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Erelund S, Södergren A, Wiklund U, Sundström N. Heart rate variability and cardiovascular risk factors in patients with rheumatoid arthritis: A longitudinal study. Auton Neurosci 2023; 249:103119. [PMID: 37703773 DOI: 10.1016/j.autneu.2023.103119] [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: 06/05/2023] [Revised: 08/28/2023] [Accepted: 09/03/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND It is established that the risk of cardiovascular disease (CVD) is increased in patients with Rheumatoid Arthritis (RA). Heart rate variability (HRV) is a method for evaluating the activity in the cardiac autonomic nervous system. Our aim was to assess the longitudinal development of HRV in patients with RA and compare with healthy controls. Furthermore, we wanted to investigate associations between HRV, inflammatory disease activity and cardiovascular complications in patients with RA over time. METHOD HRV was assessed with frequency-domain analysis at baseline and after five years in 50 patients with early RA, all being younger than 60 years. HRV indices were age-adjusted based on the estimated age-dependency in 100 age and sex matched healthy controls. Additionally, clinical data including serological markers, disease activity, and blood pressure were collected from the patients. Eleven years after inclusion CVD was assessed. RESULTS At baseline, patients with RA presented with lower HRV compared to controls during deep breathing (6 breaths/min), paced normal breathing (12 breaths/min) and after passive tilt to the upright position. No significant change in HRV was observed at the five-year follow-up. A significant negative correlation was found between HRV parameters and systolic blood pressure (SBP) at baseline. A significant positive correlation was found between heart rate and inflammatory markers at baseline but not after five years. Nine patients had developed CVD after 11 years, but no significant association was found with baseline HRV data. CONCLUSION This study showed that patients with RA have autonomic imbalance both at an early stage of the disease and after five years, despite anti-rheumatic medication, but no correlation between HRV and inflammation markers were observed. Reduced HRV was also significantly negatively correlated with increased SBP. Hypertension is a common finding in patients with RA. Thus, significant decline of HRV could be a useful early marker for development of hypertension in patients with RA.
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Affiliation(s)
- Sofia Erelund
- Department of Surgery and Perioperative Sciences, Umeå University, Umeå, Sweden.
| | - Anna Södergren
- Department of Public Health and Clinical Medicine/Rheumatology, Umeå University, Umeå, Sweden
| | - Urban Wiklund
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Nina Sundström
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden
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Wiklund U, Kadkhodaee A, Andersson K, Suhr OB, Hörnsten R. Normal scores of deep breathing tests: beware of dysrhythmia in transthyretin amyloidosis. Amyloid 2018; 25:54-61. [PMID: 29394116 DOI: 10.1080/13506129.2018.1434140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The heart rate (HR) response to paced deep breathing (DB) is a common test of cardiac autonomic function, where high heart rate variability (HRV) is considered to reflect normal autonomic function. We evaluated the DB test in patients with hereditary transthyretin amyloid (ATTRm) amyloidosis, where autonomic dysregulation and atrial arrhythmias are common. METHODS Paced DB was performed during one minute (six breaths/min) in 165 recordings in adult ATTRm amyloidosis patients with the TTR Val30Met mutation, 42 hypertrophic cardiomyopathy (HCM) patients and 211 healthy subjects. HRV was scored by traditional DB indices and by a novel regularity index, estimating the fraction of the HRV that was coherent with the breathing pattern. RESULTS Twenty per cent of ATTRm amyloidosis patients presented with age-adjusted HRV scores within normal limits but poor regularity due to subtle atrial arrhythmias and cardiac conduction disturbances. Forty-seven per cent of ATTRm amyloidosis patients presented with HRV scores below normal limits, whereas HCM patients presented with higher HRV than ATTRm amyloidosis patients. CONCLUSIONS Reduced HRV is common in ATTRm amyloidosis patients during DB, however, autonomic function cannot be evaluated in patients presenting with the combination of "normal" scores and low regularity, since their HR responses often reflects dysrhythmias.
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Affiliation(s)
- Urban Wiklund
- a Department of Radiation Sciences, Biomedical Engineering , Umeå University , Umeå , Sweden
| | - Amir Kadkhodaee
- a Department of Radiation Sciences, Biomedical Engineering , Umeå University , Umeå , Sweden
| | - Kennet Andersson
- a Department of Radiation Sciences, Biomedical Engineering , Umeå University , Umeå , Sweden
| | - Ole B Suhr
- b Department of Public Health and Clinical Medicine , Umeå University , Umeå , Sweden
| | - Rolf Hörnsten
- c Department of Surgical and Perioperative Sciences, Clinical Physiology, Heart Centre , Umeå University , Umeå , Sweden
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Obayashi K, Ueda M, Yamashita T, Tasaki M, Izaki A, Yanagisawa Y, Masuda T, Misumi Y, Ando Y. Long-term effects of liver transplantation on small-fiber dysfunction in Japanese transthyretin (ATTR) V30M hereditary amyloidosis with polyneuropathy (FAP). Amyloid 2017; 24:99. [PMID: 28434340 DOI: 10.1080/13506129.2017.1286586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Konen Obayashi
- a Department of Morphological and Physiological Sciences , Graduate School of Health Sciences, Kumamoto University , Kumamoto , Japan and
| | - Mitsuharu Ueda
- b Department of Neurology , Graduate School of Medical Sciences, Kumamoto University , Kumamoto , Japan
| | - Taro Yamashita
- b Department of Neurology , Graduate School of Medical Sciences, Kumamoto University , Kumamoto , Japan
| | - Masayoshi Tasaki
- a Department of Morphological and Physiological Sciences , Graduate School of Health Sciences, Kumamoto University , Kumamoto , Japan and
| | - Ayane Izaki
- a Department of Morphological and Physiological Sciences , Graduate School of Health Sciences, Kumamoto University , Kumamoto , Japan and
| | - Yukako Yanagisawa
- a Department of Morphological and Physiological Sciences , Graduate School of Health Sciences, Kumamoto University , Kumamoto , Japan and
| | - Teruaki Masuda
- b Department of Neurology , Graduate School of Medical Sciences, Kumamoto University , Kumamoto , Japan
| | - Yohei Misumi
- b Department of Neurology , Graduate School of Medical Sciences, Kumamoto University , Kumamoto , Japan
| | - Yukio Ando
- b Department of Neurology , Graduate School of Medical Sciences, Kumamoto University , Kumamoto , Japan
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García-Pavía P, Muñoz-Beamud F, Casasnovas C. Recomendaciones para el diagnóstico y tratamiento de la polineuropatía amiloidótica familiar por transtiretina. Med Clin (Barc) 2015; 145:211-7. [DOI: 10.1016/j.medcli.2015.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 02/04/2015] [Accepted: 02/05/2015] [Indexed: 10/23/2022]
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Severe heart disease in an unusual case of familial amyloid polyneuropathy type I. Rev Port Cardiol 2013; 32:729-33. [PMID: 23993291 DOI: 10.1016/j.repc.2013.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2012] [Accepted: 02/03/2013] [Indexed: 11/24/2022] Open
Abstract
Familial amyloid polyneuropathy type I (FAP type I) is a rare hereditary systemic amyloidosis caused by the Val30Met mutation in the transthyretin (TTR) gene. The clinical onset and spectrum are variable and depend on phenotypic heterogeneity. Cardiac complications (dysrhythmias and conduction disturbances, cardiomyopathy and dysautonomia) indicate a poor prognosis, even after liver transplantation. We report an atypical case of FAP type I, highlighting the severe cardiac involvement and its complications. Early diagnosis of amyloid heart disease is increasingly important in the context of several clinical trials of promising new and experimental drugs.
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Fagiuoli S, Daina E, D'Antiga L, Colledan M, Remuzzi G. Monogenic diseases that can be cured by liver transplantation. J Hepatol 2013; 59:595-612. [PMID: 23578885 DOI: 10.1016/j.jhep.2013.04.004] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 04/02/2013] [Accepted: 04/02/2013] [Indexed: 02/08/2023]
Abstract
While the prevalence of most diseases caused by single-gene mutations is low and defines them as rare conditions, all together, monogenic diseases account for approximately 10 in every 1000 births according to the World Health Organisation. Orthotopic liver transplantation (LT) could offer a therapeutic option in monogenic diseases in two ways: by substituting for an injured liver or by supplying a tissue that can replace a mutant protein. In this respect, LT may be regarded as the correction of a disease at the level of the dysfunctional protein. Monogenic diseases that involve the liver represent a heterogeneous group of disorders. In conditions associated with predominant liver parenchymal damage (i.e., genetic cholestatic disorders, Wilson's disease, hereditary hemochromatosis, tyrosinemia, α1 antitrypsin deficiency), hepatic complications are the major source of morbidity and LT not only replaces a dysfunctional liver but also corrects the genetic defect and effectively cures the disease. A second group includes liver-based genetic disorders characterised by an architecturally near-normal liver (urea cycle disorders, Crigler-Najjar syndrome, familial amyloid polyneuropathy, primary hyperoxaluria type 1, atypical haemolytic uremic syndrome-1). In these defects, extrahepatic complications are the main source of morbidity and mortality while liver function is relatively preserved. Combined transplantation of other organs may be required, and other surgical techniques, such as domino and auxiliary liver transplantation, have been attempted. In a third group of monogenic diseases, the underlying genetic defect is expressed at a systemic level and liver involvement is just one of the clinical manifestations. In these conditions, LT might only be partially curative since the abnormal phenotype is maintained by extrahepatic synthesis of the toxic metabolites (i.e., methylmalonic acidemia, propionic acidemia). This review focuses on principles of diagnosis, management and LT results in both paediatric and adult populations of selected liver-based monogenic diseases, which represent examples of different transplantation strategies, driven by the understanding of the expression of the underlying genetic defect.
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Affiliation(s)
- Stefano Fagiuoli
- Gastroenterology and Transplant Hepatology, Ospedale Papa Giovanni XXIII, Bergamo, Italy.
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Oliveira Santos M, Brito D. Severe heart disease in an unusual case of familial amyloid polyneuropathy type I. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2013. [DOI: 10.1016/j.repce.2013.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Wixner J, Karling P, Rydh A, Hörnsten R, Wiklund U, Anan I, Suhr OB. Gastric emptying in hereditary transthyretin amyloidosis: the impact of autonomic neuropathy. Neurogastroenterol Motil 2012; 24:1111-e568. [PMID: 22897426 PMCID: PMC3549473 DOI: 10.1111/j.1365-2982.2012.01991.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Gastrointestinal (GI) complications are common in hereditary transthyretin amyloidosis and an autonomic dysfunction has been considered to explain these symptoms. The aim of this study was to investigate the impact of autonomic neuropathy on gastric emptying in hereditary transthyretin amyloidosis and to relate these findings to nutritional status, GI symptoms, gender, and age at disease onset. METHODS Gastric emptying was evaluated with gastric emptying scintigraphy. Spectral analysis of the heart rate variability and cardiovascular responses after tilt test were used to assess the autonomic function. The nutritional status was evaluated with the modified body mass index (s-albumine × BMI). KEY RESULTS Gastric retention was found in about one-third of the patients. A weak correlation was found between the scintigraphic gastric emptying rate and both the sympathetic (rs = -0.397, P < 0.001) and parasympathetic function (rs = -0.282, P = 0.002). The gastric emptying rate was slower in those with lower or both upper and lower GI symptoms compared with those without symptoms (median T(50) 123 vs 113 min, P = 0.042 and 192 vs 113 min, P = 0.003, respectively). Multiple logistic regression analysis showed that age of onset (OR 0.10, CI 0.02-0.52) and sympathetic dysfunction (OR 0.23, CI 0.10-0.51), but not gender (OR 0.76, CI 0.31-1.84) and parasympathetic dysfunction (OR 1.81, CI 0.72-4.56), contributed to gastric retention. CONCLUSIONS AND INFERENCES Gastric retention is common in hereditary transthyretin amyloidosis early after onset. Autonomic neuropathy only weakly correlates with gastric retention and therefore additional factors must be involved.
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Affiliation(s)
- J Wixner
- Departments of Public Health and Clinical Medicine, Umeå UniversityUmeå, Sweden
| | - P Karling
- Departments of Public Health and Clinical Medicine, Umeå UniversityUmeå, Sweden
| | - A Rydh
- Radiation Sciences and Diagnostic Radiology, Umeå UniversityUmeå, Sweden
| | - R Hörnsten
- Clinical Physiology, Heart Centre and Department of Surgical and Perioperative Science, Umeå UniversityUmeå, Sweden
| | - U Wiklund
- Radiation Sciences, Biomedical Engineering, Umeå UniversityUmeå, Sweden
| | - I Anan
- Departments of Public Health and Clinical Medicine, Umeå UniversityUmeå, Sweden
| | - O B Suhr
- Departments of Public Health and Clinical Medicine, Umeå UniversityUmeå, Sweden
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Suhr OB, Gustavsson S, Heldestad V, Hörnsten R, Lindqvist P, Nordh E, Wiklund U. New insights into the clinical evaluation of hereditary transthyretin amyloidosis patients: a single center's experience. Degener Neurol Neuromuscul Dis 2012; 2:93-106. [PMID: 30890882 PMCID: PMC6065582 DOI: 10.2147/dnnd.s24652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Over the last decade, new medical treatment modalities have emerged based on increased insights into amyloid formation. With the increased possibilities for treatment of amyloidosis caused by transthyretin (TTR) amyloid deposits comes the need for diagnostic procedures for early diagnosis and better tools to follow disease progression. This is of particular importance in clinical trials evaluating the efficacy of new treatments. Until recently, the treatment of TTR amyloidosis (ATTR) was based solely on liver transplantation, a procedure that has halted disease progression in many patients. Liver transplantation has been especially effective in patients under the age of 50 years carrying the TTR V30M mutation, whereas the outcome of the procedure has been variable for others, particularly elderly male patients and those carrying a non-V30M mutation. This review concentrates on new insights derived from our center's experience with liver transplantation, how to implement this experience in evaluation of new treatment modalities for ATTR, and how to facilitate early diagnosis of neuropathy with easily available diagnostic tools. Attention has focused on manifestations of the disease that involve the heart and the peripheral nervous system; change in peripheral nerve function has been the primary endpoint in two controlled clinical trials, one finished and one ongoing. New insights into the amyloid formation process and the lessons learned from liver transplantation give the opportunity to design potentially effective treatment modalities for ATTR. It appears reasonable to suspect that a combination of different treatment modalities may be required to treat the disease, and that different treatment regimes will be designed according to the phenotype of the disease. For the patients and their relatives there is now a solid foundation for optimism, with prospects of several effective medical treatment possibilities within the coming decade.
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Affiliation(s)
- Ole B Suhr
- Department of Public Health and Clinical Medicine,
| | | | | | - Rolf Hörnsten
- Department of Surgical and Perioperative Sciences, Clinical Physiology, Heart Centre
| | | | - Erik Nordh
- Department of Pharmacology and Clinical Neuroscience
| | - Urban Wiklund
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
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Hörnsten R, Suhr OB, Olofsson BO, Wiklund U. Arrhythmia--a pitfall in tests of cardiac autonomic function after liver transplantation for familial amyloidotic polyneuropathy: a long-term follow-up of Swedish patients. Amyloid 2012; 19:81-6. [PMID: 22587458 DOI: 10.3109/13506129.2012.674073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Liver transplantation (LT) is a potentially curative treatment for hereditary transthyretin amyloidosis, of which familial amyloid polyneuropathy (FAP) is the most common form in Sweden. This study investigated the long-term development in heart rate variability (HRV) after LT in Swedish FAP patients. HRV was analyzed before LT, and during a first (<40 months) and a second (>40 months) follow-up recording after transplantation, respectively. Power spectrum analysis was performed on 2-min sequences in the supine position and after passive tilt, after careful identification of patients with arrhythmia. Data were obtained from 33 patients, but 18 patients had developed cardiac arrhythmia or were pacemaker-treated (4 before LT and 14 after LT) and three patients had not performed the first follow-up recording. In the remaining 12 patients, HRV decreased between the pretransplant evaluation and the first follow-up, thereafter no significant changes were found. In conclusion, our study showed that the progressive development of cardiac arrhythmias after LT is a major pitfall when assessing cardiac autonomic function in FAP patients, especially in patients older than 40 years. In the minority of patients with sinus rhythm in all recordings, cardiac autonomic modulation remained stable after transplantation and no improvement was noted.
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Affiliation(s)
- Rolf Hörnsten
- Department of Surgical and Perioperative Sciences, Clinical Physiology, Heart Centre, Umeå University, Sweden.
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Heldestad V, Wiklund U, Hörnsten R, Obayashi K, Suhr OB, Nordh E. Comparison of quantitative sensory testing and heart rate variability in Swedish Val30Met ATTR. Amyloid 2011; 18:183-90. [PMID: 22035563 DOI: 10.3109/13506129.2011.614294] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Patients with transthyretin amyloidosis (ATTR) polyneuropathy, a hereditary fatal disease, often report defects in both thermal perception and autonomic nervous system function as their first clinical symptoms. While elevated thermal perception thresholds (TPT) for cold and warmth only recently have been shown as an early marker of small nerve fiber dysfunction in these patients, heart rate variability (HRV) has frequently been used to quantify autonomic neuropathy. The main purpose with this report was to elucidate a possible relationship between estimates of HRV and TPT in a selected group of early and late-onset Swedish Val30Met ATTR patients. The results show significantly more pronounced elevation of TPT in early compared to late-onset patients. Significant correlations between HRV and TPT were found among late-onset cases, indicating a possible relationship between loss of thin nerve fibers in somatic and autonomic nerves, while generally no such relationships were found among early-onset cases. This observation emphasizes the importance of testing both HRV and TPT to ensure optimal early detection of neuropathic changes in an as wide as possible range of small nerve fibers in suspected ATTR patients. This is of particular importance as the phenotype of the ATTR disease varies between groups with different age of onset.
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Affiliation(s)
- Victoria Heldestad
- Department of Pharmacology and Clinical Neurosciences, Umeå University, Umeå, Sweden
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Ripoll C, Yotti R, Bermejo J, Bañares R. The heart in liver transplantation. J Hepatol 2011; 54:810-22. [PMID: 21145840 DOI: 10.1016/j.jhep.2010.11.003] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 09/27/2010] [Accepted: 11/04/2010] [Indexed: 02/08/2023]
Abstract
The heart and liver are organs that are closely related in both health and disease. Patients who undergo liver transplantation may suffer from heart disease that is: (a) related to the original cause of the liver disease such as hemochromatosis, (b) related to the liver disease itself, or (c) related to other associated conditions. Furthermore, liver transplantation is one of the most cardiovascular stressful events that a patient with cirrhosis may undergo. After liver transplantation, the progression of pre-existing or the development of new-onset cardiac disease may occur. This article reviews the relationship between the heart and liver transplantation in the pre-transplant, intra-operative, and post-transplant periods.
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Affiliation(s)
- Cristina Ripoll
- Department of Digestive Disease, Ciber EHD Hospital General Universitario Gregorio Marañón, Madrid 28007, Spain
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Okamoto S, Hörnsten R, Obayashi K, Wijayatunga P, Suhr OB. Continuous development of arrhythmia is observed in Swedish transplant patients with familial amyloidotic polyneuropathy (amyloidogenic transthyretin Val30Met variant). Liver Transpl 2011; 17:122-8. [PMID: 21280184 DOI: 10.1002/lt.22184] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In patients with familial amyloidotic polyneuropathy (FAP), heart complications are prognostic factors for mortality and morbidity after liver transplantation (LT). However, only a few studies have analyzed the development of arrhythmia in transplant patients with FAP. We investigated the development of arrhythmia requiring pacemaker insertion (PMI) in Swedish transplant patients with FAP, and we related the findings to gender, age at disease onset, and survival. One hundred four transplant patients with the amyloidogenic transthyretin Val30Met mutation were included in the study. Twenty-six (25%) received a pacemaker during the observation period (a median of 11 years after disease onset). This frequency was comparable to that noted in a previous study describing the natural course of FAP. No significant differences in PMI between early-onset cases (<50 years old) and late-onset cases (≥ 50 years old) or between genders were observed. PMI was not significantly related to patient survival. Our study confirms our previously reported short-time observation: LT does not prevent the development of heart arrhythmia necessitating PMI. The development of arrhythmia is unrelated to gender or age at disease onset, and the yearly risk does not appear to decrease with time after LT.
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Affiliation(s)
- Sadahisa Okamoto
- Departments of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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