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Criado JR, Kalafut MA. Physiological Targets for Orthostatic Hypotension: Improving Nonpharmacological Interventions in Patients with Orthostatic Cerebral Hypoperfusion. Appl Psychophysiol Biofeedback 2024; 49:383-393. [PMID: 38809485 DOI: 10.1007/s10484-024-09646-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
Orthostatic hypotension (OH) is a form of orthostatic intolerance (OI) and a key physiological indicator of autonomic dysfunction that is associated with an increased risk of major cerebrocardiovascular events. Symptoms of cerebral hypoperfusion have been reported in patients with OH, which worsens symptoms and increases the risk of syncope. Since pharmacological interventions increase blood pressure (BP) independent of posture and do not restore normal baroreflex control, nonpharmacological treatments are considered the foundation of OH management. While reductions in cerebral blood flow velocity (CBFv) during orthostatic stress are associated with a decrease in end-tidal CO2 (EtCO2) and hypocapnia in patients with OI, their contribution to the severity of OH is not well understood. These measures have been physiological targets in a wide variety of biofeedback interventions. This study explored the relationship between cardiovascular autonomic control, EtCO2 and cerebral hypoperfusion in patients (N = 72) referred for OI. Patients with systolic OH were more likely to be male, older, demonstrate reduced adrenal and vagal baroreflex sensitivity, and reduced cardiovagal control during head-up tilt (HUT) than patients without systolic OH. Greater reduction in CBFv during HUT was associated with a larger reduction in ETCO2 and systolic BP during HUT. While deficits in cardiovascular autonomic control played a more important role in systolic OH, reduced EtCO2 was a major contributor to orthostatic cerebral hypoperfusion. These findings suggest that biofeedback treatments targeting both the autonomic nervous system and EtCO2 should be part of nonpharmacological interventions complementing the standard of care in OH patients with symptoms of cerebral hypoperfusion.
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Affiliation(s)
- José R Criado
- Division of Neurology, Autonomic Neuro Lab, Scripps Clinic, 9898 Genesee Ave., La Jolla, CA, 92037, USA
| | - Mary A Kalafut
- Division of Neurology, Autonomic Neuro Lab, Scripps Clinic, 9898 Genesee Ave., La Jolla, CA, 92037, USA.
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2
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Lamotte G, McKee KE, Luthra NS, Corcos DM. Advice to People with Parkinson's in My Clinic: Orthostatic Hypotension. JOURNAL OF PARKINSON'S DISEASE 2024:JPD240149. [PMID: 39093080 DOI: 10.3233/jpd-240149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Orthostatic hypotension (OH) is the most common manifestation of cardiovascular autonomic dysfunction in Parkinson's disease. In this viewpoint, we discuss five practical questions regarding OH in Parkinson's disease: 1) How common is the problem? 2) Why should people with Parkinson's disease and providers care about OH? 3) What are the symptoms of OH? 4) How to confirm a diagnosis of OH? And 5) How to treat OH? OH is an important non-motor symptom of Parkinson's disease for which we have available treatments to significantly mitigate morbidity and possibly positively impact the disease course.
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Affiliation(s)
- Guillaume Lamotte
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
- George E. Wahlen VA Medical Center, Salt Lake City, UT, USA
| | - Kathleen E McKee
- Neurosciences Clinical Program, Intermountain Health, Murray, UT, USA
| | - Nijee S Luthra
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Daniel M Corcos
- Department of Physical Therapy & Human Movement Sciences, Northwestern University, Chicago, IL, USA
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3
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Cronin P, Collins LM, Sullivan AM. Impacts of gait freeze on quality of life in Parkinson's disease, from the perspectives of patients and their carers. Ir J Med Sci 2024; 193:2041-2050. [PMID: 38639839 PMCID: PMC11294397 DOI: 10.1007/s11845-024-03673-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/15/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND The World Health Organisation (WHO) reports that morbidity and mortality due to Parkinson's disease (PD) are increasing faster than for other neurodegenerative conditions. People with Parkinson's (PwP) present with a variety of motor symptoms, such as tremor, bradykinesia, and rigidity. Freezing of gait (FoG) is a significant motor symptom that manifests as temporary episodes of inability to move one's feet, despite the intention to walk. AIMS This study examined the impact of FoG on quality of life (QoL) within an Irish cohort of PwP, from the perspectives of both PwP and their carers, using validated questionnaires that had been adapted for online use. METHODS PwP and their carers were recruited by outreach to the Irish Parkinson's Community. Anonymous online questionnaires were distributed, which combined a demographic survey with several clinically validated surveys, including Freezing of Gait Questionnaire (FoG-Q), Parkinson's Disease Questionnaire 8 (PDQ-8), and Parkinson's Disease Carer Questionnaire (PDQ-C). RESULTS There was a strong correlation (p < 0.001) between severity of FoG and lower QoL among PwP. Significant correlation was also found between FoG severity and several motor symptoms, such as postural instability and difficulty with balance, and non-motor symptoms, such as cognitive changes and pain/discomfort. FoG severity correlated with disease progression. Significant correlation was also found between FoG and symptoms, as assessed from the perspective of the patients' carers. CONCLUSIONS This study shows that FoG is a significant detriment to the QoL of PwP, from the perspectives of patients and carers. This method of assessing FoG and QoL using online questionnaires has potential to enhance the reach and flexibility of this type of research. These findings will inform future studies on larger cohorts and highlight unmet clinical needs in PwP.
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Affiliation(s)
- Padraig Cronin
- Department of Anatomy and Neuroscience, School of Medicine, University College Cork, Cork, Ireland
- Parkinson's Disease Research Cluster, University College Cork, Cork, Ireland
| | - Lucy M Collins
- Department of Anatomy and Neuroscience, School of Medicine, University College Cork, Cork, Ireland
- Parkinson's Disease Research Cluster, University College Cork, Cork, Ireland
| | - Aideen M Sullivan
- Department of Anatomy and Neuroscience, School of Medicine, University College Cork, Cork, Ireland.
- Parkinson's Disease Research Cluster, University College Cork, Cork, Ireland.
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Cucinotta F, Swinnen B, Makovac E, Hirschbichler S, Pereira E, Little S, Morgante F, Ricciardi L. Short term cardiovascular symptoms improvement after deep brain stimulation in patients with Parkinson's disease: a systematic review. J Neurol 2024; 271:3764-3776. [PMID: 38809271 PMCID: PMC11233308 DOI: 10.1007/s00415-024-12459-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/19/2024] [Accepted: 05/17/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Autonomic dysfunction is common and disabling in Parkinson's disease (PD). The effects of deep brain stimulation (DBS) on the cardiovascular system in PD remain poorly understood. We aimed to assess the effect of DBS on cardiovascular symptoms and objective measures in PD patients. METHODS We conducted a systematic literature search in PubMed/MEDLINE. RESULTS 36 out of 472 studies were included, mostly involving DBS of the subthalamic nucleus, and to a lesser extent the globus pallidus pars interna and pedunculopontine nucleus. Seventeen studies evaluated the effect of DBS on patient-reported or clinician-rated cardiovascular symptoms, showing an improvement in the first year after surgery but not with longer-term follow-up. DBS has no clear direct effects on blood pressure during an orthostatic challenge (n = 10 studies). DBS has inconsistent effects on heart rate variability (n = 10 studies). CONCLUSION Current evidence on the impact of DBS on cardiovascular functions in PD is inconclusive. DBS may offer short-term improvement of cardiovascular symptoms in PD, particularly orthostatic hypotension, which may be attributed to dopaminergic medication reduction after surgery. There is insufficient evidence to draw conclusions on the direct effect of DBS on blood pressure and heart rate variability.
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Affiliation(s)
- Francescopaolo Cucinotta
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Neurosciences and Cell Biology Institute, Neuromodulation and Motor Control Section, St George's University of London, London, UK
| | - Bart Swinnen
- UCSF, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
- UCSF, Weill Institute for Neurosciences, Movement Disorders and Neuromodulation Centre, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology and Clinical Neurophysiology, Amsterdam Neuroscience, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Elena Makovac
- Neurosciences and Cell Biology Institute, Neuromodulation and Motor Control Section, St George's University of London, London, UK
- Centre for Neuroimaging Science, King's College, London, UK
- Brunel University London, Uxbridge, UK
| | - Stephanie Hirschbichler
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria
- Department of Neurology, University Hospital St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Austria
| | - Erlick Pereira
- Neurosciences and Cell Biology Institute, Neuromodulation and Motor Control Section, St George's University of London, London, UK
| | - Simon Little
- UCSF, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
- UCSF, Weill Institute for Neurosciences, Movement Disorders and Neuromodulation Centre, University of California San Francisco, San Francisco, CA, USA
| | - Francesca Morgante
- Neurosciences and Cell Biology Institute, Neuromodulation and Motor Control Section, St George's University of London, London, UK
| | - Lucia Ricciardi
- Neurosciences and Cell Biology Institute, Neuromodulation and Motor Control Section, St George's University of London, London, UK.
- UCSF, Weill Institute for Neurosciences, Movement Disorders and Neuromodulation Centre, University of California San Francisco, San Francisco, CA, USA.
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Zhao B, Jia W, Yuan Y, Chen Y, Gao Y, Yang B, Zhao W, Wu J. Impact of blood pressure variability and cerebral small vessel disease: A systematic review and meta-analysis. Heliyon 2024; 10:e33264. [PMID: 39022036 PMCID: PMC11252957 DOI: 10.1016/j.heliyon.2024.e33264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 07/20/2024] Open
Abstract
Importance Abnormal blood pressure pattern is an independent risk factor for vascular events. Blood pressure variability can predict cardiovascular and cerebrovascular disease outcomes and is closely associated with the risk of cognitive impairment. However, the relationship between blood pressure variability and cerebral small vessel disease neuroimaging markers remains unclear. This study aimed to evaluate the relationship between blood pressure variability and cerebral small vessel disease neuroimaging markers. Data sources We searched multiple databases, including Embase, Web of Science, PubMed, Cochrane Library, UpToDate, and World of Science, from their inception until November 27, 2023.Main Outcomes and Measures: A meta-analysis of 19 observational studies involving 14519 participants was performed. Findings: ①Systolic blood pressure variability was correlated with the cerebral small vessel disease total burden, white matter hyperintensities and lacunar infarction; ② Diastolic blood pressure variability was correlated with the cerebral small vessel disease total burden, white matter hyperintensities and cerebral microbleeds; ③ Non-dipping patterns were correlated with white matter hyperintensities and lacunar infarction. ④ Reverse-dipping patterns were significantly correlated with white matter hyperintensities and cerebral microbleeds. Conclusions and Relevance: Blood pressure variability correlates with neuroimaging markers of cerebral small vessel disease and its burden. Hence, early monitoring and intervention of blood pressure variability may be essential for the early diagnosis, prevention and treatment of cerebral small vessel disease.
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Affiliation(s)
- Bingqing Zhao
- Department of Neurology, Beijing Shijingshan Hospital Capital Medical University Shjingshan Teaching Hospital, China
| | - Weihua Jia
- Department of Neurology, Beijing Shijingshan Hospital Capital Medical University Shjingshan Teaching Hospital, China
| | - Ye Yuan
- Department of Neurology, Beijing Shijingshan Hospital Capital Medical University Shjingshan Teaching Hospital, China
| | - Ying Chen
- Department of Neurology, Beijing Shijingshan Hospital Capital Medical University Shjingshan Teaching Hospital, China
| | - Yali Gao
- Department of Neurology, Beijing Shijingshan Hospital Capital Medical University Shjingshan Teaching Hospital, China
| | - Baoling Yang
- Department of Neurology, Beijing Shijingshan Hospital Capital Medical University Shjingshan Teaching Hospital, China
| | - Wei Zhao
- Department of Neurology, Beijing Shijingshan Hospital Capital Medical University Shjingshan Teaching Hospital, China
| | - Jingyi Wu
- University of Glasgow, United kingdom
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Calvi A, Bongrani A, Verzicco I, Figus G, Vicini V, Coghi P, Montanari A, Cabassi A. Urinary hyaluronidase activity is closely related to vasopressinergic system following an oral water load in men: a potential role in blood pressure regulation and early stages of hypertension development. Front Endocrinol (Lausanne) 2024; 15:1346082. [PMID: 38982989 PMCID: PMC11231081 DOI: 10.3389/fendo.2024.1346082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 05/29/2024] [Indexed: 07/11/2024] Open
Abstract
Introduction Blood pressure (BP) regulation is a complex process involving several factors, among which water-sodium balance holds a prominent place. Arginin-vasopressin (AVP), a key player in water metabolism, has been evoked in hypertension development since the 1980s, but, to date, the matter is still controversial. Hyaluronic acid metabolism has been reported to be involved in renal water management, and AVP appears to increase hyaluronidase activity resulting in decreased high-molecular-weight hyaluronan content in the renal interstitium, facilitating water reabsorption in collecting ducts. Hence, our aim was to evaluate urinary hyaluronidase activity in response to an oral water load in hypertensive patients (HT, n=21) compared to normotensive subjects with (NT+, n=36) and without (NT-, n=29) a family history of hypertension, and to study its association with BP and AVP system activation, expressed by serum copeptin levels and urine Aquaporin 2 (AQP2)/creatinine ratio. Methods Eighty-six Caucasian men were studied. Water load test consisted in oral administration of 15-20 ml of water/kg body weight over 40-45 min. BP, heart rate, serum copeptin, urine hyaluronidase activity and AQP2 were monitored for 4 hours. Results In response to water drinking, BP raised in all groups with a peak at 20-40 min. Baseline levels of serum copeptin, urinary hyaluronidase activity and AQP2/creatinine ratio were similar among groups and all decreased after water load, reaching their nadir at 120 min and then gradually recovering to baseline values. Significantly, a blunted reduction in serum copeptin, urinary hyaluronidase activity and AQP2/creatinine ratio was observed in NT+ compared to NT- subjects. A strong positive correlation was also found between urinary hyaluronidase activity and AQP2/creatinine ratio, and, although limited to the NT- group, both parameters were positively associated with systolic BP. Discussion Our results demonstrate for the first time the existence in men of a close association between urinary hyaluronidase activity and vasopressinergic system and suggest that NT+ subjects have a reduced ability to respond to water loading possibly contributing to the blood volume expansion involved in early-stage hypertension. Considering these data, AVP could play a central role in BP regulation by affecting water metabolism through both hyaluronidase activity and AQP2 channel expression.
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Affiliation(s)
- Anna Calvi
- Clinica e Terapia Medica, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Alice Bongrani
- Cardiorenal and Hypertension Research Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Ignazio Verzicco
- Clinica e Terapia Medica, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Giuliano Figus
- Clinica e Terapia Medica, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Vanni Vicini
- Clinica e Terapia Medica, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Pietro Coghi
- Clinica e Terapia Medica, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Alberto Montanari
- Cardiorenal and Hypertension Research Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Aderville Cabassi
- Clinica e Terapia Medica, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
- Cardiorenal and Hypertension Research Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
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D'Ippolito I, Carlucci MA, D'Amato C, Lauro D, Spallone V. Determinants of Orthostatic Hypotension in Type 2 Diabetes: Is Cardiac Autonomic Neuropathy the Main Factor? Endocr Pract 2024:S1530-891X(24)00563-9. [PMID: 38908717 DOI: 10.1016/j.eprac.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/11/2024] [Accepted: 06/12/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVES To evaluate the determinants of orthostatic hypotension (OH) in type 2 diabetes (T2D) and the usefulness of Δheart rate (HR)/Δsystolic blood pressure (SBP), index of cardiac baroreflex function, in identifying neurogenic OH. METHODS In 208 participants with T2D, we diagnosed early cardiovascular autonomic neuropathy (CAN) and confirmed CAN according to 1 and 2 HR-based cardiovascular reflex tests (HR-CARTs). Through OH test we defined OH as SBP falls of ≥20 and ≥30 mm Hg with supine SBPs of <140 and ≥140 mm Hg, respectively. In participants with OH, we used the lying-to-standing and OH test and its diagnostic accuracy for neurogenic OH (as OH plus confirmed HR-CAN). RESULTS OH was present in 25 participants and associated with lower HR-CART scores, higher glycosylated hemoglobin level, the presence of CAN, retinopathy, and peripheral vascular disease, the absence of hypertension, and physical activity (all, P < .05) but not with interfering drugs and β-blockers. In a multiple logistic regression, HR-CAN was the main determinant of OH (odds ratio, 4.74) with physical activity and hypertension (odds ratios, 0.16 and 0.23; R2 = 0.22). ΔHR/ΔSBP had a good diagnostic accuracy for neurogenic OH (area under the receiver operating characteristic curve, 0.816 ± 0.087) and, at the cutoff of 0.5 bpm/mm Hg, a sensitivity of 100% and specificity of 63.2%. CONCLUSION CAN remains the primary determinant of OH in T2D but does not explain all its variance. The index ΔHR/ΔSBP may represent a useful clinical tool to identify neurogenic OH.
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Affiliation(s)
- Ilenia D'Ippolito
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Myriam Angelica Carlucci
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Cinzia D'Amato
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Davide Lauro
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Vincenza Spallone
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy.
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8
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Fedorowski A, Fanciulli A, Raj SR, Sheldon R, Shibao CA, Sutton R. Cardiovascular autonomic dysfunction in post-COVID-19 syndrome: a major health-care burden. Nat Rev Cardiol 2024; 21:379-395. [PMID: 38163814 DOI: 10.1038/s41569-023-00962-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 01/03/2024]
Abstract
Cardiovascular autonomic dysfunction (CVAD) is a malfunction of the cardiovascular system caused by deranged autonomic control of circulatory homeostasis. CVAD is an important component of post-COVID-19 syndrome, also termed long COVID, and might affect one-third of highly symptomatic patients with COVID-19. The effects of CVAD can be seen at both the whole-body level, with impairment of heart rate and blood pressure control, and in specific body regions, typically manifesting as microvascular dysfunction. Many severely affected patients with long COVID meet the diagnostic criteria for two common presentations of CVAD: postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia. CVAD can also manifest as disorders associated with hypotension, such as orthostatic or postprandial hypotension, and recurrent reflex syncope. Advances in research, accelerated by the COVID-19 pandemic, have identified new potential pathophysiological mechanisms, diagnostic methods and therapeutic targets in CVAD. For clinicians who daily see patients with CVAD, knowledge of its symptomatology, detection and appropriate management is more important than ever. In this Review, we define CVAD and its major forms that are encountered in post-COVID-19 syndrome, describe possible CVAD aetiologies, and discuss how CVAD, as a component of post-COVID-19 syndrome, can be diagnosed and managed. Moreover, we outline directions for future research to discover more efficient ways to cope with this prevalent and long-lasting condition.
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Affiliation(s)
- Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
- Department of Medicine, Karolinska Institute, Stockholm, Sweden.
- Department of Clinical Sciences, Lund University, Malmö, Sweden.
| | | | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cyndya A Shibao
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Hammersmith Hospital, National Heart & Lung Institute, Imperial College, London, UK
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Lim KB, Lim SY, Hor JW, Krishnan H, Mortadza F, Lim JL, Chinna K, Saedon NI, Tan AH. Orthostatic hypotension in Parkinson's disease: Sit-to-stand vs. supine-to-stand protocol and clinical correlates. Parkinsonism Relat Disord 2024; 123:106980. [PMID: 38657381 DOI: 10.1016/j.parkreldis.2024.106980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/14/2024] [Accepted: 04/21/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Screening for orthostatic hypotension (OH) is integral in Parkinson's disease (PD) management, yet evidence-based guidelines on best practice methods for diagnosing OH in PD are lacking. METHODS We investigated the frequency and correlates of OH, symptomatic OH, and neurogenic OH, in a large consecutively recruited PD cohort (n = 318), and compared the diagnostic performance of the sit-to-stand vs. the supine-to-stand blood pressure (BP) test. We evaluated the utility of continuous BP monitoring and tilt table testing in patients with postural symptoms or falls who were undetected to have OH with clinic-based BP measurements. Disease severity, fluid intake, orthostatic and overactive bladder symptoms, falls, comorbidities and medication history were evaluated. RESULTS Patients' mean age was 66.1 ± 9.5years, with mean disease duration 7.8 ± 5.5years. OH frequency was 35.8 % based on the supine-to-stand test. OH in PD was significantly associated with older age, lower body mass index, longer disease duration, worse motor, cognitive and overactive bladder symptoms and functional disabilities, falls, and lower fluid intake. A similar profile was seen with asymptomatic OH. Three quarters of OH were neurogenic, with the majority also having supine hypertension. The sit-to-stand test had a sensitivity of only 0.39. One quarter of patients were additionally diagnosed with OH during continuous BP monitoring. CONCLUSIONS The sit-to-stand test substantially underdiagnoses OH in PD, with the important practice implication that supine-to-stand measurements may be preferred. Screening for OH is warranted even in asymptomatic patients. Adequate fluid intake, treatment of urinary dysfunction and falls prevention are important strategies in managing PD patients with OH.
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Affiliation(s)
- Kai Bin Lim
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; The Mah Pooi Soo & Tan Chin Nam Centre for Parkinson's & Related Disorders, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Shen-Yang Lim
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; The Mah Pooi Soo & Tan Chin Nam Centre for Parkinson's & Related Disorders, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Jia Wei Hor
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; The Mah Pooi Soo & Tan Chin Nam Centre for Parkinson's & Related Disorders, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Heamah Krishnan
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Firdaus Mortadza
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Jia Lun Lim
- Department of Biomedical Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Karuthan Chinna
- Faculty of Business and Management, UCSI University, Cheras, Kuala Lumpur, Malaysia
| | - Nor Izzati Saedon
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ai Huey Tan
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; The Mah Pooi Soo & Tan Chin Nam Centre for Parkinson's & Related Disorders, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
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10
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Stige KE, Kverneng SU, Sharma S, Skeie GO, Sheard E, Søgnen M, Geijerstam SA, Vetås T, Wahlvåg AG, Berven H, Buch S, Reese D, Babiker D, Mahdi Y, Wade T, Miranda GP, Ganguly J, Tamilselvam YK, Chai JR, Bansal S, Aur D, Soltani S, Adams S, Dölle C, Dick F, Berntsen EM, Grüner R, Brekke N, Riemer F, Goa PE, Haugarvoll K, Haacke EM, Jog M, Tzoulis C. The STRAT-PARK cohort: A personalized initiative to stratify Parkinson's disease. Prog Neurobiol 2024; 236:102603. [PMID: 38604582 DOI: 10.1016/j.pneurobio.2024.102603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/15/2024] [Accepted: 04/07/2024] [Indexed: 04/13/2024]
Abstract
The STRAT-PARK initiative aims to provide a platform for stratifying Parkinson's disease (PD) into biological subtypes, using a bottom-up, multidisciplinary biomarker-based and data-driven approach. PD is a heterogeneous entity, exhibiting high interindividual clinicopathological variability. This diversity suggests that PD may encompass multiple distinct biological entities, each driven by different molecular mechanisms. Molecular stratification and identification of disease subtypes is therefore a key priority for understanding and treating PD. STRAT-PARK is a multi-center longitudinal cohort aiming to recruit a total of 2000 individuals with PD and neurologically healthy controls from Norway and Canada, for the purpose of identifying molecular disease subtypes. Clinical assessment is performed annually, whereas biosampling, imaging, and digital and neurophysiological phenotyping occur every second year. The unique feature of STRAT-PARK is the diversity of collected biological material, including muscle biopsies and platelets, tissues particularly useful for mitochondrial biomarker research. Recruitment rate is ∼150 participants per year. By March 2023, 252 participants were included, comprising 204 cases and 48 controls. STRAT-PARK is a powerful stratification initiative anticipated to become a global research resource, contributing to personalized care in PD.
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Affiliation(s)
- Kjersti Eline Stige
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Jonas Lies vei 65, Bergen 5021, Norway; Department of Clinical Medicine, University of Bergen, Pb 7804, Bergen 5020, Norway; K.G. Jebsen Center for Translational Research in Parkinson's disease, University of Bergen, Pb 7804, Bergen 5020, Norway; The Department of Neuromedicine and Movement Sciences, Norwegian University of Science and Technology, Trondheim 7491, Norway; Department of Neurology and Clinical Neurophysiology, St Olav's University Hospital, Trondheim 7006, Norway
| | - Simon Ulvenes Kverneng
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Jonas Lies vei 65, Bergen 5021, Norway; Department of Clinical Medicine, University of Bergen, Pb 7804, Bergen 5020, Norway; K.G. Jebsen Center for Translational Research in Parkinson's disease, University of Bergen, Pb 7804, Bergen 5020, Norway
| | - Soumya Sharma
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Jonas Lies vei 65, Bergen 5021, Norway; Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON N6A 5A5, Canada
| | - Geir-Olve Skeie
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Jonas Lies vei 65, Bergen 5021, Norway; Department of Clinical Medicine, University of Bergen, Pb 7804, Bergen 5020, Norway
| | - Erika Sheard
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Jonas Lies vei 65, Bergen 5021, Norway
| | - Mona Søgnen
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Jonas Lies vei 65, Bergen 5021, Norway
| | - Solveig Af Geijerstam
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Jonas Lies vei 65, Bergen 5021, Norway
| | - Therese Vetås
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Jonas Lies vei 65, Bergen 5021, Norway
| | - Anne Grete Wahlvåg
- Department of Neurology and Clinical Neurophysiology, St Olav's University Hospital, Trondheim 7006, Norway
| | - Haakon Berven
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Jonas Lies vei 65, Bergen 5021, Norway; Department of Clinical Medicine, University of Bergen, Pb 7804, Bergen 5020, Norway; K.G. Jebsen Center for Translational Research in Parkinson's disease, University of Bergen, Pb 7804, Bergen 5020, Norway
| | - Sagar Buch
- Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - David Reese
- Imaging Research Laboratories, Robarts Research Institute, Ontario, London N6A 5B7, Canada
| | - Dina Babiker
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON N6A 5A5, Canada
| | - Yekta Mahdi
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON N6A 5A5, Canada
| | - Trevor Wade
- Department of Medical Biophysics, Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, Ontario, London N6A 6B7, Canada
| | - Gala Prado Miranda
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON N6A 5A5, Canada
| | - Jacky Ganguly
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON N6A 5A5, Canada
| | - Yokhesh Krishnasamy Tamilselvam
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON N6A 5A5, Canada; Department of Electrical and Computer Engineering, Canadian Surgical Technologies and Advanced Robotics (CSTAR), University of Western Ontario (UWO), Ontario, London, Canada
| | - Jia Ren Chai
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON N6A 5A5, Canada
| | - Saurabh Bansal
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON N6A 5A5, Canada
| | - Dorian Aur
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON N6A 5A5, Canada
| | - Sima Soltani
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Jonas Lies vei 65, Bergen 5021, Norway; Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON N6A 5A5, Canada
| | - Scott Adams
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Jonas Lies vei 65, Bergen 5021, Norway; Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON N6A 5A5, Canada; School of Communication Sciences & Disorders, Faculty of Health Sciences, Western University, Canada
| | - Christian Dölle
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Jonas Lies vei 65, Bergen 5021, Norway; Department of Clinical Medicine, University of Bergen, Pb 7804, Bergen 5020, Norway; K.G. Jebsen Center for Translational Research in Parkinson's disease, University of Bergen, Pb 7804, Bergen 5020, Norway
| | - Fiona Dick
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Jonas Lies vei 65, Bergen 5021, Norway; Department of Clinical Medicine, University of Bergen, Pb 7804, Bergen 5020, Norway; K.G. Jebsen Center for Translational Research in Parkinson's disease, University of Bergen, Pb 7804, Bergen 5020, Norway
| | - Erik Magnus Berntsen
- Department of Radiology and Nuclear Medicine, St. Olav's University Hospital, Trondheim 7006, Norway; Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim 7491, Norway
| | - Renate Grüner
- Department of Physics and Technology, University of Bergen, Bergen 5007, Norway; Mohn Medical Imaging and Visualization Centre, Department of Radiology, Haukeland University Hospital, Post Office Box 1400, Bergen 5021, Norway
| | - Njål Brekke
- Department of Physics and Technology, University of Bergen, Bergen 5007, Norway; Radiology Department, Haukeland University Hospital, Jonas Lies vei 65, Bergen 5021, Norway
| | - Frank Riemer
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Jonas Lies vei 65, Bergen 5021, Norway; Mohn Medical Imaging and Visualization Centre, Department of Radiology, Haukeland University Hospital, Post Office Box 1400, Bergen 5021, Norway
| | - Pål Erik Goa
- Department of Radiology and Nuclear Medicine, St. Olav's University Hospital, Trondheim 7006, Norway; Department of Physics, Norwegian University of Science and Technology, Trondheim 7491, Norway
| | - Kristoffer Haugarvoll
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Jonas Lies vei 65, Bergen 5021, Norway
| | - E Mark Haacke
- Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, USA; Department of Radiology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Mandar Jog
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Jonas Lies vei 65, Bergen 5021, Norway; Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON N6A 5A5, Canada
| | - Charalampos Tzoulis
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Jonas Lies vei 65, Bergen 5021, Norway; Department of Clinical Medicine, University of Bergen, Pb 7804, Bergen 5020, Norway; K.G. Jebsen Center for Translational Research in Parkinson's disease, University of Bergen, Pb 7804, Bergen 5020, Norway.
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11
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Slief M, Heudebert AI, Centor RM. Listen to Your Heart: A Rare Case of Non-Neurogenic Orthostatic Hypotension. Am J Med 2024; 137:417-419. [PMID: 38163533 DOI: 10.1016/j.amjmed.2023.12.020] [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: 11/19/2023] [Revised: 12/15/2023] [Accepted: 12/16/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Matt Slief
- Department of Internal Medicine, University of Alabama at Birmingham.
| | | | - Robert M Centor
- Department of Internal Medicine, University of Alabama at Birmingham
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12
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Pena C, Moustafa A, Mohamed AR, Grubb B. Autoimmunity in Syndromes of Orthostatic Intolerance: An Updated Review. J Pers Med 2024; 14:435. [PMID: 38673062 PMCID: PMC11051445 DOI: 10.3390/jpm14040435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
Orthostatic intolerance is a broad term that represents a spectrum of dysautonomic disorders, including postural orthostatic tachycardia syndrome (POTS) and orthostatic hypotension (OH), as manifestations of severe autonomic failure. While the etiology of orthostatic intolerance has not yet fully been uncovered, it has been associated with multiple underlying pathological processes, including peripheral neuropathy, altered renin-aldosterone levels, hypovolemia, and autoimmune processes. Studies have implicated adrenergic, cholinergic, and angiotensin II type I autoantibodies in the pathogenesis of orthostatic intolerance. Several case series have demonstrated that immunomodulation therapy resulted in favorable outcomes, improving autonomic symptoms in POTS and OH. In this review, we highlight the contemporary literature detailing the association of autoimmunity with POTS and OH.
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Affiliation(s)
- Clarissa Pena
- Department of Internal Medicine, University of Toledo, Toledo, OH 43614, USA;
| | - Abdelmoniem Moustafa
- Division of Cardiovascular Medicine, University of Toledo, Toledo, OH 43614, USA; (A.M.); (B.G.)
| | - Abdel-Rhman Mohamed
- Department of Internal Medicine, University of Toledo, Toledo, OH 43614, USA;
| | - Blair Grubb
- Division of Cardiovascular Medicine, University of Toledo, Toledo, OH 43614, USA; (A.M.); (B.G.)
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13
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van der Horn HJ, Vakhtin AA, Julio K, Nitschke S, Shaff N, Dodd AB, Erhardt E, Phillips JP, Pirio Richardson S, Deligtisch A, Stewart M, Suarez Cedeno G, Meles SK, Mayer AR, Ryman SG. Parkinson's disease cerebrovascular reactivity pattern: A feasibility study. J Cereb Blood Flow Metab 2024:271678X241241895. [PMID: 38578669 DOI: 10.1177/0271678x241241895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
A mounting body of research points to cerebrovascular dysfunction as a fundamental element in the pathophysiology of Parkinson's disease (PD). In the current feasibility study, blood-oxygen-level-dependent (BOLD) MRI was used to measure cerebrovascular reactivity (CVR) in response to hypercapnia in 26 PD patients and 16 healthy controls (HC), and aimed to find a multivariate pattern specific to PD. Whole-brain maps of CVR amplitude (i.e., magnitude of response to CO2) and latency (i.e., time to reach maximum amplitude) were computed, which were further analyzed using scaled sub-profile model principal component analysis (SSM-PCA) with leave-one-out cross-validation. A meaningful pattern based on CVR latency was identified, which was named the PD CVR pattern (PD-CVRP). This pattern was characterized by relatively increased latency in basal ganglia, sensorimotor cortex, supplementary motor area, thalamus and visual cortex, as well as decreased latency in the cerebral white matter, relative to HC. There were no significant associations with clinical measures, though sample size may have limited our ability to detect significant associations. In summary, the PD-CVRP highlights the importance of cerebrovascular dysfunction in PD, and may be a potential biomarker for future clinical research and practice.
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Affiliation(s)
- Harm Jan van der Horn
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, NM, USA
| | - Andrei A Vakhtin
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, NM, USA
| | - Kayla Julio
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, NM, USA
| | - Stephanie Nitschke
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, NM, USA
| | - Nicholas Shaff
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, NM, USA
| | - Andrew B Dodd
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, NM, USA
| | - Erik Erhardt
- Department of Mathematics and Statistics, University of New Mexico, Albuquerque, NM, USA
| | - John P Phillips
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, NM, USA
| | - Sarah Pirio Richardson
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, University of New Mexico, Albuquerque, NM, USA
- New Mexico VA Health Care System, Albuquerque, NM, USA
| | - Amanda Deligtisch
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Melanie Stewart
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Gerson Suarez Cedeno
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Sanne K Meles
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Andrew R Mayer
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, NM, USA
| | - Sephira G Ryman
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, NM, USA
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, University of New Mexico, Albuquerque, NM, USA
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14
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Xia X, Jönsson L, Tazzeo C, Qiu C, Rizzuto D, Laukka EJ, Grande G, Fratiglioni L, Vetrano DL. Associations of Orthostatic Hypotension and Frailty With Dementia and Mortality in Older Adults: A Population-Based Cohort Study. J Gerontol A Biol Sci Med Sci 2024; 79:glae010. [PMID: 38195215 PMCID: PMC10919881 DOI: 10.1093/gerona/glae010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND This study aimed to assess the associations of orthostatic hypotension (OH), in the presence or absence of frailty, with dementia and mortality in older adults. METHODS We conducted a 15-year population-based cohort study including 2 703 baseline dementia-free individuals from the Swedish National Study on Aging and Care in Kungsholmen. At baseline, OH was defined as a decline in systolic/diastolic blood pressure ≥20/10 mm Hg 1 minute after standing up from a supine position. Frailty status was defined following Fried's frailty phenotype. Dementia was diagnosed following the Diagnostic and Statistical Manual of Mental Disorders-fourth edition criteria. Multistate flexible parametric survival models were used to estimate associations of OH and frailty with dementia and mortality. RESULTS Robust people with OH (adjusted hazard ratio [HR] = 2.28; 95% confidence interval [CI] = 1.47-3.54) and frail people without OH (HR = 1.98; 95% CI = 1.40-2.82) or with OH (HR = 2.73; 95% CI = 1.82-4.10) had a higher dementia risk than OH-free and robust people. Moreover, frail people, independently of the presence of OH, had higher mortality rate than OH-free and robust people. In individuals who developed dementia during the follow-up period, neither OH nor frailty was significantly associated with mortality. CONCLUSIONS Older adults with OH, whether robust or frail, may have a higher dementia risk than those without OH. Older adults with OH, when having frailty, may have a higher mortality rate than those without OH. The concurrent assessments of OH and frailty may provide prognostic values in terms of dementia and mortality risk in older adults.
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Affiliation(s)
- Xin Xia
- Aging Research Center, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet–Stockholm University, Stockholm, Sweden
| | - Linus Jönsson
- Section for Neurogeriatrics, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Stockholm, Sweden
| | - Clare Tazzeo
- Aging Research Center, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet–Stockholm University, Stockholm, Sweden
| | - Chengxuan Qiu
- Aging Research Center, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet–Stockholm University, Stockholm, Sweden
| | - Debora Rizzuto
- Aging Research Center, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet–Stockholm University, Stockholm, Sweden
- Stockholm Gerontology Research Center, Stockholm, Sweden
| | - Erika J Laukka
- Aging Research Center, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet–Stockholm University, Stockholm, Sweden
- Stockholm Gerontology Research Center, Stockholm, Sweden
| | - Giulia Grande
- Aging Research Center, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet–Stockholm University, Stockholm, Sweden
| | - Laura Fratiglioni
- Aging Research Center, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet–Stockholm University, Stockholm, Sweden
- Stockholm Gerontology Research Center, Stockholm, Sweden
| | - Davide Liborio Vetrano
- Aging Research Center, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet–Stockholm University, Stockholm, Sweden
- Stockholm Gerontology Research Center, Stockholm, Sweden
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15
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Leys F, Eschlböck S, Campese N, Mahlknecht P, Peball M, Goebel G, Sidoroff V, Krismer F, Granata R, Kiechl S, Poewe W, Seppi K, Wenning GK, Fanciulli A. Sex-related differences in the clinical presentation of multiple system atrophy. Clin Auton Res 2024; 34:253-268. [PMID: 38630378 PMCID: PMC11127878 DOI: 10.1007/s10286-024-01028-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 03/20/2024] [Indexed: 05/26/2024]
Abstract
PURPOSE To investigate sex-related differences in the clinical presentation of multiple system atrophy (MSA) through a literature review and an analysis of a retrospective cohort. METHODS The PubMed database was searched for articles including sex-related information in MSA. In a retrospective Innsbruck cohort, we investigated the baseline to last available follow-up clinical-demographic differences between men and women with MSA in a univariate fashion, followed by multivariable binary regression analysis. RESULTS The literature search yielded 46 publications with sex-related information in MSA. Most studies found comparable survival rates between the sexes, while some recent reports suggested a potential survival benefit for women, possibly due to initial motor onset and overall less severe autonomic failure compared to men. The retrospective Innsbruck MSA cohort comprised 56 female and 60 male individuals with a comparable median follow-up of 27 months. At baseline, female sex was independently associated with depression (odds ratio [OR] 4.7; p = 0.007) and male sex with severe orthostatic hypotension (OR 5.5; p = 0.016). In addition, at last follow-up, female sex was associated with the intake of central nervous system-active drugs (OR 4.1; p = 0.029), whereas male sex was associated with the presence of supine hypertension (OR 3.0; p = 0.020) and the intake of antihypertensive medications (OR 8.7; p = 0.001). Male sex was also associated with initiation of antihypertensive medications over the observation period (OR 12.4; p = 0.004). CONCLUSION The available literature and findings of the present study indicate sex-related differences in the clinical presentation of MSA and its evolution over time, highlighting the importance of considering sex in symptom exploration, therapeutic decision-making, and future clinical trial design.
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Affiliation(s)
- Fabian Leys
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sabine Eschlböck
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Neurology, Hochzirl-Natters Hospital, Zirl, Austria
| | - Nicole Campese
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Philipp Mahlknecht
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Marina Peball
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Georg Goebel
- Institute of Medical Statistics and Informatics, Medical University of Innsbruck, Innsbruck, Austria
| | - Victoria Sidoroff
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Krismer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Roberta Granata
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Werner Poewe
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Klaus Seppi
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Neurology, Provincial Hospital of Kufstein, Kufstein, Austria
| | - Gregor K Wenning
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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16
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Yoo SW, Ryu DW, Oh YS, Ha S, Lyoo CH, Kim Y, Yoo JY, Kim JS. Estimating motor progression trajectory pursuant to temporal dynamic status of cardiac denervation in Parkinson's disease. J Neurol 2024; 271:2019-2030. [PMID: 38183421 DOI: 10.1007/s00415-023-12158-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/10/2023] [Accepted: 12/11/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Parkinson's disease (PD) is a multifaceted disease that encompasses diverse clinical phenotypes. The diversity of PD could be subtyped based on the temporal dynamic status of cardiac sympathetic innervation; (1) initially, denervated myocardium (peripheral nervous system-predominant; PNS-predominant), (2) preserved myocardium (central nervous system-predominant; CNS-predominant), and (3) preserved myocardium who developed cardiac sympathetic denervation (CSD) on the subsequent imaging (Converter; delayed cardiac denervation). This study assessed how the cardiac denervation could reflect the pathobiology. We investigated whether this phenotyping could help predict the motor progression trajectory of PD. METHODS Cardiac sympathetic innervation was evaluated using initial and sequential 123I-meta-iodobenzylguanidine myocardial scintigraphy and patients were stratified into three groups as above. Motor severity and progression were evaluated in each patient. The association between subtypes and dopaminergic nigrostriatal degeneration was analyzed. The influence of cardiac denervation on motor progression was also investigated. RESULTS Among the enrolled 195 patients, 144 PD subjects were defined as PNS-predominant, 16 as Converter, and 35 as CNS-predominant. The most severe nigrostriatal degeneration was observed in the PNS-predominant group and the dopaminergic degeneration was the most asymmetric in the CNS-predominant group. Positive linear trends of nigrostriatal degeneration and its asymmetric degeneration of striatum and globus pallidus were found across the patterns of cardiac sympathetic innervation (PNS-predominant vs. Converter vs. CNS-predominant). It indicated an increasing degree of asymmetric degeneration among the groups. A longitudinal estimation of motor progression revealed distinct cardiac denervation trajectories for each subtype. CONCLUSIONS These results implicated that the subtypes of CSD might indicate a predominant origin and spreading pattern of pathobiology.
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Affiliation(s)
- Sang-Won Yoo
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong-Woo Ryu
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoon-Sang Oh
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seunggyun Ha
- Division of Nuclear Medicine, Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul Hyoung Lyoo
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yuna Kim
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji-Yeon Yoo
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joong-Seok Kim
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, 222 Banpo-Daero, Seocho-Gu, Seoul, 06591, Republic of Korea.
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17
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Lin L, Huang P, Cheng Y, Jiang S, Zhang J, Li M, Zheng J, Pan X, Wang Y. Brain white matter changes and their associations with non-motor dysfunction in orthostatic hypotension in α-synucleinopathy: A NODDI study. CNS Neurosci Ther 2024; 30:e14712. [PMID: 38615364 PMCID: PMC11016347 DOI: 10.1111/cns.14712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 03/24/2024] [Accepted: 03/28/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND The specific non-motor symptoms associated with α-synucleinopathies, including orthostatic hypotension (OH), cognitive impairment, and emotional abnormalities, have been a subject of ongoing controversy over the mechanisms underlying the development of a vicious cycle among them. The distinct structural alterations in white matter (WM) in patients with α-synucleinopathies experiencing OH, alongside their association with other non-motor symptoms, remain unexplored. This study employs axial diffusivity and density imaging (NODDI) to investigate WM damage specific to α-synucleinopathies with concurrent OH, delivering fresh evidence to supplement our understanding of the pathogenic mechanisms and pathological rationales behind the occurrence of a spectrum of non-motor functional impairments in α-synucleinopathies. METHODS This study recruited 49 individuals diagnosed with α-synucleinopathies, stratified into an α-OH group (n = 24) and an α-NOH group (without OH, n = 25). Additionally, 17 healthy controls were included for supine and standing blood pressure data collection, as well as neuropsychological assessments. Magnetic resonance imaging (MRI) was utilized for the calculation of NODDI parameters, and tract-based spatial statistics (TBSS) were employed to explore differential clusters. The fibers covered by these clusters were defined as regions of interest (ROI) for the extraction of NODDI parameter values and the analysis of their correlation with neuropsychological scores. RESULTS The TBSS analysis unveiled specific cerebral regions exhibiting disparities within the α-OH group as compared to both the α-NOH group and the healthy controls. These differences were evident in clusters that indicated a decrease in the acquisition of the neurite density index (NDI), a reduction in the orientation dispersion index (ODI), and an increase in the isotropic volume fraction (FISO) (p < 0.05). The extracted values from these ROIs demonstrated significant correlations with clinically assessed differences in supine and standing blood pressure, overall cognitive scores, and anxiety-depression ratings (p < 0.05). CONCLUSION Patients with α-synucleinopathies experiencing OH exhibit distinctive patterns of microstructural damage in the WM as revealed by the NODDI model, and there is a correlation with the onset and progression of non-motor functional impairments.
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Affiliation(s)
- Lin Lin
- Department of Neurology, Center for Cognitive NeurologyFujian Medical University Union HospitalFuzhou CityChina
- Fujian Institute of GeriatricsFujian Medical University Union HospitalFuzhou CityChina
- Institute of Clinical NeurologyFujian Medical UniversityFuzhou CityChina
- Fujian Key Laboratory of Molecular NeurologyFujian Medical UniversityFuzhou CityChina
| | - Peilin Huang
- Department of Neurology, Center for Cognitive NeurologyFujian Medical University Union HospitalFuzhou CityChina
- Fujian Institute of GeriatricsFujian Medical University Union HospitalFuzhou CityChina
- Institute of Clinical NeurologyFujian Medical UniversityFuzhou CityChina
- Fujian Key Laboratory of Molecular NeurologyFujian Medical UniversityFuzhou CityChina
| | - Yingzhe Cheng
- Department of Neurology, Center for Cognitive NeurologyFujian Medical University Union HospitalFuzhou CityChina
- Fujian Institute of GeriatricsFujian Medical University Union HospitalFuzhou CityChina
- Institute of Clinical NeurologyFujian Medical UniversityFuzhou CityChina
- Fujian Key Laboratory of Molecular NeurologyFujian Medical UniversityFuzhou CityChina
| | - Shaofan Jiang
- Department of RadiologyFujian Medical University Union HospitalFuzhou CityChina
- Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for TumorsFujian Medical UniversityFuzhou CityChina
| | - Jiejun Zhang
- Department of Neurology, Center for Cognitive NeurologyFujian Medical University Union HospitalFuzhou CityChina
- Fujian Institute of GeriatricsFujian Medical University Union HospitalFuzhou CityChina
- Institute of Clinical NeurologyFujian Medical UniversityFuzhou CityChina
- Fujian Key Laboratory of Molecular NeurologyFujian Medical UniversityFuzhou CityChina
- Center for GeriatricsHainan General HospitalHainanChina
| | - Man Li
- Department of Neurology, Center for Cognitive NeurologyFujian Medical University Union HospitalFuzhou CityChina
- Fujian Institute of GeriatricsFujian Medical University Union HospitalFuzhou CityChina
- Institute of Clinical NeurologyFujian Medical UniversityFuzhou CityChina
- Fujian Key Laboratory of Molecular NeurologyFujian Medical UniversityFuzhou CityChina
| | - Jiahao Zheng
- Department of Neurology, Center for Cognitive NeurologyFujian Medical University Union HospitalFuzhou CityChina
- Fujian Institute of GeriatricsFujian Medical University Union HospitalFuzhou CityChina
- Institute of Clinical NeurologyFujian Medical UniversityFuzhou CityChina
- Fujian Key Laboratory of Molecular NeurologyFujian Medical UniversityFuzhou CityChina
| | - Xiaodong Pan
- Department of Neurology, Center for Cognitive NeurologyFujian Medical University Union HospitalFuzhou CityChina
- Fujian Institute of GeriatricsFujian Medical University Union HospitalFuzhou CityChina
- Institute of Clinical NeurologyFujian Medical UniversityFuzhou CityChina
- Fujian Key Laboratory of Molecular NeurologyFujian Medical UniversityFuzhou CityChina
| | - Yanping Wang
- Department of EndocrinologyFujian Medical University Union HospitalFuzhou CityChina
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Qin Y, Meng DT, Jin ZH, Du WJ, Fang BY. Association between autonomic dysfunction with motor and non-motor symptoms in patients with Parkinson's disease. J Neural Transm (Vienna) 2024; 131:323-334. [PMID: 38253927 DOI: 10.1007/s00702-024-02745-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/15/2024] [Indexed: 01/24/2024]
Abstract
To investigate the association between autonomic dysfunction (AutD) and motor as well as non-motor symptoms (NMS) in patients with Parkinson's disease (PD). Fifty-three PD patients were divided into two groups based on the number of domains affected by AutD: a multi-domain AutD group (AutD-M) and a single-domain AutD group (AutD-S), as evaluated using the Scale for Outcomes in Parkinson's disease-Autonomic (SCOPA-AUT), which assesses autonomic symptoms, one of the NMS. A comprehensive comparison was conducted between the two groups, including clinical measures such as clinical scales, quantitative evaluations of motor function and exercise capacity. Spearman correlation analysis was employed to investigate the relationship between AutD severity and PD symptoms. Additionally, we performed multiple linear regression model analysis to determine whether associations between SCOPA-AUT scores and clinical assessments remained significant after adjusting for Hoehn and Yahr stage, sex, and age. PD patients in the AutD-M group exhibited significantly more severe NMS and motor symptoms compared to those in the AutD-S group. In correlation analysis, SCOPA-AUT scores showed significant correlations with multiple clinical symptoms, such as most of the NMS, 10-MWT and CPET parameters. Furthermore, regression analysis also revealed that more pronounced fatigue, anxiety, depressive symptoms, worse walking speed and impaired exercise capacity were associated with higher SCOPA-AUT scores. The presence of AutD is correlated with emotional disturbances, decreased exercise endurance, and impaired gait function in patients with PD. Early management of AutD may prove beneficial in alleviating some NMS and motor symptoms in PD.
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Affiliation(s)
- Yi Qin
- Parkinson Medical Center, Beijing Rehabilitation Hospital, Capital Medical University, Badachu, Xixiazhuang, Shijingshan District, Beijing, 100144, China
- Beijing Rehabilitation Medical College, Capital Medical University, Beijing, China
| | - De-Tao Meng
- Parkinson Medical Center, Beijing Rehabilitation Hospital, Capital Medical University, Badachu, Xixiazhuang, Shijingshan District, Beijing, 100144, China
| | - Zhao-Hui Jin
- Parkinson Medical Center, Beijing Rehabilitation Hospital, Capital Medical University, Badachu, Xixiazhuang, Shijingshan District, Beijing, 100144, China
| | - Wen-Jun Du
- Parkinson Medical Center, Beijing Rehabilitation Hospital, Capital Medical University, Badachu, Xixiazhuang, Shijingshan District, Beijing, 100144, China
| | - Bo-Yan Fang
- Parkinson Medical Center, Beijing Rehabilitation Hospital, Capital Medical University, Badachu, Xixiazhuang, Shijingshan District, Beijing, 100144, China.
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Malkiewicz JJ, Siuda J. Evaluation of Cardiovascular Autonomic Nervous System in Essential Tremor and Tremor Dominant Parkinson's Disease. Brain Sci 2024; 14:313. [PMID: 38671965 PMCID: PMC11048246 DOI: 10.3390/brainsci14040313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 03/16/2024] [Accepted: 03/23/2024] [Indexed: 04/28/2024] Open
Abstract
(1) Background: The differential diagnosis of essential tremor (ET) and tremor-dominant Parkinson's disease (TDPD) can be challenging. Only a few studies have investigated the autonomic nervous system (ANS) in ET. However, some of these suggested that heart rate variability (HRV) might be useful in the differential diagnosis. (2) Methods: Demographic and clinical data, including medications and comorbidities, were collected from 15 TDPD patients, 19 ET patients, and 20 healthy controls. Assessment with the SCOPA-AUT questionnaire, 5 min HRV analysis in time and frequency domains, and evaluation of orthostatic hypotension (OH) with tilt test were performed. (3) Results: There were no significant differences between all groups on the SCOPA-AUT questionnaire. PD patients had OH more frequently and a larger drop in systolic blood pressure (SBP) during the tilt test than ET patients and controls. HRV was affected in PD, but not in ET and controls. Power in the low frequency band, the standard deviation of all normal RR intervals and SBP drop were potentially useful in differential diagnosis with AUCs of 0.83, 0.78, and 0.83, respectively. (4) Conclusions: Cardiovascular ANS dysfunction was present in TDPD, but not in ET and controls. HRV analysis and assessment of SBP drop may be potentially useful in the differential diagnosis of ET and TDPD.
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Affiliation(s)
- Jakub J. Malkiewicz
- Department of Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia in Katowice, University Clinical Center Prof. K. Gibiński, 14 Medyków Street, 40-752 Katowice, Poland;
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20
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Poon D, Muthukumar B, Pang YL. Assessing postural hypotension in a UK District General Hospital. J R Coll Physicians Edinb 2024; 54:106-107. [PMID: 38456284 DOI: 10.1177/14782715241238785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Affiliation(s)
- Dennis Poon
- King's Mill Hospital, Sherwood Forest Hospitals NHS Foundation Trust, UK
| | | | - Yik Lam Pang
- King's Mill Hospital, Sherwood Forest Hospitals NHS Foundation Trust, UK
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21
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Ryu DW, Yoo SW, Choi KE, Oh YS, Kim JS. Correlation of olfactory function factors with cardiac sympathetic denervation in Parkinson's disease. J Neurol 2024; 271:1397-1407. [PMID: 37940708 DOI: 10.1007/s00415-023-12080-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Hyposmia is a common nonmotor symptom of Parkinson's disease (PD) and reportedly associated with dysautonomia in PD. The smell identification test for measuring olfactory function consists of multiple items to discriminate specific scents. In the present study, factor analysis of the smell identification test was performed, and the correlation of extracted factors with cardiac sympathetic denervation (CSD) in patients with PD was investigated. METHODS The present study included 183 early PD patients who underwent the Cross-Cultural Smell Identification Test (CC-SIT) and 123I-meta-iodobenzylguanidine (123I-MIBG) myocardial scintigraphy. Factor analysis of 12 items on the CC-SIT was performed using the computed correlation matrix for the binary items, and five smell factors were extracted. Multiple linear regression was performed to determine the correlation of olfactory function with late heart-to-mediastinum (H/M) ratio of 123I-MIBG uptake. RESULTS The mean CC-SIT score was 6.1 ± 2.6, and 133 patients (72.7%) had CSD. The CC-SIT score and five smell factors were not associated with dopamine transporter uptake or cognitive functions. However, the CC-SIT score significantly correlated with age (P < 0.001) and late H/M ratio (P < 0.001). Factors 1 and 5 showed an increasing trend with larger H/M ratio, although it was not statistically significant (β = 0.203, P = 0.085 and β = 0.230, P = 0.085, respectively). Factor 5 significantly correlated with the H/M ratio in PD patients with CSD (β = 0.676, P = 0.036). DISCUSSION The results showed olfactory dysfunction to be selectively associated with cardiac sympathetic burden in PD. The correlation of certain factors with CSD indicates the possibility of selective hyposmia in PD patients.
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Affiliation(s)
- Dong-Woo Ryu
- Department of Neurology, College of Medicine, The Catholic University of Korea, 222, Banpo-Daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Sang-Won Yoo
- Department of Neurology, College of Medicine, The Catholic University of Korea, 222, Banpo-Daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Ko-Eun Choi
- Department of Neurology, College of Medicine, The Catholic University of Korea, 222, Banpo-Daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Yoon-Sang Oh
- Department of Neurology, College of Medicine, The Catholic University of Korea, 222, Banpo-Daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Joong-Seok Kim
- Department of Neurology, College of Medicine, The Catholic University of Korea, 222, Banpo-Daero, Seocho-gu, Seoul, 06591, Republic of Korea.
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22
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van Zanten S, Sutton R, Hamrefors V, Fedorowski A, de Lange FJ. Tilt table testing, methodology and practical insights for the clinic. Clin Physiol Funct Imaging 2024; 44:119-130. [PMID: 37839043 DOI: 10.1111/cpf.12859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 09/18/2023] [Accepted: 10/04/2023] [Indexed: 10/17/2023]
Abstract
Tilt table testing (TTT) has been used for decades to study short-term blood pressure (BP) and heart rate regulation during orthostatic challenges. TTT provokes vasovagal reflex in many syncope patients as a background of widespread use. Despite the availability of evidence-based practice syncope guidelines, proper application and interpretation of TTT in the day-to-day care of syncope patients remain challenging. In this review, we offer practical information on what is needed to perform TTT, how results should be interpreted including the Vasovagal Syncope International Study classification, why syncope induction on TTT is necessary in patients with unexplained syncope and on indications for TTT in syncope patient care. The minimum requirements to perform TTT are a tilt table with an appropriate tilt-down time, a continuous beat-to-beat BP monitor with at least three electrocardiogram leads and trained staff. We emphasize that TTT remains a valuable asset that adds to history building but cannot replace it, and highlight the importance of recognition when TTT is abnormal even without syncope. Acknowledgement by the patient/eyewitness of the reproducibility of the induced attack is mandatory in concluding a diagnosis. TTT may be indicated when the initial syncope evaluation does not yield a certain, highly likely, or possible diagnosis, but raises clinical suspicion of (1) reflex syncope, (2) orthostatic hypotension (OH), (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT in the patient with a certain, highly likely or possible diagnosis of reflex syncope, may be to educate patients on prodromes. In patients with reflex syncope with OH TTT can be therapeutic to recognize hypotensive symptoms causing near-syncope to perform physical countermanoeuvres for syncope prevention (biofeedback). Detection of hypotensive susceptibility requiring therapy is of special value.
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Affiliation(s)
- Steven van Zanten
- Department of Cardiology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Richard Sutton
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Campus, London, UK
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
- Department of Cardiology, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Frederik J de Lange
- Department of Clinical and Experimental Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Juraschek SP, Cortez MM, Flack JM, Ghazi L, Kenny RA, Rahman M, Spikes T, Shibao CA, Biaggioni I. Orthostatic Hypotension in Adults With Hypertension: A Scientific Statement From the American Heart Association. Hypertension 2024; 81:e16-e30. [PMID: 38205630 PMCID: PMC11067441 DOI: 10.1161/hyp.0000000000000236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Although orthostatic hypotension (OH) has long been recognized as a manifestation of autonomic dysfunction, a growing body of literature has identified OH as a common comorbidity of hypertension. This connection is complex, related to pathophysiology in blood pressure regulation and the manner by which OH is derived as the difference between 2 blood pressure measurements. While traditional therapeutic approaches to OH among patients with neurodegenerative disorders focus on increasing upright blood pressure to prevent cerebral hypoperfusion, the management of OH among patients with hypertension is more nuanced; resting hypertension is itself associated with adverse outcomes among these patients. Although there is substantial evidence that intensive blood pressure treatment does not cause OH in the majority of patients with essential hypertension, some classes of antihypertensive agents may unmask OH in patients with an underlying autonomic impairment. Practical steps to manage OH among adults with hypertension start with (1) a thorough characterization of its patterns, triggers, and cause; (2) review and removal of aggravating factors (often pharmacological agents not related to hypertension treatment); (3) optimization of an antihypertensive regimen; and (4) adoption of a tailored treatment strategy that avoids exacerbating hypertension. These strategies include countermaneuvers and short-acting vasoactive agents (midodrine, droxidopa). Ultimately, further research is needed on the epidemiology of OH, the impact of hypertension treatment on OH, approaches to the screening and diagnosis of OH, and OH treatment among adults with hypertension to improve the care of these patients and their complex blood pressure pathophysiology.
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Dounia J, Kamal H, Marouane S, Meryem H, Rachida H, Abdenasser D, Leila A. A therapeutic challenge relating to the association of orthostatic hypotension and supine hypertension in a patient with cardiac autonomic neuropathy: a case report. J Med Case Rep 2024; 18:102. [PMID: 38374205 PMCID: PMC10877782 DOI: 10.1186/s13256-024-04346-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 12/29/2023] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Cardiac autonomic neuropathy is a highly prevalent pathology in the diabetic population, and is the leading cause of death in this population. Orthostatic hypotension is the main clinical manifestation of the disease. In some patients, this orthostatic hypotension is associated with supine hypertension, posing a therapeutic challenge since treatment of one entity may aggravate the other. The challenge is to manage each of these two hemodynamic opposites without exposing the patient to a life-threatening risk of severe hypotension or hypertension. CASE PRESENTATION We report a case of a 62-year-old ethnic Moroccan woman who has cardiovascular risk factors such as type 2 diabetes, arterial hypertension, and dyslipidemia. The patient's symptoms included dizziness, tremors, morning sickness, palpitations, and intolerance to exertion. Given her symptomatology, the patient benefited from an exploration of the autonomic nervous system through cardiovascular reactivity tests (Ewing tests), which confirmed the diagnosis of cardiac autonomic neuropathy. In addition to orthostatic hypotension, our patient had supine arterial hypertension, complicating management. To treat orthostatic hypotension, we advised the patient to avoid the supine position during the day, to raise the head of the bed during the night, and to have a sufficient fluid intake, with a gradual transition from decubitus to orthostatism and venous restraint of the lower limbs. Supine hypertension was treated with transdermal nitrates placed at bedtime and removed 1 hour before getting up. One week after the introduction of treatment, the patient reported a clear regression of functional symptoms, with an improvement in her quality of life. Improvement in symptomatology was maintained during quarterly follow-up consultations. CONCLUSIONS Cardiac autonomic neuropathy is a very common pathology in diabetic patients. It is a serious condition with a life-threatening prognosis. Its management must be individualized according to the symptomatology and profile of each patient. The treatment of patients with orthostatic hypotension and supine hypertension requires special attention to ensure that each entity is treated without aggravating the other.
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Affiliation(s)
- Jama Dounia
- Service of Cardiology, CHUN Ibn Rochd: Centre Hospitalier Universitaire Ibn Rochd, Casablanca, Morocco.
| | - Haless Kamal
- Service of Cardiology, CHUN Ibn Rochd: Centre Hospitalier Universitaire Ibn Rochd, Casablanca, Morocco
| | - Selmaoui Marouane
- Service of Cardiology, CHUN Ibn Rochd: Centre Hospitalier Universitaire Ibn Rochd, Casablanca, Morocco
| | - Haboub Meryem
- Service of Cardiology, CHUN Ibn Rochd: Centre Hospitalier Universitaire Ibn Rochd, Casablanca, Morocco
| | - Habbal Rachida
- Service of Cardiology, CHUN Ibn Rochd: Centre Hospitalier Universitaire Ibn Rochd, Casablanca, Morocco
| | - Drighil Abdenasser
- Service of Cardiology, CHUN Ibn Rochd: Centre Hospitalier Universitaire Ibn Rochd, Casablanca, Morocco
| | - Azzouzi Leila
- Service of Cardiology, CHUN Ibn Rochd: Centre Hospitalier Universitaire Ibn Rochd, Casablanca, Morocco
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El-Mhadi S, Mouine N, Benjelloun H, Aboudrar S, El Bakkali M. Primary autonomic failure: a complex case of orthostatic hypotension in a hypertensive elderly patient. Eur Heart J Case Rep 2024; 8:ytae073. [PMID: 38419751 PMCID: PMC10901262 DOI: 10.1093/ehjcr/ytae073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 01/24/2024] [Accepted: 02/02/2024] [Indexed: 03/02/2024]
Abstract
Background Primary autonomic failure (PAF) or Bradbury Eggleston syndrome is a neurodegenerative disorder of the autonomic nervous system characterized by orthostatic hypotension. Case summary We report the case of a 76-year-old patient with a history of hypertension, who presented with exercise-induced fatigue. He exhibited systolic hypertension and resting bradycardia in the supine position, with orthostatic hypotension without reactive tachycardia, suggesting dysautonomia. Neurological examination was unremarkable. The patient underwent cardiovascular autonomic testing, revealing evidence of beta-sympathetic deficiency associated with neurogenic orthostatic hypotension. Causes of secondary dysautonomia were excluded. The patient was diagnosed with PAF. Even if managing the combination of supine hypertension and orthostatic hypotension was challenging, significant improvements in functional and haemodynamic status were observed with a personalized management approach. Discussion Throughout this case report, we emphasize the critical need for an evaluation of autonomic function and blood pressure's dynamics in hypertensive patients experiencing orthostatic symptoms, enabling the implementation of tailored therapeutic strategies.
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Affiliation(s)
- Samah El-Mhadi
- Cardiology A Department, Ibn Sina University Hospital Center, Rabat, Morocco
| | - Najat Mouine
- Department of Cardiology, Mohammed V Military Hospital, Rabat, Morocco
| | - Halima Benjelloun
- Cardiology A Department, Ibn Sina University Hospital Center, Rabat, Morocco
| | - Souad Aboudrar
- Exercise physiology and autonomic nervous system team, Laboratory of Physiology, Mohammed V University, Rabat, Morocco
| | - Mustapha El Bakkali
- Exercise physiology and autonomic nervous system team, Laboratory of Physiology, Mohammed V University, Rabat, Morocco
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26
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Lenka A, Lamotte G, Beach P. Asymptomatic orthostatic hypotension in synucleinopathies: to treat or not to treat? Clin Auton Res 2024; 34:25-29. [PMID: 38079008 DOI: 10.1007/s10286-023-01006-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 10/21/2023] [Indexed: 03/17/2024]
Affiliation(s)
- Abhishek Lenka
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Guillaume Lamotte
- Department of Neurology, University of Utah, Salt Lake City, UT, USA.
- Department of Neurology, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA.
| | - Paul Beach
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
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27
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Earl T, Jridi A, Thulin PC, Zorn M, McKee KE, Mitrovich K, Moretti P, Alshaikh J, Kassavetis P, Cortez MM, Lamotte G. Effect of levodopa on postural blood pressure changes in Parkinson disease: a randomized crossover study. Clin Auton Res 2024; 34:117-124. [PMID: 38429568 DOI: 10.1007/s10286-024-01024-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 02/06/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE We investigated the effect of levodopa on postural blood pressure changes in individuals with Parkinson disease (PD) with (PD+OH) and without neurogenic OH (PD-OH). METHODS We performed a prospective randomized crossover study with autonomic testing performed ON and OFF levodopa. The primary outcome was the change in systolic blood pressure (SBP) from supine to 70° tilt at 3 min (ΔSBP-3'). Secondary outcomes included indices of baroreflex function and blood pressure and heart rate during tilt. RESULTS We enrolled 40 individuals with PD (21 PD+OH, 19 PD-OH), mean age (SD) 73.2 years (7.9), 13 women (32.5%)). There was no difference in age, sex, disease duration, and severity between PD+OH and PD-OH. Mean difference in ΔSBP-3' ON versus OFF levodopa in the whole study population was - 3.20 mmHg [- 7.36 to 0.96] (p = 0.14). Mean difference in ΔSBP-3' was - 2.14 mmHg [- 7.55 to 3.28] (p = 0.45) in PD+OH and - 5.14 mmHg [- 11.63 to 1.35] (p = 0.14) in PD-OH. Mean difference in ΔSBP ON versus OFF levodopa was greater at 7 and 10 min (- 7.52 mmHg [- 11.89 to - 3.15], p = 0.002, and - 7.82 mmHg [- 14.02 to - 1.67], p = 0.02 respectively). Levodopa was associated with lower absolute values of blood pressure in both PD+OH and PD-OH and cardiovascular noradrenergic baroreflex impairment. CONCLUSION Levodopa decreases blood pressure in both PD with and without autonomic failure, but it does not cause a greater fall in blood pressure from supine to standing at 3 min. Levodopa-induced baroreflex sympathetic noradrenergic impairment may contribute to lower blood pressure. Lower standing blood pressure with levodopa may increase the risks of fall and syncope.
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Affiliation(s)
- Timi Earl
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Amani Jridi
- Utah Clinical & Translational Science Institute, University of Utah, Salt Lake City, UT, USA
| | - Perla C Thulin
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Meghan Zorn
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Kathleen E McKee
- Neurosciences Clinical Program, Intermountain Health, Murray, UT, USA
| | - Kristin Mitrovich
- Neurosciences Clinical Program, Intermountain Health, Murray, UT, USA
| | - Paolo Moretti
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
- George E. Wahlen VA Medical Center, Salt Lake City, UT, USA
| | - Jumana Alshaikh
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | | | - Melissa M Cortez
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Guillaume Lamotte
- Department of Neurology, University of Utah, Salt Lake City, UT, USA.
- George E. Wahlen VA Medical Center, Salt Lake City, UT, USA.
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Lin L, Cheng Y, Huang P, Zhang J, Zheng J, Pan X. Synchronous monitoring of brain-heart electrophysiology using heart rate variability coupled with rapid quantitative electroencephalography in orthostatic hypotension patients with α-synucleinopathies: Rapid prediction of orthostatic hypotension and preliminary exploration of brain stimulation therapy. CNS Neurosci Ther 2024; 30:e14571. [PMID: 38421092 PMCID: PMC10850923 DOI: 10.1111/cns.14571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/16/2023] [Accepted: 12/03/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND In α-synucleinopathies, the dysfunction of the autonomic nervous system which typically manifests as orthostatic hypotension (OH) often leads to severe consequences and poses therapeutic challenges. This study aims to discover the brain-cardiac electrophysiological changes in OH patients with α-synucleinopathies using the rapid quantitative electroencephalography (qEEG) coupled with heart rate variability (HRV) technique to identify rapid, noninvasive biomarkers for early warning and diagnosis, as well as shed new light on complementary treatment approaches such as brain stimulation targets. METHODS In this study, 26 subjects of α-synucleinopathies with OH (α-OH group), 21 subjects of α-synucleinopathies without OH (α-NOH group), and 34 healthy controls (control group) were included from September 2021 to August 2023 (NCT05527067). The heart rate-blood pressure variations in supine and standing positions were monitored, and synchronization parameters of seated resting-state HRV coupled with qEEG were collected. Time-domain and frequency-domain of HRV measures as well as peak frequency and power of the brainwaves were extracted. Differences between these three groups were compared, and correlations between brain-heart parameters were analyzed. RESULTS The research results showed that the time-domain parameters such as MxDMn, pNN50, RMSSD, and SDSD of seated resting-state HRV exhibited a significant decrease only in the α-OH group compared to the healthy control group (p < 0.05), while there was no significant difference between the α-NOH group and the healthy control group. Several time-domain and frequency-domain parameters of seated resting-state HRV were found to be correlated with the blood pressure changes within the first 5 min of transitioning from supine to standing position (p < 0.05). Differences were observed in the power of beta1 waves (F4 and Fp2) and beta2 waves (Fp2 and F4) in the seated resting-state qEEG between the α-OH and α-NOH groups (p < 0.05). The peak frequency of theta waves in the Cz region also showed a difference (p < 0.05). The power of beta2 waves in the Fp2 and F4 brain regions correlated with frequency-domain parameters of HRV (p < 0.05). Additionally, abnormal electrical activity in the alpha, theta, and beta1 waves was associated with changes in heart rate and blood pressure within the first 5 min of transitioning from supine to standing position (p < 0.05). CONCLUSION Rapid resting-state HRV with certain time-domain parameters below normal levels may serve as a predictive indicator for the occurrence of orthostatic hypotension (OH) in patients with α-synucleinopathies. Additionally, the deterioration of HRV parameters correlates with synchronous abnormal qEEG patterns, which can provide insights into the brain stimulation target areas for OH in α-synucleinopathy patients.
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Affiliation(s)
- Lin Lin
- Department of Neurology, Center for Cognitive NeurologyFujian Medical University Union HospitalFuzhou CityChina
- Fujian Institute of GeriatricsFujian Medical University Union HospitalFuzhou CityChina
- Institute of Clinical NeurologyFujian Medical UniversityFuzhou CityChina
- Fujian Key Laboratory of Molecular NeurologyFujian Medical UniversityFuzhou CityChina
| | - Yingzhe Cheng
- Department of Neurology, Center for Cognitive NeurologyFujian Medical University Union HospitalFuzhou CityChina
- Fujian Institute of GeriatricsFujian Medical University Union HospitalFuzhou CityChina
- Institute of Clinical NeurologyFujian Medical UniversityFuzhou CityChina
- Fujian Key Laboratory of Molecular NeurologyFujian Medical UniversityFuzhou CityChina
| | - Peilin Huang
- Department of Neurology, Center for Cognitive NeurologyFujian Medical University Union HospitalFuzhou CityChina
- Fujian Institute of GeriatricsFujian Medical University Union HospitalFuzhou CityChina
- Institute of Clinical NeurologyFujian Medical UniversityFuzhou CityChina
- Fujian Key Laboratory of Molecular NeurologyFujian Medical UniversityFuzhou CityChina
| | - Jiejun Zhang
- Department of Neurology, Center for Cognitive NeurologyFujian Medical University Union HospitalFuzhou CityChina
- Fujian Institute of GeriatricsFujian Medical University Union HospitalFuzhou CityChina
- Institute of Clinical NeurologyFujian Medical UniversityFuzhou CityChina
- Fujian Key Laboratory of Molecular NeurologyFujian Medical UniversityFuzhou CityChina
- Center for GeriatricsHainan General HospitalHaikou CityHainan ProvinceChina
| | - Jiahao Zheng
- Department of Neurology, Center for Cognitive NeurologyFujian Medical University Union HospitalFuzhou CityChina
- Fujian Institute of GeriatricsFujian Medical University Union HospitalFuzhou CityChina
- Institute of Clinical NeurologyFujian Medical UniversityFuzhou CityChina
- Fujian Key Laboratory of Molecular NeurologyFujian Medical UniversityFuzhou CityChina
| | - Xiaodong Pan
- Department of Neurology, Center for Cognitive NeurologyFujian Medical University Union HospitalFuzhou CityChina
- Fujian Institute of GeriatricsFujian Medical University Union HospitalFuzhou CityChina
- Institute of Clinical NeurologyFujian Medical UniversityFuzhou CityChina
- Fujian Key Laboratory of Molecular NeurologyFujian Medical UniversityFuzhou CityChina
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Srinivas V, Choubey U, Kapparath S, Shaik T, Singh B, Mahmood R, Garg N, Aggarwal P, Jain R. Age-Related Orthostatic Hypotension: A Comprehensive Analysis of Prevalence, Mechanisms, and Management in the Geriatric Population. Cardiol Rev 2024:00045415-990000000-00186. [PMID: 38189438 DOI: 10.1097/crd.0000000000000636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Geriatric patients frequently encounter orthostatic hypotension (OH), a multifaceted condition characterized by a significant drop in blood pressure upon assuming an upright position. As the elderly population is particularly susceptible to OH, our review endeavors to comprehensively explore the complex nature of this condition and various factors contributing to its development. We investigate the impact of comorbidities, polypharmacy, age-related physiological changes, and autonomic dysfunction in the pathogenesis of OH. Geriatric patients with OH are faced with an elevated risk of falls, syncope, a decline in their overall quality of life, and hence increased mortality. These implications require careful consideration, necessitating a thorough examination of therapeutic strategies. We evaluate various pharmaceutical and nonpharmacological therapies, delving into the effectiveness and safety of each approach in managing OH within geriatric populations. We explore the role of pharmacotherapy in alleviating symptoms and mitigating OH-related complications, as well as the potential benefits of volume expansion techniques to augment blood volume and stabilize blood pressure. We place particular emphasis on the significance of lifestyle changes and nonpharmacological interventions in enhancing OH management among the elderly. These interventions encompass dietary modifications, regular physical activity, and postural training, all tailored to the unique needs of the individual patient. To optimize outcomes and ensure patient safety, we underscore the importance of individualized treatment plans that take into account the geriatric patient's overall health status, existing comorbidities, and potential interactions with other medications. This review aims to improve clinical practice and patient outcomes by advocating for early detection, properly tailored management, and targeted interventions to address OH in the elderly population. By raising awareness of OH's prevalence and complexities among healthcare professionals, we hope to foster a comprehensive understanding of OH and contribute to the overall wellness and quality of life of this vulnerable demographic.
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Affiliation(s)
- Varsha Srinivas
- From the PES Institute of Medical Sciences and Research, India
| | | | | | - Tanveer Shaik
- Avalon University School Of Medicine, Willemstad, Curacao
| | | | - Ramsha Mahmood
- Avalon University School Of Medicine, Willemstad, Curacao
| | - Nikita Garg
- Children's Hospital of Michigan, Detroit, MI
| | - Priyanka Aggarwal
- Maharishi Markandeshwar Institute of Medical Science & Research, Mullana, Haryana, India
| | - Rohit Jain
- Department of Internal Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
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Vidal-Petiot E, Pathak A, Azulay JP, Pavy-Le Traon A, Hanon O. Orthostatic hypotension: Review and expert position statement. Rev Neurol (Paris) 2024; 180:53-64. [PMID: 38123372 DOI: 10.1016/j.neurol.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/19/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
Orthostatic hypotension is defined as a drop in systolic blood pressure of at least 20mmHg or a drop in diastolic blood pressure of at least 10mmHg within 3minutes of standing. It is a common disorder, especially in high-risk populations such as elderly subjects and patients with neurological diseases, and is associated with markedly increased morbidity and mortality. Its management can be challenging, particularly in cases where supine hypertension is associated with severe orthostatic hypotension. Education of the patient, non-pharmacological measures, and drug adaptation are the cornerstones of treatment. Pharmacological treatment should be individualized according to the severity, underlying cause, 24-hour blood pressure profile, and associated coexisting conditions. First-line therapies are midodrine and fludrocortisone, which may need to be combined for optimal care of severe cases.
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Affiliation(s)
- E Vidal-Petiot
- Service de physiologie, ESH Excellence Center, hôpital Bichat, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; INSERM U1148, Université Paris-Cité and Université Sorbonne Paris Nord, LVTS, 75018 Paris, France.
| | - A Pathak
- Service de cardiologie, ESH Excellence Center, centre hospitalier Princesse Grace, 1, avenue Pasteur, 98000 Monaco, France
| | - J-P Azulay
- Service de neurologie et pathologie du mouvement, hôpital de la Timone, 13385 Marseille cedex 05, France
| | - A Pavy-Le Traon
- Service de neurologie, CHU de Toulouse, 31059 Toulouse cedex, France; UMR 1297, institut des maladies métaboliques et cardiovasculaires, Toulouse, France
| | - O Hanon
- Service de gériatrie, université Paris-Cité, EA4468, hôpital Broca, AP-HP, 75013 Paris, France
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31
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Zhang J, Gao X, Ma B, Liu L, Gao H. Synchronous Bilateral Brachial Blood Pressure Measurements Increased Orthostatic Hypotension Detection in the Elderly. Curr Hypertens Rev 2024; 20:57-63. [PMID: 38155470 DOI: 10.2174/0115734021269751231204114902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/26/2023] [Accepted: 10/25/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Orthostatic hypotension (OH) is a common clinical sign, but its detection rate is low, and it is difficult to repeat because there is no standardized screening method available. AIM This study aimed to establish a method for detecting blood pressure and assess whether it could increase the OH detection rate in the elderly. METHODS From May to October, 2022, 178 patients with symptomatic OH and 286 subjects with asymptomatic OH were selected. BP from the bilateral brachial artery was measured using two electronic sphygmomanometers on both arms at the same time, in the order of supine, sitting, and standing at 0-3 min. OH should meet 20/10 mmHg, standing BP minus sitting BP. The OH detection rates were calculated and compared. The symptomatic OH group was more often older, slimmer, had lower ADL scores, and contained fewer smokers (all P< 0.05). RESULTS The detection rate of the symptomatic OH group using the modified method was 59.55%, which was higher than that of the routine method (34.83% vs. 59.55%, P<0.05). The detection rate using the modified method in the OH group with asymptomatic OH was 20.63%, which was higher than that of the routine method (20.63% vs. 5.59%, P< 0.01). CONCLUSION Synchronous measurement of bilateral brachial artery BP in supine, sitting, and standing positions increased the detection rate of OH in the elderly.
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Affiliation(s)
- Jianying Zhang
- Department of Neurology, The Affiliated Hospital of Qingdao Binhai University, 266404, Qingdao, Shandong, China
| | - Xia Gao
- Department of Acupuncture, Affiliated Qingdao Central Hospital of Qingdao University, Qingdao Cancer Hospital, 266042, Qingdao, Shandong, China
| | - Benxu Ma
- Department of Acupuncture, Affiliated Qingdao Central Hospital of Qingdao University, Qingdao Cancer Hospital, 266042, Qingdao, Shandong, China
| | - Lili Liu
- Department of Pathology, Affiliated Qingdao Central Hospital of Qingdao University, Qingdao Cancer Hospital, 266042, Qingdao, Shandong, China
| | - Huanmin Gao
- Department of Neurology, The Affiliated Hospital of Qingdao Binhai University, 266404, Qingdao, Shandong, China
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Clement G, Cavillon G, Vuillier F, Bouhaddi M, Béreau M. Unveiling autonomic failure in synucleinopathies: Significance in diagnosis and treatment. Rev Neurol (Paris) 2024; 180:79-93. [PMID: 38216420 DOI: 10.1016/j.neurol.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/14/2024]
Abstract
Autonomic failure is frequently encountered in synucleinopathies such as multiple system atrophy (MSA), Parkinson's disease (PD), Lewy body disease, and pure autonomic failure (PAF). Cardiovascular autonomic failure affects quality of life and can be life threatening due to the risk of falls and the increased incidence of myocardial infarction, stroke, and heart failure. In PD and PAF, pathogenic involvement is mainly post-ganglionic, while in MSA, the involvement is mainly pre-ganglionic. Cardiovascular tests exploring the autonomic nervous system (ANS) are based on the analysis of continuous, non-invasive recordings of heart rate and digital blood pressure (BP). They assess facets of sympathetic and parasympathetic activities and provide indications on the integrity of the baroreflex arc. The tilt test is widely used in clinical practice. It can be combined with catecholamine level measurement and analysis of baroreflex activity and cardiac variability for a detailed analysis of cardiovascular damage. MIBG myocardial scintigraphy is the most sensitive test for early detection of autonomic dysfunction. It provides a useful measure of post-ganglionic sympathetic fiber integrity and function and is therefore an effective tool for distinguishing PD from other parkinsonian syndromes such as MSA. Autonomic cardiovascular investigations differentiate between certain parkinsonian syndromes that would otherwise be difficult to segregate, particularly in the early stages of the disease. Exploring autonomic failure by gathering information about residual sympathetic tone, low plasma norepinephrine levels, and supine hypertension can guide therapeutic management of orthostatic hypotension (OH).
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Affiliation(s)
- G Clement
- Service de neurologie électrophysiologie clinique, CHU de Besançon, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; Centre expert Parkinson, CHU de Besançon, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France.
| | - G Cavillon
- Service de neurologie électrophysiologie clinique, CHU de Besançon, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; Centre expert Parkinson, CHU de Besançon, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France
| | - F Vuillier
- Laboratoire d'anatomie, UFR santé, université de Franche-Comté, 19, rue Ambroise-Paré, 25030 Besançon cedex, France
| | - M Bouhaddi
- Laboratoire de physiologie-explorations fonctionnelles, CHU de Besançon, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France
| | - M Béreau
- Service de neurologie électrophysiologie clinique, CHU de Besançon, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; Centre expert Parkinson, CHU de Besançon, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France
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Pavy-Le Traon A, Foubert-Samier A, Fabbri M. An overview on pure autonomic failure. Rev Neurol (Paris) 2024; 180:94-100. [PMID: 38129276 DOI: 10.1016/j.neurol.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023]
Abstract
Pure autonomic failure (PAF) is a neurodegenerative disease affecting the sympathetic component of the autonomic nervous system and presenting as orthostatic hypotension (OH). It is a rare, sporadic disease of adults. Although OH is the primary symptom, the autonomic dysfunction may be more generalised, leading to genitourinary and intestinal dysfunction and sweating disorders. Autonomic symptoms in PAF may be similar to those observed in other autonomic neuropathies that need to be ruled out. PAF belongs to the group of α synucleinopathies and is characterised by predominant peripheral deposition of α-synuclein in autonomic ganglia and nerves. However, in a significant number of cases, PAF may convert into another synucleinopathy with central nervous system involvement with varying prognosis: Parkinson's disease (PD), multiple system atrophy (MSA), or dementia with Lewy bodies (DLB). The clinical features, the main differential diagnoses, the risk factors for "phenoconversion" to another synucleinopathy as well as an overview of treatment will be discussed.
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Affiliation(s)
- A Pavy-Le Traon
- Neurology department, French reference center for Multiple System Atrophy, CHU de Toulouse, Toulouse, France; I2MC Institute-Inserm U1297, Toulouse, France
| | - A Foubert-Samier
- Bordeaux University, Inserm, Bordeaux Population Health Research Center, UMR1219, Bordeaux, France; Neurodegenerative Diseases Neurology Department, CHU de Bordeaux, IMNc, CRMR AMS, Bordeaux, France; Bordeaux University, CNRS, IMN, UMR 5293, Bordeaux, France
| | - M Fabbri
- Neurology department, French reference center for Multiple System Atrophy, CHU de Toulouse, Toulouse, France; Department of Clinical Pharmacology and Neurosciences, Toulouse Parkinson Expert Centre, Toulouse NeuroToul Center of Excellence in Neurodegeneration (COEN), French NS-Park/F-CRIN Network, University of Toulouse 3, CHU of Toulouse, Inserm, Toulouse, France
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34
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Liu J, Li Y, Zhang X, Bu P, Du X, Fang L, Feng Y, Guo Y, Han F, Jiang Y, Li Y, Lin J, Liu M, Liu W, Long M, Mu J, Sun N, Wu H, Xie J, Xie J, Xie L, Yu J, Yuan H, Zha Y, Zhang Y, Zhu S, Wang J. Management of nocturnal hypertension: An expert consensus document from Chinese Hypertension League. J Clin Hypertens (Greenwich) 2024; 26:71-83. [PMID: 38126623 PMCID: PMC10795100 DOI: 10.1111/jch.14757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/20/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023]
Abstract
Nocturnal hypertension is highly prevalent among Chinese and Asian populations, which is mainly attributed to high salt intake and high salt sensitivity. Nocturnal hypertension increases the risk of cardiovascular and all-cause mortality, independent of daytime blood pressure (BP). However, it can usually be detected by 24-h ambulatory BP monitoring, rather than routine office or home BP measurement, thus is often underdiagnosed in clinical practice. Currently, no specific guidance is available for the management of nocturnal hypertension in China or worldwide. Experts from the Chinese Hypertension League summarized the epidemiologic and pathophysiologic characteristics and clinical phenotype of nocturnal hypertension and provided consensus recommendations on optimal management of nocturnal hypertension, with the goal of maximally reducing the cardiovascular disease risks. In this consensus document, 24-h ABPM is recommended for screening and diagnosis of nocturnal hypertension, especially in the elderly, patients with diabetes, chronic kidney diseases, obstructive sleep apnea and other conditions prone to high nocturnal BP. Lifestyle modifications including salt intake restriction, exercise, weight loss, sleep improvement, and mental stress relief are recommended. Long-acting antihypertensive medications are preferred for nocturnal and 24-h BP control. Some newly developed agents, renal denervation, and other device-based therapy on nocturnal BP reduction are evaluated.
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Affiliation(s)
- Jing Liu
- Peking University People's HospitalBeijingChina
| | - Yan Li
- Ruijin HospitalShanghai Jiaotong University School of MedicineShanghaiChina
| | - Xinjun Zhang
- West China Hospital of Sichuan UniversityChengduSichuanChina
| | - Peili Bu
- Qilu Hospital of Shandong UniversityJinanShandongChina
| | - Xueping Du
- Yuetan Community Health Service CenterFuxing HospitalCapital Medical UniversityBeijingChina
| | - Lizheng Fang
- Sir Run Run Shaw HospitalZhejiang University School of MedicineHangzhouZhejiangChina
| | - Yingqing Feng
- Guangdong Provincial People's HospitalGuangzhouGuangdongChina
| | - Yifang Guo
- Hebei General HospitalShijiazhuangHebeiChina
| | - Fei Han
- The First Affiliated Hospital of Zhejiang University School of MedicineHangzhouZhejiangChina
| | - Yinong Jiang
- The First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Yuming Li
- T International Cardiovascular HospitalTianjinChina
| | - Jinxiu Lin
- The First Affiliated Hospital of Fujian Medical UniversityFuzhouFujianChina
| | - Min Liu
- Henan Province People's HospitalZhengzhouHenanChina
| | - Wei Liu
- Beijing HospitalBeijingChina
| | - Mingzhi Long
- The Second Affiliated Hospital of Nanjing Medical UniversityNanjingJiangsuChina
| | - Jianjun Mu
- The First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | | | - Hao Wu
- School of General Practice and Continuing Education, Capital Medical UniversityBeijingChina
| | - Jianhong Xie
- Zhejiang Provincial People's HospitalHangzhouZhejiangChina
| | - Jingyuan Xie
- Ruijin HospitalShanghai Jiaotong University School of MedicineShanghaiChina
| | - Liangdi Xie
- The First Affiliated Hospital of Fujian Medical UniversityFuzhouFujianChina
| | - Jing Yu
- Lanzhou University Second HospitalLanzhouGansuChina
| | - Hong Yuan
- The Third Xiangya Hospital of Central South UniversityChangshaHunanChina
| | - Yan Zha
- Guizhou Provincial People's HospitalGuiyangGuizhouChina
| | - Yuqing Zhang
- Fuwai HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Shanzhu Zhu
- Zhongshan HospitalFudan UniversityShanghaiChina
| | - Jiguang Wang
- Ruijin HospitalShanghai Jiaotong University School of MedicineShanghaiChina
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Tang Z, Hirano S, Koizumi Y, Izumi M, Kitayama Y, Yamagishi K, Tamura M, Ishikawa A, Kashiwado K, Iimori T, Mukai H, Yokota H, Horikoshi T, Uno T, Kuwabara S. Diagnostic Sensitivity and Symptomatic Relevance of Dopamine Transporter Imaging and Myocardial Sympathetic Scintigraphy in Patients with Dementia with Lewy Bodies. J Alzheimers Dis 2024; 100:127-137. [PMID: 38848178 PMCID: PMC11307094 DOI: 10.3233/jad-231395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 06/09/2024]
Abstract
Background Dementia with Lewy bodies (DLB) presents with various symptoms, posing challenges for early diagnosis challenging. Dopamine transporter (123I-FP-CIT) single-photon emission tomography (SPECT) and 123I-meta-iodobenzylguanidine (123I-MIBG) imaging are crucial diagnostic biomarkers. Hypothesis about body- and brain-first subtypes of DLB indicate that some DLB may show normal 123I-FP-CIT or 123I-MIBG results; but the characteristic expression of these two subtypes remains unclear. Objective This study aimed to evaluate the diagnostic sensitivity of 123I-FP-CIT and 123I-MIBG imaging alone, combined in patients with DLB and explore symptoms associated with the abnormal imaging results. Methods Demographic data, clinical status, and imaging results were retrospectively collected from patients diagnosed with possible DLB. Both images were quantified using semi-automated software, and the sensitivity of each imaging modality and their combination was calculated. Demographic data, cognition, and motor and non-motor symptoms were compared among the subgroups based on the imaging results. Symptoms related to each imaging abnormality were examined using binomial logistic regression analyses. Results Among 114 patients with DLB, 80 underwent 123I-FP-CIT SPECT (sensitivity: 80.3%), 83 underwent 123I-MIBG imaging (68.2%), and 66 both (sensitivity of either abnormal result: 93.9%). Visual hallucinations differed among the four subgroups based on imaging results. Additionally, nocturia and orthostatic hypotension differed between abnormal and normal 123I-MIBG images. Conclusions Overall, 123I-FP-CIT SPECT was slightly higher sensitivity than 123I-MIBG imaging, with combined imaging increasing diagnostic sensitivity. Normal results of a single imaging test may not refute DLB. Autonomic symptoms may lead to abnormal 123I-MIBG scintigraphy findings indicating body-first subtype of patients with DLB.
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Affiliation(s)
- Zhihui Tang
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shigeki Hirano
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yume Koizumi
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Michiko Izumi
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yoshihisa Kitayama
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kosuke Yamagishi
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Mitsuyoshi Tamura
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ai Ishikawa
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kouichi Kashiwado
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takashi Iimori
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | - Hiroki Mukai
- Department of Diagnostic Radiology and Radiation Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hajime Yokota
- Department of Diagnostic Radiology and Radiation Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takuro Horikoshi
- Department of Diagnostic Radiology and Radiation Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takashi Uno
- Department of Diagnostic Radiology and Radiation Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Duggan E, Knight SP, Xue F, Romero-Ortuno R. Haemodynamic Parameters Underlying the Relationship between Sarcopenia and Blood Pressure Recovery on Standing. J Clin Med 2023; 13:18. [PMID: 38202023 PMCID: PMC10779883 DOI: 10.3390/jcm13010018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/12/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Sarcopenia, delayed blood pressure (BP) recovery following standing, and orthostatic hypotension (OH) pose significant clinical challenges associated with ageing. While prior studies have established a link between sarcopenia and impaired BP recovery and OH, the underlying haemodynamic mechanisms remain unclear. METHODS We enrolled 107 participants aged 50 and above from a falls and syncope clinic, conducting an active stand test with continuous non-invasive haemodynamic measurements. Hand grip strength and five-chair stand time were evaluated, and muscle mass was estimated using bioelectrical impedance analysis. Participants were categorised as non-sarcopenic or sarcopenic. Employing mixed-effects linear regression, we modelled the effect of sarcopenia on mean arterial pressure and heart rate after standing, as well as Modelflow®-derived parameters such as cardiac output, total peripheral resistance, and stroke volume, while adjusting for potential confounders. RESULTS Sarcopenia was associated with diminished recovery of mean arterial pressure during the 10-20 s period post-standing (β -0.67, p < 0.001). It also resulted in a reduced ascent to peak (0-10 s) and recovery from peak (10-20 s) of cardiac output (β -0.05, p < 0.001; β 0.06, p < 0.001). Furthermore, sarcopenia was associated with attenuated recovery (10-20 s) of total peripheral resistance from nadir (β -0.02, p < 0.001) and diminished recovery from peak (10-20 s) of stroke volume (β 0.54, p < 0.001). Notably, heart rate did not exhibit a significant association with sarcopenia status at any time interval post-standing. CONCLUSION The compromised BP recovery observed in sarcopenia appears to be driven by an initial reduction in the peak of cardiac output, followed by attenuated recovery of cardiac output from its peak and total peripheral resistance from its nadir. This cardiac output finding seems to be influenced by stroke volume rather than heart rate. Possible mechanisms for these findings include cardio-sarcopenia, the impact of sarcopenia on the autonomic nervous system, and/or the skeletal muscle pump.
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Affiliation(s)
- Eoin Duggan
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
- Falls and Syncope Unit (FASU), Mercer’s Institute for Successful Ageing, St James’s Hospital, D08 KC95 Dublin, Ireland
| | - Silvin P. Knight
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
| | - Feng Xue
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
| | - Roman Romero-Ortuno
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
- Falls and Syncope Unit (FASU), Mercer’s Institute for Successful Ageing, St James’s Hospital, D08 KC95 Dublin, Ireland
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De Azevedo SM, Pichel RC, Freitas E, Campar A, Marinho A, Mendonça T. Orthostatic hypotension as an unusual presentation of spinal calcium pyrophosphate deposition disease: case report and review of literature. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MEDECINE INTERNE 2023; 61:212-215. [PMID: 37671719 DOI: 10.2478/rjim-2023-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Indexed: 09/07/2023]
Abstract
Calcium pyrophosphate crystal deposition disease (CPPD), also known as pseudogout, with spinal involvement, is associated with clinical manifestations of acute nerve compression or chronic spinal stenosis. Precipitation of crystals of calcium pyrophosphate dihydrate in connective tissues can lead to acute inflammatory arthritis, degenerative chronic arthropathies, and radiographic evidence of cartilage calcification. We present a case of an 87-year-old woman, with unstudied chronic polyarthralgia and symptomatic orthostatic hypotension. It were documented acute calcium pyrophosphate deposition wrist arthritis, and cervical CT and MRI was suggestive of spinal involvement of CPPD. Workup excluded other causes of OH. Surgical approach could be indicated to minimize the symptoms, but it was contra-indicated due to the patient's performance status, so histological diagnosis was not possible. Muscle atrophy played an important part in the rapid progression of this insidious chronic disease. Conservative and symptomatic treatment achieve scarce short-term clinical improvement. Spinal involvement of CPPD was thought to be rare but recent studies show a higher prevalence than expected. We call for attention to the extent of structural changes that may occur when not early diagnosed nor treated. High clinical suspicion is required and this is, to our knowledge, the first report of orthostatic hypotension as a presentation of CPPD.
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Affiliation(s)
- Sofia Moura De Azevedo
- Internal Medicine Service, Centro Hospitalar Universitário de Santo António. Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - Rita Carrilho Pichel
- Medical Oncology Service, Centro Hospitalar Universitário de Santo António. Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - Egídio Freitas
- Dermatology Service, Centro Hospitalar Universitário de Santo António. Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - Ana Campar
- Clinical Immunology Unit, Centro Hospitalar Universitário de Santo António. Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - António Marinho
- Clinical Immunology Unit, Centro Hospitalar Universitário de Santo António. Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - Teresa Mendonça
- Internal Medicine Service, Centro Hospitalar Universitário de Santo António. Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
- Clinical Immunology Unit, Centro Hospitalar Universitário de Santo António. Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
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Chen B, Yang W, Luo Y, Tan EK, Wang Q. Non-pharmacological and drug treatment of autonomic dysfunction in multiple system atrophy: current status and future directions. J Neurol 2023; 270:5251-5273. [PMID: 37477834 DOI: 10.1007/s00415-023-11876-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/11/2023] [Accepted: 07/11/2023] [Indexed: 07/22/2023]
Abstract
Multiple system atrophy (MSA) is a sporadic, fatal, and rapidly progressive neurodegenerative disease of unknown etiology that is clinically characterized by autonomic failure, parkinsonism, cerebellar ataxia, and pyramidal signs in any combination. Early onset and extensive autonomic dysfunction, including cardiovascular dysfunction characterized by orthostatic hypotension (OH) and supine hypertension, urinary dysfunction characterized by overactive bladder and incomplete bladder emptying, sexual dysfunction characterized by sexual desire deficiency and erectile dysfunction, and gastrointestinal dysfunction characterized by delayed gastric emptying and constipation, are the main features of MSA. Autonomic dysfunction greatly reduces quality of life and increases mortality. Therefore, early diagnosis and intervention are urgently needed to benefit MSA patients. In this review, we aim to discuss the systematic treatment of autonomic dysfunction in MSA, and focus on the current methods, starting from non-pharmacological methods, such as patient education, psychotherapy, diet change, surgery, and neuromodulation, to various drug treatments targeting autonomic nerve and its projection fibers. In addition, we also draw attention to the interactions among various treatments, and introduce novel methods proposed in recent years, such as gene therapy, stem cell therapy, and neural prosthesis implantation. Furthermore, we elaborate on the specific targets and mechanisms of action of various drugs. We would like to call for large-scale research to determine the efficacy of these methods in the future. Finally, we point out that studies on the pathogenesis of MSA and pathophysiological mechanisms of various autonomic dysfunction would also contribute to the development of new promising treatments and concepts.
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Affiliation(s)
- BaoLing Chen
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of China
| | - Wanlin Yang
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of China
| | - Yuqi Luo
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of China
| | - Eng-King Tan
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
| | - Qing Wang
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of China.
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Liu Z, Su D, Zhou J, Wang X, Wang Z, Yang Y, Ma H, Feng T. Acute effect of levodopa on orthostatic hypotension and its association with motor responsiveness in Parkinson's disease: Results of acute levodopa challenge test. Parkinsonism Relat Disord 2023; 115:105860. [PMID: 37742502 DOI: 10.1016/j.parkreldis.2023.105860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 09/15/2023] [Accepted: 09/17/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE Levodopa administration can induce or worsen orthostatic hypotension (OH) in patients with Parkinson's disease (PD). Understanding of acute OH post levodopa (AOHPL) is important for rational drug use in PD patients. Primary objective of this study was to investigate the incidence of AOHPL in PD patients. The secondary objectives were a) hemodynamic character of AOHPL; b) risk factors of AOHPL; c) relationship between motor responsiveness and blood pressure (BP) change. METHODS 490 PD inpatients underwent acute levodopa challenge test (LCT). Supine-to-standing test (STS) was done 4 times during LCT, including before levodopa and every hour post levodopa intake within 3 h. Patients were classified into two groups, AOHPL and non-AOHPL. A comprehensive set of clinical features scales was assessed, including both motor (e.g., motor response, wearing-off) and nonmotor symptoms (e.g., autonomic dysfunction, neuropsychology). RESULTS 33.1% PD patients had OH before drug, 50.8% the same subjects had AOHPL during levodopa effectiveness. PD patients who had better response to levodopa likely to have lower standing mean artery pressure (MAP) and severer systolic BP drop after levodopa intake. BP increased when the motor performance worsened and vice versa. Beneficial response was a risk factors of AOHPL (OR = 1.624, P = 0.017). CONCLUSIONS AOHPL was very common in PD patients. We suggested that PD patients with risk factors should monitor hemodynamic change during LCT to avoid AOHPL following the introduction or increase of oral levodopa. The fluctuations of BP were complicated and multifactorial, likely caused by the process of PD and levodopa both.
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Affiliation(s)
- Zhu Liu
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Dongning Su
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Junhong Zhou
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Roslindale, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Xuemei Wang
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhan Wang
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yaqin Yang
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Huizi Ma
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Tao Feng
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China.
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Palma JA, Thijs RD. Non-Pharmacological Treatment of Autonomic Dysfunction in Parkinson's Disease and Other Synucleinopathies. JOURNAL OF PARKINSON'S DISEASE 2023:JPD230173. [PMID: 37694308 DOI: 10.3233/jpd-230173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Symptoms of autonomic dysfunction are prevalent and can be very debilitating, reducing the quality of life in patients with Parkinson's disease (PD) and other synucleinopathies such as dementia with Lewy bodies and multiple system atrophy. Non-pharmacological therapies are key to effective management and are frequently used alone in patients with mild autonomic symptoms, or in combination with pharmacological therapies in patients with moderate and severe symptoms. This article focuses on non-pharmacological approaches. Our objective was to review the non-drug and non-surgical approaches to treating autonomic symptoms in patients with PD and other synucleinopathies, focusing on cardiovascular, gastrointestinal, and genitourinary autonomic dysfunction. Evidence supporting the effectiveness of non-pharmacological treatment for the management of neurogenic orthostatic hypotension, supine hypertension, constipation, and bladder and sexual dysfunction is available. High-quality prospective trials are scarce, yet some non-pharmacological interventions (e.g., physical counter maneuvers) can be evaluated relatively quickly on an individual basis and often seem effective. The emerging variety of clinical presentations advocates for a stepwise, individualized, and non-pharmacological approach for the management of autonomic symptoms. Often, the first step is to reduce or discontinue drugs that cause or aggravate autonomic symptoms followed by lifestyle measures. While non-pharmacological and non-surgical treatments are available and, in many cases, effective to improve symptoms of autonomic dysfunction in PD and other synucleinopathies, they are often overlooked. Large randomized trials testing and comparing non-pharmacological approaches are warranted.
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Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, Netherlands
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Han J, Park J, Kang H, Lee H, Kim N. The Effect of a Biofeedback-Based Integrated Program on Improving Orthostatic Hypotension in Community-Dwelling Older Adults: A Pilot Study. J Cardiovasc Nurs 2023:00005082-990000000-00120. [PMID: 37615610 DOI: 10.1097/jcn.0000000000001026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
BACKGROUND Orthostatic hypotension (OH) is prevalent among community-dwelling older adults and is associated with multiple negative health outcomes. Older adults are susceptible to developing OH because aging alters autonomic nervous system function. Biofeedback is a noninvasive, nonpharmacological intervention that can modulate autonomic nervous system dysfunction in older adults. OBJECTIVES Our aim in this study was to examine the effect of a biofeedback-based integrated program on community-dwelling older adults with OH. METHODS We conducted a controlled pilot study. Community-dwelling older adults 65 years or older who had nonneurogenic OH were eligible. Data from 51 participants, comprising 27 in the intervention group and 24 in the control group, were analyzed. Weekly biofeedback-based integrated program consisting of biofeedback training along with group education about behavioral modification, physical activities, and telephone counseling was provided for 12 weeks. Orthostatic hypotension was evaluated by measuring the drop in systolic and diastolic blood pressure after postural changes. Autonomic nervous system function was measured using heart rate variability. RESULTS Among the indicators of heart rate variability, total power (P = .037) and low frequency (P = .017) increased significantly, suggesting that autonomic function improved. Severity of orthostatic symptoms (P < .001) and drops in systolic (P = .003) and diastolic (P = .012) blood pressure after postural changes decreased significantly in the intervention group. CONCLUSION Biofeedback-based integrated program was effective in improving autonomic nervous system function and alleviated OH. Therefore, biofeedback-based integrated program should be tested in a larger randomized controlled study with long-term follow-up.
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van der Stam AH, Shmuely S, de Vries NM, Bloem BR, Thijs RD. The Impact of Head-Up Tilt Sleeping on Orthostatic Tolerance: A Scoping Review. BIOLOGY 2023; 12:1108. [PMID: 37626994 PMCID: PMC10452159 DOI: 10.3390/biology12081108] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023]
Abstract
To systematically summarize the evidence of head-up tilt sleeping (HUTS) on orthostatic tolerance, we conducted a systematic, predefined search in PubMed, OVID Embase, Cochrane and Web of Science. We included studies assessing the effect of HUTS on orthostatic tolerance and other cardiovascular measures and rated the quality with the American Academy of Neurology risk of bias tool. We included 10 studies (n = 185) in four groups: orthostatic hypotension (OH; 6 studies, n = 103), vasovagal syncope (1 study, n = 12), nocturnal angina pectoris (1 study, n = 10) and healthy subjects (2 studies, n = 58). HUTS duration varied (1 day-4 months) with variable inclinations (5°-15°). In two of six OH studies, HUTS significantly improved standing systolic blood pressure. Orthostatic tolerance was consistently enhanced in OH studies with higher angles (≥12°), in 2 out of 3 with smaller angles (5°) but also in one studying horizontal sleeping. In vasovagal syncope, HUTS significantly augmented resilience to extreme orthostatic stress. One study was rated as a class II risk of bias, one of Class II/III and eight of Class IV. The evidence favouring HUTS to improve orthostatic tolerance is weak due to variable interventions, populations, small samples and a high risk of bias. Despite this, we found some physiological signs suggesting a beneficial effect.
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Affiliation(s)
- Amber H. van der Stam
- Department of Neurology, Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; (A.H.v.d.S.); (S.S.); (N.M.d.V.); (B.R.B.)
| | - Sharon Shmuely
- Department of Neurology, Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; (A.H.v.d.S.); (S.S.); (N.M.d.V.); (B.R.B.)
| | - Nienke M. de Vries
- Department of Neurology, Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; (A.H.v.d.S.); (S.S.); (N.M.d.V.); (B.R.B.)
| | - Bastiaan R. Bloem
- Department of Neurology, Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; (A.H.v.d.S.); (S.S.); (N.M.d.V.); (B.R.B.)
| | - Roland D. Thijs
- Department of Neurology, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands
- Stichting Epilepsie Instellingen Nederland, 2130 AM Hoofddorp, The Netherlands
- UCL Queen Square Institute of Neurology, University College London, London WC1N 1PJ, UK
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Abubakar M, Prasad R, Salim SS, Basavaraju D, Khan M, Lateef IK, Furqan A, Raza S, Gupta I, Singla D, Adil H, Naeem A. Orthostatic Hypotension in Benign Prostatic Hyperplasia Patients and Its Association With Alpha-1 Antagonist Use: A Comprehensive Literature Review. Cureus 2023; 15:e44097. [PMID: 37750139 PMCID: PMC10518119 DOI: 10.7759/cureus.44097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 09/27/2023] Open
Abstract
Orthostatic hypotension (OH) is frequently observed in benign prostatic hyperplasia (BPH) patients undergoing alpha-1 adrenergic antagonist (A1AA) therapy. While previous studies have acknowledged the prevalence of OH in BPH patients on A1AAs, limited data exist on ranking the safety of different A1AAs. This comprehensive review explores the underlying mechanisms of OH, examines numerous factors influencing its development, and provides insights into effective treatment strategies such as hydration, gradual postural changes, leg exercises, compression stockings, and tilt-table training for BPH management. The review highlights the significance of individualized care, interdisciplinary collaboration, and further research to optimize A1AA treatment, improve patient outcomes, and enhance quality of life.
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Affiliation(s)
- Muhammad Abubakar
- Department of Internal Medicine, Siddique Sadiq Memorial Trust Hospital, Gujranwala, PAK
- Department of Internal Medicine, Ameer-ud-Din Medical College, Lahore General Hospital, Lahore, PAK
| | - Rachna Prasad
- Department of Internal Medicine, Stanley Medical College, Chennai, IND
| | - Siffat S Salim
- Department of Surgery, Holy Family Red Crescent Medical College Hospital, Dhaka, BGD
| | - Deepak Basavaraju
- Department of Internal Medicine, Mysore Medical College and Research Institute, Mysore, IND
| | - Munazza Khan
- Department of Internal Medicine, Medical University Pleven, Pleven, BGR
| | - Ibrahim K Lateef
- Department of Internal Medicine, Medical University Pleven, Pleven, BGR
| | - Ahmad Furqan
- Department of Internal Medicine, Lahore Medical and Dental College, Lahore, PAK
| | - Saud Raza
- Department of Internal Medicine, Ameer-ud-Din Medical College, Lahore General Hospital, Lahore, PAK
| | - Ishita Gupta
- Department of Internal Medicine, Dr. Baba Saheb Ambedkar Medical College and Hospital, New Delhi, IND
| | - Deepak Singla
- Department of Internal Medicine, Government Medical College, Patiala, Patiala, IND
| | - Hira Adil
- Department of Community Medicine, Khyber Girls Medical College, Peshawar, PAK
| | - Ather Naeem
- Department of Cardiology, Punjab Institute of Cardiology, Lahore, PAK
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Ryman SG, Shaff N, Dodd A, Nitschke S, Wertz C, Julio K, Suarez Cedeno G, Deligtisch A, Erhardt E, Lin H, Vakhtin A, Poston KL, Tarawneh R, Pirio Richardson S, Mayer A. Reduced and Delayed Cerebrovascular Reactivity in Patients with Parkinson's Disease. Mov Disord 2023; 38:1262-1272. [PMID: 37157056 PMCID: PMC10524339 DOI: 10.1002/mds.29429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/17/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Cerebrovascular dysfunction in Parkinson's disease (PD) is heterogeneous and may contribute to disease pathophysiology or progression. There is a need to understand the mechanisms by which cerebrovascular dysfunction is altered in participants with PD. OBJECTIVES The objective of this study is to test the hypothesis that participants with PD exhibit a significant reduction in the ability of the cerebral vessels to dilate in response to vasoactive challenges relative to healthy controls (HC). METHODS The current study uses a vasodilatory challenge while participants undergo functional magnetic resonance imaging to quantify the amplitude and delay of cerebrovascular reactivity in participants with PD relative to age and sex-matched HC. An analysis of covariance was used to evaluate differences in cerebrovascular reactivity amplitude and latency between PD participants and HC. RESULTS A significant main effect of group was observed for whole-brain cerebrovascular reactivity amplitude (F(1, 28) = 4.38, p = 0.046, Hedge's g = 0.73) and latency (F(1, 28) = 16.35, p < 0.001, Hedge's g = 1.42). Participants with PD exhibited reduced whole-brain amplitude and increased latencies in cerebrovascular reactivity relative to HC. The evaluation of regional effects indicates that the largest effects were observed in the cuneus, precuneus, and parietal regions. CONCLUSIONS PD participants exhibited reduced and delayed cerebrovascular reactivity. This dysfunction may play an important role in chronic hypoxia, neuroinflammation, and protein aggregation, mechanisms that could lead to disease progression. Cerebrovascular reactivity may serve as an important biomarker and target for future interventions. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Sephira G Ryman
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Nicholas Shaff
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
| | - Andrew Dodd
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
| | - Stephanie Nitschke
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
| | - Christopher Wertz
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
| | - Kayla Julio
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
| | - Gerson Suarez Cedeno
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Amanda Deligtisch
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Erik Erhardt
- Department of Mathematics and Statistics, University of New Mexico, Albuquerque, New Mexico, USA
| | - Henry Lin
- Department of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
- Neurology|Medicine, New Mexico VA Health Care System, Albuquerque, New Mexico, USA
| | - Andrei Vakhtin
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
| | - Kathleen L Poston
- Movement Disorders Division in the Department of Neurology and Neurological Sciences, Stanford University, Stanford, California, USA
| | - Rawan Tarawneh
- Memory and Aging Center, Department of Neurology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Sarah Pirio Richardson
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, University of New Mexico, Albuquerque, New Mexico, USA
- Neurology|Medicine, New Mexico VA Health Care System, Albuquerque, New Mexico, USA
| | - Andrew Mayer
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
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Cuspidi C, Gherbesi E, Tadic M. Diabetes and orthostatic hypotension: are all patients created equal? J Hypertens 2023; 41:1217-1218. [PMID: 37259781 DOI: 10.1097/hjh.0000000000003432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Cesare Cuspidi
- Department of Medicine and Surgery, University of Milano-Bicocca
| | - Elisa Gherbesi
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marijana Tadic
- Department of Cardiology, University Hospital 'Dr Dragisa Misovic-Dedinje', Belgrade, Serbia
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Yoo SW, Oh YS, Ryu DW, Ha S, Kim Y, Yoo JY, Kim JS. A 3-year natural history of orthostatic blood pressure dysregulation in early Parkinson's disease. NPJ Parkinsons Dis 2023; 9:96. [PMID: 37344481 DOI: 10.1038/s41531-023-00546-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 06/09/2023] [Indexed: 06/23/2023] Open
Abstract
In Parkinson's disease (PD), cardiovascular dysautonomia accumulates with disease progression, but studies are lacking on the natural history behind each subtype except orthostatic hypotension. This study investigated the early natural history of orthostatic blood pressure (BP) subtypes in PD. Two hundred sixty-seven early PD patients were included. Their cardiovascular functions were assessed by head-up tilt-test and 123I-metaiodobenzylguanidine scintigraphy. All patients were classified as having supine hypertension (SH), orthostatic hypertension (OHT), delayed orthostatic hypotension (dOH), or orthostatic hypotension (OH) according to consensus criteria. The patients were assigned to one of three groups: extreme BP dysregulation (BPextreme), mild BP dysregulation (BPmild), and no BP dysregulation (BPnone) according to their orthostatic BP subtypes. The autonomic functions of 237 patients were re-assessed after approximately 3 years. Among initially enrolled subjects, 61.8% of the patients showed orthostatic BP dysregulation: 29.6% in the BPextreme group and 32.2% in the BPmild group. At follow-up, the BPextreme group increased in number, while the BPmild group diminished. Two-thirds of the initial BPextreme patients maintained their initial subtype at follow-up. In comparison, 40.7% of the initial BPmild patients progressed to the BPextreme group, and 32.4% and 14.7% of the initial BPnone group progressed to BPextreme and BPmild groups, respectively. Cardiac denervation was most severe in the BPextreme group, and a linear gradient of impairment was observed across the subtypes. In conclusion, various forms of positional BP dysregulation were observed during the early disease stage. SH and OH increased with disease progression, while OHT and dOH decreased, converting primarily to SH and/or OH.
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Affiliation(s)
- Sang-Won Yoo
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoon-Sang Oh
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong-Woo Ryu
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seunggyun Ha
- Division of Nuclear Medicine, Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yuna Kim
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji-Yeon Yoo
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joong-Seok Kim
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Hoxhaj P, Shah S, Muyolema Arce VE, Khan W, Sadeghzadegan A, Singh S, Collado GF, Goyal A, Khawaja I, Botlaguduru D, Razzaq W, Abdin ZU, Gupta I. Ampreloxetine Versus Droxidopa in Neurogenic Orthostatic Hypotension: A Comparative Review. Cureus 2023; 15:e38907. [PMID: 37303338 PMCID: PMC10257554 DOI: 10.7759/cureus.38907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/13/2023] Open
Abstract
Neurogenic orthostatic hypotension (nOH) is a disabling problem of autonomic dysfunction in patients with Parkinson's disease, which is associated with poor quality of life and higher mortality rates. The purpose of this literature review was to explore and compare the efficacy and safety of droxidopa (an existing treatment) and ampreloxetine (a newer medication) in the treatment of nOH. We used a mixed-method literature review that addresses the epidemiology, pathophysiology, and pharmacological and non-pharmacological management of nOH in Parkinson's disease in a general way, with a more exploratory approach to droxidopa- and ampreloxetine-controlled trial studies. We included a total of 10 studies of randomized controlled trials with eight studies focused on droxidopa and two studies focused on ampreloxetine. These two drugs were analyzed and compared based on the collected individual study results. Treatment of nOH in Parkinson's disease patients with droxidopa or ampreloxetine showed clinically meaningful and statistically significant improvements relative to placebo on the components of the OHSA (Orthostatic Hypotension Symptom Assessment) composite score and OHDAS (Orthostatic Hypotension Daily Activity Scale composite scores) composite score. Droxidopa had an improved effect on daily activities, with an associated increase in standing systolic blood pressure (BP), but the long-term efficacy of droxidopa has not been documented. Standing systolic BP was maintained by ampreloxetine and worsened after the withdrawal phase. This highlights the importance of conducting further research which will help us to improve the therapeutic approach for patients with nOH and Parkinson's disease.
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Affiliation(s)
| | - Shruti Shah
- Internal Medicine, Byramjee Jeejeeboy (BJ) Medical College, Pune, IND
| | | | | | | | - Saumya Singh
- Internal Medicine, Gujarat Medical Education & Research Society (GMERS) Medical College and Hospital, Gujarat, IND
| | - Gaudy F Collado
- Internal Medicine, Fleet Medical Unit, Philippine Fleet, Philippine Navy, Cavite City, PHL
| | - Abhishek Goyal
- Internal Medicine, Kasturba Medical College, Manipal, Manipal, IND
| | - Imran Khawaja
- Internal Medicine, Ayub Medical Institute, Abbottabad, PAK
| | | | - Waleed Razzaq
- Internal Medicine, Services Hospital Lahore, Lahore, PAK
| | - Zain U Abdin
- Medicine, District Head Quarters Hospital, Faisalabad, PAK
| | - Ishita Gupta
- Medicine, Dr. Rajendra Prasad Government Medical College, Tanda, IND
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Rinaldi D, Galli S, Fanciulli A, Pontieri FE. Levodopa/carbidopa intestinal gel via percutaneous endoscopic transgastric jejunostomy in advanced Parkinson's disease: hitting two birds with one stone? Parkinsonism Relat Disord 2023:105394. [PMID: 37076400 DOI: 10.1016/j.parkreldis.2023.105394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/26/2023] [Accepted: 04/02/2023] [Indexed: 04/21/2023]
Abstract
Here we focus on people with advanced PD undergoing percutaneous endoscopic transgastric jejunostomy (PEG-J) ("one stone") for LCIG infusion therapy for managing severe motor fluctuations ("first bird") and discuss its implications for improving accompanying symptoms of cardiovascular, urinary, and gastrointestinal autonomic failure ("second bird").
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Affiliation(s)
- Domiziana Rinaldi
- Dipartimento di Neuroscienze, Salute Mentale e Organi di Senso - NESMOS, Sapienza University of Rome, Rome, Italy; Fondazione Santa Lucia, IRCCS, Rome, Italy
| | - Silvia Galli
- Dipartimento di Neuroscienze, Salute Mentale e Organi di Senso - NESMOS, Sapienza University of Rome, Rome, Italy
| | | | - Francesco E Pontieri
- Dipartimento di Neuroscienze, Salute Mentale e Organi di Senso - NESMOS, Sapienza University of Rome, Rome, Italy; Fondazione Santa Lucia, IRCCS, Rome, Italy
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Park JW, Okamoto LE, Kim SH, Baek SH, Sung JH, Jeon N, Gamboa A, Shibao CA, Diedrich A, Kim BJ, Biaggioni I. Use of Valsalva Maneuver to Detect Late-Onset Delayed Orthostatic Hypotension. Hypertension 2023; 80:792-801. [PMID: 36695176 PMCID: PMC10023507 DOI: 10.1161/hypertensionaha.122.20098] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 01/08/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND Standard autonomic testing includes a 10-minute head-up tilt table test to detect orthostatic hypotension. Although this test can detect delayed orthostatic hypotension (dOH) between 3 and 10 minutes of standing, it cannot detect late-onset dOH after 10 minutes of standing. METHODS To determine whether Valsalva maneuver responses can identify patients who would require prolonged head-up tilt table test to diagnose late-onset dOH; patients with immediate orthostatic hypotension (onset <3 minutes; n=176), early-onset dOH (onset between 3 and 10 minutes; n=68), and late-onset dOH (onset >10 minutes; n=32) were retrospectively compared with controls (n=114) with normal head-up tilt table test and composite autonomic scoring scale score of 0. RESULTS Changes in baseline systolic blood pressure at late phase 2 (∆SBPVM2), heart rate difference between baseline and phase 3 (∆HRVM3), and Valsalva ratio were lower and pressure recovery time (PRT) at phase 4 was longer in late-onset dOH patients than in controls. Differences in PRT and ∆HRVM3 remained significant after correcting for age. A PRT ≥2.14 s and ∆HRVM3 ≤15 bpm distinguished late-onset dOH from age- and sex-matched controls. Patients with longer PRT (relative risk ratio, 2.189 [1.579-3.036]) and lower ∆HRVM3 (relative risk ratio, 0.897 [0.847-0.951]) were more likely to have late-onset dOH. Patients with longer PRT (relative risk ratio, 1.075 [1.012-1.133]) were more likely to have early-onset than late-onset dOH. CONCLUSIONS Long PRT and short ∆HRVM3 can help to identify patients who require prolonged head-up tilt table test to diagnose late-onset dOH.
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Affiliation(s)
- Jin-Woo Park
- Department of Neurology, Korea University Medicine, Seoul (J.-W.P., S.-H.K., S.-H.B., J.H.S., N.J., B.-J.K.)
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-W.P., L.E.O., A.G., C.A.S., A.D., I.B.)
| | - Luis E Okamoto
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-W.P., L.E.O., A.G., C.A.S., A.D., I.B.)
| | - Sung-Hwan Kim
- Department of Neurology, Korea University Medicine, Seoul (J.-W.P., S.-H.K., S.-H.B., J.H.S., N.J., B.-J.K.)
| | - Seol-Hee Baek
- Department of Neurology, Korea University Medicine, Seoul (J.-W.P., S.-H.K., S.-H.B., J.H.S., N.J., B.-J.K.)
| | - Joo Hye Sung
- Department of Neurology, Korea University Medicine, Seoul (J.-W.P., S.-H.K., S.-H.B., J.H.S., N.J., B.-J.K.)
| | - Namjoon Jeon
- Department of Neurology, Korea University Medicine, Seoul (J.-W.P., S.-H.K., S.-H.B., J.H.S., N.J., B.-J.K.)
| | - Alfredo Gamboa
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-W.P., L.E.O., A.G., C.A.S., A.D., I.B.)
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-W.P., L.E.O., A.G., C.A.S., A.D., I.B.)
| | - André Diedrich
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-W.P., L.E.O., A.G., C.A.S., A.D., I.B.)
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN (A.D.)
| | - Byung-Jo Kim
- Department of Neurology, Korea University Medicine, Seoul (J.-W.P., S.-H.K., S.-H.B., J.H.S., N.J., B.-J.K.)
- BK21 FOUR Program in Learning Health Systems, Korea University, Seoul (B.-J.K.)
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-W.P., L.E.O., A.G., C.A.S., A.D., I.B.)
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Crnošija L, Adamec I, Krbot Skorić M, Habek M. How to explore and explain autonomic changes in multiple sclerosis. Neurophysiol Clin 2023; 53:102854. [PMID: 36966707 DOI: 10.1016/j.neucli.2023.102854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 03/29/2023] Open
Abstract
Autonomic dysfunction (AD) in people with MS (pwMS) is a frequent finding. This narrative review will present an overview of central neural mechanisms involved in the control of cardiovascular and thermoregulatory systems, and methods of autonomic nervous system testing will be discussed thereafter. Since the need for standardization of autonomic nervous system (ANS) testing, we will focus on the standard battery of tests (blood pressure and heart rate response to Valsalva maneuver and head-up tilt, and heart rate response to deep breathing test plus one of the tests for sudomotor function), which can detect ANS pathology in the majority of pwMS. The review will briefly discuss the other types of AD in pwMS and the use of appropriate tests. While performing ANS testing in pwMS one has to consider the multiple sclerosis phenotypes, disease duration, and its activity, the degree of clinical disability of patients included in the study, and the disease-modifying therapies taken, as these factors may have a great influence on the results of ANS testing. In other words, detailed patient characteristics presentation and patient stratification are beneficial when reporting results of ANS testing in pwMS.
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