1
|
Okamoto LE, Celedonio JE, Smith EC, Paranjape SY, Black BK, Wahba A, Park JW, Shibao CA, Diedrich A, Biaggioni I. Continuous Positive Airway Pressure for the Treatment of Supine Hypertension and Orthostatic Hypotension in Autonomic Failure. Hypertension 2023; 80:650-658. [PMID: 36601916 PMCID: PMC10128890 DOI: 10.1161/hypertensionaha.122.20081] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 12/14/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Supine hypertension affects most patients with orthostatic hypotension (OH) due to autonomic failure, but it is often untreated for fear of worsening OH. We hypothesized that increasing intrathoracic pressure with continuous positive airway pressure (CPAP) had a Valsalva-like blood-pressure-lowering effect that could be used to treat nocturnal supine hypertension in these patients, while reducing nocturnal pressure diuresis and improving daytime OH. METHODS In Protocol 1, we determined the acute hemodynamic effects of increasing levels of CPAP (0, 4, 8, 12, and 16 cm H2O, 3 minutes each) in 26 patients with autonomic failure and supine hypertension studied while awake and supine. In Protocol 2 (n=11), we compared the effects of overnight therapy with CPAP (8-12 cm H2O for 8 hours) versus placebo on nocturnal supine hypertension, nocturnal diuresis and daytime OH in a 2-night crossover study. RESULTS In Protocol 1, acute CPAP (4-16 cm H2O) decreased systolic blood pressure in a dose-dependent manner (maximal drop 22±4 mmHg with CPAP 16) due to reductions in stroke volume (-16+3%) and cardiac output (-14±3%). Systemic vascular resistance and heart rate remained unchanged. In Protocol 2, overnight CPAP lowered nighttime systolic blood pressure (maximal change -23±5 versus placebo -1±7 mmHg; P=0.023) and was associated with lower nighttime diuresis (609±84 versus placebo 1004±160 mL; P=0.004) and improved morning orthostatic tolerance (AUC upright SBP 642±121 versus placebo 410±109 mmHg*min; P=0.014). CONCLUSIONS CPAP is a novel nonpharmacologic approach to treat the supine hypertension of autonomic failure while improving nocturia and daytime OH. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03312556.
Collapse
Affiliation(s)
- Luis E. Okamoto
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jorge E. Celedonio
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Emily C. Smith
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sachin Y. Paranjape
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bonnie K. Black
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amr Wahba
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jin-Woo Park
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cyndya A. Shibao
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - André Diedrich
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Italo Biaggioni
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
2
|
Giannini G, Calandra-Buonaura G, Asioli GM, Cecere A, Barletta G, Mignani F, Ratti S, Guaraldi P, Provini F, Cortelli P. The natural history of idiopathic autonomic failure: The IAF-BO cohort study. Neurology 2018; 91:e1245-e1254. [PMID: 30135257 DOI: 10.1212/wnl.0000000000006243] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 06/28/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To retrospectively describe clinical and instrumental features of a cohort of patients with at least a 5-year history of idiopathic autonomic failure (IAF) longitudinally evaluated at the Autonomic Unit of the University of Bologna (IAF-Bo cohort). METHODS We identified patients with at least a 5-year history of IAF who were referred to our department from 1989 to 2016 and evaluated at least once a year during the disease course. Clinical and instrumental data were collected from medical records. Clinical variables were categorized as early if presenting within 3 years from disease onset. Predictors associated with conversion to other synucleinopathies were identified in a Cox regression analysis. RESULTS The IAF-Bo cohort included 50 patients (39 male, 19 deceased at the last follow-up). At the last follow-up visit, 34 patients retained IAF phenotype (ncIAF group), while 16 developed a CNS synucleinopathy (converters group). Specific clinical and instrumental features were represented differently in the converters and ncIAF groups. The converters group showed a higher risk of death than the ncIAF group. Early onset of urinary dysfunction, early onset of REM sleep behavior disorder, and a Valsalva ratio ≥1.25 were identified as variables associated with phenoconversion. CONCLUSIONS This is one of the largest studies on the natural history of a cohort of patients with at least a 5-year history of IAF, showing a percentage of phenoconversion of 32%. We demonstrated that specific clinical and instrumental features entail an increased probability of phenoconversion. These findings could contribute to a better definition of the nature of IAF and to the identification of early markers of phenoconversion.
Collapse
Affiliation(s)
- Giulia Giannini
- From the IRCCS Institute of Neurological Sciences of Bologna (G.G., G.C.-B, A.C., G.B., F.M., F.P., P.C.); Department of Biomedical and NeuroMotor Sciences (G.G., G.C.-B., G.M.A., G.B., S.R., F.P., P.C.), Alma Mater Studiorum-University of Bologna; and Neurology Outpatient Clinic (P.G.), Department of Primary Care, Local Health Authority of Modena, Italy
| | - Giovanna Calandra-Buonaura
- From the IRCCS Institute of Neurological Sciences of Bologna (G.G., G.C.-B, A.C., G.B., F.M., F.P., P.C.); Department of Biomedical and NeuroMotor Sciences (G.G., G.C.-B., G.M.A., G.B., S.R., F.P., P.C.), Alma Mater Studiorum-University of Bologna; and Neurology Outpatient Clinic (P.G.), Department of Primary Care, Local Health Authority of Modena, Italy
| | - Gian Maria Asioli
- From the IRCCS Institute of Neurological Sciences of Bologna (G.G., G.C.-B, A.C., G.B., F.M., F.P., P.C.); Department of Biomedical and NeuroMotor Sciences (G.G., G.C.-B., G.M.A., G.B., S.R., F.P., P.C.), Alma Mater Studiorum-University of Bologna; and Neurology Outpatient Clinic (P.G.), Department of Primary Care, Local Health Authority of Modena, Italy
| | - Annagrazia Cecere
- From the IRCCS Institute of Neurological Sciences of Bologna (G.G., G.C.-B, A.C., G.B., F.M., F.P., P.C.); Department of Biomedical and NeuroMotor Sciences (G.G., G.C.-B., G.M.A., G.B., S.R., F.P., P.C.), Alma Mater Studiorum-University of Bologna; and Neurology Outpatient Clinic (P.G.), Department of Primary Care, Local Health Authority of Modena, Italy
| | - Giorgio Barletta
- From the IRCCS Institute of Neurological Sciences of Bologna (G.G., G.C.-B, A.C., G.B., F.M., F.P., P.C.); Department of Biomedical and NeuroMotor Sciences (G.G., G.C.-B., G.M.A., G.B., S.R., F.P., P.C.), Alma Mater Studiorum-University of Bologna; and Neurology Outpatient Clinic (P.G.), Department of Primary Care, Local Health Authority of Modena, Italy
| | - Francesco Mignani
- From the IRCCS Institute of Neurological Sciences of Bologna (G.G., G.C.-B, A.C., G.B., F.M., F.P., P.C.); Department of Biomedical and NeuroMotor Sciences (G.G., G.C.-B., G.M.A., G.B., S.R., F.P., P.C.), Alma Mater Studiorum-University of Bologna; and Neurology Outpatient Clinic (P.G.), Department of Primary Care, Local Health Authority of Modena, Italy
| | - Stefano Ratti
- From the IRCCS Institute of Neurological Sciences of Bologna (G.G., G.C.-B, A.C., G.B., F.M., F.P., P.C.); Department of Biomedical and NeuroMotor Sciences (G.G., G.C.-B., G.M.A., G.B., S.R., F.P., P.C.), Alma Mater Studiorum-University of Bologna; and Neurology Outpatient Clinic (P.G.), Department of Primary Care, Local Health Authority of Modena, Italy
| | - Pietro Guaraldi
- From the IRCCS Institute of Neurological Sciences of Bologna (G.G., G.C.-B, A.C., G.B., F.M., F.P., P.C.); Department of Biomedical and NeuroMotor Sciences (G.G., G.C.-B., G.M.A., G.B., S.R., F.P., P.C.), Alma Mater Studiorum-University of Bologna; and Neurology Outpatient Clinic (P.G.), Department of Primary Care, Local Health Authority of Modena, Italy
| | - Federica Provini
- From the IRCCS Institute of Neurological Sciences of Bologna (G.G., G.C.-B, A.C., G.B., F.M., F.P., P.C.); Department of Biomedical and NeuroMotor Sciences (G.G., G.C.-B., G.M.A., G.B., S.R., F.P., P.C.), Alma Mater Studiorum-University of Bologna; and Neurology Outpatient Clinic (P.G.), Department of Primary Care, Local Health Authority of Modena, Italy
| | - Pietro Cortelli
- From the IRCCS Institute of Neurological Sciences of Bologna (G.G., G.C.-B, A.C., G.B., F.M., F.P., P.C.); Department of Biomedical and NeuroMotor Sciences (G.G., G.C.-B., G.M.A., G.B., S.R., F.P., P.C.), Alma Mater Studiorum-University of Bologna; and Neurology Outpatient Clinic (P.G.), Department of Primary Care, Local Health Authority of Modena, Italy.
| |
Collapse
|
6
|
Clinicopathologic correlations in 172 cases of rapid eye movement sleep behavior disorder with or without a coexisting neurologic disorder. Sleep Med 2013; 14:754-62. [PMID: 23474058 DOI: 10.1016/j.sleep.2012.10.015] [Citation(s) in RCA: 269] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Revised: 10/09/2012] [Accepted: 10/15/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the pathologic substrates in patients with rapid eye movement (REM) sleep behavior disorder (RBD) with or without a coexisting neurologic disorder. METHODS The clinical and neuropathologic findings were analyzed on all autopsied cases from one of the collaborating sites in North America and Europe, were evaluated from January 1990 to March 2012, and were diagnosed with polysomnogram (PSG)-proven or probable RBD with or without a coexisting neurologic disorder. The clinical and neuropathologic diagnoses were based on published criteria. RESULTS 172 cases were identified, of whom 143 (83%) were men. The mean±SD age of onset in years for the core features were as follows - RBD, 62±14 (range, 20-93), cognitive impairment (n=147); 69±10 (range, 22-90), parkinsonism (n=151); 68±9 (range, 20-92), and autonomic dysfunction (n=42); 62±12 (range, 23-81). Death age was 75±9 years (range, 24-96). Eighty-two (48%) had RBD confirmed by PSG, 64 (37%) had a classic history of recurrent dream enactment behavior, and 26 (15%) screened positive for RBD by questionnaire. RBD preceded the onset of cognitive impairment, parkinsonism, or autonomic dysfunction in 87 (51%) patients by 10±12 (range, 1-61) years. The primary clinical diagnoses among those with a coexisting neurologic disorder were dementia with Lewy bodies (n=97), Parkinson's disease with or without mild cognitive impairment or dementia (n=32), multiple system atrophy (MSA) (n=19), Alzheimer's disease (AD)(n=9) and other various disorders including secondary narcolepsy (n=2) and neurodegeneration with brain iron accumulation-type 1 (NBAI-1) (n=1). The neuropathologic diagnoses were Lewy body disease (LBD)(n=77, including 1 case with a duplication in the gene encoding α-synuclein), combined LBD and AD (n=59), MSA (n=19), AD (n=6), progressive supranulear palsy (PSP) (n=2), other mixed neurodegenerative pathologies (n=6), NBIA-1/LBD/tauopathy (n=1), and hypothalamic structural lesions (n=2). Among the neurodegenerative disorders associated with RBD (n=170), 160 (94%) were synucleinopathies. The RBD-synucleinopathy association was particularly high when RBD preceded the onset of other neurodegenerative syndrome features. CONCLUSIONS In this large series of PSG-confirmed and probable RBD cases that underwent autopsy, the strong association of RBD with the synucleinopathies was further substantiated and a wider spectrum of disorders which can underlie RBD now are more apparent.
Collapse
|