Cardiovascular Disorders Mediated by Autonomic Nervous System Dysfunction

A retrospective analysis of neurogenic orthostatic hypotension in long-term care facility residents with recurrent falls

INTRODUCTION

Approximately 50 % of residents in long-term care facilities fall yearly and orthostatic hypotension accounts for a significant portion of them. Neurogenic orthostatic hypotension - a subtype of orthostatic hypotension - is important to be recognized as its management is far more complex; undertreatment of these older adults can lead to recurrent falls, high healthcare cost burden, and increased morbidity and mortality. The primary purpose of our study was to describe the rate of neurogenic orthostatic hypotension in older adults in a long-term care facility, with a secondary purpose to describe risk factors for neurogenic orthostatic hypotension in this population.

METHODS

We conducted a retrospective case-control study of residents with recurrent falls at the Dayton Veteran's Affairs long-term care facility. Charts were manually reviewed. Inclusion criterion was three or more falls and age 65 or greater; we did not have exclusion criteria. ICD10 codes and most recent primary care physician notes were used to identify comorbidity diagnoses. Recent orthostatic vitals were used to assess orthostatic hypotension or neurogenic orthostatic hypotension diagnoses.

RESULTS

Of our sample of 224 residents, we observed a prevalence of 20.5 % for neurogenic orthostatic hypotension and 32.1 % for orthostatic hypotension. Neither of them had diagnosis of neurogenic orthostatic hypotension documented. Parkinson's disease was associated with neurogenic orthostatic hypotension (OR-4.3; p = 0.002). Hypertension was prevalent in 69.6 % of residents with orthostatic vitals suggestive of neurogenic orthostatic hypotension.

CONCLUSION

Older adults with recurrent falls at a long-term care facility meet criteria for neurogenic orthostatic hypotension diagnosis far more often than is documented. Common comorbidities associated with neurogenic orthostatic hypotension in this population include Parkinson's disease.

Unraveling the role of Xist RNA in cardiovascular pathogenesis

Understanding the molecular pathways behind cardiovascular illnesses is crucial due to the enormous worldwide health burden they impose. New insights into the role played by Xist (X-inactive specific transcript) RNA in the onset and progression of cardiovascular diseases have emerged from recent studies. Since its discovery, Xist RNA has been known for its role in X chromosome inactivation during embryogenesis; however, new data suggest that its function extends well beyond the control of sex chromosomes. The regulatory roles of Xist RNA are extensive, encompassing epigenetic changes, gene expression, cellular identity, and sex chromosomal inactivation. There is potential for the involvement of this complex regulatory web in a wide range of illnesses, including cardiovascular problems. Atherosclerosis, hypertrophy, and cardiac fibrosis are all conditions linked to dysregulation of Xist RNA expression. Alterations in DNA methylation and histones are two examples of epigenetic changes that Xist RNA orchestrates, leading to modifications in gene expression patterns in different cardiovascular cells. Additionally, Xist RNA has been shown to contribute to the development of cardiovascular illnesses by modulating endothelial dysfunction, inflammation, and oxidative stress responses. New treatment approaches may become feasible with a thorough understanding of the complex function of Xist RNA in cardiovascular diseases. By focusing on Xist RNA and the regulatory network with which it interacts, we may be able to slow the progression of atherosclerosis, cardiac hypertrophy, and fibrosis, thereby opening novel therapeutic options for cardiovascular diseases amenable to precision medicine. This review summarizes the current state of knowledge concerning the impact of Xist RNA in cardiovascular disorders.

Multimorbidity patterns and the association with health status of the oldest-old in long-term care facilities in China: a two-step analysis

BACKGROUND

The increasing prevalence of multimorbidity has created a serious global public health problem in aging populations. Certain multimorbidity patterns across different age ranges and their association with health status remain unclear. The main aim of this study is to identify multimorbidity patterns discrepancies and associated health status between younger-old and oldest-old.

METHODS

The Ethics Committee of Nanjing Medical University approved the study protocol (No.2019-473). Convenience sampling method was used to recruit older adults aged ≥ 60 years with multimorbidity from July to December 2021 from 38 Landsea long-term care facilities in China. The multimorbidity patterns were analyzed using network analysis and two-step cluster analysis. One-Way ANOVA was utilized to explore their association with health status including body function, activity of daily living, and social participation. A Sankey diagram visualized the flow of health status within different multimorbidity patterns. This study is reported following the STROBE guidelines.

RESULTS

A total of 214 younger-old (60-84 years) and 173 oldest-old (≥ 85 years) were included. Leading coexisting diseases were cardiovascular disease (CD), metabolic and endocrine disease (MED), neurological disease (ND), and orthopedic disease (OD). Cluster 1 (53, 24.8%) of CD-ND (50, 94.3%; 31, 58.8%), cluster 2 (39, 18.2%) of MED-ND-CD (39, 100%; 39, 100%; 37, 94.9%), cluster 3 (37, 17.3%) of OD-CD-MED-ND (37, 100%; 33, 89.2%; 27, 73.0%; 16, 43.2%), and cluster 4 (34, 15.9%) of CD-MED (34, 100%; 34, 100%) were identified in the younger-old. In the oldest-old, the primary multimorbidity patterns were: cluster 1 (33, 19.1%) of CD-respiratory disease-digestive disease-urogenital disease (CD-RD-DSD-UD) (32, 97.0%; 9, 27.3%; 8, 24.2%; 7, 21.2%), cluster 2 (42, 24.3%) of ND-CD-MED (42, 100%; 35, 83.3%; 14, 33.3%), cluster 3 (28, 16.2%) of OD-CD-MED (28, 100%; 25, 89.3%; 18, 64.3%), and cluster 4 (35, 20.2%) of CD-MED (35, 100%; 35, 100%). Younger-old with CD-ND or MED-ND-CD, and oldest-old with ND-CD-MED have worse health status compared with other multimorbidity patterns (e.g., CD-MED and OD-CD-MED).

CONCLUSION

Discrepancies in common patterns of multimorbidity across age groups suggest that caregivers in long-term care facilities should consider changes in multimorbidity patterns with ageing when developing prevention plans for individualized management. Neurological disease concurrent with other diseases was the major determinant of health status, especially for the oldest-old. Interventions targeting multimorbidity need to be focused, yet generic. It is essential to assess complex needs and health outcomes that arise from different multimorbidity patterns and manage them through an interdisciplinary approach and consider their priorities to gain high-quality primary care for older adults living in long-term care facilities.

Altered Cardiac Autonomic Regulation in Individuals with Myasthenia Gravis-A Systematic Review and Meta-Analysis

The aim of this systematic review with meta-analysis was to determine differences in cardiovascular autonomic parameters between patients with myasthenia gravis (MG) and healthy controls (HCs). Two reviewers searched four electronic databases, namely PubMed, Web of Science, EMBASE, and SCOPUS, from database inception to 7 July 2023 for studies investigating cardiovascular autonomic parameters in MG vs. HCs. A random-effects meta-analysis was performed to compute Hedges' g ± 95% confidence intervals (CI). Out of a total of 2200 records, 8 observational studies with a sample size of 301 patients with MG and 454 HCs were included in the systematic review. Meta-analysis revealed lower values of expiration/inspiration ratio (g = -0.45, I2 = 74.7), baroreflex sensitivity (g = -0.56, 95%CI -0.80, -0.33; I2 = 0.3), percentage of adjacent NN intervals differing by more than 50 ms (g = -1.2, I2 = 82.8), square root of the mean of squared differences between successive beat intervals (g = -1.94, I2 = 95.1), mean of the standard deviations of all NN intervals (g = -0.83, 95%CI -1.37, -0.28; I2 = 55.5), and high frequency of HRV during tilt (g = -0.75, 95%CI -0.11, -0.39; I2 = 0). MG patients vs. HCs had higher systolic blood pressure (g = 0.39; I2 = 56.1), sympathovagal balance at rest/during tilt (LF/HF-RRIsupine, g = 0.44; I2 = 0; LF/HF-RRItilt, g = 0.86; I2 = 0; LF/HFtilt, g = 0.40; I2 = 0). As a group, MG patients have altered cardiac autonomic function, including decreased parasympathetic function, lower baroreflex sensitivity, and higher sympathovagal balance at rest and during orthostatic challenges.

Monitoring of the regulatory ability and regulatory state of the autonomic nervous system and its application to the management of hypertensive patients: a study protocol for randomised controlled trials

INTRODUCTION

Many causes lead to sympathetic-vagus imbalance, which promotes the development of hypertension and accelerates the process of target organ damage. Many studies have shown that exercise training and heart rate variability (HRV) biofeedback can improve diseases caused by autonomic nerve dysfunction, such as hypertension. Based on these theories and the Yin-Yang balance theory of traditional Chinese medicine and Cannon's homeostasis theory, we have developed an assessment system of autonomic nerve regulation system and a harmony instrument. In this study, we aimed to find a new way to control blood pressure of hypertensive patients via cardiopulmonary resonance indices-based respiratory feedback training.

METHODS AND ANALYSIS

This is a prospective, randomised, parallel-controlled clinical trial, which aims to evaluate the effectiveness and safety of biofeedback therapy and exercise rehabilitation combined intervention in hypertension management. 176 healthy individuals will be recruited to get their autonomic nerve function parameters as normal control, while 352 hypertensive patients will be enrolled and randomly divided into a conventional treatment group and an experiment group in a ratio of 1:1. All patients will continue to receive standard hypertension blood pressure treatment, except that patients in the experiment group will have to complete additional daily respiratory training for 6 months. The primary outcome is the difference of clinical systolic blood pressure (SBP) between the two groups after 6 months of intervention. The secondary outcomes include the changes in the mean SBP and diastolic blood pressure (DBP) by 24-hour blood pressure monitoring, home SBP, clinical and home DBP, clinical and home heart rate, the standard-reaching rate of clinic and home SBP and the incidence of composite endpoint events at 6 months.

ETHICS AND DISSEMINATION

This study has been approved by the clinical research ethics committee of China-Japan Friendship Hospital (No. 2018-132 K98-2), the results of this study will be disseminated via peer-reviewed publications or conference presentations.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry, ChiCTR1800019457, registered on 12 August 2018.

Overview of Cardiac Arrhythmias and Treatment Strategies

Maintenance of normal cardiac rhythm requires coordinated activity of ion channels and transporters that allow well-ordered propagation of electrical impulses across the myocardium. Disruptions in this orderly process provoke cardiac arrhythmias that may be lethal in some patients. Risk of common acquired arrhythmias is increased markedly when structural heart disease caused by myocardial infarction (due to fibrotic scar formation) or left ventricular dysfunction is present. Genetic polymorphisms influence structure or excitability of the myocardial substrate, which increases vulnerability or risk of arrhythmias in patients. Similarly, genetic polymorphisms of drug-metabolizing enzymes give rise to distinct subgroups within the population that affect specific drug biotransformation reactions. Nonetheless, identification of triggers involved in initiation or maintenance of cardiac arrhythmias remains a major challenge. Herein, we provide an overview of knowledge regarding physiopathology of inherited and acquired cardiac arrhythmias along with a summary of treatments (pharmacologic or non-pharmacologic) used to limit their effect on morbidity and potential mortality. Improved understanding of molecular and cellular aspects of arrhythmogenesis and more epidemiologic studies (for a more accurate portrait of incidence and prevalence) are crucial for development of novel treatments and for management of cardiac arrhythmias and their consequences in patients, as their incidence is increasing worldwide.

Association between vitamin B12 status and heart rate variability in patients with ischemic stroke

Autonomic dysfunction is common in patients with ischemic stroke. An ischemic stroke may induce abnormalities in autonomic tone, resulting in poor heart rate regulation and an increased risk of severe cardiac arrest and sudden death. Heart rate variability (HRV) is a reliable index for evaluating autonomic dysfunction. Vitamin B12 deficiency is frequent among older adults and is a known risk factor for ischemic stroke. As vitamin B12 deficiency affects the peripheral nerves and the central nervous system, it can lead to autonomic dysfunction. However, no study has been published on the correlation between HRV and vitamin B12 status in patients with ischemic stroke. This study aimed to investigate the relationship between HRV and vitamin B12 status and to determine whether the serum vitamin B12 level can be a predictor of HRV parameters. This retrospective study enrolled patients with ischemic stroke between January 2015 and December 2022. The patients underwent serum vitamin B12 level measurements and 24-h Holter monitoring. Pearson correlation analysis was used to investigate the correlation between serum vitamin B12 levels and HRV parameters. The impact of serum vitamin B12 status on HRV parameters was determined using multiple linear regression analysis. A total of 87 patients with ischemic stroke were included in this study. HRV parameters were significantly correlated with serum vitamin B12 status in the frequency domain. In multiple linear regression analysis, the serum vitamin B12 status was a significant predictor of HRV parameters. HRV parameters may be correlated with serum vitamin B12 status in patients with ischemic stroke. Therefore, the serum vitamin B12 status may be a significant predictor of autonomic dysfunction. Our results may provide objective evidence for the impact of serum vitamin B12 status on autonomic dysfunction in patients with ischemic stroke.

Thirty Obesity Myths, Misunderstandings, and/or Oversimplifications: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) is intended to provide clinicians an overview of 30 common obesity myths, misunderstandings, and/or oversimplifications.

Methods

The scientific support for this CPS is based upon published citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

This CPS discusses 30 common obesity myths, misunderstandings, and/or oversimplifications, utilizing referenced scientific publications such as the integrative use of other published OMA CPSs to help explain the applicable physiology/pathophysiology.

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on 30 common obesity myths, misunderstandings, and/or oversimplifications is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity. Knowledge of the underlying science may assist the obesity medicine clinician improve the care of patients with obesity.

Post-Acute Effect of SARS-CoV-2 Infection on the Cardiac Autonomic Function

Background

Methods

Results

Conclusion

Association between non-alcoholic fatty liver disease and impaired cardiac sympathetic/parasympathetic balance in subjects with and without type 2 diabetes-The Cooperative Health Research in South Tyrol (CHRIS)-NAFLD sub-study

BACKGROUND AND AIMS

Cardiovascular disease (CVD) is the leading cause of death in patients with non-alcoholic fatty liver disease (NAFLD), both with and without type 2 diabetes mellitus (T2DM). Cardiac autonomic dysfunction is a risk factor for CVD morbidity and mortality. The aim of this pilot study was to assess whether there is an association between NAFLD and impaired cardiac autonomic function.

METHODS AND RESULTS

Among the first 4979 participants from the Cooperative Health Research in South Tyrol (CHRIS) study, we randomly recruited 173 individuals with T2DM and 183 age- and sex-matched nondiabetic controls. Participants underwent ultrasonography and vibration-controlled transient elastography (Fibroscan®, Echosens) to assess hepatic steatosis and liver stiffness. The low-to-high-frequency (LF/HF) power ratio and other heart rate variability (HRV) measures were calculated from a 20-min resting electrocardiogram (ECG) to derive a measure of cardiac sympathetic/parasympathetic imbalance. Among the 356 individuals recruited for the study, 117 had NAFLD and T2DM, 56 had T2DM alone, 68 had NAFLD alone, and 115 subjects had neither condition. Individuals with T2DM and NAFLD (adjusted odds ratio [OR] 4.29, 95% confidence intervals [CI] 1.90-10.6) and individuals with NAFLD alone (adjusted OR 3.41, 95% CI 1.59-7.29), but not those with T2DM alone, had a substantially increased risk of having cardiac sympathetic/parasympathetic imbalance, compared with those without NAFLD and T2DM. Logistic regression models were adjusted for age, sex, body mass index (BMI), hypertension, dyslipidemia, insulin resistance, hemoglobin A1c (HbA1c), C-reactive protein (CRP), and Fibroscan®-measured liver stiffness.

CONCLUSIONS

NAFLD was associated with cardiac sympathetic/parasympathetic imbalance, regardless of the presence or absence of T2DM, liver stiffness, and other potential confounding factors.

Exploring autonomic regulation in children with ADHD with and without comorbid anxiety disorder through three systematic levels of cardiac vagal control analysis: Rest, reactivity, and recovery

Autonomic nervous system (ANS) dysregulation, characterized by reduced vagally mediated Heart Rate Variability (HRV), has been associated with Attention-Deficit/ Hyperactivity Disorder (ADHD). This study investigated the dynamic vagal modulation of cardiac output in response to shifts in environmental demands in children and adolescents with ADHD, with and without a comorbid anxiety disorder. High-frequency HRV (HF-HRV) measures were obtained from 46 children and adolescents ranging from 6 to 17 (M = 9.38; SD = 2.31) years old, during three successive experimental conditions: a baseline recording followed by a sustained attention task, and a post-task recovery period. Findings support the reliability of the d2 Test, a cancelation test of attention and concentration, to induce parasympathetic withdrawal and extend prior work on "vagal flexibility". Further, these findings suggest a pattern of group differences in ANS functioning in children with ADHD, with and without a comorbid anxiety disorder. Only the ADHD without comorbid anxiety group showed a normative autonomic response to the cognitive challenge (reduced HF-HRV). The participants did not display an adaptive process of restoration following the cognitive challenge; the HRV suppression was prolonged during post-task recovery period, suggesting that ANS responded as if the cognitive stressor was still present. The current paper covers and discusses theoretical implications for the abnormalities in neurophysiological functioning and the different physiological responses in the two ADHD subtypes.