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Robertson AD, Udow SJ, Espay AJ, Merola A, Camicioli R, Lang AE, Masellis M. Orthostatic hypotension and dementia incidence: links and implications. Neuropsychiatr Dis Treat 2019; 15:2181-2194. [PMID: 31447560 PMCID: PMC6683958 DOI: 10.2147/ndt.s182123] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/09/2019] [Indexed: 12/14/2022] Open
Abstract
Orthostatic hypotension (OH) is a common condition, particularly in patients with α-synucleinopathies such as Parkinson's disease, and has a significant impact on activities of daily living and quality of life. Recent data suggest an association with cognitive impairment. Herein, we review the evidence that OH increases the odds of incident mild cognitive impairment and dementia. Potential mechanisms underlying the putative relationship are discussed, including cerebral hypoperfusion, supine hypertension, white matter hyperintensities, and neurodegeneration. Finally, we highlight the challenges with respect to treatment and the negative impact on the quality of life and long-term prognosis presented by the coexistence of OH and dementia. Large population-based studies have reported that OH is associated with about a 20% increased risk of dementia in the general population, while smaller cohort studies suggest an even greater effect in patients with α-synucleinopathies (3- to 7-fold higher than controls). Ultimately, OH exposure is difficult to quantify, predominantly limited to pressure regulation during a one-time orthostatic challenge, and the causative association with dementia may turn out to be bidirectional, especially in α-synucleinopathies. Early diagnosis and treatment of OH may improve long-term prognosis.
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Affiliation(s)
- Andrew D Robertson
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, ON, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - Sean J Udow
- Division of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Alberto J Espay
- Department of Neurology, James and Joan Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, Cincinnati, OH, USA
| | - Aristide Merola
- Department of Neurology, James and Joan Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, Cincinnati, OH, USA
| | - Richard Camicioli
- Department of Medicine (Neurology), University of Alberta, Edmonton, AB, Canada
| | - Anthony E Lang
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, University Health Network, Toronto, ON, Canada.,Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Mario Masellis
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada.,Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Cognitive and Movement Disorders Clinic, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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52
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Bhidayasiri R, Sringean J, Reich SG, Colosimo C. Red flags phenotyping: A systematic review on clinical features in atypical parkinsonian disorders. Parkinsonism Relat Disord 2018; 59:82-92. [PMID: 30409560 DOI: 10.1016/j.parkreldis.2018.10.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 09/28/2018] [Accepted: 10/04/2018] [Indexed: 12/18/2022]
Abstract
To establish a clinical diagnosis of a parkinsonian disorder, physicians rely on their ability to identify relevant red flags, in addition to cardinal features, to support or refute their working diagnosis in an individual patient. The term 'red flag', was originally coined in 1989 to define the presence of non-cardinal features that may raise a suspicion of multiple system atrophy (MSA), or at least suggest alternative diagnosis to Parkinson's disease (PD). Since then, the term 'red flag', has been consistently used in the literature to denote the clinical history or signs that may signal to physicians the possibility of an atypical parkinsonian disorder (APD). While most red flags were originally based on expert opinion, many have gained acceptance and are now included in validated clinical diagnostic criteria of PD and APDs. The clinical appreciation of red flags, in conjunction with standard criteria, may result in a more accurate and earlier diagnosis compared to standard criteria alone. However, red flags can be clinical signs that are non-neurological, making the systematic assessment for them a real challenge in clinical practice. Here, we have conducted a systematic review to identify red flags and their clinical evidence in the differential diagnosis of common degenerative parkinsonism, including PD, MSA, progressive supranuclear palsy (PSP), corticobasal degeneration (CBD), and dementia with Lewy body (DLB). Increasing awareness and appropriate use of red flags in clinical practice may benefit physicians in the diagnosis and management of their patients with parkinsonism.
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Affiliation(s)
- Roongroj Bhidayasiri
- Chulalongkorn Center of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, 10330, Thailand; Department of Neurology, Juntendo University, Tokyo, Japan.
| | - Jirada Sringean
- Chulalongkorn Center of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, 10330, Thailand
| | - Stephen G Reich
- Department of Neurology, University of Maryland School of Medicine, Baltimore, USA
| | - Carlo Colosimo
- Department of Neurology, Santa Maria University Hospital, Terni, Italy
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Shirai T, Kitaura A, Uehara K, Uchida T, Fuyuta M, Iwamoto T, Hiramatsu K, Nakao S. Unusually large ephedrine-induced blood pressure increases due to cardiac sympathetic denervation supersensitivity in a patient with Parkinson's disease. JA Clin Rep 2018; 4:44. [PMID: 32026022 PMCID: PMC6967280 DOI: 10.1186/s40981-018-0181-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 05/27/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Parkinson's disease (PD) patients often suffer from cardiac sympathetic denervation, a hallmark of which is orthostatic hypotension. Denervation supersensitivity to sympathomimetic drugs is also seen in such patients, and this phenomenon is important and can be sometimes dangerous. CASE PRESENTATION A 65-year-old male underwent gastrojejunostomy. The patient had severe PD and did not exhibit metaiodobenzylguanidine (MIBG) accumulation in his heart, which was indicative of cardiac sympathetic nerve denervation. When 8 mg of ephedrine was administered intravenously, an unexpectedly large increase in blood pressure was observed. The phenomenon recurred when 4 mg of ephedrine was administered again, and nicardipine was required to suppress the patient's blood pressure. CONCLUSIONS Denervation supersensitivity is not as well recognized as other complications seen in PD patients, but anesthesiologists should be aware of it because sympathomimetic drugs can have excessively strong effects in patients with the condition.
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Affiliation(s)
- Toru Shirai
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2, Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan.
| | - Atsuhiro Kitaura
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2, Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Keiji Uehara
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2, Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Tomohisa Uchida
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2, Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Masaki Fuyuta
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2, Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Tatushige Iwamoto
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2, Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Kenji Hiramatsu
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2, Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Shinichi Nakao
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2, Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan
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Consensus statement on the definition of neurogenic supine hypertension in cardiovascular autonomic failure by the American Autonomic Society (AAS) and the European Federation of Autonomic Societies (EFAS) : Endorsed by the European Academy of Neurology (EAN) and the European Society of Hypertension (ESH). Clin Auton Res 2018; 28:355-362. [PMID: 29766366 PMCID: PMC6097730 DOI: 10.1007/s10286-018-0529-8] [Citation(s) in RCA: 152] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 04/24/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Patients suffering from cardiovascular autonomic failure often develop neurogenic supine hypertension (nSH), i.e., high blood pressure (BP) in the supine position, which falls in the upright position owing to impaired autonomic regulation. A committee was formed to reach consensus among experts on the definition and diagnosis of nSH in the context of cardiovascular autonomic failure. METHODS As a first and preparatory step, a systematic search of PubMed-indexed literature on nSH up to January 2017 was performed. Available evidence derived from this search was discussed in a consensus expert round table meeting in Innsbruck on February 16, 2017. Statements originating from this meeting were further discussed by representatives of the American Autonomic Society and the European Federation of Autonomic Societies and are summarized in the document presented here. The final version received the endorsement of the European Academy of Neurology and the European Society of Hypertension. RESULTS In patients with neurogenic orthostatic hypotension, nSH is defined as systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg, measured after at least 5 min of rest in the supine position. Three severity degrees are recommended: mild, moderate and severe. nSH may also be present during nocturnal sleep, with reduced-dipping, non-dipping or rising nocturnal BP profiles with respect to mean daytime BP values. Home BP monitoring and 24-h-ambulatory BP monitoring provide relevant information for a customized clinical management. CONCLUSIONS The establishment of expert-based criteria to define nSH should standardize diagnosis and allow a better understanding of its epidemiology, prognosis and, ultimately, treatment.
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55
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Palma JA, Norcliffe-Kaufmann L, Kaufmann H. Diagnosis of multiple system atrophy. Auton Neurosci 2018; 211:15-25. [PMID: 29111419 PMCID: PMC5869112 DOI: 10.1016/j.autneu.2017.10.007] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 10/19/2017] [Accepted: 10/20/2017] [Indexed: 02/08/2023]
Abstract
Multiple system atrophy (MSA) may be difficult to distinguish clinically from other disorders, particularly in the early stages of the disease. An autonomic-only presentation can be indistinguishable from pure autonomic failure. Patients presenting with parkinsonism may be misdiagnosed as having Parkinson disease. Patients presenting with the cerebellar phenotype of MSA can mimic other adult-onset ataxias due to alcohol, chemotherapeutic agents, lead, lithium, and toluene, or vitamin E deficiency, as well as paraneoplastic, autoimmune, or genetic ataxias. A careful medical history and meticulous neurological examination remain the cornerstone for the accurate diagnosis of MSA. Ancillary investigations are helpful to support the diagnosis, rule out potential mimics, and define therapeutic strategies. This review summarizes diagnostic investigations useful in the differential diagnosis of patients with suspected MSA. Currently used techniques include structural and functional brain imaging, cardiac sympathetic imaging, cardiovascular autonomic testing, olfactory testing, sleep study, urological evaluation, and dysphagia and cognitive assessments. Despite advances in the diagnostic tools for MSA in recent years and the availability of consensus criteria for clinical diagnosis, the diagnostic accuracy of MSA remains sub-optimal. As other diagnostic tools emerge, including skin biopsy, retinal biomarkers, blood and cerebrospinal fluid biomarkers, and advanced genetic testing, a more accurate and earlier recognition of MSA should be possible, even in the prodromal stages. This has important implications as misdiagnosis can result in inappropriate treatment, patient and family distress, and erroneous eligibility for clinical trials of disease-modifying drugs.
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Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, NY, USA
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, NY, USA
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, NY, USA.
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56
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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: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [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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57
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Klanbut S, Phattanarudee S, Wongwiwatthananukit S, Suthisisang C, Bhidayasiri R. Symptomatic orthostatic hypotension in Parkinson's disease patients: Prevalence, associated factors and its impact on balance confidence. J Neurol Sci 2017; 385:168-174. [PMID: 29406900 DOI: 10.1016/j.jns.2017.12.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 12/26/2017] [Accepted: 12/28/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND Orthostatic hypotension (OH) is a commonly reported sign of the cardiovascular autonomic dysfunctions associated with Parkinson's disease (PD). Patients might suffer from a variety of the clinical symptoms of OH, including dizziness, lightheadedness, or problems with vision and fatigue. OBJECTIVES To determine the prevalence of, and factors associated with, symptomatic orthostatic hypotension (OH) in Parkinson's disease (PD) and to identify any relationships between the clinical symptoms of OH and balance confidence in this patient population. METHODS Symptomatic OH was defined as a systolic or diastolic BP fall of ≥20 or ≥10mmHg respectively, within 3min of standing and an Orthostatic Hypotension Questionnaire (OHQ) score of more than zero. Factors related to symptomatic OH were identified from a multivariate logistic regression analysis. Pearson's correlation test was used to reveal any relationships between the clinical symptoms of OH and a patient's confidence in their ability to balance, assessed using the Activities-specific Balance Confidence (ABC) scale. RESULTS 100 Thai PD patients were consecutively recruited into this study. The prevalence of symptomatic OH was 18%, asymptomatic OH was 4%, while 78% were patients without OH. Factors associated with symptomatic OH were age (OR, 95%CI: 1.06, 1.003-1.115, p=0.038) and hypertension (OR, 95%CI: 6.16, 1.171-32.440, p=0.032). A significant and negative correlation (r=-0.229, p=0.022) between OHQ composite scores and item 3 of the ABC scale (picking up slippers from floor), one of the movements in a vertical orientation, was found. CONCLUSION Elderly PD patients and with a co-morbidity of essential hypertension should be closely evaluated for the presence of symptomatic OH. In addition, they should be advised to change positions slowly, especially those in a vertical orientation.
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Affiliation(s)
- Siranan Klanbut
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Siripan Phattanarudee
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand.
| | | | | | - Roongroj Bhidayasiri
- Chulalongkorn Center of Excellence for Parkinson's Disease and Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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58
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Di Stefano C, Maule S. Treatment of supine hypertension in autonomic failure: a case series. Clin Auton Res 2017; 28:245-246. [PMID: 29080922 DOI: 10.1007/s10286-017-0479-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 10/14/2017] [Indexed: 11/24/2022]
Affiliation(s)
- Cristina Di Stefano
- Department of Medical Sciences, Autonomic Unit and Hypertension Unit, Città della Salute e della Scienza Hospital, University of Turin, via Genova, 3, 10126, Turin, Italy
| | - Simona Maule
- Department of Medical Sciences, Autonomic Unit and Hypertension Unit, Città della Salute e della Scienza Hospital, University of Turin, via Genova, 3, 10126, Turin, Italy.
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59
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Piqueras-Flores J, López-García A, Moreno-Reig Á, González-Martínez A, Hernández-González A, Vaamonde-Gamo J, Jurado-Román A. Structural and functional alterations of the heart in Parkinson’s disease. Neurol Res 2017; 40:53-61. [DOI: 10.1080/01616412.2017.1390933] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Jesús Piqueras-Flores
- Cardiology Department, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - Ana López-García
- Neurology Department. Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Álvaro Moreno-Reig
- Cardiology Department, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | | | | | - Julia Vaamonde-Gamo
- Neurology Department. Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - Alfonso Jurado-Román
- Cardiology Department, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
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Eschlböck S, Wenning G, Fanciulli A. Evidence-based treatment of neurogenic orthostatic hypotension and related symptoms. J Neural Transm (Vienna) 2017; 124:1567-1605. [PMID: 29058089 PMCID: PMC5686257 DOI: 10.1007/s00702-017-1791-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 09/18/2017] [Indexed: 02/06/2023]
Abstract
Neurogenic orthostatic hypotension, postprandial hypotension and exercise-induced hypotension are common features of cardiovascular autonomic failure. Despite the serious impact on patient’s quality of life, evidence-based guidelines for non-pharmacological and pharmacological management are lacking at present. Here, we provide a systematic review of the literature on therapeutic options for neurogenic orthostatic hypotension and related symptoms with evidence-based recommendations according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Patient’s education and non-pharmacological measures remain essential, with strong recommendation for use of abdominal binders. Based on quality of evidence and safety issues, midodrine and droxidopa reach a strong recommendation level for pharmacological treatment of neurogenic orthostatic hypotension. In selected cases, a range of alternative agents can be considered (fludrocortisone, pyridostigmine, yohimbine, atomoxetine, fluoxetine, ergot alkaloids, ephedrine, phenylpropanolamine, octreotide, indomethacin, ibuprofen, caffeine, methylphenidate and desmopressin), though recommendation strength is weak and quality of evidence is low (atomoxetine, octreotide) or very low (fludrocortisone, pyridostigmine, yohimbine, fluoxetine, ergot alkaloids, ephedrine, phenylpropanolamine, indomethacin, ibuprofen, caffeine, methylphenidate and desmopressin). In case of severe postprandial hypotension, acarbose and octreotide are recommended (strong recommendation, moderate level of evidence). Alternatively, voglibose or caffeine, for which a weak recommendation is available, may be useful.
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Affiliation(s)
- Sabine Eschlböck
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Gregor Wenning
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Alessandra Fanciulli
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Vernino S, Claassen D. Polypharmacy: droxidopa to treat neurogenic orthostatic hypotension in a patient with Parkinson disease and type 2 diabetes mellitus. Clin Auton Res 2017; 27:33-34. [PMID: 28674868 PMCID: PMC5524866 DOI: 10.1007/s10286-017-0435-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 06/08/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Steven Vernino
- Department of Neurology and Neurotherapeutics, UT Southwestern, Dallas, TX, USA.
| | - Daniel Claassen
- Department of Neurology, University of Southern California, Los Angeles, CA, USA
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62
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Adding droxidopa to fludrocortisone or midodrine in a patient with neurogenic orthostatic hypotension and Parkinson disease. Clin Auton Res 2017; 27:29-31. [PMID: 28674867 PMCID: PMC5524861 DOI: 10.1007/s10286-017-0434-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 06/08/2017] [Indexed: 10/26/2022]
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63
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Mehdirad A, Karabin B, Gupta F. Managing neurogenic orthostatic hypotension with droxidopa in a patient with Parkinson disease, atrial fibrillation, and hypertension. Clin Auton Res 2017. [PMID: 28634637 PMCID: PMC5524863 DOI: 10.1007/s10286-017-0433-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Ali Mehdirad
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Internal Medicine, Saint Louis University, St. Louis, MO, USA.
| | - Beverly Karabin
- Syncope and Autonomic Disorders Center, University of Toledo, Toledo, OH, USA
| | - Fiona Gupta
- Movement Disorders Center, Hackensack University Medical Center, Hackensack, NJ, USA
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64
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Goodman BP, Gupta F. Defining successful treatment of neurogenic orthostatic hypotension with droxidopa in a patient with multiple system atrophy. Clin Auton Res 2017. [PMID: 28631222 PMCID: PMC5524855 DOI: 10.1007/s10286-017-0432-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Brent P Goodman
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA.
| | - Fiona Gupta
- Movement Disorders Center, Hackensack University Medical Center, Hackensack, NJ, USA
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65
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Goodman BP, Claassen D, Mehdirad A. Adjusting droxidopa for neurogenic orthostatic hypotension in a patient with Parkinson disease. Clin Auton Res 2017. [PMID: 27838779 PMCID: PMC5292066 DOI: 10.1007/s10286-017-0431-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Brent P Goodman
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA.
| | - Daniel Claassen
- Department of Neurology, Vanderbilt University, Nashville, TN, USA
| | - Ali Mehdirad
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Internal Medicine, Saint Louis University, St. Louis, MO, USA
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66
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Claassen D, Lew M. Initiating droxidopa for neurogenic orthostatic hypotension in a patient with Parkinson disease. Clin Auton Res 2017. [PMID: 28631224 PMCID: PMC5524864 DOI: 10.1007/s10286-017-0429-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Daniel Claassen
- Department of Neurology, Vanderbilt University, Nashville, TN, USA.
| | - Mark Lew
- Department of Neurology, University of Southern California, Los Angeles, CA, USA
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67
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Espay AJ, LeWitt PA, Hauser RA, Merola A, Masellis M, Lang AE. Neurogenic orthostatic hypotension and supine hypertension in Parkinson's disease and related synucleinopathies: prioritisation of treatment targets. Lancet Neurol 2017; 15:954-966. [PMID: 27478953 DOI: 10.1016/s1474-4422(16)30079-5] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 03/21/2016] [Accepted: 05/12/2016] [Indexed: 12/18/2022]
Abstract
Neurogenic orthostatic hypotension and supine hypertension are common manifestations of cardiovascular dysautonomia in Parkinson's disease and related synucleinopathies. Because these disorders are haemodynamic opposites, improvement in one might be achieved at the expense of worsening of the other. Thus, management decisions necessitate assessment of the individual risks for patients with coexistent neurogenic orthostatic hypotension and supine hypertension. Whereas neurogenic orthostatic hypotension poses risks for falls and can be associated with cognitive impairment in the short term, chronic supine hypertension can be associated with stroke and myocardial infarction in the long term. Because few clinical trial data exist for outcomes in patients with coexistent neurogenic orthostatic hypotension and supine hypertension, clinicians need to balance, on the basis of comorbidities and disease staging, the potential immediate benefits of treatment for neurogenic orthostatic hypotension and the long-term risks of supine hypertension treatment in each patient. Future research needs to focus on ascertaining a safe degree of supine hypertension when treating neurogenic orthostatic hypotension; the effectiveness of nocturnal antihypertensive therapy in patients with coexistent neurogenic orthostatic hypotension and supine hypertension; and the prevalence, scope, and therapeutic requirements for managing neurogenic orthostatic hypotension that manifests with falls or cognitive impairment, but without postural lightheadedness or near syncope.
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Affiliation(s)
- Alberto J Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA.
| | - Peter A LeWitt
- Parkinson's Disease and Movement Disorders Program, Henry Ford Hospital, West Bloomfield, MI, USA; Department of Neurology, Wayne State University School of Medicine, West Bloomfield, MI, USA
| | - Robert A Hauser
- USF Health Byrd NPF Parkinson's Disease and Movement Disorders Center of Excellence, Tampa, FL, USA
| | - Aristide Merola
- Department of Neuroscience, University of Torino, Torino, Italy
| | - Mario Masellis
- Cognitive & Movement Disorders Clinic, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Anthony E Lang
- Movement Disorders Clinic and the Edmond J Safra Program in Parkinson's Disease, University Health Network, University of Toronto, Toronto, ON, Canada
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Abstract
Multiple system atrophy (MSA) is a devastating and fatal neurodegenerative disorder. The clinical presentation of this disease is highly variable, with parkinsonism, cerebellar ataxia and autonomic failure being the most common - and often debilitating - symptoms. These symptoms progress rapidly, and patients die from MSA-related complications after 9 years of symptom duration on average. Unfortunately, the course of the disease cannot be improved by drug or surgical treatment. In addition, symptomatic treatment options are currently limited, and therapeutic benefits are often only transient. Thus, further interventional studies of candidate disease-modifying and symptomatic therapies are essential to improve patient care. In the past 15 years, the understanding of MSA-specific requirements in trial methodology has improved, resulting in a substantial increase in high-quality interventional studies. In this Review, we discuss MSA risk factors, clinical presentation and neuropathology, and we provide a hypothesis on key pathophysiological events, a summary of recent randomized controlled trials, and an overview of ongoing international collaborations.
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Kaufmann H, Jordan J. The Clinical Autonomic Research journal 2017 and onward. Clin Auton Res 2017; 27:1-2. [PMID: 28124174 DOI: 10.1007/s10286-016-0394-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 12/26/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Horacio Kaufmann
- Department of Neurology, New York University School of Medicine, New York, USA. .,Clinical Autonomic Research Editorial Office, New York, USA.
| | - Jens Jordan
- Institute of Aerospace Medicine, German Aerospace Center, Cologne, Germany
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Al-Khateeb AA, Limberg JK, Barnes JN, Joyner MJ, Charkoudian N, Curry TB. Acute cyclooxygenase inhibition and baroreflex sensitivity in lean and obese adults. Clin Auton Res 2016; 27:17-23. [PMID: 27838779 DOI: 10.1007/s10286-016-0389-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 11/02/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE Obese adults exhibit increased levels of inflammation, which may negatively affect blood pressure regulation. Based on existing literature, we hypothesized: (1) baroreflex sensitivity would be lower in obese adults when compared to lean adults; (2) acute ibuprofen (IBU, a cyclooxygenase inhibitor and nonsteroidal antiinflammatory agent) administration would increase baroreflex sensitivity in obese adults, with no effect in lean adults. METHODS Seven lean (4 male, 3 female) and six obese (5 M, 1 F) adults completed two visits randomized to control (CON) or IBU (800 mg oral). On each visit, blood pressure (intra-arterial catheter), heart rate (ECG), and muscle sympathetic nerve activity (MSNA, microneurography) were measured continuously. Sympathetic and cardiac baroreflex sensitivities were assessed using the modified Oxford technique. RESULTS Measures of systemic inflammation [C-reactive protein (CRP) and interleukin-6 (IL-6)] were higher in obese adults when compared to lean adults and tended to decrease with IBU (IL-6: p < 0.05; CRP: p = 0.14). Cardiac baroreflex sensitivity was lower in obese adults (14 ± 2 vs. 24 ± 2 ms/mmHg, p = 0.02), whereas sympathetic baroreflex sensitivity was higher in obese adults (-3.6 ± 0.5 vs. -2.1 ± 0.5 bursts/100 beats/mmHg, p = 0.03) when compared to lean. There was no effect of IBU on cardiac or sympathetic baroreflex sensitivity in either group (p value range 0.20-0.71). CONCLUSION Despite obese individuals exhibiting higher levels of systemic inflammation and lower cardiac baroreflex sensitivity when compared to lean adults, an acute dose of IBU has no effect on cardiac or sympathetic baroreflex sensitivity.
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Affiliation(s)
- Abdulrahman A Al-Khateeb
- Department of Anesthesiology, Mayo Clinic, 200 1st Street SW, Rochester, MN, USA.,College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Jacqueline K Limberg
- Department of Anesthesiology, Mayo Clinic, 200 1st Street SW, Rochester, MN, USA
| | - Jill N Barnes
- Department of Anesthesiology, Mayo Clinic, 200 1st Street SW, Rochester, MN, USA
| | - Michael J Joyner
- Department of Anesthesiology, Mayo Clinic, 200 1st Street SW, Rochester, MN, USA
| | - Nisha Charkoudian
- Thermal and Mountain Medicine Division, US Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Timothy B Curry
- Department of Anesthesiology, Mayo Clinic, 200 1st Street SW, Rochester, MN, USA.
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