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Magkas N, Tsioufis C, Thomopoulos C, Dilaveris P, Georgiopoulos G, Sanidas E, Papademetriou V, Tousoulis D. Orthostatic hypotension: From pathophysiology to clinical applications and therapeutic considerations. J Clin Hypertens (Greenwich) 2019; 21:546-554. [DOI: 10.1111/jch.13521] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 02/14/2019] [Accepted: 02/20/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Nikolaos Magkas
- First Department of Cardiology “Hippokration” Hospital, University of Athens, Medical School Athens Greece
| | - Costas Tsioufis
- First Department of Cardiology “Hippokration” Hospital, University of Athens, Medical School Athens Greece
| | | | - Polychronis Dilaveris
- First Department of Cardiology “Hippokration” Hospital, University of Athens, Medical School Athens Greece
| | - Georgios Georgiopoulos
- First Department of Cardiology “Hippokration” Hospital, University of Athens, Medical School Athens Greece
| | - Elias Sanidas
- Hypertension Excellence Centre‐ESH, Department of Cardiology LAIKO General Hospital Athens Greece
| | - Vasilios Papademetriou
- Cardiology Department Georgetown University and Veterans Affairs Medical Center Washington District of Columbia
| | - Dimitrios Tousoulis
- First Department of Cardiology “Hippokration” Hospital, University of Athens, Medical School Athens Greece
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Peng AW, Appel LJ, Mueller NT, Tang O, Miller ER, Juraschek SP. Effects of sodium intake on postural lightheadedness: Results from the DASH-sodium trial. J Clin Hypertens (Greenwich) 2019; 21:355-362. [PMID: 30690866 PMCID: PMC6420359 DOI: 10.1111/jch.13487] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/28/2018] [Accepted: 12/11/2018] [Indexed: 12/22/2022]
Abstract
Lightheadedness after standing contributes to adverse clinical events, including falls. Recommendations for higher sodium intake to treat postural lightheadedness have not been evaluated in a trial setting. The Dietary Approaches to Stop Hypertension (DASH)-Sodium trial (1998-1999) tested the effects of the DASH diet and sodium reduction on blood pressure (BP). Participants were randomly assigned to DASH or a typical Western diet (control). During either diet, participants ate three sodium levels (50, 100, 150 meq/d at 2100 kcal) in random order for 30-days, separated by 5-day breaks. Participants reported the presence and severity of postural lightheadedness at baseline and after each feeding period. There were 412 participants (mean age 48 years; 57% women; 57% black). Mean baseline SBP/DBP was 135/86 mm Hg; 9.5% reported baseline lightheadedness. Among those consuming the DASH diet, high vs low sodium increased lightheadedness (OR 1.71; 95% CI: 1.01, 2.90; P = 0.047) and severity of lightheadedness (P = 0.02), but did not affect lightheadedness in those consuming the control diet (OR 0.77; 95% CI: 0.46, 1.29; P = 0.32). Among those consuming high vs low sodium in the context of the DASH diet, adults <60 vs ≥60 years old experienced more lightheadedness (P-interaction = 0.04), along with obese vs non-obese adults (P-interaction = 0.01). In the context of the DASH diet, higher sodium intake was associated with more frequent and severe lightheadedness. These findings challenge traditional recommendations to increase sodium intake to prevent lightheadedness.
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Affiliation(s)
- Allison W. Peng
- The Johns Hopkins University School of MedicineThe Johns Hopkins Bloomberg School of Public Health, and The Welch Center for Prevention, Epidemiology and Clinical ResearchBaltimoreMaryland
| | - Lawrence J. Appel
- The Johns Hopkins University School of MedicineThe Johns Hopkins Bloomberg School of Public Health, and The Welch Center for Prevention, Epidemiology and Clinical ResearchBaltimoreMaryland
| | - Noel T. Mueller
- The Johns Hopkins University School of MedicineThe Johns Hopkins Bloomberg School of Public Health, and The Welch Center for Prevention, Epidemiology and Clinical ResearchBaltimoreMaryland
| | - Olive Tang
- The Johns Hopkins University School of MedicineThe Johns Hopkins Bloomberg School of Public Health, and The Welch Center for Prevention, Epidemiology and Clinical ResearchBaltimoreMaryland
| | - Edgar R. Miller
- The Johns Hopkins University School of MedicineThe Johns Hopkins Bloomberg School of Public Health, and The Welch Center for Prevention, Epidemiology and Clinical ResearchBaltimoreMaryland
| | - Stephen P. Juraschek
- Division of General Medicine and Primary CareBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonMassachusetts
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Kim YH, Paik SH, V ZP, Jeon NJ, Kim BJ, Kim BM. Cerebral Perfusion Monitoring Using Near-Infrared Spectroscopy During Head-Up Tilt Table Test in Patients With Orthostatic Intolerance. Front Hum Neurosci 2019; 13:55. [PMID: 30837856 PMCID: PMC6389826 DOI: 10.3389/fnhum.2019.00055] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 01/31/2019] [Indexed: 11/13/2022] Open
Abstract
The head-up tilt table test (HUT) is one of the primary clinical examinations for evaluating orthostatic intolerance (OI). HUT can be divided into three phases: dynamic tilt phase (supine to tilt up), static tilt phase (remain tilted at 70°), and post tilt phase (tilt down back to supine position). Commonly, blood pressure (BP) and heart rate (HR) are monitored to observe for OI symptoms, but are indirect measurements of cerebral perfusion and can lead to inaccurate HUT evaluation. In this study, we implemented a 108-channel near-infrared spectroscopy (NIRS) probe to characterize HUT performance by monitoring cerebral hemodynamic changes for healthy controls (HCs), OI patients with normal HUT results, and OI patients with positive HUT results: vasovagal syncope (VS), postural orthostatic tachycardia syndrome (POTS), orthostatic hypotension (OH), and orthostatic hypertension (OHT). By the end of the static tilt phase, OI patients typically did not show a complete recovery back to baseline cerebral oxygenation and total blood volume compared to HCs. We characterized the return to cerebral homeostasis by polynomial fitting total blood volume changes and determining the inflection point. The OI patients with normal HUT results, VS, OH, or OHT showed a delay in the return to cerebral homeostasis compared to the HC group during HUT.
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Affiliation(s)
- Yoo Hwan Kim
- Department of Neurology, Hallym University College of Medicine, Seoul, South Korea.,Department of Neurology, Korea University Medical Center, Seoul, South Korea
| | - Seung-Ho Paik
- Department of Bio-convergence Engineering, Korea University College of Health Science, Seoul, South Korea
| | - Zephaniah Phillips V
- Department of Bio-convergence Engineering, Korea University College of Health Science, Seoul, South Korea
| | - Nam-Joon Jeon
- Neurophysiology Laboratory, Korea University Anam Hospital, Seoul, South Korea
| | - Byung-Jo Kim
- Department of Neurology, Korea University Medical Center, Seoul, South Korea.,Brain Convergence Research Center, Korea University Anam Hospital, Seoul, South Korea
| | - Beop-Min Kim
- Department of Bio-convergence Engineering, Korea University College of Health Science, Seoul, South Korea
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54
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Spallone V. Update on the Impact, Diagnosis and Management of Cardiovascular Autonomic Neuropathy in Diabetes: What Is Defined, What Is New, and What Is Unmet. Diabetes Metab J 2019; 43:3-30. [PMID: 30793549 PMCID: PMC6387879 DOI: 10.4093/dmj.2018.0259] [Citation(s) in RCA: 140] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 02/01/2019] [Indexed: 12/15/2022] Open
Abstract
The burden of diabetic cardiovascular autonomic neuropathy (CAN) is expected to increase due to the diabetes epidemic and its early and widespread appearance. CAN has a definite prognostic role for mortality and cardiovascular morbidity. Putative mechanisms for this are tachycardia, QT interval prolongation, orthostatic hypotension, reverse dipping, and impaired heart rate variability, while emerging mechanisms like inflammation support the pervasiveness of autonomic dysfunction. Efforts to overcome CAN under-diagnosis are on the table: by promoting screening for symptoms and signs; by simplifying cardiovascular reflex tests; and by selecting the candidates for screening. CAN assessment allows for treatment of its manifestations, cardiovascular risk stratification, and tailoring therapeutic targets. Risk factors for CAN are mainly glycaemic control in type 1 diabetes mellitus (T1DM) and, in addition, hypertension, dyslipidaemia, and obesity in type 2 diabetes mellitus (T2DM), while preliminary data regard glycaemic variability, vitamin B12 and D changes, oxidative stress, inflammation, and genetic biomarkers. Glycaemic control prevents CAN in T1DM, whereas multifactorial intervention might be effective in T2DM. Lifestyle intervention improves autonomic function mostly in pre-diabetes. While there is no conclusive evidence for a disease-modifying therapy, treatment of CAN manifestations is available. The modulation of autonomic function by SGLT2i represents a promising research field with possible clinical relevance.
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Affiliation(s)
- Vincenza Spallone
- Division of Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
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55
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Implications of blood pressure variations in older populations. Hypertens Res 2018; 42:19-25. [DOI: 10.1038/s41440-018-0125-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 09/30/2018] [Accepted: 10/03/2018] [Indexed: 11/08/2022]
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Abstract
PURPOSE OF REVIEW This review considers the relationship between abnormal blood pressure (BP) variability and autonomic dysfunction through an attempt to answer questions about its clinical relevance and pertinence to diabetes and cardiovascular autonomic neuropathy (CAN) and which therapeutic measures can lessen its cardiovascular impact. RECENT FINDINGS Office, ambulatory, and home BP monitoring identify posture-related, circadian, short-term, and long-term BP variabilities. Abnormal BP variability is a risk marker for organ damage, mortality, and cardiovascular events. Moreover, BP variability changes are common in diabetes and associated with CAN and possibly exacerbated by comorbidities like nephropathy, obstructive sleep apnoea syndrome, and chronic pain. The prognostic role of nondipping and reverse dipping is well documented in diabetes. Some findings suggest the possibility of restoring dipping with the dosage time of antihypertensive agents. Diabetes is a favorable scenario for altered BP variability, which might mediate the harmful effects of CAN. Preliminary data suggest the protective effect of targeting BP variability. However, further longitudinal outcome studies are needed. In the meantime, BP variability measures and practical expedients in antihypertensive treatment should be implemented in diabetes.
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Affiliation(s)
- Vincenza Spallone
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier, 1, 00133, Rome, Italy.
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Lip GYH, Coca A, Kahan T, Boriani G, Manolis AS, Olsen MH, Oto A, Potpara TS, Steffel J, Marín F, de Oliveira Figueiredo MJ, de Simone G, Tzou WS, Chiang CE, Williams B, Dan GA, Gorenek B, Fauchier L, Savelieva I, Hatala R, van Gelder I, Brguljan-Hitij J, Erdine S, Lovic D, Kim YH, Salinas-Arce J, Field M. Hypertension and cardiac arrhythmias: a consensus document from the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE). Europace 2018; 19:891-911. [PMID: 28881872 DOI: 10.1093/europace/eux091] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 03/11/2017] [Indexed: 12/23/2022] Open
Abstract
Hypertension is a common cardiovascular risk factor leading to heart failure (HF), coronary artery disease, stroke, peripheral artery disease and chronic renal insufficiency. Hypertensive heart disease can manifest as many cardiac arrhythmias, most commonly being atrial fibrillation (AF). Both supraventricular and ventricular arrhythmias may occur in hypertensive patients, especially in those with left ventricular hypertrophy (LVH) or HF. Also, some of the antihypertensive drugs commonly used to reduce blood pressure, such as thiazide diuretics, may result in electrolyte abnormalities (e.g. hypokalaemia, hypomagnesemia), further contributing to arrhythmias, whereas effective control of blood pressure may prevent the development of the arrhythmias such as AF. In recognizing this close relationship between hypertension and arrhythmias, the European Heart Rhythm Association (EHRA) and the European Society of Cardiology (ESC) Council on Hypertension convened a Task Force, with representation from the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE), with the remit to comprehensively review the available evidence to publish a joint consensus document on hypertension and cardiac arrhythmias, and to provide up-to-date consensus recommendations for use in clinical practice. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and the patient in light of all of the circumstances presented by that patient.
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Affiliation(s)
- Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Antonio Coca
- Hypertension and Vascular Risk Unit, Department of Internal Medicine, Hospital Clínic (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Thomas Kahan
- Karolinska Institutet Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden.,Department of Cardiology, Danderyd University Hospital Corp, Stockholm, Sweden
| | - Giuseppe Boriani
- Cardiology Department, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Antonis S Manolis
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
| | - Michael Hecht Olsen
- Department of Internal Medicine, Holbaek Hospital and Centre for Individualized Medicine in Arterial Diseases (CIMA), Odense University Hospital, University of Southern Denmark, Denmark
| | - Ali Oto
- Department of Cardiology, Memorial Ankara Hospital, Heart and Health Foundation of Turkey, Ankara, Turkey
| | - Tatjana S Potpara
- School of Medicine, Cardiology Clinic, Clinical Centre of Serbia, Belgrade University, Belgrade, Serbia
| | - Jan Steffel
- Electrophysiology and Cardiac Devices, Department of Cardiology, University Heart Center Zurich; Zurich, Switzerland
| | - Francisco Marín
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, Murcia, Spain
| | | | - Giovanni de Simone
- Department of Translational Medical Sciences, Federico II University Hospital, via S. Pansini 5, bld # 1, Napoli 80131, Italy
| | - Wendy S Tzou
- Cardiac Electrophysiology, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Chern-En Chiang
- Division of Cardiology, Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan
| | - Bryan Williams
- Institute of Cardiovascular Science, University College London, UK
| | | | - Gheorghe-Andrei Dan
- Colentina University Hospital, Medicine Faculty, University of Medicine "Carol Davila"-Bucharest Romania
| | | | | | | | - Robert Hatala
- National Cardiovascular Institute, NUSCH, Bratislava, Slovak Republic
| | - Isabelle van Gelder
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jana Brguljan-Hitij
- University Medical Centre, Hypertension Department, Hospital Dr. Peter Drzaja, Ljubljana, Slovenia
| | - Serap Erdine
- Istanbul University Cerrahpasa Medical School, Head of Hypertension Department, Istanbul, Turkey
| | - Dragan Lovic
- Clinic for internal disease Intermedica, Cardiology department-Hypertension centere, Serbia
| | | | | | - Michael Field
- University of Wisconsin, Clinical Science Center, Madison, USA
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58
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Seok HY, Kim YH, Kim H, Kim BJ. Patterns of Orthostatic Blood Pressure Changes in Patients with Orthostatic Hypotension. J Clin Neurol 2018; 14:283-290. [PMID: 29856151 PMCID: PMC6031984 DOI: 10.3988/jcn.2018.14.3.283] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 01/05/2018] [Accepted: 01/09/2018] [Indexed: 01/07/2023] Open
Abstract
Background and Purpose The objective of this study was to determine the patterns of blood pressure (BP) changes during the head-up tilt (HUT) test, particularly in terms of its clinical significance for patients with orthostatic hypotension (OH). Methods OH was divided into four categories based on systolic BP changes occurring within the first 10 minutes of the HUT test: sustained orthostatic hypotension (SOH), progressive orthostatic hypotension (POH), orthostatic hypotension with partial recovery (OHPR), and transient orthostatic hypotension (TOH). Results In total, 151 patients were analyzed: 65 with SOH, 38 with POH, 21 with OHPR, and 27 with TOH. POH patients exhibited the greatest reduction in systolic BP after HUT and were also the most likely to develop symptoms requiring early termination of the HUT test (42.1%, p<0.001). Additionally, SOH patients exhibited smaller heart-rate variation with deep breathing values (p=0.003) and Valsalva ratios (p=0.022) compared to POH patients. The sweat volume was greatest in OHPR patients. Conclusions Clinical characteristics, including the findings of autonomic function tests, differed between the OH patient groups. This might reflect differences in the underlying pathophysiologic mechanisms. Determining the patterns of BP changes during the HUT test may facilitate the development of effective management strategies in patients with OH.
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Affiliation(s)
- Hung Youl Seok
- Department of Neurology, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea.,Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Yoo Hwan Kim
- Department of Neurology, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea.,Department of Neurology, Hangang Sacred Heart Hospital, Hallym University Medical Center, Seoul, Korea
| | - Hayom Kim
- Department of Neurology, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea
| | - Byung Jo Kim
- Department of Neurology, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea.
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Dorey TW, O'Brien MW, Robinson SA, Kimmerly DS. Knee-high compression socks minimize head-up tilt-induced cerebral and cardiovascular responses following dynamic exercise. Scand J Med Sci Sports 2018; 28:1766-1774. [PMID: 29575406 DOI: 10.1111/sms.13084] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2018] [Indexed: 11/30/2022]
Abstract
In healthy individuals during a non-exercised state, knee-high compression socks (CS) may reduce the magnitude of lower limb venous pooling during orthostasis but are not effective at minimizing the incidence of pre-syncopal symptoms. However, exaggerated reductions in cerebral blood flow velocity (CBV) and cardiac stroke volume (SV) occur during passive head-up tilt (HUT) testing following dynamic exercise. It is unknown if CS can minimize post-exercise HUT-induced decrements in CBV and SV in this population. To test the hypothesis that CS will attenuate the reductions in SV and CBV during 60° HUT following 60 minutes of moderate-intensity (60% VO2 peak) cycling exercise. Ten healthy volunteers (22.6 ± 2.1 years, 24.1 ± 2.5 kg/m2 ) completed pre- and post-exercise 15-minute HUT tests during randomized CS and Control (no CS) conditions. Changes in blood pressure (finger plethysmography), SV (Modelflow® method), and CBV (Transcranial Doppler) were measured during HUT and preceding supine rest periods. Pre-exercise HUT-induced similar (all, P > .47) reductions in SV (Control; -23.1 ± 11.5%, CS; -20.5 ± 10.9%) and CBV (Control; -18.1 ± 6.3%, CS; -15.3 ± 9.0%). However, larger post-exercise decreases in SV and CBV during HUT were observed in the Control versus CS condition. Specifically, CS attenuated the drop in SV (Control: -32.9 ± 5.6%, CS: -24.3 ± 11.6%; P = .01) and CBV (Control: -25.1 ± 5.8%, CS: -17.6 ± 7.8%; P = .02) during the post-exercise HUT test. These results indicate that CS attenuated HUT-induced reductions in SV and CBV following moderate-intensity cycling exercise and suggest that CS may be an effective countermeasure to reduce the incidence of post-exercise syncope in vulnerable populations.
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Affiliation(s)
- T W Dorey
- School of Health and Human Performance, Division of Kinesiology, Dalhousie University, Halifax, NS, Canada
| | - M W O'Brien
- School of Health and Human Performance, Division of Kinesiology, Dalhousie University, Halifax, NS, Canada
| | - S A Robinson
- School of Health and Human Performance, Division of Kinesiology, Dalhousie University, Halifax, NS, Canada
| | - D S Kimmerly
- School of Health and Human Performance, Division of Kinesiology, Dalhousie University, Halifax, NS, Canada
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Abstract
PURPOSE OF REVIEW Parkinson disease often spans decades of a patient's lifetime. Over time, nonmotor symptoms predominate and may limit dopaminergic therapy. Neurologists continue to play a vital role in treatment. In addition to balancing neurobehavioral complications of Parkinson disease with motor benefit, addressing nonmotor symptoms common in the advanced stage may improve quality of life and reduce symptom burden. Symptoms such as dysphagia, constipation, urinary dysfunction, orthostatic hypotension, and pain respond to nonpharmacologic and pharmacologic therapies. RECENT FINDINGS Evidence for treatment of many nonmotor symptoms is weak or lacking. The evidence for treatment of the atypical parkinsonian syndromes (progressive supranuclear palsy, multiple system atrophy, and corticobasal degeneration) in advanced stages is even more scant. SUMMARY Engaging palliative care physicians in the joint care of patients can provide patients with access to expertise in end-of-life issues. Neurologic illnesses have specific hospice criteria to guide clinicians for referrals. Evidence supports that assisting patients with advance directives can result in improved satisfaction with care and improved quality of life in the last weeks of life. Neurologists can remain engaged in their patients' care throughout the course of illness.
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Kim YH, Phillips V Z, Paik SH, Jeon NJ, Kim BM, Kim BJ. Prefrontal hemodynamic changes measured using near-infrared spectroscopy during the Valsalva maneuver in patients with orthostatic intolerance. NEUROPHOTONICS 2018; 5:015002. [PMID: 29392157 PMCID: PMC5786506 DOI: 10.1117/1.nph.5.1.015002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 01/04/2018] [Indexed: 05/04/2023]
Abstract
The Valsalva maneuver (VM) with beat-to-beat blood pressure and heart rate monitoring are used to evaluate orthostatic intolerance (OI). However, they lack the ability to detect cerebral hemodynamic changes, which may be a cause of OI symptoms. Therefore, we utilized near-infrared spectroscopy during VM. Patients with OI symptoms and normal healthy subjects were recruited. Patients were subgrouped according to VM results: patients with normal VM (NVM) and abnormal VM (AbVM). Oxyhemoglobin (HbO), deoxyhemoglobin, and total hemoglobin changes were measured at four different source-detector distances (SD) (15, 30, 36, and 45 mm), and latency, amplitude, duration, and integrated total signal were calculated. Those parameters were compared between a normal healthy control (HC) group and the two OI patient subgroups. We found that HbO increment latency at 30-mm SD in the HC, NVM, and AbVM groups was as follows: [Formula: see text], [Formula: see text], and [Formula: see text], respectively ([Formula: see text]). Among the four parameters we evaluated, latency of HbO increment was the best marker for differentiating OI.
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Affiliation(s)
- Yoo Hwan Kim
- Hallym University Medical Center, Department of Neurology, Seoul, Republic of Korea
- Korea University Medical Center, Department of Neurology, Seoul, Republic of Korea
| | - Zephaniah Phillips V
- Korea University College of Health Science, Department of Bioconvergence Engineering, Seoul, Republic of Korea
| | - Seung-ho Paik
- Korea University College of Health Science, Department of Bioconvergence Engineering, Seoul, Republic of Korea
| | - Nam-Joon Jeon
- Korea University Anam Hospital, Neurophysiology Laboratory, Seoul, Republic of Korea
| | - Beop-Min Kim
- Korea University College of Health Science, Department of Bioconvergence Engineering, Seoul, Republic of Korea
- Address all correspondence to: Beop-Min Kim, E-mail: ; Byung-Jo Kim, E-mail:
| | - Byung-Jo Kim
- Korea University Medical Center, Department of Neurology, Seoul, Republic of Korea
- Korea University Anam Hospital, Brain Convergence Research Center, Seoul, Republic of Korea
- Address all correspondence to: Beop-Min Kim, E-mail: ; Byung-Jo Kim, E-mail:
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McNicholas T, Tobin K, O'Callaghan S, Kenny RA. Is orthostatic hypotension more common in individuals with atrial fibrillation?-Findings from The Irish Longitudinal Study on Ageing (TILDA). Age Ageing 2017; 46:1006-1010. [PMID: 28985288 DOI: 10.1093/ageing/afx096] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 05/30/2017] [Indexed: 12/17/2022] Open
Abstract
Introduction atrial fibrillation (AF) and orthostatic hypotension (OH) share common risk factors such as age, hypertension and cardiovascular (CV) disease. The autonomic nervous system (ANS) also plays a role in the pathogenesis of both AF and OH. The aim of this study is to assess whether individuals with AF are more likely to have OH than those without AF. Methods data from wave 1 of The Irish Longitudinal Study on Ageing were used. Beat-to-beat blood pressure was measured during active stand lasting 110 s. OH, defined as a drop in systolic blood pressure (SBP) ≥20 mmHg or a drop in diastolic blood pressure ≥10 mmHg at 30, 60 and 90 s was assessed. Initial OH (IOH) was assessed as a drop in SBP ≥40 mmHg or a drop in diastolic BP≥20 mmHg. Results in total 4,408 participants aged ≥50 had active stand and electrocardiogram data suitable for analysis. AF was identified in 101 of these. Logistic regression found participants with AF were more likely to have OH at 30 (odds ratio (OR) 1.95, 95% confidence interval (CI) 1.24-3.06) and 60 (OR 2.13, 95% CI 1.18-3.87) seconds, and IOH (OR 1.81, 95% CI 1.21-2.70). The association between IOH and OH at 30 s remained significant following adjustment for confounders (age, sex, baseline HR, education, BP, smoking, frailty, beta blocker (BB) use, anti-hypertensive use (excluding BBs) and number of CV conditions). Conclusion OH is more common in individuals with AF, this may reflect the role of the ANS in both AF and OH.
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Affiliation(s)
- T McNicholas
- The Irish Longitudinal Study on Ageing, Lincoln gate, Trinity College Dublin, Dublin, Ireland
- Mercer's Institute for Successful Ageing, St James' Hospital, Dublin, Ireland
| | - K Tobin
- The Irish Longitudinal Study on Ageing, Lincoln gate, Trinity College Dublin, Dublin, Ireland
- Global Brain Health Institute, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - S O'Callaghan
- The Irish Longitudinal Study on Ageing, Lincoln gate, Trinity College Dublin, Dublin, Ireland
- Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
| | - R A Kenny
- The Irish Longitudinal Study on Ageing, Lincoln gate, Trinity College Dublin, Dublin, Ireland
- Mercer's Institute for Successful Ageing, St James' Hospital, Dublin, Ireland
- Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
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Barochiner J, Aparicio LS, Alfie J, Rada MA, Morales MS, Galarza CR, Cuffaro PE, Marín MJ, Martínez R, Waisman GD. Hemodynamic characterization of hypertensive patients with an exaggerated orthostatic blood pressure variation. Clin Exp Hypertens 2017; 40:287-291. [PMID: 28895755 DOI: 10.1080/10641963.2017.1368539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Exaggerated orthostatic blood pressure variation (EOV) is a poorly understood phenomenon related to high cardiovascular risk. We aimed to determine whether hypertensive patients with EOV have a distinct hemodynamic pattern, assessed through impedance cardiography. METHODS In treated hypertensive patients, we measured the cardiac index (CI), systemic vascular resistance index (SVRI), blood pressure (BP), and heart rate (HR) in the supine and standing (after 3 minutes) positions, defining three groups according to BP variation: 1) Normal orthostatic BP variation (NOV): standing systolic BP (stSBP)-supine systolic BP (suSBP) between -20 and 20 mmHg and standing diastolic BP (stDBP)-supine diastolic BP (suDBP) between -10 and 10 mmHg; 2) orthostatic hypotension (OHypo): stSBP-suSBP≤-20 or stDBP-suDBP≤-10 mmHg; 3) orthostatic hypertension (OHyper): stSBP-suSBP≥20 or stDBP-suDBP≥10 mmHg. We performed multivariable analyses to determine the association of hemodynamic variables with EOV. RESULTS We included 186 patients. Those with OHyper had lower suDBP and higher orthostatic SVRI variation compared to NOV. In multivariable analyses, orthostatic HR variation (OR = 1.06 (95%CI 1.01-1.13), p = 0.03) and orthostatic SVRI variation (OR = 1.16 (95%CI 1.06-1.28), p = 0.002) were independently related to OHyper. No variables were independently associated with OHypo. CONCLUSION Patients with OHyper have a distinct hemodynamic pattern, with an exaggerated increase in SVRI and HR when standing.
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Affiliation(s)
- Jessica Barochiner
- a Hypertension Section, Internal Medicine Department , Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Lucas S Aparicio
- a Hypertension Section, Internal Medicine Department , Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - José Alfie
- a Hypertension Section, Internal Medicine Department , Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Marcelo A Rada
- a Hypertension Section, Internal Medicine Department , Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Margarita S Morales
- a Hypertension Section, Internal Medicine Department , Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Carlos R Galarza
- a Hypertension Section, Internal Medicine Department , Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Paula E Cuffaro
- a Hypertension Section, Internal Medicine Department , Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Marcos J Marín
- a Hypertension Section, Internal Medicine Department , Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Rocío Martínez
- a Hypertension Section, Internal Medicine Department , Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Gabriel D Waisman
- a Hypertension Section, Internal Medicine Department , Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
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Zhou Y, Ke SJ, Qiu XP, Liu LB. Prevalence, risk factors, and prognosis of orthostatic hypotension in diabetic patients: A systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e8004. [PMID: 28885363 PMCID: PMC6392609 DOI: 10.1097/md.0000000000008004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Orthostatic hypotension (OH) is a major clinical sign of cardiovascular autonomic dysfunction in diabetic patients. Our aim was to quantitatively evaluate the prevalence and risk factors of OH in patients with diabetes mellitus (DM) and assess its prognosis. METHODS A comprehensive search of the PubMed, Embase, China National Knowledge Infrastructure, VIP Chinese Journal, Wanfang, and SINOMED databases was conducted for related published work up to September 25, 2016, and manually searched eligible studies from the references in accordance with the inclusion criteria. RESULTS We included 21 studies in the analysis, with a total sample size of 13,772. The pooled prevalence of OH in DM was 24% (95% confidence interval [CI]: 19-28%). Potential risk factors, that is, glycosylated hemoglobin A (HbA1c) (odds ratio [OR], 1.13, 95% CI, 1.07-1.20), hypertension (OR, 1.02, 95% CI, 1.01-1.02), and diabetic nephropathy (OR, 2.37, 95% CI, 1.76-3.19), were significantly associated with OH in DM. In addition, the prognosis of OH in DM was associated with higher risk of total mortality and cardiovascular events. CONCLUSION The pooled prevalence of OH in DM appears high. HbA1c, hypertension, and diabetic nephropathy are risk factors for OH in DM. OH indicates poor prognosis in diabetic patients. Attention should be focused on diabetic patients with the stated risk factors to prevent OH.
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Hackett KL, Gotts ZM, Ellis J, Deary V, Rapley T, Ng WF, Newton JL, Deane KHO. An investigation into the prevalence of sleep disturbances in primary Sjögren's syndrome: a systematic review of the literature. Rheumatology (Oxford) 2017; 56:570-580. [PMID: 28013207 PMCID: PMC5410987 DOI: 10.1093/rheumatology/kew443] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Indexed: 01/31/2023] Open
Abstract
Objectives. To identify whether sleep disturbances are more prevalent in primary SS (pSS) patients compared with the general population and to recognize which specific sleep symptoms are particularly problematic in this population. Methods. Electronic searches of the literature were conducted in PubMed, Medline (Ovid), Embase (Ovid), PsychINFO (Ovid) and Web of Science and the search strategy registered a priori. Titles and abstracts were reviewed by two authors independently against a set of prespecified inclusion/exclusion criteria, reference lists were examined and a narrative synthesis of the included articles was conducted. Results. Eight whole-text papers containing nine separate studies met the inclusion criteria and were included in the narrative analysis. Few of these studies met all of the quality assessment criteria. The studies used a range of self-reported measures and objective measures, including polysomnography. Mixed evidence was obtained for some of the individual sleep outcomes, but overall compared with controls, pSS patients reported greater subjective sleep disturbances and daytime somnolence and demonstrated more night awakenings and pre-existing obstructive sleep apnoea. Conclusions. A range of sleep disturbances are commonly reported in pSS patients. Further polysomnography studies are recommended to confirm the increased prevalence of night awakenings and obstructive sleep apnoea in this patient group. pSS patients with excessive daytime somnolence should be screened for co-morbid sleep disorders and treated appropriately. Interventions targeted at sleep difficulties in pSS, such as cognitive behavioural therapy for insomnia and nocturnal humidification devices, have the potential to improve quality of life in this patient group and warrant further investigation.
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Affiliation(s)
- Katie L Hackett
- Musculoskeletal Research Group, Institute of Cellular Medicine & NIHR Biomedical Research Centre for Ageing and Chronic Diseases.,Newcastle upon Tyne Hospitals NHS Foundation Trust
| | - Zoe M Gotts
- Institute of Health and Society, Newcastle University
| | - Jason Ellis
- Northumbria Centre for Sleep Research, Faculty of Health and Life Sciences, Northumbria University
| | - Vincent Deary
- Newcastle upon Tyne Hospitals NHS Foundation Trust.,Faculty of Health and Life Sciences, Northumbria University
| | - Tim Rapley
- Institute of Health and Society, Newcastle University
| | - Wan-Fai Ng
- Musculoskeletal Research Group, Institute of Cellular Medicine & NIHR Biomedical Research Centre for Ageing and Chronic Diseases.,Newcastle upon Tyne Hospitals NHS Foundation Trust
| | - Julia L Newton
- Newcastle upon Tyne Hospitals NHS Foundation Trust.,Institute of Cellular Medicine & NIHR Biomedical Research Centre for Ageing and Chronic Diseases, Newcastle upon Tyne
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Sauerbier A, Cova I, Rosa-Grilo M, Taddei RN, Mischley LK, Chaudhuri KR. Treatment of Nonmotor Symptoms in Parkinson's Disease. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2017; 132:361-379. [PMID: 28554415 DOI: 10.1016/bs.irn.2017.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Nonmotor symptoms (NMS) are integral to Parkinson's disease (PD) and the management can often be challenging. In spite of the growing evidence that NMS have a key impact on the quality of life of patients and caregivers, most clinical trials still focus on motor symptoms as primary outcomes. As a consequence strong evidence-based treatment recommendations for NMS occurring in PD are spare. In this chapter, the current data addressing the treatment of major NMS such as sleep, cognitive and autonomic dysfunction, and depression and anxiety are described.
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Affiliation(s)
- Anna Sauerbier
- King's College London and King's College Hospital, London, United Kingdom.
| | - Ilaria Cova
- Center for Research and Treatment on Cognitive Dysfunctions, Institute of Clinical Neurology, Luigi Sacco' Hospital, University of Milan, Milan, Italy
| | - Miguel Rosa-Grilo
- King's College London and King's College Hospital, London, United Kingdom
| | - Raquel N Taddei
- King's College London and King's College Hospital, London, United Kingdom
| | - Laurie K Mischley
- Bastyr University Research Institute, Kenmore, WA, United States; UW Graduate Program in Nutritional Sciences, Seattle, WA, United States; University of Washington (UW), Seattle, WA, United States
| | - K Ray Chaudhuri
- National Parkinson Foundation International Centre of Excellence, Kings College and Kings College Hospital, London, United Kingdom; Maurice Wohl Clinical Neuroscience Institute, Kings College, London, United Kingdom; National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre (BRC) and Dementia Unit at South London and Maudsley NHS Foundation Trust, London, United Kingdom
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Affiliation(s)
- Eun Sook Suh
- Department of Pediatrics, Soonchunhyang University School of Medicine, Seoul, Korea
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Pop-Busui R, Boulton AJM, Feldman EL, Bril V, Freeman R, Malik RA, Sosenko JM, Ziegler D. Diabetic Neuropathy: A Position Statement by the American Diabetes Association. Diabetes Care 2017; 40:136-154. [PMID: 27999003 PMCID: PMC6977405 DOI: 10.2337/dc16-2042] [Citation(s) in RCA: 1179] [Impact Index Per Article: 168.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Rodica Pop-Busui
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | | | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor, MI
| | - Vera Bril
- Department of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, Boston, MA
| | - Rayaz A Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar and New York, NY
| | - Jay M Sosenko
- Division of Endocrinology, University of Miami Miller School of Medicine, Miami, FL
| | - Dan Ziegler
- German Diabetes Center Düsseldorf, Leibniz Center for Diabetes Research at Heinrich Heine University, and Department of Endocrinology and Diabetology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
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Chang CH, Lee KY, Shim YH. Normal aging: definition and physiologic changes. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2017. [DOI: 10.5124/jkma.2017.60.5.358] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Chul Ho Chang
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ki-Young Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Yon Hee Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Kim JS, Ryu DW, Oh JH, Lee YH, Park SJ, Jeon K, Lee JY, Ho SH, So J, Im JH, Lee KS. Cardiovascular Autonomic Dysfunction in Patients with Drug-Induced Parkinsonism. J Clin Neurol 2016; 13:15-20. [PMID: 27730767 PMCID: PMC5242160 DOI: 10.3988/jcn.2017.13.1.15] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 05/07/2016] [Accepted: 05/10/2016] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND AND PURPOSE Recent studies have shown that several nonmotor symptoms differ between Parkinson's disease (PD) and drug-induced parkinsonism (DIP). However, there have been no reports on cardiovascular autonomic function in DIP, and so this study investigated whether cardiovascular autonomic function differs between PD and DIP patients. METHODS This study consecutively enrolled 20 DIP patients, 99 drug-naïve PD patients, and 25 age-matched healthy controls who underwent head-up tilt-table testing and 24-h ambulatory blood pressure monitoring. RESULTS Orthostatic hypotension was more frequent in patients with PD or DIP than in healthy controls. In DIP, orthostatic hypotension was associated with the underlying psychiatric diseases and neuroleptics use, whereas prokinetics were not related to orthostatic hypotension. The supine blood pressure, nighttime blood pressure, and nocturnal blood pressure dipping did not differ significantly between the DIP and control groups. Supine hypertension and nocturnal hypertension were more frequent in PD patients than in controls. CONCLUSIONS The included DIP patients frequently exhibited orthostatic hypotension that was associated with the underlying diseases as well as the nature of and exposure time to the offending drugs. Clinicians should individualize the manifestations of DIP according to underlying diseases as well as the action mechanism of and exposure time to each offending drug.
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Affiliation(s)
- Joong Seok Kim
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Dong Woo Ryu
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ju Hee Oh
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yang Hyun Lee
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Jin Park
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kipyung Jeon
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Yun Lee
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seong Hee Ho
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jungmin So
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Hee Im
- Department of Neurology, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Kwang Soo Lee
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Briggler AM, Egloff HM, Ratelle JT. 55-Year-Old Woman With Recurrent Syncope. Mayo Clin Proc 2016; 91:1467-1470. [PMID: 27502462 DOI: 10.1016/j.mayocp.2016.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 03/14/2016] [Accepted: 03/16/2016] [Indexed: 11/20/2022]
Affiliation(s)
- Andrew M Briggler
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN
| | - Heidi M Egloff
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN
| | - John T Ratelle
- Advisor to residents and Consultant in Hospital Internal Medicine, Mayo Clinic, Rochester, MN.
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Costa A, Bosone D, Ramusino MC, Ghiotto N, Guaschino E, Zoppi A, D'Angelo A, Fogari R. Twenty-four-hour blood pressure profile, orthostatic hypotension, and cardiac dysautonomia in elderly type 2 diabetic hypertensive patients. Clin Auton Res 2016; 26:433-439. [PMID: 27624333 DOI: 10.1007/s10286-016-0381-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 07/24/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE The aim of this study was to evaluate the relationship between orthostatic hypotension (OH), defined as a decrease in systolic blood pressure (SBP) ≥20 mmHg and/or a decrease in diastolic blood pressure (DBP) ≥10 mmHg, and 24-h ambulatory BP profile in elderly hypertensive type 2 diabetic patients. METHODS After a 2-week antihypertensive wash-out period, 200 hypertensive well-controlled diabetic outpatients, aged 65-75 years, underwent a clinical examination, including BP measurements, ECG, 24-h ABP monitoring (ABPM), an orthostatic test, and three tests for cardiovascular autonomic function assessment [deep breathing, heart rate (HR) variability, resting HR]. RESULTS According to their nighttime BP profile, patients were divided into three groups: dippers (n = 86) (BP fall during nighttime ≥10 %), non-dippers (n = 80) (BP fall during nighttime 0-10 %), and reverse dippers (n = 34) (nighttime BP > daytime BP). Orthostatic test produced a significantly greater orthostatic SBP fall in dippers and even more in reverse dippers. In these latter, a significant fall was observed also in DBP. Prevalence of OH was 9.3 % in dippers, 30 % in non-dippers, and 79.4 % in reverse dippers. CONCLUSIONS In elderly hypertensive type 2 diabetics, a blunted nocturnal BP fall is associated with OH and autonomic dysfunction. These data suggest that ABPM should be performed in the assessment of hypertensive diabetic patients in whom the cardiovascular dysautonomia is suspected or the signs of it are present (such as OH).
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Affiliation(s)
- Alfredo Costa
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Daniele Bosone
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Matteo Cotta Ramusino
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Natascia Ghiotto
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Elena Guaschino
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Annalisa Zoppi
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Angela D'Angelo
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Roberto Fogari
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy.
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Clinical benefit of midodrine hydrochloride in symptomatic orthostatic hypotension: a phase 4, double-blind, placebo-controlled, randomized, tilt-table study. Clin Auton Res 2016; 26:269-77. [PMID: 27372462 PMCID: PMC4951503 DOI: 10.1007/s10286-016-0363-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 05/16/2016] [Indexed: 12/13/2022]
Abstract
Objective Midodrine hydrochloride is a short-acting pressor agent that raises blood pressure in the upright position in patients with orthostatic hypotension. The US Food and Drug Administration’s Subpart H approval, under which midodrine was initially approved, requires post-marketing studies to confirm midodrine’s clinical benefit in this indication. The purpose of this study was to evaluate the clinical benefit of midodrine with regard to symptom response. Methods This was a double-blind, placebo-controlled, randomized, crossover, multicenter study (NCT01518946). Following screening, patients aged ≥18 years with severe symptomatic orthostatic hypotension and on a stable dose of midodrine for at least 3 months were randomized to treatment with either their previous midodrine dose or placebo on day 1 and the respective alternate treatment on day 2. The primary endpoint measured time to syncopal symptoms or near-syncope using a 45-min tilt-table test at 1 h post-dose. Results Thirty-three patients were screened for inclusion: 19 received at least one dose of midodrine and had at least one post-dose measurement of the primary endpoint. The least-squares mean time to syncopal symptoms or near-syncope after tilt-table initiation (mean ± standard error) was 1626.6 ± 186.8 s for midodrine and 1105.6 ± 186.8 s for placebo (difference, 521.0 s; 95 % confidence interval 124.2–971.7 s; p = 0.0131). There were 15 adverse events in 10 patients; all of these were mild or moderate in severity, with none considered by the investigators to be related to midodrine. Interpretation Midodrine is a well-tolerated and clinically effective treatment for symptomatic orthostatic hypotension.
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Soysal P, Aydin AE, Koc Okudur S, Isik AT. When should orthostatic blood pressure changes be evaluated in elderly: 1st, 3rd or 5th minute? Arch Gerontol Geriatr 2016; 65:199-203. [DOI: 10.1016/j.archger.2016.03.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 03/27/2016] [Accepted: 03/29/2016] [Indexed: 10/22/2022]
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Jones GD, James DC, Thacker M, Jones EJ, Green DA. Sit-to-walk and sit-to-stand-and-walk task dynamics are maintained during rising at an elevated seat-height independent of lead-limb in healthy individuals. Gait Posture 2016; 48:226-229. [PMID: 27336849 DOI: 10.1016/j.gaitpost.2016.06.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 06/04/2016] [Accepted: 06/06/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Sit-to-walk (STW) is a common transitional motor task not usually included in rehabilitation. Typically, sit-to-stand (STS), pause, then gait initiation (GI) before walking is used, which we term sit-to-stand-and-walk (STSW). Separation between centre-of-pressure (COP) and whole-body centre-of-mass (BCOM) during GI is associated with dynamic postural stability. Rising from seats higher than knee-height (KH) is more achievable for patients, but whether this and/or lead-limb significantly affects task dynamics is unclear. This study tested whether rising from seat-heights and lead-limb affects STW and STSW task dynamics in young healthy individuals. METHODS Ten (5F) young (29±7.7 years) participants performed STW and STSW from a standardised position. Five trials of each task were completed at 100 and 120%KH leading with dominant and non-dominant legs. Four force-plates and optical motion capture delineated key movement events and phases with effect of seat-height and lead-limb determined by 2-way ANOVA within tasks. RESULTS At 120%KH, lower peak vertical ground-reaction-forces (vGRFs) and vertical BCOM velocities were observed during rising irrespective of lead-limb. No other parameters differed between seat-heights or lead-limbs. During GI in STSW there was more lateral, and less posterior, COP excursion than expected. CONCLUSION Reduction in vGRFs and velocity during rising at 120%KH is consistent with reduced effort in young healthy individuals and is likely therefore to be an appropriate seat-height for patients. Lead-limb had no effect upon STSW or STW parameters suggesting that normative data independent of lead-limb can be utilised to monitor motor rehabilitation should differences be observed in patients. STSW should be considered an independent movement transition.
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Affiliation(s)
- Gareth D Jones
- Centre of Human & Aerospace Physiological Sciences, King's College London, UK; Guy's & St Thomas' NHS Foundation Trust Physiotherapy Department, London, UK.
| | - Darren C James
- School of Applied Sciences, London South Bank University, London, UK
| | - Michael Thacker
- Centre of Human & Aerospace Physiological Sciences, King's College London, UK; Guy's & St Thomas' NHS Foundation Trust Physiotherapy Department, London, UK
| | - Eleanor J Jones
- Centre of Human & Aerospace Physiological Sciences, King's College London, UK
| | - David A Green
- Centre of Human & Aerospace Physiological Sciences, King's College London, UK
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Neurocardiovascular Instability and Cognition. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2016; 89:59-71. [PMID: 27505017 PMCID: PMC4797838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Neurocardiovascular instability (NCVI) refers to abnormal neural control of the cardiovascular system affecting blood pressure and heart rate behavior. Autonomic dysfunction and impaired cerebral autoregulation in aging contribute to this phenomenon characterized by hypotension and bradyarrhythmia. Ultimately, this increases the risk of falls and syncope in older people. NCVI is common in patients with neurodegenerative disorders including dementia. This review discusses the various syndromes that characterize NCVI icluding hypotension, carotid sinus hypersensitivity, postprandial hypotension and vasovagal syncope and how they may contribute to the aetiology of cognitive decline. Conversely, they may also be a consequence of a common neurodegenerative process. Regardless, recognition of their association is paramount in optimizing management of these patients.
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Sousa AGP, Cabral JVDS, El-Feghaly WB, Sousa LSD, Nunes AB. Hyporeninemic hypoaldosteronism and diabetes mellitus: Pathophysiology assumptions, clinical aspects and implications for management. World J Diabetes 2016; 7:101-111. [PMID: 26981183 PMCID: PMC4781902 DOI: 10.4239/wjd.v7.i5.101] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 01/12/2016] [Accepted: 01/29/2016] [Indexed: 02/05/2023] Open
Abstract
Patients with diabetes mellitus (DM) frequently develop electrolyte disorders, including hyperkalemia. The most important causal factor of chronic hyperkalemia in patients with diabetes is the syndrome of hyporeninemic hypoaldosteronism (HH), but other conditions may also contribute. Moreover, as hyperkalemia is related to the blockage of the renin-angiotensin-aldosterone system (RAAS) and HH is most common among patients with mild to moderate renal insufficiency due to diabetic nephropathy (DN), the proper evaluation and management of these patients is quite complex. Despite its obvious relationship with diabetic nephropathy, HH is also related to other microvascular complications, such as DN, particularly the autonomic type. To confirm the diagnosis, plasma aldosterone concentration and the levels of renin and cortisol are measured when the RAAS is activated. In addition, synthetic mineralocorticoid and/or diuretics are used for the treatment of this syndrome. However, few studies on the implications of HH in the treatment of patients with DM have been conducted in recent years, and therefore little, if any, progress has been made. This comprehensive review highlights the findings regarding the epidemiology, diagnosis, and management recommendations for HH in patients with DM to clarify the diagnosis of this clinical condition, which is often neglected, and to assist in the improvement of patient care.
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Kim JS, Oh YS, Park HE, Lee SH, Park JW, Song IU, An JY, Park HJ, Son BC, Lee KS. Cardiovascular autonomic dysfunctions in elderly patients with essential tremor: comparison with healthy controls. Neurol Sci 2016; 37:711-6. [PMID: 26728270 DOI: 10.1007/s10072-015-2465-x] [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: 10/14/2015] [Accepted: 12/22/2015] [Indexed: 11/24/2022]
Abstract
Questionnaire-based analyses show that patients with essential tremor (ET) may have several autonomic dysfunctions, especially in the cardiovascular and genitourinary domains; yet the laboratory correlates of autonomic dysfunction in ET are unknown and have not been studied. Herein, we explored whether sympathetic and parasympathetic functions differed between control subjects and patients with ET. Seventy-five elderly patients with ET were enrolled in this study, along with 25 age-matched controls. Orthostatic vital signs, ambulatory 24-h blood pressure monitoring and 24-h Holter monitoring values were recorded and metaiodobenzylguanidine (MIBG) uptake was assessed using the heart-to-mediastinum ratio (H/M ratio). The frequencies of orthostatic hypotension, supine hypertension, nocturnal hypertension and non-dipping were not different between the ET patients and the controls, although ET patients had more episodes of orthostatic intolerance. The ET group also had similar heart rate variations as the control group for all the time-domains. The mean H/M ratios for the ET group were not statistically different from that of the control group. This result proves that the autonomic control of the cardiovascular system is normal in ET.
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Affiliation(s)
- Joong-Seok Kim
- Department of Neurology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, 06591, Seoul, Republic of Korea.
| | - Yoon-Sang Oh
- Department of Neurology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, 06591, Seoul, Republic of Korea
| | - Hyung-Eun Park
- Department of Neurology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, 06591, Seoul, Republic of Korea
| | - Si-Hoon Lee
- Department of Neurology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, 06591, Seoul, Republic of Korea
| | - Jeong-Wook Park
- Department of Neurology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, 06591, Seoul, Republic of Korea
| | - In-Uk Song
- Department of Neurology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, 06591, Seoul, Republic of Korea
| | - Jae-Young An
- Department of Neurology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, 06591, Seoul, Republic of Korea
| | - Hun-Jun Park
- Department of Cardiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byung-Chul Son
- Department of Neurosurgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kwang-Soo Lee
- Department of Neurology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, 06591, Seoul, Republic of Korea
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Gaspar L, Kruzliak P, Komornikova A, Celecova Z, Krahulec B, Balaz D, Sabaka P, Caprnda M, Kucera M, Rodrigo L, Uehara Y, Dukat A. Orthostatic hypotension in diabetic patients-10-year follow-up study. J Diabetes Complications 2016; 30:67-71. [PMID: 26412028 DOI: 10.1016/j.jdiacomp.2015.08.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 08/26/2015] [Accepted: 08/27/2015] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Cardiovascular autonomic neuropathy in diabetics is a common but often underestimated and underdiagnosed complication of diabetes mellitus. One of the most clinical apparent forms of cardiovascular autonomic neuropathy is orthostatic hypotension. OBJECTIVES To retrospectively assess the association of the orthostatic hypotension (OH) with macrovascular and microvascular complications of diabetes mellitus and to determine its effect on mortality. DESIGN AND METHODS We retrospectively analyzed 187 patients with diabetes mellitus (60 patients with diabetes type 1 and 127 patients with diabetes type 2). Patients were divided into groups according to presence or absence of OH and type of diabetes. Association of OH with macrovascular and microvascular complications was evaluated and the effect of OH on 10-year all-cause mortality was also assessed. RESULTS OH was present in 31.7% of patients with diabetes type 1 (DM1) and in 32.3% of patients with diabetes type 2 (DM2). OH was positively associated with the prevalence of myocardial infarction in DM1 (OR=10.67) and with prevalence of stroke in DM2 (OR=3.33). There was also a strong association of OH and the prevalence of peripheral artery disease in both DM1 (OR=14.18) and DM2 (OR=3.26). Patients with both types of diabetes and OH had significantly higher prevalence of nephropathy (DM1 OR=8.68, DM2 OR=3.24), retinopathy (DM1 OR=8.09, DM2 OR=4.08) and peripheral neuropathy (DM1 OR=17.14, DM2 OR=7.51) Overall 10year mortality rate was higher in diabetic patients with OH. CONCLUSIONS Presence of OH in diabetics is associated with higher prevalence of macrovascular and microvascular complications of diabetes mellitus and also with higher 10-year mortality.
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Affiliation(s)
- Ludovit Gaspar
- 2(nd) Department of Internal Medicine, Comenius University and University Hospital, Bratislava, Slovak Republic.
| | - Peter Kruzliak
- 2(nd) Department of Internal Medicine, St. Anne's University Hospital and Masaryk University, Brno, Czech Republic.
| | - Andrea Komornikova
- 2(nd) Department of Internal Medicine, Comenius University and University Hospital, Bratislava, Slovak Republic
| | - Zuzana Celecova
- 2(nd) Department of Internal Medicine, Comenius University and University Hospital, Bratislava, Slovak Republic
| | - Boris Krahulec
- 2(nd) Department of Internal Medicine, Comenius University and University Hospital, Bratislava, Slovak Republic
| | - David Balaz
- 2(nd) Department of Internal Medicine, Comenius University and University Hospital, Bratislava, Slovak Republic
| | - Peter Sabaka
- 2(nd) Department of Internal Medicine, Comenius University and University Hospital, Bratislava, Slovak Republic
| | - Martin Caprnda
- 2(nd) Department of Internal Medicine, Comenius University and University Hospital, Bratislava, Slovak Republic
| | - Marek Kucera
- 2(nd) Department of Internal Medicine, Comenius University and University Hospital, Bratislava, Slovak Republic
| | - Luis Rodrigo
- Department of Gastroenterology, Central University Hospital of Asturias (HUCA), Oviedo, Spain
| | - Yoshio Uehara
- Division of Clinical Nutrition, Faculty of Home Economics, Kyoritsu Women's University, Tokyo, Japan
| | - Andrej Dukat
- 2(nd) Department of Internal Medicine, Comenius University and University Hospital, Bratislava, Slovak Republic
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