninou E, Karagiorgou K, Tsantila A, Mantegazza R, Francesca A, Furlan R, Dudeck L, Steiner J, Tzartos J, Tzartos S. Autoimmunity to Neuronal Nicotinic Acetylcholine Receptors. Pharmacol Res 2023; 192:106790. [PMID: 37164280 DOI: 10.1016/j.phrs.2023.106790] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 04/30/2023] [Accepted: 05/05/2023] [Indexed: 05/12/2023]
Abstract
Nicotinic acetylcholine receptors (nAChRs) are widely expressed in many and diverse cell types, participating in various functions of cells, tissues and systems. In this review, we focus on the autoimmunity against neuronal nAChRs, the specific autoantibodies and their mechanisms of pathological action in selected autoimmune diseases. We summarize the current relevant knowledge from human diseases as well as from experimental models of autoimmune neurological disorders related to antibodies against neuronal nAChR subunits. Despite the well-studied high immunogenicity of the muscle nAChRs where autoantibodies are the main pathogen of myasthenia gravis, autoimmunity to neuronal nAChRs seems infrequent, except for the autoantibodies to the ganglionic receptor, the α3 subunit containing nAChR (α3-nAChR), which are detected and are likely pathogenic in Autoimmune Autonomic Ganglionopathy (AAG). We describe the detection, presence and function of these antibodies and especially the recent development of a cell-based assay (CBA) which, contrary to until recently available assays, is highly specific for AAG. Rare reports of autoantibodies to the other neuronal nAChR subtypes include a few cases of antibodies to α7 and/or α4β2 nAChRs in Rasmussen encephalitis, schizophrenia, autoimmune meningoencephalomyelitis, and in some myasthenia gravis patients with concurrent CNS symptoms. Neuronal-type nAChRs are also present in several non-excitable tissues, however the presence and possible role of antibodies against them needs further verification. It is likely that the future development of more sensitive and disease-specific assays would reveal that neuronal nAChR autoantibodies are much more frequent and may explain the mechanisms of some seronegative autoimmune diseases.
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Affiliation(s)
| | | | - Katerina Karagiorgou
- Tzartos NeuroDiagnostics, Athens, Greece; Department of Biochemistry and Biotechnology, University of Thessaly, Larissa, Greece
| | | | - Renato Mantegazza
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy
| | - Andreetta Francesca
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy
| | - Raffaello Furlan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Rozzano, Milan, Italy; Clinical and Research Center - IRCCS, Humanitas University, Rozzano, Milan, Italy
| | - Leon Dudeck
- Department of Psychiatry and Psychotherapy, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany; Laboratory of Translational Psychiatry, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Johann Steiner
- Department of Psychiatry and Psychotherapy, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany; Laboratory of Translational Psychiatry, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany; Center for Behavioral Brain Sciences (CBBS), Magdeburg, Germany; Center for Health and Medical Prevention (CHaMP), Magdeburg, Germany; German Center for Mental Health DZPG, Center for Intervention and Research on Adaptive and Maladaptive Brain Circuits Underlying Mental Health C-I-R-C, Halle-Jena-Magdeburg, Germany
| | - John Tzartos
- 2(nd) Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece.
| | - Socrates Tzartos
- Tzartos NeuroDiagnostics, Athens, Greece; Department of Neurobiology, Hellenic Pasteur Institute, Athens, Greece; Department of Pharmacy, University of Patras, Patras, Greece.
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6
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Okamoto LE, Celedonio JE, Smith EC, Paranjape SY, Black BK, Wahba A, Park JW, Shibao CA, Diedrich A, Biaggioni I. Continuous Positive Airway Pressure for the Treatment of Supine Hypertension and Orthostatic Hypotension in Autonomic Failure. Hypertension 2023; 80:650-658. [PMID: 36601916 PMCID: PMC10128890 DOI: 10.1161/hypertensionaha.122.20081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 12/14/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Supine hypertension affects most patients with orthostatic hypotension (OH) due to autonomic failure, but it is often untreated for fear of worsening OH. We hypothesized that increasing intrathoracic pressure with continuous positive airway pressure (CPAP) had a Valsalva-like blood-pressure-lowering effect that could be used to treat nocturnal supine hypertension in these patients, while reducing nocturnal pressure diuresis and improving daytime OH. METHODS In Protocol 1, we determined the acute hemodynamic effects of increasing levels of CPAP (0, 4, 8, 12, and 16 cm H2O, 3 minutes each) in 26 patients with autonomic failure and supine hypertension studied while awake and supine. In Protocol 2 (n=11), we compared the effects of overnight therapy with CPAP (8-12 cm H2O for 8 hours) versus placebo on nocturnal supine hypertension, nocturnal diuresis and daytime OH in a 2-night crossover study. RESULTS In Protocol 1, acute CPAP (4-16 cm H2O) decreased systolic blood pressure in a dose-dependent manner (maximal drop 22±4 mmHg with CPAP 16) due to reductions in stroke volume (-16+3%) and cardiac output (-14±3%). Systemic vascular resistance and heart rate remained unchanged. In Protocol 2, overnight CPAP lowered nighttime systolic blood pressure (maximal change -23±5 versus placebo -1±7 mmHg; P=0.023) and was associated with lower nighttime diuresis (609±84 versus placebo 1004±160 mL; P=0.004) and improved morning orthostatic tolerance (AUC upright SBP 642±121 versus placebo 410±109 mmHg*min; P=0.014). CONCLUSIONS CPAP is a novel nonpharmacologic approach to treat the supine hypertension of autonomic failure while improving nocturia and daytime OH. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03312556.
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Affiliation(s)
- Luis E. Okamoto
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jorge E. Celedonio
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Emily C. Smith
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sachin Y. Paranjape
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bonnie K. Black
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amr Wahba
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jin-Woo Park
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cyndya A. Shibao
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - André Diedrich
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Italo Biaggioni
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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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.
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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
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Eschlböck S, Kiss G, Krismer F, Fanciulli A, Kaindlstorfer C, Raccagni C, Seppi K, Kiechl S, Panicker JN, Wenning GK. Urodynamic Evaluation in Multiple System Atrophy: A Retrospective Cohort Study. Mov Disord Clin Pract 2021; 8:1052-1060. [PMID: 34631941 PMCID: PMC8485589 DOI: 10.1002/mdc3.13307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/13/2021] [Accepted: 06/27/2021] [Indexed: 12/19/2022] Open
Abstract
Background Urological dysfunction in patients with multiple system atrophy (MSA) is one of the main manifestations of autonomic failure. Urodynamic examination is clinically relevant since underlying pathophysiology of lower urinary tract (LUT) dysfunction can be variable. Objective Evaluation of the pathophysiology of urological symptoms and exploration of differences in urodynamic patterns of LUT dysfunction between MSA-P and MSA-C. Methods Retrospective study of patients with possible and probable MSA who were referred for urodynamic studies between 2004 and 2019. Demographic data, medical history, physical examination and urodynamic studies assessing storage and voiding dysfunction were obtained. Results Seventy-four patients were included in this study (MSA-P 64.9% n = 48; median age 62.5 (IQR 56.8-70) years). Detrusor overactivity during filling phase was noted in 58.1% (n = 43) of the patients. In the voiding phase, detrusor sphincter dyssynergia and detrusor underactivity were observed in 24.6% (n = 17) and in 62.1% (n = 41) of the patients, respectively. A postmicturition residual volume of over 100 ml was present in 71.4% (n = 50) of the patients. Comparison of MSA subtypes showed weaker detrusor contractility in MSA-P compared to MSA-C [pdetQmax 26.2 vs. 34.4 cmH20, P = 0.04]. In 56.2% (n = 41) of patients pathophysiology of LUT dysfunction was deemed to be neurogenic and consistent with the diagnosis of MSA. In 35.6% (n = 26) urodynamic pattern suggested other urological co-morbidities. Conclusion Urodynamic evaluation is an important tool to analyze the pattern of LUT dysfunction in MSA. Impaired detrusor contractility was seen more in MSA-P which needs to be investigated in further studies.
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Affiliation(s)
- Sabine Eschlböck
- Department of Neurology Medical University of Innsbruck Innsbruck Austria
| | - Gustav Kiss
- Division of Neurourology, Department of Urology Medical University of Innsbruck Innsbruck Austria
| | - Florian Krismer
- Department of Neurology Medical University of Innsbruck Innsbruck Austria
| | | | | | - Cecilia Raccagni
- Department of Neurology Medical University of Innsbruck Innsbruck Austria.,Department of Neurology Regional General Hospital Bolzano Italy
| | - Klaus Seppi
- Department of Neurology Medical University of Innsbruck Innsbruck Austria
| | - Stefan Kiechl
- Department of Neurology Medical University of Innsbruck Innsbruck Austria
| | - Jalesh N Panicker
- Department of Uro-Neurology The National Hospital for Neurology and Neurosurgery, and UCL Queen Square Institute of Neurology London United Kingdom
| | - Gregor K Wenning
- Department of Neurology Medical University of Innsbruck Innsbruck Austria
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9
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Borg MJ, Xie C, Rayner CK, Horowitz M, Jones KL, Wu T. Potential for Gut Peptide-Based Therapy in Postprandial Hypotension. Nutrients 2021; 13:nu13082826. [PMID: 34444986 PMCID: PMC8399874 DOI: 10.3390/nu13082826] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/06/2021] [Accepted: 08/14/2021] [Indexed: 02/07/2023] Open
Abstract
Postprandial hypotension (PPH) is an important and under-recognised disorder resulting from inadequate compensatory cardiovascular responses to meal-induced splanchnic blood pooling. Current approaches to management are suboptimal. Recent studies have established that the cardiovascular response to a meal is modulated profoundly by gastrointestinal factors, including the type and caloric content of ingested meals, rate of gastric emptying, and small intestinal transit and absorption of nutrients. The small intestine represents the major site of nutrient-gut interactions and associated neurohormonal responses, including secretion of glucagon-like peptide-1, glucose-dependent insulinotropic peptide and somatostatin, which exert pleotropic actions relevant to the postprandial haemodynamic profile. This review summarises knowledge relating to the role of these gut peptides in the cardiovascular response to a meal and their potential application to the management of PPH.
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Affiliation(s)
- Malcolm J. Borg
- Adelaide Medical School and Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide 5000, Australia; (M.J.B.); (C.X.); (C.K.R.); (M.H.); (K.L.J.)
| | - Cong Xie
- Adelaide Medical School and Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide 5000, Australia; (M.J.B.); (C.X.); (C.K.R.); (M.H.); (K.L.J.)
| | - Christopher K. Rayner
- Adelaide Medical School and Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide 5000, Australia; (M.J.B.); (C.X.); (C.K.R.); (M.H.); (K.L.J.)
| | - Michael Horowitz
- Adelaide Medical School and Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide 5000, Australia; (M.J.B.); (C.X.); (C.K.R.); (M.H.); (K.L.J.)
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide 5000, Australia
| | - Karen L. Jones
- Adelaide Medical School and Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide 5000, Australia; (M.J.B.); (C.X.); (C.K.R.); (M.H.); (K.L.J.)
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide 5000, Australia
| | - Tongzhi Wu
- Adelaide Medical School and Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide 5000, Australia; (M.J.B.); (C.X.); (C.K.R.); (M.H.); (K.L.J.)
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide 5000, Australia
- Correspondence: ; Tel.: +61-8-8313-6535
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10
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Matsuzono K, Kumutpongpanich T, Kubota K, Okuyama T, Furuya K, Yagisawa T, Horikiri A, Igarashi T, Miura K, Ozawa T, Mashiko T, Shimazaki H, Koide R, Tanaka R, Shimizu H, Imai Y, Kario K, Nishino I, Fujimoto S. Noteworthy Cardiovascular Involvement with Sporadic Late-onset Nemaline Myopathy. Intern Med 2021; 60:2327-2332. [PMID: 33612671 PMCID: PMC8355391 DOI: 10.2169/internalmedicine.6068-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Cardiac involvement has recently been the focus of sporadic late-onset nemaline myopathy (SLONM). However, right ventricular failure and pulmonary hypertension, in addition to repetitive cardiac arrest, are noteworthy characteristics of SLONM. We herein report a 66-year-old woman with SLONM whose main symptoms were cardiac arrest, right ventricular failure, and pulmonary hypertension. Despite permanent pacemaker replacement, cardiac arrest occurred repetitively, and even with continuous positive airway pressure, right ventricular failure and pulmonary hypertension persisted. The patient was finally diagnosed with SLONM by a muscle biopsy. Our case suggests the possibility of cardiovascular involvement in SLONM, especially right ventricular failure and pulmonary hypertension.
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Affiliation(s)
- Kosuke Matsuzono
- Division of Neurology, Department of Medicine, Jichi Medical University School of Medicine, Japan
| | - Theerawat Kumutpongpanich
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Japan
| | - Kana Kubota
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Japan
| | - Takafumi Okuyama
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Japan
- Department of Cardiology, Sano Kosei General Hospital, Japan
| | - Kohei Furuya
- Division of Neurology, Department of Medicine, Jichi Medical University School of Medicine, Japan
| | - Tomoya Yagisawa
- Division of Neurology, Department of Medicine, Jichi Medical University School of Medicine, Japan
| | - Akie Horikiri
- Division of Neurology, Department of Medicine, Jichi Medical University School of Medicine, Japan
| | - Takeshi Igarashi
- Division of Neurology, Department of Medicine, Jichi Medical University School of Medicine, Japan
| | - Kumiko Miura
- Division of Neurology, Department of Medicine, Jichi Medical University School of Medicine, Japan
| | - Tadashi Ozawa
- Division of Neurology, Department of Medicine, Jichi Medical University School of Medicine, Japan
| | - Takafumi Mashiko
- Division of Neurology, Department of Medicine, Jichi Medical University School of Medicine, Japan
| | - Haruo Shimazaki
- Division of Neurology, Department of Medicine, Jichi Medical University School of Medicine, Japan
| | - Reiji Koide
- Division of Neurology, Department of Medicine, Jichi Medical University School of Medicine, Japan
| | - Ryota Tanaka
- Division of Neurology, Department of Medicine, Jichi Medical University School of Medicine, Japan
| | - Hayato Shimizu
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Japan
- Department of Cardiology, Sano Kosei General Hospital, Japan
| | - Yasushi Imai
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Japan
| | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Japan
| | - Shigeru Fujimoto
- Division of Neurology, Department of Medicine, Jichi Medical University School of Medicine, Japan
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11
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Kitazaki Y, Ikawa M, Kishitani T, Kamisawa T, Nakane S, Nakamoto Y, Hamano T. Progressive Encephalomyelitis with Rigidity and Myoclonus (PERM)-like Symptoms Associated with Anti-ganglionic Acetylcholine Receptor Antibodies. Intern Med 2021; 60:2307-2313. [PMID: 33583893 PMCID: PMC8355408 DOI: 10.2169/internalmedicine.6419-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This report describes a 59-year-old woman who presented with progressive encephalomyelitis with rigidity and myoclonus (PERM)-like symptoms and severe dysautonomia, including orthostatic hypotension, sinus bradycardia, dysuria, and prolonged constipation. Her neurological symptoms improved after immunotherapy, but the dysautonomia persisted. Anti-ganglionic acetylcholine receptor (gAChR) α3 subunit antibodies, which are frequently identified in patients with autoimmune autonomic ganglionopathy, were detected in the pre-treatment serum. The central distribution of the nicotinic acetylcholine receptors, a target of anti-gAChR antibodies, and immunotherapeutic efficacy observed in this case indicate that anti-gAChR α3 subunit antibodies are associated with the PERM-like features accompanied by autonomic manifestations.
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Affiliation(s)
- Yuki Kitazaki
- Department of Neurology, Fukui-ken Saiseikai Hospital, Japan
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Masamichi Ikawa
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
- Department of Advanced Medicine for Community Healthcare, Faculty of Medical Sciences, University of Fukui, Japan
| | - Toru Kishitani
- Department of Neurology, Fukui-ken Saiseikai Hospital, Japan
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Tomoko Kamisawa
- Department of Neurology, Fukui-ken Saiseikai Hospital, Japan
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Shunya Nakane
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Yasunari Nakamoto
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Tadanori Hamano
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
- Department of Aging and Dementia, Faculty of Medical Sciences, University of Fukui, Japan
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12
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Giannini G, Provini F, Cortelli P, Calandra-Buonaura G. REM Sleep Behaviour Disorder in Multiple System Atrophy: From Prodromal to Progression of Disease. Front Neurol 2021; 12:677213. [PMID: 34194385 PMCID: PMC8238043 DOI: 10.3389/fneur.2021.677213] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 05/04/2021] [Indexed: 12/25/2022] Open
Abstract
A higher frequency of motor and breathing sleep-related disorders in multiple system atrophy (MSA) populations is reported. REM sleep behaviour disorder (RBD) is one of the most robust markers of an underlying alpha-synucleinopathy. Although a large corpus of literature documented the higher prevalence of RBD in MSA, few studies have systematically investigated the prevalence of RBD as mode of disease onset and its role in disease progression. Moreover, there has been increasing interest in phenoconversion into synucleinopathies of cohorts of patients with isolated RBD (iRBD). Finally, some studies investigated RBD as predictive factor of conversion in isolated autonomic failure, a synucleinopathy presenting with autonomic failure as the sole clinical manifestation that could convert to a manifest central nervous system synucleinopathy. As the field of neurodegenerative disorders moves increasingly towards developing disease-modifying therapies, detecting individuals in the prodromal stage of these synucleinopathies becomes crucial. The aims of this review are to summarise (1) the prevalence of RBD during the course of MSA and as presenting feature of MSA (iRBD), (2) the RBD features in MSA, (3) MSA progression and prognosis in the subgroup of patients with RBD predating disease onset, and (4) the prevalence of MSA conversion in iRBD cohorts. Moreover, we summarise previous results on the role of RBD in the context of isolated autonomic failure as marker of phenoconversion to other synucleinopathies and, in particular, to MSA.
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Affiliation(s)
- Giulia Giannini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Unità Operativa Complessa (UOC) Clinica Neurologica Rete Metropolitana NEUROMET, Bologna, Italy.,Department of Biomedical and NeuroMotor Sciences (DiBiNeM), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Federica Provini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Unità Operativa Complessa (UOC) Clinica Neurologica Rete Metropolitana NEUROMET, Bologna, Italy.,Department of Biomedical and NeuroMotor Sciences (DiBiNeM), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Pietro Cortelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Unità Operativa Complessa (UOC) Clinica Neurologica Rete Metropolitana NEUROMET, Bologna, Italy.,Department of Biomedical and NeuroMotor Sciences (DiBiNeM), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Giovanna Calandra-Buonaura
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Unità Operativa Complessa (UOC) Clinica Neurologica Rete Metropolitana NEUROMET, Bologna, Italy.,Department of Biomedical and NeuroMotor Sciences (DiBiNeM), Alma Mater Studiorum - University of Bologna, Bologna, Italy
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13
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Okamoto LE, Celedonio JE, Smith EC, Gamboa A, Shibao CA, Diedrich A, Paranjape SY, Black BK, Muldowney JAS, Peltier AC, Habermann R, Crandall CG, Biaggioni I. Local Passive Heat for the Treatment of Hypertension in Autonomic Failure. J Am Heart Assoc 2021; 10:e018979. [PMID: 33739123 PMCID: PMC8174330 DOI: 10.1161/jaha.120.018979] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Supine hypertension affects a majority of patients with autonomic failure; it is associated with end‐organ damage and can worsen daytime orthostatic hypotension by inducing pressure diuresis and volume loss during the night. Because sympathetic activation prevents blood pressure (BP) from falling in healthy subjects exposed to heat, we hypothesized that passive heat had a BP‐lowering effect in patients with autonomic failure and could be used to treat their supine hypertension. Methods and Results In Protocol 1 (n=22), the acute effects of local heat (40–42°C applied with a heating pad placed over the abdomen for 2 hours) versus sham control were assessed in a randomized crossover fashion. Heat acutely decreased systolic BP by −19±4 mm Hg (versus 3±4 with sham, P<0.001) owing to decreases in stroke volume (−18±5% versus −4±4%, P=0.013 ) and cardiac output (−15±5% versus −2±4%, P=0.013). In Protocol 2 (proof‐of‐concept overnight study; n=12), we compared the effects of local heat (38°C applied with a water‐perfused heating pad placed under the torso from 10 pm to 6 am) versus placebo pill. Heat decreased nighttime systolic BP (maximal change −28±6 versus −2±6 mm Hg, P<0.001). BP returned to baseline by 8 am. The nocturnal systolic BP decrease correlated with a decrease in urinary volume (r=0.57, P=0.072) and an improvement in the morning upright systolic BP (r=−0.76, P=0.007). Conclusions Local heat therapy effectively lowered overnight BP in patients with autonomic failure and supine hypertension and offers a novel approach to treat this condition. Future studies are needed to assess the long‐term safety and efficacy in improving nighttime fluid loss and daytime orthostatic hypotension. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02417415 and NCT03042988.
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Affiliation(s)
- Luis E Okamoto
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Jorge E Celedonio
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Emily C Smith
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Alfredo Gamboa
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Cyndya A Shibao
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - André Diedrich
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN.,Department of Biomedical Engineering Vanderbilt University Medical Center Nashville TN
| | - Sachin Y Paranjape
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Bonnie K Black
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - James A S Muldowney
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Division of Cardiology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Amanda C Peltier
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Neurology Vanderbilt University Medical Center Nashville TN
| | - Ralf Habermann
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Division of Geriatrics Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Craig G Crandall
- Institute for Exercise and Environmental Medicine Texas Health Presbyterian Hospital and UT Southwestern Medical Center Dallas TX
| | - Italo Biaggioni
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN.,Department of Pharmacology Vanderbilt University Medical Center Nashville TN
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14
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Stiefel P, Muñoz-Hernández R, Alfaro-Lara V, González-Estrada A, Espinosa-Torre F, Beltrán-Romero LM. The Peripheral Nervous System and Changes in Blood Pressure: Lights and Darkness. Am J Hypertens 2020; 33:958-961. [PMID: 32521544 DOI: 10.1093/ajh/hpaa095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/06/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Pablo Stiefel
- Unidad de Epidemiología Clínica y Riesgo Vascular, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Spain
- Unidad de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Rocío Muñoz-Hernández
- Unidad de Epidemiología Clínica y Riesgo Vascular, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Spain
| | - Verónica Alfaro-Lara
- Unidad de Epidemiología Clínica y Riesgo Vascular, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Spain
- Unidad de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Aurora González-Estrada
- Unidad de Epidemiología Clínica y Riesgo Vascular, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Spain
- Unidad de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Luis M Beltrán-Romero
- Unidad de Epidemiología Clínica y Riesgo Vascular, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Spain
- Unidad de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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15
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Leung JH, Bayomy OF, Bonyhay I, Celli J, White J, Freeman R, Adler GK. ACTH Infusion Impairs Baroreflex Sensitivity-Implications for Cardiovascular Hypoglycemia-Associated Autonomic Failure. J Clin Endocrinol Metab 2020; 105:5827417. [PMID: 32353115 PMCID: PMC7255850 DOI: 10.1210/clinem/dgaa221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/27/2020] [Indexed: 01/22/2023]
Abstract
CONTEXT Hypoglycemia attenuates cardiovascular homeostatic autonomic control. This attenuation, known as the cardiovascular component of hypoglycemia-associated autonomic failure (HAAF), is characterized most notably by decreased baroreflex sensitivity (BRS) that begins during hypoglycemia and persists until at least the next day, despite return to euglycemia. Understanding the mechanisms underlying this reduction in BRS is important because BRS attenuation is associated with increased morbidity and mortality. OBJECTIVE The objective of this work is to investigate the role of the adrenocorticotropin (ACTH)-adrenal axis in decreasing BRS. We tested the hypothesis that infusion of ACTH 1-24 (cosyntropin), as compared to placebo, would acutely suppress BRS, and that this decrease in BRS would be present the next day. DESIGN A double-blind, placebo-controlled, random-order, cross-over study was conducted. SETTING This study took place in a clinical research center. PARTICIPANTS Participants included healthy men and women. INTERVENTIONS Interventions included an intravenous infusion of cosyntropin (70 μg/hour for 2.5 hours in the morning and again in the early afternoon) vs normal saline placebo. MAIN OUTCOME MEASURES Outcome measures included BRS during and 16 hours after cosyntropin vs placebo infusions. RESULTS Cosyntropin infusion attenuated BRS (mm Hg/ms) as compared to placebo (baseline 17.8 ± 1.38 vs 17.0 ± 2.07; during 14.4 ± 1.43 vs 17.3 ± 1.65; and next day 14.8 ± 1.42 vs 18.9 ± 2.04; P < .05, time by treatment, analysis of variance). BRS was decreased during the final 30 minutes of the morning cosyntropin infusion as compared to baseline (P < .01) and remained suppressed the next day (16 hours after afternoon infusion) (P < .025). Placebo infusion did not significantly change BRS. Corrected QT interval was not affected. CONCLUSIONS ACTH attenuates BRS, raising the possibility that hypoglycemia-induced increases in ACTH may contribute to the cardiovascular component of HAAF.
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Affiliation(s)
- Janet H Leung
- Division of Endocrinology and Diabetes, Virginia Mason Medical Center, Seattle, Washington
| | - Omar F Bayomy
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Istvan Bonyhay
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Johanna Celli
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jeffrey White
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Gail K Adler
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Correspondence and Reprint Requests: Gail K. Adler, MD, PhD, FAHA, Brigham and Women’s Hospital, Division of Endocrinology, Diabetes and Hypertension, 221 Longwood Avenue, Boston, MA 02115. E-mail:
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16
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Porubcin MG, Novak P. Diagnostic Accuracy of Electrochemical Skin Conductance in the Detection of Sudomotor Fiber Loss. Front Neurol 2020; 11:273. [PMID: 32425871 PMCID: PMC7212463 DOI: 10.3389/fneur.2020.00273] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 03/24/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Small fiber neuropathy (SFN) is a common health problem. SFN is associated with loss of small fibers, either sensory, autonomic or both. Reduced autonomic sudomotor sweat gland nerve fiber density (SGNFD) and sensory epidermal nerve fiber density (ENFD) can be seen in SFN. Electrochemical skin conductance (ESC) is a non-invasive test for measurement of sudomotor function. This study evaluated the diagnostic accuracy of ESC to detect abnormal SGNFD and ENFD. Methods: This was a retrospective blinded study of participants referred for evaluation of SFN. The primary outcome measure was the specificity and sensitivity of ESC to diagnose loss of small fibers using SGNFD and ENFD as reference tests. The secondary outcome measures were the correlation between ESC and neuropathy severity, pain, and autonomic clinical scales. Results: Two hundred ten patients were enrolled in the study, age (mean ± sd) 45.5 ± 16.1 years, men/women = 52/158. ESC adjusted for weight (ESC/kg) was reduced in subjects with abnormally low SGNFD (normal/abnormal, ESC/kg = 1.19 ± 0.31/0.94 ± 0.37 μS/kg, p < 0.0001) and abnormally low ENFD (normal/abnormal ESC/kg 1.20 ± 0.37/1.04 ± 0.33 μS/kg, p < 0.0011). ESC/kg correlated with SGNFD (ρ = 0.39, p < 0.0001) and ENFD (ρ = 0.47, p < 0.0001). ESC/kg did not correlate with symptom scales. ESC/kg had 64% sensitivity and 77% specificity (ROC 0.73, p = 0.0001) to predict abnormal SGNFD and 69% sensitivity and 55% specificity (ROC 0.63, p = 0.0017) to predict abnormal ENFD. In comparison, SGNFD had 50.1% sensitivity and 85.1% specificity to predict abnormal ENFD (ROC 0.69, p = 0.0001). Conclusion: ESC/kg has modest accuracy to detect SGNFD loss. ESC may be a useful test in characterization of small fiber neuropathy.
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Affiliation(s)
- Michal G Porubcin
- Brigham and Women's Faulkner Hospital, Harvard Medical School, Boston, MA, United States
| | - Peter Novak
- Brigham and Women's Faulkner Hospital, Harvard Medical School, Boston, MA, United States
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17
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Krämer HH, Lautenschläger G, de Azevedo M, Doppler K, Schänzer A, Best C, Oertel WH, Reuter I, Sommer C, Birklein F. Reduced central sympathetic activity in Parkinson's disease. Brain Behav 2019; 9:e01463. [PMID: 31691543 PMCID: PMC6908869 DOI: 10.1002/brb3.1463] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/15/2019] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE With a combination of different sympathetic tests, we aimed to elucidate whether impairment of sympathetic function in Parkinson's disease (PD) is the consequence of a central or peripheral efferent dysfunction. METHODS Thirty-five patients with early-to-intermediate PD (median age: 63 years; IQR: 57-67 years; disease duration 1-9 years, 15 women) and 20 age- and sex-matched healthy controls (median age: 64.5 years; IQR: 58-68 years; 10 women) were recruited. Autonomic testing was performed in two subgroups and included the assessment of resting cardiovascular parameters, postprandial hypotension (PPH), orthostatic hypotension (OH), and vasoconstriction induced by intradermal microdialysis with different concentrations of norepinephrine (NE; 10-5 ; 10-6 ; 10-7 ; 10-8 ) and by cold through forehead cooling. We also used sympathetic multiunit microneurography (muscle sympathetic nerve activity; MSNA; burst frequency (BF): bursts per minute; burst incidence (BI): bursts per 100 heart beats) and evaluated the presence of phosphorylated α-synuclein deposits in skin innervation in biopsies from the thighs by immunohistohemistry. RESULTS Diastolic blood pressure was higher in the PD group at rest (p < .001) and during OH (F = 6.533; p = .022). Vasoconstriction induced by NE microdialysis and cold was unchanged in PD patients. MSNA was lower in PD patients than in controls (BF: p = .001; BI: p = .025). Phosphorylated α-synuclein deposits could be found only in PD patients. CONCLUSION We did not find indications for peripheral sympathetic nerve fiber dysfunction or adrenoreceptor sensitivity changes. The decreased MSNA argues in favor of central sympathetic impairment.
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Affiliation(s)
- Heidrun H Krämer
- Department of Neurology, Justus-Liebig-University, Giessen, Germany
| | | | | | - Kathrin Doppler
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Anne Schänzer
- Institute of Neuropathology, Justus-Liebig-University, Giessen, Germany
| | - Christoph Best
- Department of Neurology, Philipps-University, Marburg, Germany
| | | | - Iris Reuter
- Department of Neurology, Justus-Liebig-University, Giessen, Germany
| | - Claudia Sommer
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Frank Birklein
- Department of Neurology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
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18
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Okamoto LE, Shibao CA, Gamboa A, Diedrich A, Raj SR, Black BK, Robertson D, Biaggioni I. Synergistic Pressor Effect of Atomoxetine and Pyridostigmine in Patients With Neurogenic Orthostatic Hypotension. Hypertension 2019; 73:235-241. [PMID: 30571543 DOI: 10.1161/hypertensionaha.118.11790] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with autonomic failure are characterized by disabling orthostatic hypotension because of impaired sympathetic activity, but even severely affected patients have residual sympathetic tone which can be harnessed for their treatment. For example, norepinephrine transporter blockade with atomoxetine raises blood pressure (BP) in autonomic failure patients by increasing synaptic norepinephrine concentrations; acetylcholinesterase inhibition with pyridostigmine increases BP by facilitating ganglionic cholinergic neurotransmission to increase sympathetic outflow. We tested the hypothesis that pyridostigmine will potentiate the pressor effect of atomoxetine and improve orthostatic tolerance and symptoms in patients with severe autonomic failure. Twelve patients received a single oral dose of either placebo, pyridostigmine 60 mg, atomoxetine 18 mg or the combination on separate days in a single blind, crossover study. BP was assessed seated and standing before and 1-hour postdrug. In these severely affected patients, neither pyridostigmine nor atomoxetine improved BP or orthostatic tolerance compared with placebo. The combination, however, significantly increased seated BP in a synergistic manner (133±9/80±4 versus 107±6/66±4 mm Hg for placebo, 105±5/67±3 mm Hg for atomoxetine, and 99±6/64±4 mm Hg for pyridostigmine; P<0.001); the maximal increase in seated BP with the combination was 33±8/18±3 mm Hg at 60 minutes postdrug. Only the combination showed a significant improvement of orthostatic tolerance and symptoms. In conclusion, the combination pyridostigmine and atomoxetine had a synergistic effect on seated BP which was associated with improvement in orthostatic tolerance and symptoms. This pharmacological approach could be useful in patients with severe autonomic failure but further safety and long-term efficacy studies are needed.
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Affiliation(s)
- Luis E Okamoto
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
| | - Cyndya A Shibao
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
| | - Alfredo Gamboa
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
| | - André Diedrich
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Biomedical Engineering (A.D.), Vanderbilt University School of Medicine, Nashville, TN
| | - Satish R Raj
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Pharmacology (S.R.R., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (S.R.R.)
| | - Bonnie K Black
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
| | - David Robertson
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Pharmacology (S.R.R., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Neurology (D.R.), Vanderbilt University School of Medicine, Nashville, TN
| | - Italo Biaggioni
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Pharmacology (S.R.R., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
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Ahmed A, Ruzieh M, Kanjwal S, Kanjwal K. Syndrome of Supine Hypertension with Orthostatic Hypotension: Pathophysiology and Clinical Approach. Curr Cardiol Rev 2019; 16:48-54. [PMID: 31215392 PMCID: PMC7393597 DOI: 10.2174/1573403x15666190617095032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/04/2019] [Accepted: 05/07/2019] [Indexed: 12/20/2022] Open
Abstract
This article is intended to provide guidance and clinical considerations for physicians managing patients suffering from supine hypertension with orthostatic hypotension, referred to as “SH-OH”. We review the normal physiologic response to orthostasis, focusing on the appropriate changes to autonomic output in this state. Autonomic failure is discussed with a generalized overview of the disease and examination of specific syndromes that help shed light on the pathophysiology of SH-OH. The goal of this review is to provide a better framework for clinical evaluation of these patients, review treatment options, and ultimately work toward achieving a better quality of life for patients afflicted with this disease.
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Affiliation(s)
- Aamir Ahmed
- Department of Internal Medicine, Rush University, Chicago, IL 60612, United States
| | - Mohammed Ruzieh
- Penn State Heart and Vascular Institute. Hershey, PA 17033, United States
| | | | - Khalil Kanjwal
- McLaren Greater Lansing Hospital, Lansing, MI 48910, United States
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20
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Pavy-Le Traon A, Cotterill N, Amarenco G, Duerr S, Kaufmann H, Lahrmann H, Tison F, Wenning GK, Goetz CG, Poewe W, Sampaio C, Schrag A, Rascol O, Martinez-Martin P, Stebbins GT. Clinical Rating Scales for Urinary Symptoms in Parkinson Disease: Critique and Recommendations. Mov Disord Clin Pract 2018; 5:479-491. [PMID: 30515437 DOI: 10.1002/mdc3.12636] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 03/12/2018] [Accepted: 04/15/2018] [Indexed: 12/18/2022] Open
Abstract
Background The prevalence of lower urinary tract symptoms (LUTS) is high in Parkinson's disease (PD). These problems negatively affect quality of life and include both storage and voiding problems. The International Parkinson and Movement Disorder Society established a task force to review clinical rating scales/questionnaires for the assessment of urinary symptoms in PD. Methods According to prespecified criteria, these scales/questionnaires were classified as "Recommended" or "Recommended with caveats" when clinimetric properties were satisfactory for Recommended status but had not been assessed specifically in PD, "Suggested" or "Listed." These assessments were applied to rate scales as screening tools for the diagnosis of LUTS and for the rating of symptom severity. Results Among scales that included LUTS but focused on overall autonomic or non-motor symptoms in PD, no scale reached the clinimetric rigor to be designated as Recommended or Recommended with caveats, but some were Suggested for either diagnostic screening tools or severity measures. Among primary urological scales, most are well validated in urological setting, but none was validated specifically in PD. DAN-PSS (Danish PSS), ICIQ (International Consultation for Incontinence Questionnaire)-MLUTS (Male Lower Urinary Tract Symptoms), OABq, OABq-SF (ICIQ-OABqol), OAB-V8 (as screening tool), and OABSS (OAB Symptom Score) met criteria for Recommended with caveats. Conclusion The Task Force does not recommend the development of a new scale. However, all above-mentioned questionnaires need to be studied further and specifically validated in PD.
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Affiliation(s)
- Anne Pavy-Le Traon
- French Reference Center for MSA, Department of Neurology University Hospital of Toulouse France
- Institute of Cardiovascular and Metabolic Diseases (I2MC-UMR1048) Toulouse France
| | - Nikki Cotterill
- Bristol Urological Institute, Southmead Hospital Westbury-on-Trym Bristol United Kingdom
| | - Gerard Amarenco
- Neuro-Urology Department Hôpital Tenon, and GRC01 UPMC Paris France
| | - Susanne Duerr
- Department of Neurology University Hospital Innsbruck Austria
| | | | | | - François Tison
- Institute for Neurodegenerative Diseases, University of Bordeaux University Hospital of Bordeaux Bordeaux France
| | | | - Christopher G Goetz
- Department of Neurological Services Rush University School of Medicine Chicago IL USA
| | - Werner Poewe
- Department of Neurology University Hospital Innsbruck Austria
| | - Cristina Sampaio
- Laboratory of Clinical Pharmacology and Therapeutics Lisbon School of Medicine Lisbon Portugal
| | - Anette Schrag
- Department of Clinical Neurosciences, Royal Free Hospital University College London London United Kingdom
| | - Olivier Rascol
- French Reference Center for MSA, Department of Neurology University Hospital of Toulouse France
- Laboratoire de Pharmacologie Médicale et Clinique Toulouse France
| | - Pablo Martinez-Martin
- National Center of Epidemiology and CIBERNED Carlos III Institute of Health Madrid Spain
| | - Glenn T Stebbins
- Department of Neurological Services Rush University School of Medicine Chicago IL USA
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21
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Cutsforth-Gregory JK, McKeon A, Coon EA, Sletten DM, Suarez M, Sandroni P, Singer W, Benarroch EE, Fealey RD, Low PA. Ganglionic Antibody Level as a Predictor of Severity of Autonomic Failure. Mayo Clin Proc 2018; 93:1440-1447. [PMID: 30170741 PMCID: PMC6173625 DOI: 10.1016/j.mayocp.2018.05.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 04/30/2018] [Accepted: 05/07/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess antibody level as a test of autonomic failure (AF) associated with ganglionic nicotinic acetylcholine receptor antibody (AChR-Ab) autoimmunity. PATIENTS AND METHODS We searched the Mayo Clinic laboratory database of 926 ganglionic AChR-Ab-seropositive patients seen at our institution between October 1, 1997, and April 1, 2015, for initial level of 0.05 nmol/L or higher and contemporaneous autonomic reflex screen (standardized evaluation of adrenergic, cardiovagal, and sudomotor functions) from which Composite Autonomic Scoring Scale (CASS) scores could be calculated. RESULTS Of 289 patients who met inclusion criteria, 163 (56.4%) were women, median age was 54 years (range, 10-87 years), median antibody level was 0.11 nmol/L (range, 0.05-22.10 nmol/L), and median CASS total score was 2.0 (range, 0-10). Using receiver operating characteristic curve analysis, a level above 0.40 nmol/L predicted severe AF (CASS score, ≥7) with 92% specificity and 56% sensitivity. For at least moderate AF (CASS score ≥4 and anhidrosis ≥25%), a level of at least 0.20 nmol/L had 80% specificity and 59% sensitivity. Levels below 0.20 nmol/L were not predictive of the presence or absence of AF. For predicting orthostatic hypotension, ganglionic AChR-Ab level had excellent specificity above 0.4 nmol/L but lacked sensitivity. Autoantibodies to additional targets were present in 61 patients (21.1%). CONCLUSION Ganglionic AChR-Ab level of at least 0.40 nmol/L is a moderately sensitive and highly specific marker for severe AF, as is a level of at least 0.20 nmol/L for moderate AF if CASS score is coupled with anhidrosis of 25% or more, among patients with suspected ganglionic AChR-Ab autoimmune autonomic ganglionopathy. Antibody levels of less than 0.20 nmol/L have little clinical importance in the absence of clinical AF.
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Affiliation(s)
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | | | - Phillip A Low
- Department of Neurology, Mayo Clinic, Rochester, MN.
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22
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Norcliffe-Kaufmann L, Kaufmann H, Palma JA, Shibao CA, Biaggioni I, Peltier AC, Singer W, Low PA, Goldstein DS, Gibbons CH, Freeman R, Robertson D. Orthostatic heart rate changes in patients with autonomic failure caused by neurodegenerative synucleinopathies. Ann Neurol 2018; 83:522-531. [PMID: 29405350 PMCID: PMC5867255 DOI: 10.1002/ana.25170] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 02/01/2018] [Accepted: 02/01/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Blunted tachycardia during hypotension is a characteristic feature of patients with autonomic failure, but the range has not been defined. This study reports the range of orthostatic heart rate (HR) changes in patients with autonomic failure caused by neurodegenerative synucleinopathies. METHODS Patients evaluated at sites of the U.S. Autonomic Consortium (NCT01799915) underwent standardized autonomic function tests and full neurological evaluation. RESULTS We identified 402 patients with orthostatic hypotension (OH) who had normal sinus rhythm. Of these, 378 had impaired sympathetic activation (ie, neurogenic OH) and based on their neurological examination were diagnosed with Parkinson disease, dementia with Lewy bodies, pure autonomic failure, or multiple system atrophy. The remaining 24 patients had preserved sympathetic activation and their OH was classified as nonneurogenic, due to volume depletion, anemia, or polypharmacy. Patients with neurogenic OH had twice the fall in systolic blood pressure (SBP; -44 ± 25 vs -21 ± 14 mmHg [mean ± standard deviation], p < 0.0001) but only one-third of the increase in HR of those with nonneurogenic OH (8 ± 8 vs 25 ± 11 beats per minute [bpm], p < 0.0001). A ΔHR/ΔSBP ratio of 0.492 bpm/mmHg had excellent sensitivity (91.3%) and specificity (88.4%) to distinguish between patients with neurogenic from nonneurogenic OH (area under the curve = 0.96, p < 0.0001). Within patients with neurogenic OH, HR increased more in those with multiple system atrophy (p = 0.0003), but there was considerable overlap with patients with Lewy body disorders. INTERPRETATION A blunted HR increase during hypotension suggests a neurogenic cause. A ΔHR/ΔSBP ratio < 0.5 bpm/mmHg is diagnostic of neurogenic OH. Ann Neurol 2018;83:522-531.
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Affiliation(s)
- Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY
| | - Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY
| | - Cyndya A. Shibao
- Departments of Medicine and Pharmacology, Vanderbilt University Medical Center, Nashville, TN
| | - Italo Biaggioni
- Departments of Medicine and Pharmacology, Vanderbilt University Medical Center, Nashville, TN
| | - Amanda C. Peltier
- Departments of Medicine and Pharmacology, Vanderbilt University Medical Center, Nashville, TN
| | | | | | - David S. Goldstein
- Clinical Neurocardiology Section, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD
| | - Christopher H. Gibbons
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - David Robertson
- Departments of Medicine and Pharmacology, Vanderbilt University Medical Center, Nashville, TN
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23
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Palma JA, Kaufmann H. Treatment of autonomic dysfunction in Parkinson disease and other synucleinopathies. Mov Disord 2018; 33:372-390. [PMID: 29508455 PMCID: PMC5844369 DOI: 10.1002/mds.27344] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/11/2018] [Accepted: 01/24/2018] [Indexed: 12/12/2022] Open
Abstract
Dysfunction of the autonomic nervous system afflicts most patients with Parkinson disease and other synucleinopathies such as dementia with Lewy bodies, multiple system atrophy, and pure autonomic failure, reducing quality of life and increasing mortality. For example, gastrointestinal dysfunction can lead to impaired drug pharmacodynamics causing a worsening in motor symptoms, and neurogenic orthostatic hypotension can cause syncope, falls, and fractures. When recognized, autonomic problems can be treated, sometimes successfully. Discontinuation of potentially causative/aggravating drugs, patient education, and nonpharmacological approaches are useful and should be tried first. Pathophysiology-based pharmacological treatments that have shown efficacy in controlled trials of patients with synucleinopathies have been approved in many countries and are key to an effective management. Here, we review the treatment of autonomic dysfunction in patients with Parkinson disease and other synucleinopathies, summarize the nonpharmacological and current pharmacological therapeutic strategies including recently approved drugs, and provide practical advice and management algorithms for clinicians, with focus on neurogenic orthostatic hypotension, supine hypertension, dysphagia, sialorrhea, gastroparesis, constipation, neurogenic overactive bladder, underactive bladder, and sexual dysfunction. © 2018 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, New York, USA
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, New York, USA
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24
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Palma JA. Autonomic dysfunction in Parkinson's disease and other synucleinopathies: Introduction to the series. Mov Disord 2018; 33:347-348. [PMID: 29436737 PMCID: PMC5840012 DOI: 10.1002/mds.27347] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 01/26/2018] [Indexed: 12/24/2022] Open
Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York
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Abstract
PURPOSE OF REVIEW Orthostatic hypotension is a phenomenon commonly encountered in a cardiologist's clinical practice that has significant diagnostic and prognostic value for a cardiologist. Given the mounting evidence associating cardiovascular morbidity and mortality with orthostatic hypotension, cardiologists will play an increasing role in treating and managing patients with orthostatic hypotension. RECENT FINDINGS The American College of Cardiology, American Heart Association, and Heart Rhythm Society recently published consensus guidelines on the diagnosis, treatment, and management of syncope and their instigators, including orthostatic hypotension. Additionally, consensus guidelines have also been recently updated, reinforcing the universal definition orthostatic hypotension and its closely associated pathologies. Finally, the United States Food and Drug Administration (FDA) recently approved droxidopa, a synthetic oral norepinephrine prodrug, in 2014 for the treatment of neurogenic orthostatic hypotension (nOH), and it represents a well tolerated, effective, and easy to use intervention for nOH. This represents only the second drug approved by the FDA for orthostatic hypotension, the first being midodrine in 1986. A handful of smaller head-to-head studies have pitted not only pharmacologic agents to one another but also nonpharmacologic interventions to pharmacologic agents. Additionally, recent studies have also reported on more convenient screening tools for orthostatic hypotension. SUMMARY Though there have been many advances in the management of orthostatic hypotension, nOH remains a chronic, debilitating, and often progressively fatal condition. Cardiologists can play a very important role in optimizing hemodynamics in this patient population to improve quality of life and minimize cardiovascular risk.
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Affiliation(s)
- Philip L Mar
- Krannert Institute of Cardiology, Indiana University, Indianapolis, IN, USA
| | - Satish R Raj
- Libin Cardiovascular Institute, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Autonomic Dysfunction Center, Vanderbilt University, Nashville, TN, USA
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Abstract
Botulinum toxin A (BTXA) can disrupt the neuromuscular and autonomic functions. We herein report a case of autonomic system dysfunction that manifested as Takotsubo-like myocardial dysfunction in a patient with botulism. Takotsubo syndrome results in acute cardiac insufficiency, another fatal complication of botulism in addition to respiratory muscle paralysis, particularly in patients with cardiovascular disease.
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Affiliation(s)
| | | | - Masatoshi Sato
- Department of Infectious Disease, Nara City Hospital, Japan
| | - Yuki Naito
- Department of Neurology, Nara City Hospital, Japan
| | | | - Yasunobu Goto
- Department of Intensive Care Unit, Nara City Hospital, Japan
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27
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Baschieri F, Calandra-Buonaura G, Cecere A, Barletta G, Contin M, Parchi P, Cortelli P. Iodine-123-meta-iodobenzylguanidine Myocardial Scintigraphy in Isolated Autonomic Failure: Potential Red Flag for Future Multiple System Atrophy. Front Neurol 2017; 8:225. [PMID: 28603516 PMCID: PMC5445132 DOI: 10.3389/fneur.2017.00225] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 05/09/2017] [Indexed: 11/13/2022] Open
Abstract
Pure autonomic failure is challenging as it can be the presenting feature of a central nervous system syncleinopathy such as Parkinson’s disease (PD) or multiple system atrophy (MSA). Because the prognosis of MSA and PD is so different, predictive features for a possible conversion can be extremely valuable. In this paper, we report three cases (two with autopsy-proven diagnosis) that had isolated AF for many years before converting to MSA or PD. Of all the tests that were performed during the premotor stage, Iodine-123-meta-iodobenzylguanidine (MIBG) myocardial scintigraphy was predictive of the conversion to MSA. We suggest that MIBG myocardial scintigraphy, when performed in patients with isolated AF, may be a valuable predictor of conversion to MSA. On the contrary, the role of such test in parkinsonian patients irrespective of the presence of AF is still to be clarified.
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Affiliation(s)
- Francesca Baschieri
- Clinica Neurologica, Dipartimento di Medicina, Università degli Studi di Perugia, Ospedale S. Maria della Misericordia, Perugia, Italy
| | - Giovanna Calandra-Buonaura
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS, Institute of Neurological Sciences, Bellaria Hospital, Bologna, Italy
| | - Annagrazia Cecere
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS, Institute of Neurological Sciences, Bellaria Hospital, Bologna, Italy
| | - Giorgio Barletta
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS, Institute of Neurological Sciences, Bellaria Hospital, Bologna, Italy
| | - Manuela Contin
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS, Institute of Neurological Sciences, Bellaria Hospital, Bologna, Italy
| | - Piero Parchi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS, Institute of Neurological Sciences, Bellaria Hospital, Bologna, Italy
| | - Pietro Cortelli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS, Institute of Neurological Sciences, Bellaria Hospital, Bologna, Italy
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Umehara T, Nakahara A, Matsuno H, Toyoda C, Oka H. Body weight and dysautonomia in early Parkinson's disease. Acta Neurol Scand 2017; 135:560-567. [PMID: 27357472 DOI: 10.1111/ane.12633] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Patients with Parkinson's disease (PD) begin to lose weight several years before diagnosis, which suggests weight variation is associated with some factor(s) that precede the onset of motor symptoms. This study aimed to investigate the association of autonomic nervous system with body weight in patients with PD. MATERIALS AND METHODS The subjects were 90 patients with early de novo PD. We examined the associations of body mass index (BMI) with sympathetic nervous activity reflected in orthostatic intolerance or cardiac uptake of 123 I-metaiodobenzylguanidine and parasympathetic nervous activity reflected in constipation or heart rate variability (HRV). RESULTS Twelve patients (13.3%) were overweight (BMI>25 kg/m2 ), 62 patients (68.9%) were normal-weight (18.5≦BMI<25 kg/m2 ), and 16 patients (17.8%) were underweight (BMI<18.5 kg/m2 ). Underweight patients had greater disease severity and decrease in blood pressure on head-up tilt-table testing, higher cardiac washout ratio of 123 I-metaiodobenzylguanidine, and lower HRV and complained of constipation more often than those with normal-weight or overweight patients. On multiple regression analyses, the correlation of these variables with BMI maintained statistical significance after adjustment for age, sex, symptom duration, and motor subtype. CONCLUSIONS Dysautonomia and disease severity are closely related to body weight independently of age, sex, symptom duration, and motor subtype. Dysautonomia may play a partial role on weight variation in the early stage of PD.
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Affiliation(s)
- T. Umehara
- Department of Neurology; Daisan Hospital; The Jikei University School of Medicine; Tokyo Japan
| | - A. Nakahara
- Department of Neurology; Daisan Hospital; The Jikei University School of Medicine; Tokyo Japan
| | - H. Matsuno
- Department of Neurology; The Jikei University School of Medicine; Tokyo Japan
| | - C. Toyoda
- Department of Neurology; The Jikei University School of Medicine; Tokyo Japan
| | - H. Oka
- Department of Neurology; Daisan Hospital; The Jikei University School of Medicine; Tokyo Japan
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Matsuzono K, Honda H, Sato K, Morihara R, Deguchi K, Hishikawa N, Yamashita T, Kono S, Ohta Y, Iwaki T, Abe K. 'PrP systemic deposition disease': clinical and pathological characteristics of novel familial prion disease with 2-bp deletion in codon 178. Eur J Neurol 2016; 23:196-200. [PMID: 26768678 DOI: 10.1111/ene.12905] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 10/01/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE A novel TYPE of prion disease associated mainly with autonomic-sensory polyneuropathy was reported by us previously. METHODS Here the autopsy pathology for patient 1 (the sister) and the clinical characteristics of her younger brother (patient 2) are newly reported. Polymerase chain reaction based restriction fragment length polymorphism analysis of the prion protein gene (PRNP) was performed on both patients and their father (normal control). RESULTS Polymerase chain reaction based restriction fragment length polymorphism analysis revealed a 2-bp deletion (CT) in codon 178 that causes an additional variable 25 amino acids at the C terminal, from the mutation site to the premature stop codon at codon 203, in both patients 1 and 2 but not in their father. The autopsy of patient 1 showed remarkable prion protein (PrP) deposits in the sympathetic ganglion and peripheral nerves, correlated to her severe autonomic sensory failure. PrP deposits were also found in the central nervous system and peripheral organs such as the heart, lung, stomach, jejunum, ileum, colon, urinary bladder and adrenal gland. The symptoms and biopsy findings of patient 2 were nearly the same as those reported previously for patient 1. His cognitive function was well preserved, but autonomic functions were severely impaired. His biopsied samples showed PrP deposits in the sural nerve and nerve plexuses of the stomach and colon. CONCLUSION The present unique 2-bp deletion (CT) in codon 178 induced a 'PrP systemic deposition disease' such as pan-autonomic failure, sensory neuropathy and mild cognitive impairment with a specific pathology.
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Affiliation(s)
- K Matsuzono
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - H Honda
- Department of Neuropathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - K Sato
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - R Morihara
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - K Deguchi
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - N Hishikawa
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - T Yamashita
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - S Kono
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Y Ohta
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - T Iwaki
- Department of Neuropathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - K Abe
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
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Hayashi K, Mochizuki Y, Koide R, Kawata A, Homma T, Shimizu T, Komori T, Isozaki E. A Japanese familial ALS patient with autonomic failure and a p.Cys146Arg mutation in the gene for SOD1 (SOD1). Neuropathology 2016; 36:551-555. [PMID: 27090969 DOI: 10.1111/neup.12303] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 03/04/2016] [Accepted: 03/05/2016] [Indexed: 12/13/2022]
Abstract
We describe a Japanese man with familial amyotrophic lateral sclerosis (ALS) associated with a p.Cys146Arg mutation in the copper/zinc superoxide dismutase gene (SOD1). The patient developed bulbar signs followed by rapidly progressive limb muscle weakness. The prominent clinical feature was orthostatic hypotension due to autonomic failure, which occurred after he underwent tracheostomy 1 year and 3 months after the onset. Thereafter, he required mechanical ventilation and progressed to communication stage V (totally locked-in state) 7 years after the onset. Neuropathology showed ALS with posterior column degeneration and multiple system degeneration. Severe neuronal loss in the intermediolateral nucleus was also observed. Two previously reported cases of ALS patients with autonomic failure showed severe neuronal loss in the intermediolateral nucleus in addition to degeneration of the motor neurons. Thus, autonomic failure due to neuronal loss in the intermediolateral nucleus could present in patients with ALS associated with certain mutations in SOD1.
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Affiliation(s)
- Kentaro Hayashi
- Department of Neurology, Tokyo Metropolitan Neurological Hospital
| | - Yoko Mochizuki
- Department of Pathology, Tokyo Metropolitan Neurological Hospital.,Department of Neurology, Tokyo Metropolitan Kita Medical and Rehabilitation center for the disabled
| | - Reiji Koide
- Department of Neurology, Tokyo Metropolitan Neurological Hospital.,Division of Neurology, Department of Medicine, Jichi Medical University School of Medicine
| | - Akihiro Kawata
- Department of Neurology, Tokyo Metropolitan Neurological Hospital
| | - Taku Homma
- Department of Pathology, Tokyo Metropolitan Neurological Hospital.,Department of Pathology, Nihon University School of Medicine
| | - Toshio Shimizu
- Department of Neurology, Tokyo Metropolitan Neurological Hospital
| | - Takashi Komori
- Department of Pathology, Tokyo Metropolitan Neurological Hospital
| | - Eiji Isozaki
- Department of Neurology, Tokyo Metropolitan Neurological Hospital
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Abstract
Orthostatic hypotension (OH) leads to a significant number of hospitalizations each year, and is associated with significant morbidity and mortality among affected individuals. Given the increased risk for cardiovascular events and falls, it is important to identify the underlying etiology of OH and to choose appropriate therapeutic agents. OH can be non-neurogenic or neurogenic (arising from a central or peripheral lesion). The initial evaluation includes orthostatic vital signs, complete history and a physical examination. Patients should also be evaluated for concomitant symptoms of post-prandial hypotension and supine hypertension. Non-pharmacologic interventions are the first step for treatment of OH. The appropriate selection of medications can also help with symptomatic relief. This review highlights the pathophysiology, clinical features, diagnostic work-up and treatment of patients with neurogenic OH.
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Affiliation(s)
- Pearl K Jones
- a 1 Department of Neurology, University of Texas Health Sciences Center, San Antonio, TX, USA
| | - Brett H Shaw
- b 2 Department of Cardiac Science, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Satish R Raj
- b 2 Department of Cardiac Science, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada.,c 3 Department of Medicine, Division of Clinical Pharmacology, Autonomic Dysfunction Center, Vanderbilt University, Nashville, Tennessee, USA
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Abstract
Neurogenic orthostatic hypotension (nOH) is a fall in blood pressure (BP) on standing due to reduced norepinephrine release from sympathetic nerve terminals. nOH is a feature of several neurological disorders that affect the autonomic nervous system, most notably Parkinson disease (PD), multiple system atrophy (MSA), pure autonomic failure (PAF), and other autonomic neuropathies. Droxidopa, an orally active synthetic amino acid that is converted to norepinephrine by the enzyme aromatic L-amino acid decarboxylase (dopa-decarboxylase), was recently approved by the FDA for the short-term treatment of nOH. It is presumed to raise BP by acting at the neurovascular junction to increase vascular tone. This article summarizes the pharmacological properties of droxidopa, its mechanism of action, and the efficacy and safety results of clinical trials.
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Affiliation(s)
- Horacio Kaufmann
- Department of Neurology, New York University School of Medicine, New York, NY, USA
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Palma JA, Gomez-Esteban JC, Norcliffe-Kaufmann L, Martinez J, Tijero B, Berganzo K, Kaufmann H. Orthostatic hypotension in Parkinson disease: how much you fall or how low you go? Mov Disord 2015; 30:639-45. [PMID: 25678194 DOI: 10.1002/mds.26079] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 09/14/2014] [Accepted: 10/01/2014] [Indexed: 11/09/2022] Open
Abstract
Orthostatic hypotension (OH) is frequent in patients with Parkinson's disease (PD) and can occur with or without symptoms. Pharmacological treatments are effective, but often exacerbate supine hypertension. Guidelines exist for the diagnosis, but not for the treatment of OH. We examined the relationship between blood pressure (BP) and symptoms in a cohort of PD patients with the goal of identifying a hemodynamic target to guide treatment. We measured BP supine and upright (tilt or active standing) and identified the presence or absence of symptomatic OH by using a validated patient-reported outcome questionnaire in 210 patients with PD. We evaluated the usefulness of the 20/10 and 30/15 mmHg diagnostic criteria (systolic/diastolic) to identify symptomatic OH. Fifty percent of the PD patient cohort met criteria for the 20/10 fall and 30% for the 30/15 BP fall. Among the patients who met either OH criteria, the percentage of those with symptoms was small (33% of those with 20/10 and 44% of those with 30/15 mmHg; 16% and 13%, respectively, overall). Symptomatic OH was associated with an upright mean BP below 75 mmHg. A mean standing BP <75 mmHg had a sensitivity of 97% and a specificity of 98% for detecting symptomatic OH. Although the prevalence of OH in PD is high, not all patients have symptoms of organ hypoperfusion. A mean standing BP below 75 mmHg appears to be a useful benchmark when deciding whether the benefits of initiating pharmacological treatment of OH outweigh the risks of exacerbating supine hypertension.
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Affiliation(s)
- Jose-Alberto Palma
- Dysautonomia Center, Department of Neurology, New York University Medical Center, New York, New York, USA
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Jelani QUA, Norcliffe-Kaufmann L, Kaufmann H, Katz SD. Vascular endothelial function and blood pressure regulation in afferent autonomic failure. Am J Hypertens 2015; 28:166-72. [PMID: 25128693 DOI: 10.1093/ajh/hpu144] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Familial dysautonomia (FD) is a rare hereditary disease characterized by loss of afferent autonomic neural fiber signaling and consequent profound impairment of arterial baroreflex function and blood pressure regulation. Whether vascular endothelial dysfunction contributes to defective vasomotor control in this form of afferent autonomic failure is not known. METHODS We assessed blood pressure response to orthostatic stress and vascular endothelial function with brachial artery reactivity testing in 34 FD subjects with afferent autonomic failure and 34 healthy control subjects. RESULTS Forty-four percent of the afferent autonomic failure subjects had uncontrolled hypertension at supine rest (median systolic blood pressure = 148mm Hg, interquartile range (IQR) = 144-155mm Hg; median diastolic blood pressure = 83mm Hg, IQR = 78-105mm Hg), and 88% had abnormal response to orthostatic stress (median decrease in systolic blood pressure after upright tilt = 48mm Hg, IQR = 29-61mm Hg). Flow-mediated brachial artery reactivity did not differ in subjects with afferent autonomic failure vs. healthy control subjects (median = 6.00%, IQR = 1.86-11.77%; vs. median = 6.27%, IQR = 4.65-9.34%; P = 0.75). In afferent autonomic failure subjects, brachial artery reactivity was not associated with resting blood pressure or the magnitude of orthostatic hypotension but was decreased in association with reduced glomerular filtration rate (r = 0.62; P < 0.001). CONCLUSIONS Brachial artery reactivity was preserved in subjects with afferent autonomic failure despite the presence of marked blood pressure dysregulation. Comorbid renal dysfunction was associated with reduced brachial artery reactivity.
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Affiliation(s)
- Qurat-Ul-Ain Jelani
- Leon H. Charney Division of Cardiology, New York University School of Medicine, New York University Langone Medical Center, New York, New York
| | - Lucy Norcliffe-Kaufmann
- Dysautonomia Center, New York University School of Medicine, New York University Langone Medical Center, New York, New York
| | - Horacio Kaufmann
- Dysautonomia Center, New York University School of Medicine, New York University Langone Medical Center, New York, New York
| | - Stuart D Katz
- Leon H. Charney Division of Cardiology, New York University School of Medicine, New York University Langone Medical Center, New York, New York;
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35
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Ramirez CE, Okamoto LE, Arnold AC, Gamboa A, Diedrich A, Choi L, Raj SR, Robertson D, Biaggioni I, Shibao CA. Efficacy of atomoxetine versus midodrine for the treatment of orthostatic hypotension in autonomic failure. Hypertension 2014; 64:1235-40. [PMID: 25185131 PMCID: PMC4231172 DOI: 10.1161/hypertensionaha.114.04225] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The clinical presentation of autonomic failure is orthostatic hypotension. Severely affected patients require pharmacological treatment to prevent presyncopal symptoms or frank syncope. We previously reported in a proof of concept study that pediatric doses of the norepinephrine transporter blockade, atomoxetine, increases blood pressure in autonomic failure patients with residual sympathetic activity compared with placebo. Given that the sympathetic nervous system is maximally activated in the upright position, we hypothesized that atomoxetine would be superior to midodrine, a direct vasoconstrictor, in improving upright blood pressure and orthostatic hypotension-related symptoms. To test this hypothesis, we compared the effect of acute atomoxetine versus midodrine on upright systolic blood pressure and orthostatic symptom scores in 65 patients with severe autonomic failure. There were no differences in seated systolic blood pressure (means difference=0.3 mm Hg; 95% confidence [CI], -7.3 to 7.9; P=0.94). In contrast, atomoxetine produced a greater pressor response in upright systolic blood pressure (means difference=7.5 mm Hg; 95% CI, 0.6 to 15; P=0.03) compared with midodrine. Furthermore, atomoxetine (means difference=0.4; 95% CI, 0.1 to 0.8; P=0.02), but not midodrine (means difference=0.5; 95% CI, -0.1 to 1.0; P=0.08), improved orthostatic hypotension-related symptoms as compared with placebo. The results of our study suggest that atomoxetine could be a superior therapeutic option than midodrine for the treatment of orthostatic hypotension in autonomic failure.
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Affiliation(s)
- Claudia E Ramirez
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Luis E Okamoto
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Amy C Arnold
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Alfredo Gamboa
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - André Diedrich
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Leena Choi
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Satish R Raj
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - David Robertson
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Italo Biaggioni
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Cyndya A Shibao
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.).
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Tateno F, Sakakibara R, Ogata T, Kishi M, Tsuyusaki Y, Takahashi O, Sugiyama M, Tateno A. Lower urinary tract function in dementia with Lewy bodies (DLB). Mov Disord 2014; 30:411-5. [PMID: 25356960 DOI: 10.1002/mds.25985] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 06/18/2014] [Accepted: 07/02/2014] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES Dementia with Lewy bodies (DLB) is the second most common degenerative cause of dementia, whereas lower urinary tract (LUT) function in DLB patients has not been fully delineated. We investigated LUT function in DLB by clinical-urodynamic observations. METHODS We examined 32 patients with DLB (23 men, 9 women; aged 59-86 [mean, 75.9] years; disease duration, 0.2-17 [3.3] years). All patients underwent an electromyography-cystometry, and 21 patients underwent the sphincter motor unit potential analysis. RESULTS Ninety-one percent of patients had LUT symptoms: nighttime frequency (>8 times), 84%, and urinary incontinence (>1 per week), 50%. Detrusor overactivity was revealed in 87.1%, whereas postvoid residual was minimal. Neurogenic changes were shown in 50%. CONCLUSION LUT dysfunction is a common feature in DLB, attributable not only to dementia and immobility, but also to central and peripheral types of somato-autonomic dysfunction.
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Affiliation(s)
- Fuyuki Tateno
- Neurology, Internal Medicine, Sakura Medical Center, Toho University, Sakura, Japan
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Klein G, Burghaus L, Vaillant M, Pieri V, Fink GR, Diederich N. Dysautonomia in narcolepsy: evidence by questionnaire assessment. J Clin Neurol 2014; 10:314-9. [PMID: 25324880 PMCID: PMC4198712 DOI: 10.3988/jcn.2014.10.4.314] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 07/14/2014] [Accepted: 07/16/2014] [Indexed: 12/24/2022] Open
Abstract
Background and Purpose Excessive daytime sleepiness and sudden sleep attacks are the main features of narcolepsy, but rapid-eye-movement sleep behavior disorder (RBD), hyposmia, and depression can also occur. The latter symptoms are nonmotor features in idiopathic Parkinson's disease (IPD). In the present study, IPD-proven diagnostic tools were tested to determine whether they are also applicable in the assessment of narcolepsy. Methods This was a case-control study comparing 15 patients with narcolepsy (PN) and 15 control subjects (CS) using the Scales for Outcomes in Parkinson's Autonomic Test (SCOPA-AUT), Parkinson's Disease Nonmotor Symptoms (PDNMS), University of Pennsylvania Smell Test, Farnsworth-Munsell 100 Hue test, Beck Depression Inventory, and the RBD screening questionnaire. Results Both the PN and CS exhibited mild hyposmia and no deficits in visual tests. Frequent dysautonomia in all domains except sexuality was found for the PN. The total SCOPA-AUT score was higher for the PN (18.47±10.08, mean±SD) than for the CS (4.40±3.09), as was the PDNMS score (10.53±4.78 and 1.80±2.31, respectively). RBD was present in 87% of the PN and 0% of the CS. The PN were more depressed than the CS. The differences between the PN and CS for all of these variables were statistically significant (all p<0.05). Conclusions The results of this study provide evidence for the presence of dysautonomia and confirm the comorbidities of depression and RBD in narcolepsy patients. The spectrum, which is comparable to the nonmotor complex in IPD, suggests wide-ranging, clinically detectable dysfunction beyond the narcoleptic core syndrome.
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Affiliation(s)
- Gilles Klein
- Department of Neurosciences, Centre Hospitalier de Luxembourg, Luxembourg-City, Luxembourg. ; Department of Internal Medicine, Brothers of Charity Hospital, Trier, Germany
| | - Lothar Burghaus
- Department of Neurology, University Hospital of Cologne, Cologne, Germany
| | - Michel Vaillant
- Competences Center for Methodology and Statistics, CRP Santé, Strassen, Luxembourg
| | - Vannina Pieri
- Department of Neurosciences, Centre Hospitalier de Luxembourg, Luxembourg-City, Luxembourg
| | - Gereon R Fink
- Department of Neurology, University Hospital of Cologne, Cologne, Germany. ; Institute of Neuroscience and Medicine (INM-3), Cognitive Neuroscience, Research Centre Juelich, Juelich, Germany
| | - Nico Diederich
- Department of Neurosciences, Centre Hospitalier de Luxembourg, Luxembourg-City, Luxembourg. ; Department of Neurology, University Hospital of Cologne, Cologne, Germany
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Arnold AC, Ramirez CE, Choi L, Okamoto LE, Gamboa A, Diedrich A, Raj SR, Robertson D, Biaggioni I, Shibao CA. Combination ergotamine and caffeine improves seated blood pressure and presyncopal symptoms in autonomic failure. Front Physiol 2014; 5:270. [PMID: 25104940 PMCID: PMC4109567 DOI: 10.3389/fphys.2014.00270] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 06/30/2014] [Indexed: 11/29/2022] Open
Abstract
Severely affected patients with autonomic failure require pressor agents to counteract the blood pressure fall and improve presyncopal symptoms upon standing. Previous studies suggest that combination ergotamine and caffeine may be effective in the treatment of autonomic failure, but the efficacy of this drug has not been evaluated in controlled trials. Therefore, we compared the effects of ergotamine/caffeine on seated blood pressure and orthostatic tolerance and symptoms in 12 primary autonomic failure patients without history of coronary artery disease. Patients were randomized to receive a single oral dose of placebo, midodrine (5–10 mg), or ergotamine and caffeine (1 and 100 mg, respectively) in a single-blind, crossover study. Blood pressure was measured while patients were seated and after standing for up to 10 min, at baseline and at 1 h post-drug. Ergotamine/caffeine increased seated systolic blood pressure (SBP), the primary outcome, compared with placebo (131 ± 19 and 95 ± 12 mmHg, respectively, at 1 h post-drug; p = 0.003 for time effect). Midodrine also significantly increased seated SBP (121 ± 19 mmHg at 1 h post-drug; p = 0.015 for time effect vs. placebo), but this effect was not different from ergotamine/caffeine (p = 0.621). There was no significant effect of either medication on orthostatic tolerance; however, ergotamine/caffeine improved presyncopal symptoms (p = 0.034). These findings suggest that combination ergotamine and caffeine elicits a seated pressor response that is similar in magnitude to midodrine, and improves symptoms in autonomic failure. Thus, ergotamine/caffeine could be used as an alternate treatment for autonomic failure, in carefully selected patients without comorbid coronary artery disease.
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Affiliation(s)
- Amy C Arnold
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University School of Medicine Nashville, TN, USA
| | - Claudia E Ramirez
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University School of Medicine Nashville, TN, USA
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University School of Medicine Nashville, TN, USA
| | - Luis E Okamoto
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University School of Medicine Nashville, TN, USA
| | - Alfredo Gamboa
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University School of Medicine Nashville, TN, USA
| | - André Diedrich
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University School of Medicine Nashville, TN, USA
| | - Satish R Raj
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University School of Medicine Nashville, TN, USA
| | - David Robertson
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University School of Medicine Nashville, TN, USA
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University School of Medicine Nashville, TN, USA
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University School of Medicine Nashville, TN, USA
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Figueroa JJ, Singer W, Parsaik A, Benarroch EE, Ahlskog JE, Fealey RD, Parisi JE, Sandroni P, Mandrekar J, Iodice V, Low PA, Bower JH. Multiple system atrophy: prognostic indicators of survival. Mov Disord 2014; 29:1151-7. [PMID: 24909319 DOI: 10.1002/mds.25927] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 04/24/2014] [Accepted: 05/04/2014] [Indexed: 12/19/2022] Open
Abstract
Neurological and autonomic presentation in multiple system atrophy (MSA) may predict early mortality. Quantification of early autonomic failure as a mortality predictor is lacking. Early neurological and autonomic clinical features were retrospectively reviewed in 49 MSA cases (median age at onset, 56.1 years; 16 women) confirmed by autopsy at Mayo Clinic. When available, the 10-point composite autonomic severity score derived from the autonomic reflex screen provided quantification of the degree of autonomic failure and thermoregulatory sweat test quantitated body surface anhidrosis. Symptoms at onset were autonomic in 50%, parkinsonian in 30%, and cerebellar in 20% of cases. Survival (median [95% confidence interval]) was 8.6 [6.7-10.2] years. Survival was shorter in patients with early laboratory evidence of generalized (composite autonomic severity score ≥ 6) autonomic failure (7.0 [3.9-9.8] vs. 9.8 [4.6-13.8] years; P = 0.036), and early requirement of bladder catheterization (7.3 [3.1-10.2] vs. 13.7 [8.5-14.9] years; P = 0.003) compared with those without these clinical features. On Cox proportional analysis, prognostic indicators of shorter survival were older age at onset (hazard ratio [95% confidence interval], 1.04 [1.01-1.08]; P = 0.03), early requirement of bladder catheterization (7.9 [1.88-38.63]; P = 0.004), and early generalized (composite autonomic severity score ≥ 6) autonomic failure (2.8 [1.01-9.26]; P = 0.047). Gender, phenotype, and early development of gait instability, aid-requiring ambulation, orthostatic symptoms, neurogenic bladder, or significant anhidrosis (thermoregulatory sweat test ≥ 40%) were not indicators of shorter survival. Our data suggest that early development of severe generalized autonomic failure more than triples the risk of shorter survival in patients with MSA.
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Affiliation(s)
- Juan J Figueroa
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI
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Webb AJS, Rothwell PM. Physiological correlates of beat-to-beat, ambulatory, and day-to-day home blood pressure variability after transient ischemic attack or minor stroke. Stroke 2014; 45:533-8. [PMID: 24407950 DOI: 10.1161/strokeaha.113.003321] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Visit-to-visit and day-to-day variability in systolic blood pressure (SBP) are associated with an increased risk of stroke, more strongly than variability on 24-hour ambulatory BP monitoring, but underlying physiological mechanisms are unclear. We related potentially relevant physiological characteristics to beat-to-beat, ambulatory, and day-to-day BP variability to identify underlying mechanisms and potential therapeutic targets. METHODS BP variability (coefficient of variation [CV]) on 1-month home BP monitoring (3 sitting readings, 3× daily), on 24-hour ambulatory BP monitoring, and on 5-minute beat-to-beat monitoring was related to BP reactivity (to mental arithmetic), arterial aging (aortic stiffness: carotid-femoral pulse wave velocity; aortic pulsatility), heart rate variability (CV of normal-to-normal R-R interval), and orthostatic responses. RESULTS In 223 patients within 6 weeks of a transient ischemic attack or minor stroke, beat-to-beat and home SBP-CVs were associated with response to arithmetic (beat-to-beat odds ratio per SD=1.64; P<0.0001 and home BP monitoring, 1.41; P=0.025), aortic stiffness (1.84; P<0.0001 and 1.31; P=0.04), aortic pulsatility (1.98; P<0.0001 and 1.61; P<0.0001), and heart rate variability-CV of normal-to-normal R-R interval (1.34; P=0.03 and 1.35; P=0.03), independently of age, sex, and aortic BP. Orthostatic BP changes were associated only with SBP-CV on home BP monitoring (0.62; P=0.002). In contrast, no physiological measures were associated with within-day BP variability on awake ambulatory BP monitoring except response to mental arithmetic (1.40; P=0.01). CONCLUSIONS Beat-to-beat and day-to-day SBP variability, but not variability on ambulatory BP monitoring, had similar physiological correlates, suggesting common underlying mechanisms and identifying potentially treatable targets that may be responsible for the relationship between SBP variability and stroke risk.
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Affiliation(s)
- Alastair John Stewart Webb
- From the Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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41
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Abstract
We report two cases of anti-glutamic acid receptor (anti-GluR) antibody-positive encephalitis in males with symptoms such as Parkinsonism, urinary retention, and paralytic ileus. Although non-herpetic encephalitis typically shows magnetic resonance imaging (MRI) lesions in the limbic system during early stages, the present cases showed MRI lesions during later stages in the bilateral claustrum and pons. In both cases, anti-GluRɛ2 and δ2 antibodies were later shown to be positive in the cerebrospinal fluid but negative in the serum. Although early detection of anti-GluR antibodies is essential, early treatment may be significantly more important.
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Affiliation(s)
- Kosuke Matsuzono
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Abstract
The sympathetic nervous system regulates thermogenesis and energy homeostasis in humans. When activated it increases energy expenditure, particularly resting energy expenditure. Most human studies used acute infusion of β-blockers as a model to eliminate sympathetic stimulation and to examine the contribution of the sympathetic nervous system to energy metabolism and balance. Clinically, however, it is also important to assess the effect of chronic sympathetic attenuation on energy metabolism. In this context, we hypothesized that resting energy expenditure is decreased in patients with autonomic failure who, by definition, have low sympathetic tone. We measured 24-hour energy expenditure using whole-room indirect calorimeter in 10 adults with chronic autonomic failure (6 women; age, 64.9±9.1 years; body mass index, 25.2±4.4 kg/m(2)) and 15 sedentary healthy controls of similar age and body composition (8 women; age, 63.1±4.0 years; body mass index, 24.4±3.9 kg/m(2)). In 4 patients, we eliminated residual sympathetic activity with the ganglionic blocker trimethaphan. We found that, after adjusting for body composition, resting energy expenditure did not differ between patients with autonomic failure and healthy controls. However, resting energy expenditure significantly decreased when residual sympathetic activity was eliminated. Our findings suggest that sympathetic tonic support of resting energy expenditure is preserved, at least in part, in pathophysiological models of chronic sympathetic attenuation.
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Affiliation(s)
- Cyndya Shibao
- Division of Clinical Pharmacology and Autonomic Dysfunction Center, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
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Okamoto LE, Shibao C, Gamboa A, Choi L, Diedrich A, Raj SR, Black BK, Robertson D, Biaggioni I. Synergistic effect of norepinephrine transporter blockade and α-2 antagonism on blood pressure in autonomic failure. Hypertension 2012; 59:650-6. [PMID: 22311903 PMCID: PMC3312003 DOI: 10.1161/hypertensionaha.111.184812] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with autonomic failure have disabling orthostatic hypotension because of impaired sympathetic activity. Norepinephrine transporter blockade with atomoxetine raises blood pressure in autonomic failure by increasing synaptic norepinephrine concentrations in postganglionic sympathetic neurons. This effect requires tonic release of norepinephrine, which is decreased in patients with low sympathetic tone. We hypothesized that increasing residual sympathetic outflow with the α-2 antagonist yohimbine would potentiate the pressor effect of norepinephrine transporter blockade with atomoxetine and improve orthostatic tolerance in peripheral autonomic failure. Seventeen patients received a single oral dose of either placebo, yohimbine 5.4 mg or atomoxetine 18.0 mg, and the combination yohimbine and atomoxetine in a single blind, crossover study. Blood pressure was assessed while patients were seated and standing for ≤10 minutes before and 1 hour postdrug. Neither yohimbine nor atomoxetine significantly increased seated systolic blood pressure or orthostatic tolerance compared with placebo. The combination, however, significantly increased seated systolic blood pressure and orthostatic tolerance (P<0.001 and P=0.016, respectively) in a synergistic manner. The maximal increase in seated systolic blood pressure seen with the combination was 31±33 mm Hg at 60 minutes postdrug. Only the combination showed a significant improvement in orthostatic symptoms. In conclusion, the combination of yohimbine and atomoxetine had a synergistic effect on blood pressure and orthostatic tolerance in peripheral autonomic failure, which may be explained by an increased release of norepinephrine in peripheral sympathetic neurons by α-2 antagonism combined with a reduced norepinephrine clearance by norepinephrine transporter blockade. Safety studies are required to address the clinical usefulness of this pharmacological approach.
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Affiliation(s)
- Luis E. Okamoto
- Vanderbilt Autonomic Dysfunction Center, Vanderbilt University School of Medicine
- Division of Clinical Pharmacology, Vanderbilt University School of Medicine
- Department of Medicine, Vanderbilt University School of Medicine
| | - Cyndya Shibao
- Vanderbilt Autonomic Dysfunction Center, Vanderbilt University School of Medicine
- Division of Clinical Pharmacology, Vanderbilt University School of Medicine
- Department of Medicine, Vanderbilt University School of Medicine
| | - Alfredo Gamboa
- Vanderbilt Autonomic Dysfunction Center, Vanderbilt University School of Medicine
- Division of Clinical Pharmacology, Vanderbilt University School of Medicine
- Department of Medicine, Vanderbilt University School of Medicine
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University School of Medicine
| | - André Diedrich
- Vanderbilt Autonomic Dysfunction Center, Vanderbilt University School of Medicine
- Division of Clinical Pharmacology, Vanderbilt University School of Medicine
- Department of Medicine, Vanderbilt University School of Medicine
- Department of Biomedical Engineering, Vanderbilt University School of Medicine
| | - Satish R. Raj
- Vanderbilt Autonomic Dysfunction Center, Vanderbilt University School of Medicine
- Division of Clinical Pharmacology, Vanderbilt University School of Medicine
- Department of Medicine, Vanderbilt University School of Medicine
- Department of Pharmacology, Vanderbilt University School of Medicine
| | - Bonnie K. Black
- Vanderbilt Autonomic Dysfunction Center, Vanderbilt University School of Medicine
- Division of Clinical Pharmacology, Vanderbilt University School of Medicine
- Department of Medicine, Vanderbilt University School of Medicine
| | - David Robertson
- Vanderbilt Autonomic Dysfunction Center, Vanderbilt University School of Medicine
- Division of Clinical Pharmacology, Vanderbilt University School of Medicine
- Department of Medicine, Vanderbilt University School of Medicine
- Department of Pharmacology, Vanderbilt University School of Medicine
- Department of Neurolog, Vanderbilt University School of Medicine
| | - Italo Biaggioni
- Vanderbilt Autonomic Dysfunction Center, Vanderbilt University School of Medicine
- Division of Clinical Pharmacology, Vanderbilt University School of Medicine
- Department of Medicine, Vanderbilt University School of Medicine
- Department of Pharmacology, Vanderbilt University School of Medicine
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Kiyono K, Hayano J, Kwak S, Watanabe E, Yamamoto Y. Non-gaussianity of low frequency heart rate variability and sympathetic activation: lack of increases in multiple system atrophy and Parkinson disease. Front Physiol 2012; 3:34. [PMID: 22371705 PMCID: PMC3284201 DOI: 10.3389/fphys.2012.00034] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Accepted: 02/07/2012] [Indexed: 12/02/2022] Open
Abstract
The correlates of indices of long-term ambulatory heart rate variability (HRV) of the autonomic nervous system have not been completely understood. In this study, we evaluated conventional HRV indices, obtained from the daytime (12:00–18:00) Holter recording, and a recently proposed non-Gaussianity index (λ; Kiyono et al., 2008) in 12 patients with multiple system atrophy (MSA) and 10 patients with Parkinson disease (PD), known to have varying degrees of cardiac vagal and sympathetic dysfunction. Compared with the age-matched healthy control group, the MSA patients showed significantly decreased HRV, most probably reflecting impaired vagal heart rate control, but the PD patients did not show such reduced variability. In both MSA and PD patients, the low-to-high frequency (LF/HF) ratio and the short-term fractal exponent α1, suggested to reflect the sympathovagal balance, were significantly decreased, as observed in congestive heart failure (CHF) patients with sympathetic overdrive. In contrast, the analysis of the non-Gaussianity index λ showed that a marked increase in intermittent and non-Gaussian HRV observed in the CHF patients was not observed in the MSA and PD patients with sympathetic dysfunction. These findings provide additional evidence for the relation between the non-Gaussian intermittency of HRV and increased sympathetic activity.
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Affiliation(s)
- Ken Kiyono
- College of Engineering, Nihon University Koriyama, Japan
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Yamanaka Y, Sakakibara R, Asahina M, Uchiyama T, Liu Z, Yamamoto T, Ito T, Suenaga T, Odaka T, Yamaguchi T, Uehara K, Hattori T. Chronic intestinal pseudo-obstruction as the initial feature of pure autonomic failure. J Neurol Neurosurg Psychiatry 2006; 77:800. [PMID: 16705209 PMCID: PMC2077441 DOI: 10.1136/jnnp.2005.079905] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Abstract
A 47 year old woman with pure autonomic failure complained of dizziness during emotional stress. Emotional stimuli have not previously been reported to cause hypotension in patients with autonomic failure. In the patient, ambulatory blood pressure recording revealed severe hypotension (50/30 mm Hg) after a stressful event. During a tilt table test, hyperventilation was shown to cause a significant fall of blood pressure. This suggests that emotional stress can induce hypotension, probably through hyperventilation, in subjects with autonomic failure.
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Affiliation(s)
- R D Thijs
- Department of Neurology and Clinical Neurophysiology, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, The Netherlands.
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Abstract
A fundamental human expectation is to stand upright. This exposes the cardiovascular system to gravitational forces, with a fall in pressure above heart level exposing organs such as the brain to impaired perfusion if adequate adaptive mechanisms are not activated. The autonomic nervous system plays an important role in the initial response to standing upright, and can be affected by several disorders, some rare, some common. Autonomic failure can result in orthostatic hypotension with hypoperfusion of vital organs, causing a variety of symptoms including syncope. Thus, it is important to recognise orthostatic hypotension, determine its aetiology, evaluate and treat it. Intermittent autonomic dysfunction (such as neurally mediated syncope without chronic neurogenic failure) also results in falls and syncope; various forms include the 'common faint' (vasovagal syncope) and carotid sinus hypersensitivity (especially in the elderly). Orthostatic intolerance without orthostatic hypotension is increasingly recognised as due to an autonomic disturbance. New techniques are helping to unravel the functional anatomy of cerebral autonomic centres and their pathways in the causation of orthostatic intolerance.
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Affiliation(s)
- Christopher J Mathias
- Neurovascular Medicine Unit, Faculty of Medicine, Imperial College of Science, Technology & Medicine at St Mary's Hospital, London.
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