Cardiac involvement in Wilson disease: Review of the literature and description of three cases of sudden death

Wilson disease (WD) is a rare genetic condition that results from a build-up of copper in the body. It requires life-long treatment and is mainly characterized by hepatic and neurological features. Copper accumulation has been reported to be related to the occurrence of heart disease, although little is known regarding this association. We have conducted a systematic review of the literature to document the association between WD and cardiac involvement. Thirty-two articles were retained. We also described three cases of sudden death. Cardiac manifestations in WD include cardiomyopathy (mainly left ventricular (LV) remodeling, hypertrophy, and LV diastolic dysfunction, and less frequently LV systolic dysfunction), increased levels of troponin, and/or brain natriuretic peptide, electrocardiogram (ECG) abnormalities, and rhythm or conduction abnormalities, which can be life-threatening. Dysautonomia has also been reported. The mechanism of cardiac damage in WD has not been elucidated. It may be the result of copper accumulation in the heart, and/or it could be due to a toxic effect of copper, resulting in the release of free oxygen radicals. Patients with signs and/or symptoms of cardiac involvement or who have cardiovascular risk factors should be examined by a cardiologist in addition to being assessed by their interdisciplinary treating team. Furthermore, ECG, cardiac biomarkers, echocardiography, and 24-hours or more of Holter monitoring at the diagnosis and/or during the follow-up of patients with WD need to be evaluated. Cardiac magnetic resonance imaging, although not always available, could also be a useful diagnostic tool, allowing assessment of the risk of ventricular arrhythmias and further guidance of the cardiac workup.

I drank too much and now I can't walk: a case of alcohol-induced dysautonomia

Dysautonomia is a dysfunction of the autonomic nervous system, which mediates both sympathetic and parasympathetic functions of the human body. Alcohol has been established to affect the autonomic function through liver injury and accumulation of vasodilators. Alcohol can induce peripheral neurological diseases as well. This case report describes a patient who had a chronic history of alcoholism and uncontrolled diabetes mellitus presenting for orthostatic hypotension and peripheral neuropathy without underlying liver disease or other endocrinopathies. Although diabetes mellitus was controlled pharmacologically and risk factors for orthostatic hypotension were managed conservatively, his symptoms did not improve which indicated an alcohol-related autonomic dysfunction, shedding light on one of long-term complications of alcoholism.

Takotsubo Cardiomyopathy as a Manifestation of Dysautonomia in Guillain-Barré Syndrome: A Case Series and Review of the Literature

Guillain-Barré syndrome (GBS) is an inflammatory polyneuropathy that classically presents with low back pain, sensory paresthesias, and rapidly progressive weakness. Patients with GBS can develop dysautonomia, and Takotsubo cardiomyopathy (TCM) is a rare potential manifestation of this dysautonomia. This association has been reported only 12 times in the literature so far, which we review here. We present two cases of GBS associated with TCM, to increase awareness with regard to this comorbid relationship, which would encourage prompt initiation of proper supportive care to avoid morbidity and mortality.

We report the case of two patients - a 58-year-old man and a 79-year-old woman - who developed TCM in the setting of axonal variants of GBS. Electrodiagnostic results, cerebrospinal fluid profiles, and echocardiogram findings were consistent with these diagnoses. Both patients were treated with intravenous immunoglobulin (IVIG) in an intensive care unit (ICU) setting. Echocardiogram findings were reversible.

TCM should be recognized as a potential complication of GBS in patients with dysautonomia. This case series adds to the sparse body of literature describing the association between these two conditions. It is not clear if patients with axonal variants of GBS are more predisposed to developing TCM; further, larger case series in the future may help identify the risk factors associated with it. We hope to shed more light on this possible association to expedite the diagnosis and management of this condition.

Head Trauma not Associated with Long Term Effects on Autonomic Function

Contact-sports can elicit concussions, which impacts autonomic function, as well as elicit repetitive head trauma, where autonomic function has not yet been assessed. The purpose of this study was to determine if differences in autonomic function exist among three groups (CTRL: healthy non-contact-sport participant, RHT: repetitive head trauma contact-sport participant, CONC: previous concussion). Forty participants (16 men and 24 women), aged 18-37 (22 ± 3), participated in the study. Participants were grouped based on their sport and concussion history (CTRL, RHT, and CONC). Body composition was measured via air displacement plethysmography. Prior to testing, participants were outfitted with equipment to evaluate heart rate, blood pressure, and cerebral-artery blood flow velocity (CBFv). The participant performed against three stimuli: deep breathing, Valsalva maneuver, and a 70° head-up tilt test. Following autonomic function testing, a YMCA submaximal cycle test was performed. All group comparisons were analyzed using a one-way ANOVA and all data are presented as means ± standard deviation. The results of this study indicated that the groups did not differ in respiratory sinus arrhythmia (CTRL: 22 ± 6 bpm, RHT: 21 ± 8 bpm, CONC: 19 ± 7 bpm, p = 0.471), Valsalva ratio (CTRL: 2.19 ± 0.39, RHT: 2.09 ± 0.37, CONC: 2.00 ± 0.47, p = 0.519), CBFv (CTRL: 47.74 ± 25.28 cm/s, RHT: 40.99 ± 10.93 cm/s, CONC: 43.97 ± 17.55 cm/s, p = 0.657), or tilt time (CTRL: 806.09 ± 368.37 sec, RHT: 943.07 ± 339.54 sec, CONC: 978.40 ± 387.98 sec, p = 0.479). However, CONC (113.24 ± 11.64 mmHg) had a significantly higher mean systolic blood pressure during the tilt test than CTRL (102.66 ± 7.79 mmHg, p = 0.026), while RHT (107.9 ± 9.0 mmHg) was not significantly different than CTRL (p = 0.39) or CONC (p = 0.319). The results of this study are the first step in determining if long-lasting deficits to the autonomic nervous system occur following a diagnosis of concussion. However, concussions do not seem to have lasting effects on autonomic function. Overwhelmingly, dysautonomia is not present during chronic recovery from concussions or in individuals with RHT from contact-sports. In the future, sex should be considered as a variable.

COVID-19-Associated Dysautonomia

Orthostatic hypotension (OH) refers to a significant reduction in blood pressure (BP) that occurs on standing. It mainly results when autonomic reflexes are impaired or when the intravascular volume is depleted. Symptoms can range from syncope, dizziness, even angina or stroke. Major mechanisms causing OH are autonomic dysfunction affecting the baroreflex, severe volume depletion, and adverse medication effects. Case reports have described neurologic symptom association with coronavirus disease 2019 (COVID-19) including dysautonomia. Although most common symptoms of COVID have been primarily respiratory including fever, cough, shortness of breath, myriad other presentations including neurological, gastrointestinal, cardiac, and thromboembolic presentations have also been described. We describe a patient who was found to have OH and recurrent falls secondary to underlying COVID-19 infection and associated dysautonomia who was successfully treated with midodrine and fludrocortisone.

Dysautonomia in hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders is associated with exercise intolerance and cardiac atrophy

Dysautonomia is a recognized manifestation in patients with joint hypermobility (JH) disorders. Symptoms can be highly debilitating and commonly include physical deconditioning and poor aerobic fitness. In this study, the prevalence of dysautonomia, range of associated symptoms, patient-reported physical activity levels, and echocardiographic features were assessed retrospectively in a cohort of 144 patients (94% female) with hypermobile Ehlers-Danlos syndrome (hEDS) or hypermobility spectrum disorder (HSD). Echocardiographic parameters of left ventricular size and function were compared between patients with and without dysautonomia as well as to reported values from healthy controls. Dysautonomia was identified in 65% of female and 44% of male subjects and was associated with a high burden of symptomatology, most commonly exercise intolerance (78%). Exercise capacity was limited by dysautonomia, often postural symptoms, in half of all patients. We observed a reduction in physical activity following the onset or significant flare of hEDS/HSD, most strikingly noting the proportion of dysautonomic patients with sedentary lifestyle, which increased from 44% to 85%. JH-related dysautonomia was associated with smaller cardiac chamber sizes, consistent with the previous reports in positional orthostatic tachycardia syndrome. Dysautonomia is prevalent in patients with hEDS/HSD, and exercise intolerance is a key feature and leads to drastic decline in physical activity. Unfavorable cardiac geometry may underlie dysautonomia symptoms and may be due to cardiac atrophy in the setting of aerobic deconditioning.

A case of parasympathetic hyperactivity and associated Parry-Romberg syndrome

This case report describes a 46-year-old female with a history of multiple endocrine neoplasia type 1 syndrome status post-parathyroidectomy, thymectomy via robotic video-assisted thoracoscopic surgery, and pituitary adenoma resection presenting with parasympathetic hyperactivity and Parry-Romberg syndrome. Parry-Romberg syndrome is a rare disorder that manifests as facial hemiatrophy. Reported symptoms include cognitive dysfunction, olfactory hallucinations, and parasympathetic hyperactivity: miosis of the right eye, anhidrosis, diarrhea, urinary incontinence, bowel incontinence, and orthostatic hypotension. Previous reports have noted associations between Parry-Romberg syndrome and sympathetic hyperactivity and dysregulation. This case report focuses on an association between Parry-Romberg syndrome and unopposed parasympathetic activity.

Dysautonomia Causing Severe Orthostatic Hypotension: An Important, Early Finding in Neurodegenerative Disorders

Orthostatic hypotension is common and dangerous; it has neurogenic and nonneurogenic causes. We present the case of a 40-year-old man with severe neurogenic hypotension, caused by young-onset multiple system atrophy. In patients presenting with neurogenic orthostatic hypotension, underlying neurodegenerative diseases should always be considered. (Level of Difficulty: Advanced.)

Clinical and Dopamine Depletion Patterns in Hyposmia- and Dysautonomia-Dominant Parkinson's Disease

BACKGROUND

Olfactory or autonomic dysfunction is one of the earliest prodromal symptoms of Parkinson's disease (PD). It has not been investigated whether PD patients have different phenotypes depending on the presence of these prodromal symptoms.

OBJECTIVE

To investigate whether hyposmia-dominant and dysautonomia-dominant patients with early PD have different clinical manifestations and nigrostriatal degeneration.

METHODS

This cross-sectional study recruited 168 drug-naive PD patients and 34 control subjects. PD patients were classified as patients without hyposmia and dysautonomia (PD-H-D-, n = 51), hyposmia-dominant patients (PD-H+D-, n = 36), dysautonomia-dominant patients (PD-H-D+, n = 33), and patients with hyposmia and dysautonomia (PD-H+D+, n = 48). We then compared the baseline clinical characteristics, striatal specific to non-specific binding ratio (SNBR), neuropsychological performance, and neuropsychiatric symptoms among the groups.

RESULTS

The PD-H+D-group had a lower SNBR in the ventral striatum (p = 0.013), a greater asymmetric index of striatal SNBRs, and higher prevalence of apathy (p = 0.021) than the PD-H-D+ group. The PD-H-D+ group had older age at onset (p = 0.043) and a higher prevalence of REM sleep behavior disorder (p = 0.041) than the PD-H+D-group. The PD-H+D+ group had higher motor deficits, lower cognitive function, and lower SNBRs in all striatal subregions than the PD-H-D-group. Decreased SNBRs in the anterior caudate, posterior caudate, and ventral striatum were associated with the presence of apathy.

CONCLUSION

The present study suggests that hyposmia-dominant and dysautonomia-dominant PD have different clinical characteristics and patterns of striatal dopamine depletion.

Clinical and histopathological studies on neurodegeneration and dysautonomia in buffalo calves during foot-and-mouth disease outbreaks in Egypt

Background and Aim

Signs of dysautonomia were frequently observed in calves that died during foot-and-mouth disease (FMD) virus (FMDV) outbreaks in Egypt from 2015 to 2018. This study aimed to describe the clinical and histopathological features of the central nervous system in malignant cases of FMD and excluding possible concurrent bacterial, and bovine herpes virus 4 (BHV4) infections or both.

Materials and Methods

In this study, 335 FMDV-infected buffalo calves aged 1-22 months were clinically examined and followed until recovery or death. Of the 335 calves, 134 died (malignant group) and 201 recovered after exhibiting classic symptoms of FMD (recover group). The calves were subjected to clinical examination. For the malignant group, several laboratory trials were conducted to assess the possible cause/s of dysautonomia-related viral, bacterial, or concurrent infections. Koch's postulates and polymerase chain reaction were employed. Postmortem and histopathological examinations of nervous tissue were performed.

Results

In the malignant group, signs of dysautonomia were observed before death, including partial or complete gut dysfunction, loss of anal sphincter tone, rapid breathing sounds, fluctuating body temperature, and cardiac arrhythmias. In the malignant group, histopathological examination of the spinal cord, pons, medulla oblongata, hypothalamus, cerebellum, and cerebrum revealed demyelination, neuronal degeneration, and focal areas of malacia and gliosis. The nervous tissue and heart samples from malignant cases were positive for serotype O FMDV.

Conclusion

Findings revealed in this study support the existence of neurodegeneration induced by FMDV infection in buffalo calves.

A Case of Postural Orthostatic Tachycardia Syndrome Secondary to the Messenger RNA COVID-19 Vaccine

Postural orthostatic tachycardia syndrome (POTS) is an impaction of the autonomic nervous system initiating orthostatic tachycardia. There are numerous triggers for POTS including viruses, vaccines, and an autoimmune basis. This case report is clinically relevant to better understand the pathophysiology behind the messenger RNA (mRNA) coronavirus disease 2019 (COVID-19) vaccine and the mechanism that triggers autonomic nervous system dysfunction. Furthermore, the overall goal of this case study is to report a unique side effect associated with the novel mRNA COVID-19 vaccine. A 42-year-old male, with no prior symptoms of sinus tachycardia and presyncope episodes, is diagnosed with POTS secondary to the first dose of the mRNA COVID-19 vaccine. Symptoms to this date include sinus tachycardia, dizziness, headaches, and fatigue that are often triggered after a large meal or standing for a longer duration. Numerous diagnostic tests and images failed to confirm any other diagnosis other than POTS. There was a sequential connection between the onset of symptoms approximately one week after taking the first dose of the mRNA COVID-19 vaccine. Currently, POTS in this patient is controlled by lifestyle modification. This case report has broader implications as it can help us understand how the mRNA vaccine works on the body relative to the immune system. Our theory is that the development of antibodies activates an autoimmune reaction that triggers POTS disease. The prevalence of the POTS dysautonomia post-vaccination will be clearer as more data and research are conducted on the side effects from the innovative mRNA vaccines created to combat severe acute respiratory syndrome coronavirus 2.

Adolescent and Young Adult ME/CFS After Confirmed or Probable COVID-19

Introduction: Fatigue is a common acute symptom following SARS-CoV-2 infection (COVID-19). The presence of persistent fatigue and impaired daily physical and cognitive function has led to speculation that like SARS-CoV-1 infection, COVID-19 will be followed by myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Methods and Results: We describe three adolescent and young adult patients who had confirmed or probable COVID-19 infections early on during the pandemic and were referred for evaluation to the Chronic Fatigue Clinic at the Johns Hopkins Children's Center. All patients reported orthostatic intolerance symptoms within the first 2 weeks of illness, and 10-min passive standing tests were consistent with postural tachycardia syndrome. After 6 months of illness, all three patients met criteria for ME/CFS. Clinical features of interest included strong histories of allergies in all three patients, two of whom had elevations in plasma histamine. Each demonstrated limitations in symptom-free range of motion of the limbs and spine and two presented with pathological Hoffman reflexes. These comorbid features have been reported in adolescents and young adults with ME/CFS. Conclusion: ME/CFS can be triggered by COVID-19 in adolescents and young adults. Further work is needed to determine the pathogenesis of ME/CFS after COVID-19 and optimal methods of treating these patients. Our preliminary study calls attention to several comorbid features that deserve further attention as potential targets for intervention. These include neuromuscular limitations that could be treated with manual forms of therapy, orthostatic intolerance and POTS for which there are multiple medications and non-pharmacologic therapies, treatable allergic and mast cell phenomena, and neurologic abnormalities that may require specific treatment. Larger studies will need to ascertain the prevalence of these abnormalities.

Dysautonomia and Clinical Outcome in Vegetative State

A dramatic disorder tentatively attributed to diencephalic-hypothalamic damage or dysfunction, dysautonomia, affects recovery from brain injury. Its incidence, correlation with etiology, and relevance as a predictor of outcome were retrospectively surveyed in 333 patients in vegetative state (VS) for more than 2 weeks at admission. Outcome was assessed according to the Glasgow Outcome Scale. Data were treated statistically by multi-variate analyses. Dysautonomia occurred in 26.1% of patients, with greater incidence among post-traumatic (31.9%) than non-traumatic (15.8%) patients. Outcome was worse among non-traumatic than post-traumatic patients irrespective of dysautonomia, and worst among non-traumatic patients with dysautonomia. Dysautonomia proved common among patients in VS (with incidence depending on etiology and age) and influenced the patients' outcome through mechanisms still to be defined, but conceivably mediated by diencephalic-hypothalamic unbalance.

COVID-19 Dysautonomia

Objective: To report a case series of dysautonomia associated with COVID-19 infection.

Methods: This is a retrospective review of patients evaluated in the autonomic clinic at our institution with suspected signs and symptoms of dysautonomia who underwent formal evaluation, including autonomic testing.

Results: Six patients were identified with signs and symptoms suggestive of dysautonomia who underwent autonomic testing. All patients had symptoms typical of COVID-19 infection, though none were hospitalized for these or other symptoms. All patients reported symptoms of postural lightheadedness and near-syncope, fatigue, and activity intolerance. Five patients reported the onset of autonomic symptoms concomitant with other COVID-19 symptoms, with the other patient reporting symptom onset 6 weeks following initial COVID-19 symptoms. Autonomic testing demonstrated an excessive postural tachycardia in 4 patients, a hypertensive response with head-up tilt in 3 patients, orthostatic hypotension in 1 patient, and sudomotor impairment in 1 of the patients with excessive postural tachycardia.

Conclusions: We present clinical features and results of autonomic testing in 6 patients with a history COVID-19 infection. While all patients reported typical features of orthostatic intolerance, fatigue, and activity intolerance, the results of autonomic testing were heterogenous, with orthostatic hypotension in 1 patient, excessive postural tachycardia typical of postural tachycardia syndrome in 4 patients, and postural hypertension in 3 patients.

Subtle differences in autonomic symptoms in people diagnosed with hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders

The hypermobile Ehlers-Danlos syndrome (hEDS) GENE study is a multicenter, cohort study with the goal to identify genes associated with hypermobile EDS. Of the 148 people enrolled in the hEDS GENE study, 98 meet the 2017 hEDS criteria, 27 have a hypermobility spectrum disorder (HSD) and 23 are asymptomatic family members. More than 80% of participants are female with an average age of 41 years. Each participant has completed seven questionnaires to quantify disease-related symptomatology. People with hypermobility experience a variety of physical and somatic symptoms, especially in the areas of fatigue, kinesiophobia, gastrointestinal, and autonomic function. These cause a significant decrease in health-related quality of life. The frequency and severity of most symptoms were indistinguishable between participants with hEDS and HSD; however, there were significant differences in autonomic symptoms. Less than 20% of participants had autoantibodies known to be associated with dysautonomia. Subtle symptomatic differences in people meeting the 2017 diagnostic criteria suggest focusing further etiologic studies on autonomic pathways.

Prevalence of QTc Prolongation in Patients with Parkinson's Disease. Assessment of the Effects of Drugs, Clinical Risk Factors and Used Correction Formula

BACKGROUND

Parkinson's disease (PD) is a possible risk factor for corrected QT interval (QTc) prolongation. PD patients frequently take QTc-prolonging drugs. The aim of the study was to assess the prevalence of QTc prolongation in PD and the influence of drugs and other potential risk factors on the QTc length in PD.

METHODS

101 patients with PD and a good quality ECG were included in the study. The prolonged QTc was defined as ≥450 ms for men and ≥460 ms for women. Bazett's (QTcB) and Framingham (QTcF) formulas were utilized to calculate QTc. Data about sex, age, PD duration, disease's severity, comorbidities and QTc-prolonging drugs were collected. Multiple linear regressions with backward elimination were used to assess factors influencing the QTc.

RESULTS

A long QTc was presented in 13 patients (12.9%) for QTcB and 4 patients (4%) for QTcF. Longer QTc in PD patients was associated with older age, male sex and QTc-prolonging drugs regardless of the used formula. The QTcB was also significantly affected by the heart rate (HR).

CONCLUSION

QTc prolongation is common in PD. Age, drugs and male gender are potential risk factors for QTc prolongation in PD.

Arterial Blood Pressure Variability and Other Vascular Factors Contribution to the Cognitive Decline in Parkinson's Disease

Dementia is one of the most disabling non-motor symptoms in Parkinson’s disease (PD). Unlike in Alzheimer’s disease, the vascular pathology in PD is less documented. Due to the uncertain role of commonly investigated metabolic or vascular factors, e.g., hypertension or diabetes, other factors corresponding to PD dementia have been proposed. Associated dysautonomia and dopaminergic treatment seem to have an impact on diurnal blood pressure (BP) variability, which may presumably contribute to white matter hyperintensities (WMH) development and cognitive decline. We aim to review possible vascular and metabolic factors: Renin-angiotensin-aldosterone system, vascular endothelial growth factor (VEGF), hyperhomocysteinemia (HHcy), as well as the dopaminergic treatment, in the etiopathogenesis of PD dementia. Additionally, we focus on the role of polymorphisms within the genes for catechol-O-methyltransferase (COMT), apolipoprotein E (APOE), vascular endothelial growth factor (VEGF), and for renin-angiotensin-aldosterone system components, and their contribution to cognitive decline in PD. Determining vascular risk factors and their contribution to the cognitive impairment in PD may result in screening, as well as preventive measures.

Supraventricular Tachycardia and Postural Orthostatic Tachycardia Syndrome Overlap: A Retrospective Study

Postural orthostatic tachycardia syndrome (POTS) and supraventricular tachycardia (SVT) are disease states with distinctive features but overlapping clinical manifestations. Currently, studies on the presence of underlying SVT in patients with POTS are lacking. This retrospective study analyzed 64 patients [mean age: 43 years; 41 (61%) women] who had a POTS diagnosis and were found to have concomitant SVT during rhythm monitoring from September 1, 2013 to September 30, 2019 at our Syncope and Autonomic Disorders Clinic. The outcomes assessed were changes in disease severity, frequency of symptoms, heart rate, and blood pressure between before and after SVT ablation. The most frequent types of SVT noted on the electrophysiologic study were atrioventricular nodal reentrant tachycardia (57.81%), atrial flutter (29.68%), atrioventricular reentrant tachycardia (9.37%), atrial tachycardia (1.56%), and junctional tachycardia (1.56%). After SVT ablation, all 64 patients experienced an improvement in symptoms. Palpitations and lightheadedness experienced the most improvement after the procedure (72% vs. 31%; p < 0.001 and 63% vs. 22%; p < 0.001, respectively). There was a significant improvement in the resting heart rate (81.1 ± 12.8 vs. 75.8 ± 15.6 bpm; p < 0.002), but the orthostatic tachycardia on standing persisted (93.6 ± 16.5 vs. 77.3 ± 19.8 bpm; p = 0.14). Underlying SVT in patients with POTS can be missed easily. A strong suspicion and long-term ambulatory cardiac rhythm monitoring can help in diagnosing the condition.

Non-motor complications in late stage Parkinson's disease: recognition, management and unmet needs

Introduction: The burden of non-motor symptoms (NMS) is a major determinant of health-related quality of life in Parkinson's disease (PD), particularly at its late stage.Areas covered: The late stage is usually defined as the period from unstable advanced to the palliative stage, characterized by a combination of emerging treatment-resistant axial motor symptoms (freezing of gait, postural instability, falls and dysphagia), as well as both non-dopaminergic and dopaminergic NMS: cognitive decline, neuropsychiatric symptoms, aspects of dysautonomia, pain and sleep disturbances (insomnia and excessive day-time sleepiness). Here, the authors summarize the current knowledge on NMS dominating the late stage of PD and propose a pragmatic and clinically focused approach for their recognition and treatment.Expert opinion: The NMS progression pattern is complex and remains under-researched. While dopamine-dependent NMS may improve with dopamine replacement therapy, non-dopamine dependent NMS worsen progressively and culminate at the late stages of PD. Furthermore, some PD specific features could interact negatively with other comorbidities, multiple medication use and frailty - the evaluation of these aspects is important in the creation of personalized management plans in the late stage of PD.

Blood Pressure Patterns in Patients with Parkinson's Disease: A Systematic Review

(1) Background: Cardiovascular autonomic dysfunction is a non-motor feature in Parkinson’s disease with negative impact on functionality and life expectancy, prompting early detection and proper management. We aimed to describe the blood pressure patterns reported in patients with Parkinson’s disease, as measured by 24-h ambulatory blood pressure monitoring. (2) Methods: We conducted a systematic search on the PubMed database. Studies enrolling patients with Parkinson’s disease undergoing 24-h ambulatory blood pressure monitoring were included. Data regarding study population, Parkinson’s disease course, vasoactive drugs, blood pressure profiles, and measurements were recorded. (3) Results: The search identified 172 studies. Forty studies eventually fulfilled the inclusion criteria, with 3090 patients enrolled. Abnormal blood pressure profiles were commonly encountered: high blood pressure in 38.13% of patients (938/2460), orthostatic hypotension in 38.68% (941/2433), supine hypertension in 27.76% (445/1603) and nocturnal hypertension in 38.91% (737/1894). Dipping status was also altered often, 40.46% of patients (477/1179) being reverse dippers and 35.67% (310/869) reduced dippers. All these patterns were correlated with negative clinical and imaging outcomes. (4) Conclusion: Patients with Parkinson’s disease have significantly altered blood pressure patterns that carry a negative prognosis. Ambulatory blood pressure monitoring should be validated as a biomarker of PD-associated cardiovascular dysautonomia and a tool for assisting therapeutic interventions.

Heart Matters: Cardiac Dysfunction and Other Autonomic Changes in Parkinson's Disease

It has been more than 200 years since James Parkinson made the first descriptions of the disease that bears his name. Since then, knowledge about Parkinson's disease has been improved, and its pathophysiology, diagnosis, and treatments are well described in the scientific and medical literature. However, there is no way to prevent the disease from its progressive nature yet and only its symptoms can be minimized. It is known that the process of neurodegeneration begins before the onset of motor signs and symptoms of the disease, when diagnosis is usually made. Therefore, recognizing manifested non-motor symptoms can make an early diagnosis possible and lead to a better understanding of the disease. Autonomic dysfunctions are important non-motor manifestations of Parkinson's disease and affect the majority of patients. Importantly, heart failure is the third leading cause of death in people suffering from Parkinson's disease. Several evidences have shown the correlation between Parkinson's disease and the preexistence of cardiovascular diseases. Therefore, cardiovascular monitoring and identification of its dysfunctions can have a prodromal role for Parkinson's disease. This review presents studies of the literature that can lead to a better understanding of Parkinson's disease with special attention to its relation to heart and cardiovascular parameters.

Insights From Invasive Cardiopulmonary Exercise Testing of Patients With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

BACKGROUND

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) affects tens of millions worldwide; the causes of exertional intolerance are poorly understood. The ME/CFS label overlaps with postural orthostatic tachycardia (POTS) and fibromyalgia, and objective evidence of small fiber neuropathy (SFN) is reported in approximately 50% of POTS and fibromyalgia patients.

RESEARCH QUESTION

Can invasive cardiopulmonary exercise testing (iCPET) and PGP9.5-immunolabeled lower-leg skin biopsies inform the pathophysiology of ME/CFS exertional intolerance and potential relationships with SFN?

STUDY DESIGN AND METHODS

We analyzed 1,516 upright invasive iCPETs performed to investigate exertional intolerance. After excluding patients with intrinsic heart or lung disease and selecting those with right atrial pressures (RAP) <6.5 mm Hg, results from 160 patients meeting ME/CFS criteria who had skin biopsy test results were compared with 36 control subjects. Rest-to-peak changes in cardiac output (Qc) were compared with oxygen uptake (Qc/VO₂ slope) to identify participants with low, normal, or high pulmonary blood flow by Qc/VO₂ tertiles.

RESULTS

During exercise, the 160 ME/CFS patients averaged lower RAP (1.9 ± 2 vs 8.3 ± 1.5; P < .0001) and peak VO₂ (80% ± 21% vs 101.4% ± 17%; P < .0001) than control subjects. The low-flow tertile had lower peak Qc than the normal and high-flow tertiles (88.4% ± 19% vs 99.5% ± 23.8% vs 99.9% ± 19.5% predicted; P < .01). In contrast, systemic oxygen extraction was impaired in high-flow vs low- and normal-flow participants (0.74% ± 0.1% vs 0.88 ± 0.11 vs 0.86 ± 0.1; P < .0001) in association with peripheral left-to-right shunting. Among the 160 ME/CFS patient biopsies, 31% were consistent with SFN (epidermal innervation ≤5.0% of predicted; P < .0001). Denervation severity did not correlate with exertional measures.

INTERPRETATION

These results identify two types of peripheral neurovascular dysregulation that are biologically plausible contributors to ME/CFS exertional intolerance-depressed Qc from impaired venous return, and impaired peripheral oxygen extraction. In patients with small-fiber pathology, neuropathic dysregulation causing microvascular dilation may limit exertion by shunting oxygenated blood from capillary beds and reducing cardiac return.

Long-Term Influence of Concussion on Cardio-Autonomic Function in Adolescent Hockey Players

CONTEXT

Concussion may negatively influence cardiovascular function and the autonomic nervous system, defined by alteration in heart rate variability (HRV). Differences in HRV most commonly emerge during a physical challenge, such as the final steps of the return-to-sport progression.

OBJECTIVE

To assess the effect of concussion history on aspects of cardio-autonomic function during recovery from a bout of submaximal exercise in adolescent male hockey athletes.

DESIGN

Case-control study.

SETTING

Research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Thirty-three male athletes participating in Midget-AAA hockey were divided into those with (n = 15; age = 16 ± 1 years, height = 1.78 ± 0.06 m, mass = 73.9 ± 7.4 kg, 10.5 ± 1.6 years of sport experience, 25.2 ± 18.3 months since last injury) or without (n = 18; age = 16 ± 1 years, height = 1.78 ± 0.05 m, mass = 74.8 ± 7.6 kg, 10.6 ± 1.9 years of sport experience) a concussion history. Those with a concussion history were binned on total count: concussion) or 2 or more concussions.

INTERVENTION(S)

All athletes underwent 5 minutes of resting HRV assessment, followed by 20 minutes of aerobic exercise at 60% to 70% of their maximal target heart rate and a 9-minute, postexercise HRV assessment.

MAIN OUTCOME MEASURE(S)

Heart rate variability measures of mean NN interval, root mean square of successive differences, and standard deviation of NN interval (SDNN).

RESULTS

Group demographic characteristics were not different. When the control and concussed groups were compared, group and time main effects for heart rate recovery, root mean square of successive differences, and SDNN (P values < .01), and an interaction effect for SDNN (P < .05) were demonstrated. Recovery trends for each group indicated that a history of 2 or more concussions may negatively affect cardio-autonomic recovery postexercise.

CONCLUSIONS

Our findings suggest that those with more than 1 previous concussion may be associated with a greater risk for long-term dysautonomia. Future use of HRV may provide clinicians with objective guidelines for concussion-management and safe return-to-participation protocols.

Acute post-injury blockade of α2δ-1 calcium channel subunits prevents pathological autonomic plasticity after spinal cord injury

After spinal cord injury (SCI), normally innocuous visceral or somatic stimuli can trigger uncontrolled reflex activation of sympathetic circuitry, causing pathological dysautonomia. We show that remarkable structural remodeling and plasticity occur within spinal autonomic circuitry, creating abnormal sympathetic reflexes that promote dysautonomia. However, when mice are treated early after SCI with human-equivalent doses of the US Food and Drug Administration (FDA)-approved drug gabapentin (GBP), it is possible to block multi-segmental excitatory synaptogenesis and abolish sprouting of autonomic neurons that innervate immune organs and sensory afferents that trigger pain and autonomic dysreflexia (AD). This “prophylactic GBP” regimen decreases the frequency and severity of AD and protects against SCI-induced immune suppression. These benefits persist even 1 month after stopping treatment. GBP could be repurposed to prevent dysautonomia in at-risk individuals with high-level SCI.

Brennan et al. show that α2δ−1 calcium channel subunits drive remarkable structural reorganization of autonomic circuitry and autonomic dysfunction after spinal cord injury. Early (prophylactic) post-injury treatment with gabapentin, an FDA-approved drug, prevents α2δ−1-dependent structural changes and autonomic dysfunction. Prophylactic gabapentin could be repurposed clinically for at-risk individuals.