EFNS guidelines on the diagnosis and management of orthostatic hypotension

Cardiovascular dysautonomia and cognitive impairment in Parkinson's disease (Review)

Cognitive impairment is a prevalent non-motor symptom of Parkinson's disease (PD), which can result in significant disability and distress for patients and caregivers. There is a marked variation in the timing, characteristics and rate at which cognitive decline occurs in patients with PD. This decline can vary from normal cognition to mild cognitive impairment and dementia. Cognitive impairment is associated with several pathophysiological mechanisms, including the accumulation of β-amyloid and tau in the brain, oxidative stress and neuroinflammation. Cardiovascular autonomic dysfunctions are commonly observed in patients with PD. These dysfunctions play a role in the progression of cognitive impairment, the incidents of falls and even in mortality. The majority of symptoms of dysautonomia arise from changes in the peripheral autonomic nervous system, including both the sympathetic and parasympathetic nervous systems. Cardiovascular changes, including orthostatic hypotension, supine hypertension and abnormal nocturnal blood pressure (BP), can occur in both the early and advanced stages of PD. These changes tend to increase as the disease advances. The present review aimed to describe the cognitive changes in the setting of cardiovascular dysautonomia and to discuss strategies through which these changes can be modified and managed. It is a multifactorial process usually involving decreased blood flow to the brain, resulting in the development of cerebral ischemic lesions, an increased presence of abnormal white matter signals in the brain, and a potential influence on the process of neurodegeneration in PD. Another possible explanation is this association being independent observations of PD progression. Patients with clinical symptoms of dysautonomia should undergo 24-h ambulatory BP monitoring, as they are frequently subtle and underdiagnosed.

Atomoxetine on neurogenic orthostatic hypotension: a randomized, double-blind, placebo-controlled crossover trial

PURPOSE

We previously reported that single doses of the norepinephrine transporter inhibitor, atomoxetine, increased standing blood pressure (BP) and ameliorated symptoms in patients with neurogenic orthostatic hypotension (nOH). We aimed to evaluate the effect of atomoxetine over four weeks in patients with nOH.

METHODS

A randomized, double-blind, placebo-controlled crossover clinical trial between July 2016 and May 2021 was carried out with an initial open-label, single-dose phase (10 or 18 mg atomoxetine), followed by a 1-week wash-out, and a subsequent double-blind 4-week treatment sequence (period 1: atomoxetine followed by placebo) or vice versa (period 2). The trial included a 2-week wash-out period. The primary endpoint was symptoms of nOH as measured by the orthostatic hypotension questionnaire (OHQ) assessed at 2 weeks.

RESULTS

A total of 68 patients were screened, 40 were randomized, and 37 completed the study. We found no differences in the OHQ composite score between atomoxetine and placebo at 2 weeks (-0.3 ± 1.7 versus -0.4 ± 1.5; P = 0.806) and 4 weeks (-0.6 ± 2.4 versus -0.5 ± 1.6; P = 0.251). There were no differences either in the OHSA scores at 2 weeks (3 ± 1.9 versus 4 ± 2.1; P = 0.062) and at 4 weeks (3 ± 2.2 versus 3 ± 2.0; P = 1.000) or in the OH daily activity scores (OHDAS) at 2 weeks (4 ± 3.0 versus 5 ± 3.1, P = 0.102) and 4 weeks (4 ± 3.0 versus 4 ± 2.7, P = 0.095). Atomoxetine was well-tolerated.

CONCLUSIONS

While previous evidence suggested that acute doses of atomoxetine might be efficacious in treating nOH; results of this clinical trial indicated that it was not superior to placebo to ameliorate symptoms of nOH.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT02316821.

Orthostatic Hypotension: a clinical marker for the body-first subtype of patients with Parkinson's Disease

Our study aimed to investigate the clinical characteristics of PD patients stratified by OH status before and after levodopa challenge to explore the hypothesis that OH might serve as a clinical marker for the body-first subtype of PD. Supine and standing blood pressure were measured in a large cross-sectional cohort of PD patients at the OFF status before and after levodopa challenge test (LCT). Based on OH status, patients were divided into three groups: spontaneous OH (SOH), only levodopa-induced OH (LOH) and non-OH (NOH). Clinical characteristics and associated factors were compared among the groups. A total of 928 patients with a mean age of 62.4 years and average disease duration of 7.9 years were included. There were 224 (24.1%) patients with SOH, 321 (34.6%) with LOH, and 383 (41.3%) with NOH. Compared to NOH, both SOH and LOH were associated with older age, motor fluctuations, and probable rapid eye movement sleep behavior disorder (pRBD). In addition, OH was more associated with cardiovascular and digestive dysfunction, disease severity and worse quality of life. Results of the current study suggest that PD patients developed OH which is more likely to comorbid with RBD, severe autonomic dysfunction and motor fluctuations, consistent with the body-first subtype of PD.

Analysis of fall risk factors and environmental hazards for older adults in Japan: assessing fall situations and locations

[Purpose] This study aimed to examine falls among older adults in Japanese households and determine the risk associated with each fall location. [Participants and Methods] This study included 99 participants (249 fall events) who received daycare rehabilitation at a nursing care facility. Data on fall circumstances were collected from the medical records and accident reports. The analyzed variables included age, medical status, level of care required, fall history, location, and mode of transportation during the falls. [Results] Falls occurred most commonly in bedrooms. Falls at an entrance were associated with no assistive device (OR: 1.76, 95% CI: 1.06-1.80) and 1 history of falls (OR: 1.22, 95% CI: 1.03-3.10). Risk factors for falls in bedrooms included Parkinson's disease (OR: 1.83, 95% CI: 1.11-1.87), orthopedic disease (OR: 1.11, 95% CI: 1.15-3.43), and cane walking (OR: 1.08, 95% CI: 1.33-4.13). Falls in a hallway were associated with no assistive device (OR: 1.75, 95% CI: 1.15-1.91). [Conclusion] Bedrooms and hallways in Japanese households were identified as locations with a high risk of falls. The unique architectural and cultural features of Japanese homes may contribute to this risk. Rehabilitation programs should consider individual fall histories, medical conditions, and differences in mobility.

Orthostatic Vital Signs After Sport-Related Concussion: A Cohort Study

BACKGROUND

The 6th International Consensus Statement on Concussion in Sport guidelines identified that measuring autonomic nervous system dysfunction using orthostatic vital signs (VSs) is an important part of the clinical evaluation; however, there are limited data on the frequency of autonomic nervous system dysfunction captured via orthostatic VSs after concussion.

PURPOSE

To compare orthostatic changes in heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP) between athletes with acute sport-related concussion (SRC) and control athletes.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

We compared 133 athletes (mean age, 15.3 years; age range, 8-28 years; 45.9% female) with acute SRC (<30 days after injury) with 100 control athletes (mean age, 15.7 years; age range, 10-28 years; 54.0% female). Given the broad age range eligible for study inclusion, participants were subdivided into child (younger than 13 years of age), adolescent (13-17 years of age), and adult (18 years of age and older) age groups for subanalyses. Participants completed a single standard orthostatic VS evaluation including HR, SBP, and DBP in the supine position then immediately and 2 minutes after standing. Linear regression was used to compare delayed supine-to-standing changes in HR, SBP, and DBP as a continuous variable (ΔHR, ΔSPB, and ΔDBP) between groups, and logistic regression was used to compare patients with positive orthostatic VS changes (sustained HR increase ≥30 beats per minute [bpm], SBP decrease ≥20 mm Hg, and DBP ≥10 mm Hg at 2 minutes) between groups, accounting for age and sex.

RESULTS

Between-group differences were present for delayed ΔHR (18.4 ± 12.7 bpm in patients with SRC vs 13.2 ± 11.0 bpm in controls; P = .002) and ΔSPB (-3.1 ± 6.6 bpm in patients with SRC vs -0.4 ± 6.5 bpm in controls; P = .001), with positive orthostatic HR changes present more frequently in patients with SRC (18% vs 7%; odds ratio, 2.79; P = .027). In the SRC group, a weak inverse relationship was present between age and ΔHR (r = -0.171; P = .049), with positive orthostatic HR findings occurring primarily in the child and adolescent SRC subgroups.

CONCLUSION

Patients with acute SRC had greater orthostatic VS changes compared with controls, the most prominent being sustained HR elevations. Clinical evaluation of autonomic change after SRC via standard orthostatic VS assessment may be a helpful clinical biomarker in the assessment of SRC, especially in children and adolescents.

Advancing Guideline-Directed Medical Therapy in Heart Failure: Overcoming Challenges and Maximizing Benefits

The delayed titration of guideline-directed drug therapy (GDMT) is a complex event influenced by multiple factors that often result in poor prognosis for patients with heart failure (HF). Individualized adjustments in GDMT titration may be necessary based on patient characteristics, and every clinician is responsible for promptly initiating GDMT and titrating it appropriately within the patient's tolerance range. This review examines the current challenges in GDMT implementation and scrutinizes titration considerations within distinct subsets of HF patients, with the overarching goal of enhancing the adoption and effectiveness of GDMT. The authors also underscore the significance of establishing a novel management strategy that integrates cardiologists, nurse practitioners, pharmacists, and patients as a unified team that can contribute to the improved promotion and implementation of GDMT.

Factors associated with transient bradycardia during local anesthesia administration to the oral cavity under intravenous sedation: A retrospective cohort study

Background/purpose

The possibility of triggering the trigeminocardiac reflex (TCR) during oral surgery is considerably lower than that during other surgeries. A reduced heart rate (HR) of ≥20% from baseline is usually considered a diagnostical criterion for the TCR. Our automated anesthesia charting system often revealed cases of slight transient HR decrease during sedation. We aimed to explore its incidence and associated factors during local anesthesia administration under intravenous sedation.

Materials and methods

This study analyzed the data of 2636 cases that received infiltration anesthesia under intravenous sedation from 2008 to 2010 and had vital signs recorded using an automated anesthesia charting system. Especially, data concerning the average HR before anesthesia and the minimum HR between the initiation and end of anesthesia from anesthetic records were extracted. Moreover, data regarding patients' medical history and unusual reactions during dental treatment were collected. Multivariate logistic regression analysis was performed to identify factors associated with transient bradycardia (TB).

Results

TB occurred in 472 patients (17.9%); no patient developed hypotension or any associated symptoms, suggesting that intravenous sedation was effective in stabilizing vital signs. The factors associated with TB were younger age, gag reflex, and allergy to local anesthetics. There were no differences in sex, patient history, or dose of sedatives between patients with TB and those without TB.

Conclusion

The incidence of TB during infiltration anesthesia under sedation was found to be higher than that previously reported. Additionally, young age and gag reflex were identified as factors associated with bradycardia development.

Associations of age-adjusted coefficient of variation of R-R intervals with autonomic and peripheral nerve function in non-elderly persons with diabetes

AIMS/INTRODUCTION

Early diagnosis of diabetes-associated cardiac autonomic neuropathy using the coefficient of variation of R-R intervals (CVRR) may improve outcomes for individuals with diabetes. The present study examined the associations of decreased CVRR at rest and during deep breathing (DB) with other autonomic nerve function parameters.

MATERIALS AND METHODS

The electronic records of 141 inpatients with diabetes (22-65 years) admitted to our hospital between March 2015 and March 2019 were analyzed retrospectively. After assessment by exclusion criteria, 51 inpatients were included. All inpatients were assessed for peripheral and autonomic nerve function, clinical characteristics, and physical abilities.

RESULTS

Inpatients with decreased CVRR at rest (n = 9 (17.6%)) and during DB (n = 12 (23.5%)) had a longer duration of known diabetes, a higher prevalence of diabetic retinopathy, lower body mass index (BMI), skeletal mass index (SMI), and knee extension strength, and a higher proportion of impaired standing balance. Decreased CVRR at rest was associated with a greater fall in diastolic BP from supine to standing, higher resting HR, longer QTc, longer time of voiding, and sensory symptoms.

CONCLUSIONS

Decreased CVRR at rest and during deep breathing was associated with lower BMI, SMI, and knee strength and a higher proportion of impaired standing balance among non-elderly inpatients with diabetes. Decreased CVRR at rest appeared more strongly associated with a greater orthostatic BP decline, higher resting heart rate, longer QTc, lower urinary tract dysfunction, and sensory symptoms than a decreased CVRR during deep breathing.

Orthostatic hypotension: Review and expert position statement

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.

Acute orthostatic responses during early mobilisation of patients with acquired brain injury - Innowalk pro versus standing frame

Introduction

Early mobilisation is paramount in the rehabilitation of patients with acquired brain injuries. However, the effectiveness of mobilisation to standing combined with passive leg movement in mitigating orthostatic intolerance remains uncertain. Hence, we investigated whether participants exhibited better tolerance standing in a motorized standing device with passive leg movements, Innowalk Pro, compared to a traditional standing frame.

Methods

17 patients with acquired brain injury (<1 year post-injury) performed two sessions in each standing device on four separate days. Maximum standing time was 30 min, less when symptoms of syncope or volitional exhaustion occurred. Besides total standing time, electromyography of thigh muscles, and changes in mean arterial pressure and heart rate were monitored at rest and during standing.

Results

No significant differences were found in standing time, changes in mean arterial pressure or heart rate between standing in Innowalk Pro and the standing frame. However, participants had significantly more thigh muscle activation (p = 0.006) when standing in Innowalk Pro.

Conclusions

Mobilising participants with a subacute acquired brain injury in a standing frame with motorised passive movements of the lower limbs did, despite higher thigh muscle activation, not lead to better orthostatic tolerance or prolonged standing time compared to a traditional standing frame.

Non-Pharmacological Treatment of Autonomic Dysfunction in Parkinson's Disease and Other Synucleinopathies

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.

Effects of Blood Flow Restriction Resistance Training on Autonomic and Endothelial Function in Persons with Parkinson's Disease

Background

Autonomic dysfunction precedes endothelial dysfunction in Parkinson's disease (PD) and causes blood pressure and circulation abnormalities that are highly disruptive to one's quality of life. While exercise interventions have proven helpful for motor symptoms of PD, improving associated non-motor symptoms is limited. Low-intensity resistance training with blood flow restriction (LIRT-BFR) improves autonomic dysfunction in non-PD patients and high-intensity resistance training (HIRT) is recommended for motor symptom improvements for people with PD (PwPD).

Objective

To determine the effects of LIRT-BFR and HIRT on homocysteine and autonomic and endothelial function in PwPD and to determine the hemodynamic loads during LIRT-BFR and HIRT in PwPD using a novel exercise protocol.

Methods

Thirty-eight PwPD were assigned LIRT-BFR, HIRT or to a control (CNTRL) group. The LIRT-BFR and HIRT groups exercised three days per week for four weeks. The LIRT-BFR protocol used 60% limb occlusion pressure (LOP) and performed three sets of 20 repetitions at 20% of the one-repetition maximum (1RM). The HIRT group performed three sets of eight repetitions at 80% 1RM. The CNTRL group was asked to continue their normal daily routines.

Results

LIRT-BFR significantly improved orthostatic hypotension (p = 0.026), homocysteine levels (p < 0.001), peripheral circulation (p = 0.003), supine blood pressure (p = 0.028) and heart rate variability (p = 0.041); LIRT-BFR improved homocysteine levels (p < 0.018), peripheral circulation (p = 0.005), supine blood pressure (p = 0.007) and heart rate variability (p = 0.047) more than HIRT; and hemodynamic loads for LIRT-BFR and HIRT were similar.

Conclusions

LIRT-BFR may be more effective than HIRT for autonomic and endothelial function improvements in PwPD and hemodynamic loads may be lessened in LIRT-BFR protocols using single-joint exercises with intermittent blood flow restriction. Further research is needed to determine if non-motor symptoms improve over time and if results are sustainable.

Setting the clinical context to non-motor symptoms reflected by Park-pain, Park-sleep, and Park-autonomic subtypes of Parkinson's disease

Non-motor symptoms (NMS) of Parkinson's disease (PD) are well described in both clinical practice and the literature, enabling their management and enhancing our understanding of PD. NMS can dominate the clinical pictures and NMS subtypes have recently been proposed, initially based on clinical observations, and later confirmed in data driven analyses of large datasets and in biomarker-based studies. In this chapter, we provide an update on what is known about three common subtypes of NMS in PD. The pain (Park-pain), sleep dysfunction (Park-sleep), and autonomic dysfunction (Park-autonomic), providing an overview of their individual classification, clinical manifestation, pathophysiology, diagnosis, and potential treatments.

Cardiovascular autonomic neuropathy in patients with type 2 diabetes with and without sensorimotor polyneuropathy

BACKGROUND AND AIMS

Cardiovascular autonomic neuropathy (CAN) in patients with diabetes is associated with poor prognosis. We aimed to assess signs of CAN and autonomic symptoms and to investigate the impact of sensorimotor neuropathy on CAN by examining type 2 diabetes patients with (DPN [distal sensorimotor polyneuropathy]) and without distal sensorimotor polyneuropathy (noDPN) and healthy controls (HC). Secondarily, we aimed to describe the characteristics of patients with CAN.

METHODS

A population of 374 subjects from a previously described cohort of the Danish Centre for Strategic Research in Type 2 Diabetes (DD2) were included. Subjects were examined with the Vagus™ device for the diagnosis of CAN, where two or more abnormal cardiovascular autonomic reflex tests indicate definite CAN. Autonomic symptoms were assessed with Composite Autonomic Symptom Score 31 (COMPASS 31) questionnaire. DPN was defined according to the Toronto consensus panel definition.

RESULTS

Definite CAN was present in 22% with DPN, 7% without DPN and 3% of HC, and 91% of patients with definite CAN had DPN. Patients with DPN and definite CAN reported higher COMPASS 31 scores compared to patients with noDPN (20.0 vs. 8.3, p < 0.001) and no CAN (22.1 vs. 12.3, p = 0.01). CAN was associated with HbA1c and age in a multivariate logistic regression analysis but was not associated with IEFND or triglycerides.

INTERPRETATION

One in five patients with DPN have CAN and specific CAN characteristics may help identify patients at risk for developing this severe diabetic complication. Autonomic symptoms were strongly associated with having both DPN and CAN, but too unspecific for diagnosing CAN.

The Effect of a Biofeedback-Based Integrated Program on Improving Orthostatic Hypotension in Community-Dwelling Older Adults: A Pilot Study

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.

The Impact of Head-Up Tilt Sleeping on Orthostatic Tolerance: A Scoping Review

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.

Increased Parasympathetic Activity as a Fall Risk Factor Beyond Conventional Factors in Institutionalized Older Adults with Mild Cognitive Impairment

PURPOSE

This study aimed to investigate autonomic nervous function during the orthostatic challenge and its relationship with depression and fall, and to elucidate fall-associated factors, including autonomic function, executive function, and depression among institutionalized older adults with mild cognitive impairment (MCI).

METHODS

This study employed a descriptive cross-sectional design. Fall experiences in the current institutions were researched. Heart rate variability (HRV) during the orthostatic challenge was measured. Executive function was evaluated using the semantic verbal fluency test and clock drawing test. Depression was assessed using the Geriatric Depression Scale.

RESULTS

Of the 115 older adults, 17 (14.8%) experienced falls in the current institution. None of the HRV indices during the orthostatic challenge showed any significant changes except for the standard deviation of normal RR intervals (p = .037) in the institutionalized older adults with MCI. None of the HRV indices was significantly related to the depressive symptoms. Multivariate logistic regression analysis showed that normalized high frequency on lying was independently associated with falls (OR = 1.027, p = .049) after adjusting for other conventional fall risk factors although executive function and depressive symptoms were not significant factors for falls.

CONCLUSIONS

Institutionalized older adults with MCI were vulnerable to autonomic nervous modulation, especially to sympathetic modulation, during the orthostatic challenge, which was not associated with depressive symptoms. As increased resting parasympathetic activity seemed to play a key role in association with falls, autonomic nervous function assessment should be considered for fall risk evaluation.

Ampreloxetine Versus Droxidopa in Neurogenic Orthostatic Hypotension: A Comparative Review

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.

Variability of blood pressure response to orthostatism and reproducibility of orthostatic hypotension in hospitalized patients with acute ischemic stroke

OBJECTIVE

Orthostatic hypotension (OH) which diagnosis is based on the measurement of the blood pressure response to orthostatism (BPRO) is a common condition associated with adverse cerebrovascular and cognitive prognosis. It is likely that the single measurement might underestimate the true prevalence of OH. This study investigated the prevalence and reproducibility of the diagnosis of OH and related risk factors in hospitalized acute ischemic stroke (AIS) patients with multiple measurements.

MATERIALS AND METHODS

This study was a prospective cohort analysis of consecutive AIS patients admitted to the hospital. A total of 211 patients were included. BPRO was assessed five times at the same time on different days.

RESULTS

OH was found in 33 cases (15.6%) in the initial set of measurements of the first day. A cumulative diagnosis of OH after five BPRO tests was found in 75 cases (35.5%). The reproducibility of the diagnosis of OH was mild or poor. In patients with a cumulative diagnosis of OH, 29 (38.7%) patients had orthostatic hypertension (OHTN). In multivariate analysis, the Fazekas scale (odds radio = 1.28, 95% confidence interval (CI), 1.04-1.59, P  = 0.023) and extracranial carotid stenosis (≥70%) (odds radio = 3.64, 95% CI, 1.19-11.13, P  = 0.023) were independent risk factors for OH.

CONCLUSION

The reproducibility of OH is poor and the concurrent appearance of OH and OHTN is common in hospitalized AIS patients. Multiple measurements should be taken in hospitalized AIS patients when screening for OH especially patients with higher Fazekas scale and extracranial carotid stenosis (≥70%).

A case of dysautonomia after COVID-19 infection in a patient with poorly controlled type I diabetes

COVID-19 has been linked to dysautonomia in the current literature, as has uncontrolled diabetes. Here, we present a case report of severe dysautonomia following a COVID-19 infection in a patient with pre-existing poorly controlled type-1 diabetes. This patient exhibited symptoms consistent with both postural orthostatic tachycardia syndrome (POTS), as well as orthostatic hypotension. His symptoms became so severe that he was unable to come to a standing position without experiencing syncope. Extensive workup was completed to identify an alternative cause of his dysautonomia with inconclusive results. Dysautonomia can have devastating consequences in regard to physical, social, and psychological health. Counseling individuals with poorly controlled diabetes about the importance of maintaining tight blood glucose control and avoiding COVID-19 infection should be primary interventions when treating patients with this DM1. Early detection and management of diabetes mellitus, COVID-19, and of possible resultant dysautonomia through medical interventions, as well as lifestyle changes, are extremely important measures to avoid development of dangerous and potentially life-threatening consequences.

Can sitting and lying blood pressure measurements be considered interchangeable in older frail adults?

BACKGROUND

To compare blood pressure (BP) values in the lying and sitting positions, and the effect of orthostatism when moving from each of these positions to the upright position in a geriatric population with various frailty levels.

METHODS

In two sub-studies, we included a total of 157 consecutive patients, aged 75+ admitted to the Geriatric Department of Nancy University Hospital. BP and heart rate were sequentially measured three times in 1-min intervals each in lying, sitting and upright positions (Protocol#1, n = 107) or lying and upright positions (Protocol#2, n = 50) with an automatic validated Blood Pressure device. Patients were classified into two increasing frailty status (FS) categories: Low/Moderate (L/M-FS, n = 98) and High (H-FS, n = 59).

RESULTS

BP levels were similar in the lying and sitting positions (Protocol#1, SBP 141 ± 22 mmHg vs. 142 ± 21 mmHg, respectively, and DBP 72 ± 12 mmHg vs. 72 ± 12 mmHg, respectively) in both frailty groups. In the H-FS, orthostatic drop of SBP was more pronounced from the lying (22.1 ± 5.8 mmHg, Protocol#2) as compared to the sitting to upright position (9.4 ± 1.9 mmHg, Protocol#1) (p < 0.008), and the same trend was observed for DBP. No such differences were observed in the L-M/FS frailty individuals.

CONCLUSIONS

Orthostatic BP changes are more pronounced in the frailest patients when going from lying to the upright position than from the sitting to the upright position. Consequently, in these individuals, lying and sitting BP measurements cannot be interchangeable baseline positions to investigate orthostatic BP effects, and therefore, precise patient positioning should be specified when referring to "baseline BP measurements".

Corneal confocal microscopy differentiates patients with Parkinson’s disease with and without autonomic involvement

Autonomic dysregulation in Parkinson’s disease (PD) can precede motor deficits and is associated with reduced quality of life, disease progression, and increased mortality. Objective markers of autonomic involvement in PD are limited. Corneal confocal microscopy (CCM) is a rapid ophthalmic technique that can quantify small nerve damage in a range of peripheral and autonomic neuropathies. Here we investigated whether CCM can be used to assess autonomic symptoms in PD. Based on the scale for outcomes in Parkinson’s disease for autonomic symptoms (SCOPA-AUT), patients with PD were classified into those without autonomic symptoms (AutD-N), with single (AutD-S), and multiple (AutD-M) domain autonomic dysfunction. Corneal nerve fiber pathology was quantified using CCM, and the relationship with autonomic symptoms was explored. The study enrolled 71 PD patients and 30 control subjects. Corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD), corneal nerve fiber length (CNFL), and CNBD/CNFD ratio were lower in PD patients with autonomic symptoms compared to those without autonomic symptoms. Autonomic symptoms correlated positively with CNFD (r = −0.350, p = 0.004), and were not related to Levodopa equivalent daily dose (r = 0.042, p = 0.733) after adjusting for age, disease severity, disease duration or cognitive function. CCM parameters had high sensitivity and specificity in distinguishing patients with PD with and without autonomic symptoms. PD patients with autonomic symptoms have corneal nerve loss, and CCM could serve as an objective ophthalmic imaging technique to identify patients with PD and autonomic symptoms.

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

Background

Methods

Results

Conclusion

New horizons in the ageing autonomic nervous system: orthostatic hypotension and supine hypertension

Blood pressure regulation is an automatic, moment-by-moment buffering of the blood pressure in response to physiological changes such as orthostasis, exercise and haemorrhage. This finely orchestrated reflex is called the baroreflex. It is a regulated arc of afferent, central and efferent arms. Multiple physiological changes occur with ageing that can disrupt this reflex, making blood pressure regulation less effective. In addition, multiple changes can occur with ageing-related diseases such as neurodegeneration, atherosclerosis, deconditioning and polypharmacy. These changes commonly result in orthostatic hypotension, hypertension or both, and are consistently associated with multiple adverse outcomes. In this article, we discuss the healthy baroreflex, and physiological and pathophysiological reasons for impaired baroreflex function in older people. We discuss why the common clinical manifestations of orthostatic hypotension and concomitant supine hypertension occur, and strategies for balancing these conflicting priorities. Finally, we discuss strategies for treating them, outlining our practice alongside consensus and expert guidance.

Autonomic dysfunction in non-critically ill COVID-19 patients during the acute phase of disease: an observational, cross-sectional study

Introduction

Evidence is emerging about an extra-pulmonary involvement of SARS-CoV-2, including the nervous system. Autonomic dysfunction in patients recovering from acute coronavirus disease 2019 (COVID-19) has been recently described. Dysautonomic symptoms have been reported in the acute phase of the disease, but clear evidence is lacking, especially in the non-critical forms of the infection.

Objective

The aim of this study is to assess the prevalence of dysautonomia in acute, non-critically ill COVID-19 patients.

Methods

In this observational, cross-sectional study, we compared 38 non-critically ill patients with acute COVID-19 (COVID + group) to 38 healthy volunteers (COVID − group) in order to assess the prevalence of signs and symptoms of dysautonomia through the administration of the composite autonomic symptom score 31 (COMPASS-31) and an active standing test. Comparisons between groups were performed by means of both univariate and multivariate analyses.

Results

The prevalence of orthostatic hypotension was significantly higher in the COVID + group. Higher total scores of COMPASS-31 were observed in the COVID + group than controls. Significant differences between groups emerged in the secretomotor, orthostatic intolerance, and gastrointestinal COMPASS-31 domains. All these results maintained the statistical significance after the adjustment for concomitant drugs with a known effect on the autonomic nervous system assumed by the study participants, except for the differences in the gastrointestinal domain of COMPASS-31.

Conclusion

Our results suggest that an autonomic dysfunction could be an early manifestation of COVID-19, even in the contest of mild forms of the infection.

The baroreceptor reflex brought to life outside the classroom - an e-learning based asynchronous laboratory class using a non-supervised modified Active Standing Test

BACKGROUND

E-learning based laboratory classes can replace or enhance in-classroom laboratories. They typically offer temporal flexibility, self-determined learning speed, repeatability and do not require supervision or face-to-face contact. The aim of this feasibility study was to investigate whether the established in-classroom laboratory class on the baroreceptor reflex (BRR) can be transformed into a new e-learning based asynchronous laboratory class for untrained, non-supervised students without medical equipment. The BRR is a fundamental cardiovascular process which is regularly visualized in physiology during in-classroom laboratories by a student-performed Active Standing Test (AST). During this voluntary provocation of orthostatic stress, the BRR reliably causes a solid rise in heart rate (HR) and a stabilization or even increase in blood pressure (BP).

METHODS

The conventional AST was modified by omission of BP measurements which would require medical devices and was embedded into a framework of interactive digital material allowing independent student performance. With specific adaptions, this instrument was implemented to 1st and 2nd year curricula of human medicine, dental medicine, midwifery and pharmacy. An audience response system was used to collect the students' data on HR, epidemiology, technical problems, satisfaction and orthostatic symptoms. As primary outcome, we investigated the students' correct performance of the modified AST regarding textbook conformity of the HR data. Secondary outcomes included technical feasibility, the students' satisfaction and consistency of HR data within predefined subgroups (e.g., gender, curricula). Descriptive statistics are reported.

RESULTS

The class was completed by 217 students (mean age: 23 ± 8 [SD], 81% female, 19% male). Mean reported rise of HR during standing was ~ 20 bpm (~ 30%) which is highly concordant to textbooks. Reported feasibility (~ 80% negated any technical issues) and students' satisfaction (4.4 on 5-point Likert-scale) were high. The HR data were consistent within the subgroups.

CONCLUSION

This study demonstrates that the highly relevant BRR can be successfully addressed in an e-learning based asynchronous laboratory class implementing a non-supervised AST restricted to HR measurements embedded in digital material. The robust HR response and the adjustable complexity allow an application to different healthcare-related curricula. This class, therefore, provides a broad audience access to a fundamental concept of cardiovascular physiology.

Postacute Sequelae of Severe Acute Respiratory Syndrome Coronavirus 2 Infection

Postacute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or long coronavirus disease (COVID) is an emerging syndrome characterized by multiple persisting or newly emergent symptoms following the acute phase of SARS-CoV-2 infection. For affected patients, these prolonged symptoms can have a relapsing and remitting course and may be associated with disability and frequent health care utilization. Although many symptom-driven treatments are available, management remains challenging and often requires a multidisciplinary approach. This article summarizes the emerging consensus on definitions, epidemiology, and pathophysiology of long COVID and discusses what is understood about prevention, evaluation, and treatment of this syndrome.

Comprehensive telemedicine solution for remote monitoring of Parkinson's disease patients with orthostatic hypotension during COVID-19 pandemic

OBJECTIVE

Orthostatic hypotension (OH) represents a frequent but under-recognized phenomenon in Parkinson's disease (PD). During COVID-19 pandemic, Information and Communication Technologies (ICT) have become pivotal in the management of chronic diseases like PD, not only to assess motor impairment, but also for vital signs monitoring. This pilot study aimed to propose a real-time remote home-monitoring system and protocol for PD patients with OH.

METHODS

Vital parameters were acquired by wireless devices and transmitted to an ICT platform, providing data and smart notifications to the healthcare provider through an interactive web portal. Eight patients with idiopathic PD and OH underwent 5-day monitoring. Data about OH episodes, therapeutic interventions, impact on daily activities, and patient satisfaction were collected and analyzed.

RESULTS

The proposed solution allowed the identification of 65 OH episodes and subsequent medical interventions. Thirty-five episodes were asymptomatic, especially in the postprandial and in the afternoon recordings. Systolic-blood-pressure (SBP) and diastolic-blood-pressure (DBP) were significantly lower in symptomatic episodes, while the pressure drops resulted significantly higher in presence of symptoms. High usability and patient satisfaction scores were observed.

CONCLUSION

The proposed home-monitoring system and protocol have proved to provide useful information and to allow prompt interventions in the management of PD patients with OH during COVID-19 pandemic.

Post-acute sequelae of COVID-19 (PASC): a meta-narrative review of pathophysiology, prevalence, and management

Coronavirus Disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Over 220 countries and territories have been affected by this virus, and the infection rate has continued to rise. As patients recover from the virus, many are experiencing lingering symptoms. Understanding the impact of demographics and comorbidities on symptom prevalence, manifestations, and severity is not only relevant during acute infection, it is critical to the clinical management of patients with post-acute sequelae of COVID-19, also known as PASC. Herein, we provide a comprehensive review on the most recent research related to PASC. Specifically, we focus on the description of the disorder itself, compared to acute COVID-19, and which types of patients are most affected by long-term sequelae. Further, we share recommendations for management of the most common complications of PASC.

Anti-hypotensive effect of “Yahom Navakot” in rats with orthostatic hypotension

Background and aim

Yahom Navakot (YN), is a Thai traditional medicine, consisting of 54 plants, for treating fainting and dizziness. Thus, YN might relieve orthostatic hypotension (OH) symptoms, but its therapeutic action is unclear. Therefore, this study evaluated YN in OH rats, using a head-up tilt test (HUT).

Experimental procedure

Rats were anesthetized, and OH induced via a 90^oHUT, before and after administering vehicle, a YN powder suspension (10, 100 mg/kg), a YN aqueous extract (100 mg/kg), and midodrine (5 mg/kg). The systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressure (MAP), pulse pressure (PP) and heart rate (HR) were determined via the carotid artery. Plasma noradrenaline (NA) was evaluated. YN-induced vasoconstriction of isolated rat aorta rings was determined using organ bath technique.

Results and conclusion

Baseline BP increased with the 100 mg/kg YN powder suspension, the YN aqueous extract or midodrine, while HR decreased, compared with vehicle and control. 90^oHUT rapidly reduced SBP, DPB and MAP, but increased HR, for control and vehicle-treated groups, but BP was steady with the 100 mg/kg YN powder suspension, the YN aqueous extract or midodrine. The 90^oHUT-increase in HR was most pronounced with the 100 mg/kg YN powder suspension (the traditional formulation). This accords with increased plasma NA. YN also induced vasoconstriction in rat aorta via α₁-receptor activation. Thus, the anti-hypotensive action of YN involved a stimulating effect on the heart and blood vessels via sympathetic activation. The results support the traditional use of YN and demonstrated the effectiveness of YN for OH prevention.

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Yahom Navakot is an effective treatment for orthostatic hypotension.

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Yahom Navakot possesses chronotropic effect and vasoconstrictor action.

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Yahom Navakot increases plasma noradrenaline leading to the increase in blood pressure.

Oral and intravenous hydration in the treatment of orthostatic hypotension and postural tachycardia syndrome

Hydration with water and salt is the mainstay of treatment for autonomic nervous system disorders that impair orthostatic tolerance. The goal is to expand intravascular volume to compensate for the downward displacement of blood volume that occurs when standing and thereby sustain cerebral perfusion and restore quality of life. Despite strong consensus recommendations for salt supplementation as standard treatment of these disorders, published evidence of benefit is relatively weak, and no randomized clinical trials have occurred. This review summarizes the physiological rationale for hydration and evaluates the literature on oral and intravenous hydration in the treatment of neurogenic orthostatic hypotension, postural tachycardia syndrome, and recurrent vasovagal syncope. We conclude that oral salt replacement is indicated for treatment of neurogenic orthostatic hypotension because these patients have excessive renal sodium excretion, and for treatment of chronic orthostatic intolerance because these patients are often hypovolemic. As not all patients are able to tolerate sufficient oral hydration, there is also a role for intravenous volume-loading in severe cases of postural tachycardia syndrome. We offer guidance, based on review of the literature and the clinical judgment of a cardiologist and neurologist with experience treating autonomic disorders, regarding the option of ongoing intravenous hydration for treatment of severe, refractory cases of postural tachycardia syndrome.

The Pressor Response to the Drinking of Cold Water and Cold Carbonated Water in Healthy Younger and Older Adults

Purpose: Water drinking has been proposed for the treatment of orthostatic hypotension because it can increase blood pressure in patients. This study aimed to investigate whether drinking water with a cold or carbonation stimulus would cause a more effective pressor response, and whether it would be greater in older than in younger adults.

Methods: We assessed blood pressure and heart rate from non-invasive arterial pressure (a volume-clamp method) and type II electrocardiography in 13 healthy young adults (6 females, 7 males; mean age, 19.9 ± 1.1 years) and nine healthy older adults (all females; mean age, 71.4 ± 4.2 years) who drank 200 mL of cold, cold carbonated, and room temperature water.

Results: The pressor response to the drinking of cold and cold carbonated water was greater than that to room temperature water in both younger and older participants (p < 0.05; changes in systolic blood pressure of room temperature water, cold water and cold carbonated water in young: 15.31 ± 9.66, 22.56 ± 11.51 and 32.6 ± 17.98 mmHg, respectively; changes in systolic blood pressure of room temperature water, cold water and cold carbonated water in elderly: 21.84 ± 14.31, 41.53 ± 19.82 and 48.16 ± 16.77 mmHg, respectively). In addition, the pressor response to cold and cold carbonated water was persistent during the recovery period by about 5–10 mmHg (p < 0.05). Furthermore, the pressor response during the drinking and recovery periods was greater in the older than in the younger participants (p < 0.05).

Conclusion: Our data suggest that even smaller amounts of water are able to elicit a sustained pressor response, in particular if the water is cold and carbonated. We speculate that the pressor effect may render cold and carbonated water an appropriate first aid method against certain forms of acute hypotension.

Trajectory Analysis of Orthostatic Hypotension in Parkinson's Disease: Results From Parkinson's Progression Markers Initiative Cohort

Background: Orthostatic hypotension (OH) in Parkinson’s disease (PD) can lead to falls, impair quality of life, and increase mortality. A trajectory analysis of OH could be useful to predict and prevent the hypotension incidence early.

Methods: The longitudinal data of 660 patients with PD with disease duration up to 12 years were extracted from an integrated PD database. We used latent class mixed modeling (LCMM) to identify patient subgroups, demonstrating trajectories of changes in orthostatic blood pressure (BP) over time. The optimal number of subgroups was selected by several criteria including the Bayesian Information Criterion. Baseline information comparison between groups and backward stepwise logistic regression were conducted to define the distinguishing characteristics of these subgroups and to investigate the predictors for BP trajectory.

Results: We identified three trajectories for each orthostatic change of systolic blood pressure (ΔSBP), namely, Class 1 (i.e., the increasing class) consisted of 18 participants with low ΔSBP that increased continuously during the follow-up; Class 2 (i.e., the low-stable class) consisted of 610 participants with low ΔSBP that remained low throughout the follow-up; and Class 3 (i.e., the high-stable class) consisted of 32 participants with high ΔSBP at baseline that was relatively stable throughout the follow-up. Several parameters differed among subgroups, but only male sex [odds ratio (OR) = 4.687, 95% confidence interval (CI) = 1.024–21.459], lower supine diastolic blood pressure (DBP) (OR = 0.934, 95% CI = 0.876–0.996), and lower level of total protein at baseline (OR = 0.812, 95% CI = 0.700–0.941) were significant predictors of an increasing ΔSBP trajectory.

Conclusion: This study provides new information on the longitudinal development of ΔSBP in patients with PD with distinct trajectories of rapidly increasing, low-stable, and high-stable class. The parameters such as male sex, lower supine DBP, and lower total proteins help to identify the rapidly increasing class.

Burden of caregiving for cardiovascular dysautonomia in Parkinson's disease

PURPOSE

We sought to estimate the impact of cardiovascular autonomic neuropathy (cAN) on informal caregivers of patients with Parkinson's disease (PD), defined as individuals providing regular care to a friend, partner, or family member with PD, and to evaluate the mutual relationship between caregiver burden and patient health-related quality of life (HRQoL).

METHODS

We enrolled 36 consecutive patients with PD and their informal caregivers. Patients underwent a detailed motor, autonomic, cognitive, and functional assessment. Caregivers were assessed using the Zarit Burden Interview (ZBI). Differences in caregiver burden, expressed by the ZBI score, and strength of association between caregiver burden, cAN, and HRQoL were assessed using analysis of covariance (ANCOVA), logistic regression, and linear regression analyses. Analyses were adjusted for patients' age, PD duration, and motor and cognitive disability, as well as caregivers' age.

RESULTS

Moderate-severe caregiver burden was reported in 41.7% of PDcAN⁺ versus 8.7% of PDcAN^- (p < 0.001). The ZBI score was increased in PDcAN⁺ versus PDcAN^- (31.5 ± 3.4 versus 15.2 ± 2.3; p < 0.001), with tenfold higher odds (p = 0.012) of moderate-severe caregiver burden in PDcAN⁺, even after adjusting for potential confounders. The ZBI score correlated with cAN severity (p = 0.005), global autonomic impairment (p = 0.012), and HRQoL impairment (p < 0.001).

CONCLUSION

These results highlight the significant impact of cAN on PD caregivers and the need for targeted interventions addressing this frequently overlooked and insufficiently treated source of nonmotor disability in PD.

Heart rate variability as a marker of cardiovascular dysautonomia in post-COVID-19 syndrome using artificial intelligence

Introduction

Cardiovascular dysautonomia comprising postural orthostatic tachycardia syndrome (POTS) and orthostatic hypotension (OH) is one of the presentations in COVID-19 recovered subjects. We aim to determine the prevalence of cardiovascular dysautonomia in post COVID-19 patients and to evaluate an Artificial Intelligence (AI) model to identify time domain heart rate variability (HRV) measures most suitable for short term ECG in these subjects.

Methods

This observational study enrolled 92 recently COVID-19 recovered subjects who underwent measurement of heart rate and blood pressure response to standing up from supine position and a 12-lead ECG recording for 60 s period during supine paced breathing. Using feature extraction, ECG features including those of HRV (RMSSD and SDNN) were obtained. An AI model was constructed with ShAP AI interpretability to determine time domain HRV features representing post COVID-19 recovered state. In addition, 120 healthy volunteers were enrolled as controls.

Results

Cardiovascular dysautonomia was present in 15.21% (OH:13.04%; POTS:2.17%). Patients with OH had significantly lower HRV and higher inflammatory markers. HRV (RMSSD) was significantly lower in post COVID-19 patients compared to healthy controls (13.9 ± 11.8 ms vs 19.9 ± 19.5 ms; P = 0.01) with inverse correlation between HRV and inflammatory markers. Multiple perceptron was best performing AI model with HRV(RMSSD) being the top time domain HRV feature distinguishing between COVID-19 recovered patients and healthy controls.

Conclusion

Present study showed that cardiovascular dysautonomia is common in COVID-19 recovered subjects with a significantly lower HRV compared to healthy controls. The AI model was able to distinguish between COVID-19 recovered patients and healthy controls.

Treatment strategies for clozapine-induced hypotension: a systematic review

BACKGROUND

Clozapine is the most effective medication for treatment-refractory schizophrenia but is associated with significant adverse drug effects, including hypotension and dizziness, which have a negative impact on quality of life and treatment compliance. Available evidence for the management of clozapine-induced hypotension is scant.

OBJECTIVES

Due to limited guidance on the safety and efficacy of pharmacological treatments for clozapine-induced hypotension, we set out to systematically review and assess the evidence for the management of clozapine-induced hypotension and provide guidance to clinicians, patients, and carers.

DESIGN

We undertook a systematic review of the safety and efficacy of interventions for clozapine-induced hypotension given the limited available evidence.

DATA SOURCES AND METHODS

PubMed, Embase, PsycINFO, CINAHL, and the Cochrane trial Registry were searched from inception to November 2021 for literature on the treatment strategies for clozapine-induced hypotension and dizziness using a PROSPERO pre-registered search strategy. For orthostatic hypotension, we developed a management framework to assist in the choice of intervention.

RESULTS

We identified nine case studies and four case series describing interventions in 15 patients. Hypotension interventions included temporary clozapine dose reduction, non-pharmacological treatments, and pharmacological treatments. Midodrine, fludrocortisone, moclobemide and Bovril^® combination, and etilefrine were associated with improvement in symptoms or reduction in orthostatic hypotension. Angiotensin II, arginine vasopressin, and noradrenaline successfully restored and maintained mean arterial pressure in critical care situations. A paradoxical reaction of severe hypotension was reported with adrenaline use.

CONCLUSION

Orthostatic hypotension is a common side effect during clozapine titration. Following an assessment of the titration schedule, salt and fluid intake, and review of hypertensive and nonselective α1-adrenergic agents, first-line treatment should be a temporary reduction in clozapine dose or non-pharmacological interventions. If orthostatic hypotension persists, fludrocortisone should be trialled with monitoring of potassium levels and sodium and fluid intake. Midodrine may be considered second-line or where fludrocortisone is contraindicated or poorly tolerated. For patients on clozapine with hypotension in critical care settings, the use of adrenaline to maintain mean arterial pressure should be avoided.

REGISTRATION

PROSPERO (Registration No. CRD42020191530).

Prevalence and incidence of Parkinson's disease and other forms of parkinsonism in a cohort of elderly individuals in Southern Brazil: protocol for a population-based study

INTRODUCTION

Parkinsonism is one of the most common neurological disorders affecting the elderly. Several population-based studies have determined the epidemiology of parkinsonism, mainly Parkinson's disease (PD), but there is still little evidence in the Brazilian population. This protocol study aims to assess the prevalence and incidence of cases of PD and other parkinsonian syndromes in a 5-year cohort in a population-based study in the southern region of Brazil.

METHODS AND ANALYSIS

A prospective population-based longitudinal study, with a cohort of development of cases of parkinsonism, divided into two phases: in phase I, two questionnaires to screen for parkinsonism (Tanner's questionnaire), Rapid Eyes Movement (REM) sleep behaviour disorder (REM Sleep Behavior Disorder Single-Question Screen) and a short interview will be conducted with all elderly residents of Veranópolis (the first longevity Brazilian county located in the Rio Grande do Sul, Brazil) aged 60 or over. The positive screened cases will be examined independently by at least two movement disorder-trained physicians and prevalence will be determined. A comprehensive evaluation of prodromic symptoms, risk factors and clinical characteristics will be carried out. Subjects with subtle parkinsonism and a sample of healthy subjects will be followed for 5 years in a developmental cohort of parkinsonism cases. For crude incidence, all individuals admitted at the beginning of the study will be re-evaluated.

ETHICS AND DISSEMINATION

The study was approved by the research ethics committee of the Hospital de Clínicas de Porto Alegre (protocol n° 4.095.609). All participants provide their informed consent before evaluations. Findings from this survey will be disseminated through peer-reviewed publications and will be presented at conferences.

Salt supplementation in the management of orthostatic intolerance: Vasovagal syncope and postural orthostatic tachycardia syndrome

Salt supplementation is a common non-pharmacological approach to the management of recurrent orthostatic syncope or presyncope, particularly for patients with vasovagal syncope (VVS) or postural orthostatic tachycardia syndrome (POTS), although there is limited consensus on the optimal dosage, formulation and duration of treatment. Accordingly, we reviewed the evidence for the use of salt supplementation to reduce susceptibility to syncope or presyncope in patients with VVS and POTS. We found that short-term (~3 months) salt supplementation improves susceptibility to VVS and associated symptoms, with little effect on supine blood pressure. In patients with VVS, salt supplementation is associated with increases in plasma volume, and an increase in the time taken to provoke a syncopal event during orthostatic tolerance testing, with smaller orthostatic heart rate increases, enhanced peripheral vascular responses to orthostatic stress, and improved cerebral autoregulation. Responses were most pronounced in those with a baseline sodium excretion <170 mmol/day. Salt supplementation also improved symptoms, plasma volume, and orthostatic responses in patients with POTS. Salt supplementation should be considered for individuals with recurrent and troublesome episodes of VVS or POTS without cardiovascular comorbidities, particularly if their typical urinary sodium excretion is low, and their supine blood pressure is not elevated. The efficacy of the response, in terms of the improvement in subjective and objective markers of orthostatic intolerance, and any potential deleterious effect on supine blood pressure, should be routinely monitored in individuals on high salt regimes.

Salt: The paradoxical philosopher's stone of autonomic medicine

Sodium chloride, or common table salt, for millennia has played a prominent role in human affairs. Salt is also a key molecule for regulating intravascular fluid volume in patients with orthostatic disorders. In this first article of a special issue of the journal focusing on salt and the autonomic nervous system, the historical and physiologic significance of salt is reviewed, highlighting its importance to society and to medicine. The relevance of salt both for civilization and for autonomic physiology penetrates into nearly every aspect of life and health. Replacing salt that has been depleted or administering salt to expand intravascular volume is considered standard treatment for patients with orthostatic hypotension and syndromes of orthostatic intolerance. The potential longterm effects of added salt, including effects unrelated to intravascular volume, have been insufficiently studied in patients with autonomic disorders. A salient concern is the potential increased risk of developing hypertension. Underappreciated aspects of salt include its ability to increase anxiety and through nonosmotic mechanisms to contribute to local tissue inflammation. Salt may be either salubrious or detrimental, or possibly both at the same time, depending on the clinical conditions. Reconciling these opposite effects in clinical practice requires weighing benefits against potential risks, assessing what is known alongside what is uncertain, and titrating treatment decisions to the particular needs of each individual patient.

Blood pressure regulation in autonomic failure by dietary sodium, blood volume and posture

In normal subjects natriuresis is tightly coupled to dietary salt ingestion to maintain sodium balance. Likewise, blood pressure remains unchanged over a wide range of salt intake because of pressure natriuresis, whereby an increase in blood pressure stimulates renal sodium excretion to restore homeostasis. These sodium handling mechanisms are impaired in autonomic failure. When exposed to salt restriction, autonomic failure patients are unable to reduce renal sodium excretion, and their orthostatic hypotension worsens. It follows that increased dietary salt would improve orthostatic tolerance. Indeed, most clinical practice guidelines emphasize a high salt intake (6-10 g/day) in the treatment of neurogenic orthostatic hypotension. This approach has been shown to improve other conditions such as syncope and postural tachycardia syndrome, but surprisingly there is no empirical evidence to support this recommendation in orthostatic hypotension. Even though there is expert opinion consensus in its favor, it would be reassuring if at least mechanistic proof of concept studies were available. Fludrocortisone is often added to a high salt diet to improve sodium retention and increase plasma volume, but these effects are transient. Fludrocortisone is contraindicated in patients with heart failure and should be used with caution, if at all, if supine hypertension is present. In patients with supine hypertension posture is an important determinant of sodium balance; blood pressure substantially increases while supine, triggering pressure natriuresis and extensive sodium loss. Thus, avoiding the supine posture may be as important as increasing dietary salt in the management of orthostatic hypotension.

Correlation of orthostatic hypotension with extracranial carotid and intracranial cerebral arteries atherosclerosis in patients with acute ischemic stroke under cerebral angiography

OBJECTIVE

The clinical management of patients with acute ischemic stroke (AIS) is complicated by orthostatic hypotension, which might have close relationship with the atherosclerosis of cerebral arteries. The primary objectives were to evaluate the relationship of orthostatic hypotension with extracranial carotid arteries atherosclerosis (ECAS) and intracranial atherosclerosis (ICAS) in AIS patients.

METHODS

This study was a prospective cohort analysis of consecutive AIS patients under cerebrovascular angiography. A total of 289 patients were included. orthostatic hypotension was defined as a systolic BP decline ≥20 mmHg or a diastolic BP decline ≥10 mmHg within 3 min of standing. Univariate and multivariate analysis were performed to investigate the association of the clinical variables with orthostatic hypotension.

RESULTS

Orthostatic hypotension was identified in 80 (27.7%) of all patients. ECAS (≥70%) and ICAS (≥50%) was found in 39 (13.5%) and 71 (24.6%) respectively. In multivariate analysis, only diabetes mellitus (odds ratio = 2.00, 95% confidence interval, 1.12-3.58, P = 0.019) and ECAS (odds ratio = 1.97, 95% confidence interval, 1.54-2.51, P < 0.001) were independent risk factors for orthostatic hypotension.

CONCLUSIONS

Orthostatic hypotension is a relatively common finding among patients with AIS. AIS patients should be screened for orthostatic hypotension, especially combined with severe ECAS and diabetes mellitus.

Autonomic dysfunction in post-COVID patients with and witfhout neurological symptoms: a prospective multidomain observational study

The autonomic nervous system (ANS) can be affected by COVID-19, and dysautonomia may be a possible complication in post-COVID individuals. Orthostatic hypotension (OH) and postural tachycardia syndrome (POTS) have been suggested to be common after SARS-CoV-2 infection, but other components of ANS function may be also impaired. The Composite Autonomic Symptom Scale 31 (COMPASS-31) questionnaire is a simple and validated tool to assess dysautonomic symptoms. The aim of the present study was to administer the COMPASS-31 questionnaire to a sample of post-COVID patients with and without neurological complaints. Participants were recruited among the post-COVID ambulatory services for follow-up evaluation between 4 weeks and 9 months from COVID-19 symptoms onset. Participants were asked to complete the COMPASS-31 questionnaire referring to the period after COVID-19 disease. Heart rate and blood pressure were manually taken during an active stand test for OH and POTS diagnosis. One-hundred and eighty participants were included in the analysis (70.6% females, 51 ± 13 years), and OH was found in 13.8% of the subjects. Median COMPASS-31 score was 17.6 (6.9-31.4), with the most affected domains being orthostatic intolerance, sudomotor, gastrointestinal and pupillomotor dysfunction. A higher COMPASS-31 score was found in those with neurological symptoms (p < 0.01), due to more severe orthostatic intolerance symptoms (p < 0.01), although gastrointestinal (p < 0.01), urinary (p < 0.01), and pupillomotor (p < 0.01) domains were more represented in the non-neurological symptoms group. This study confirms the importance of monitoring ANS symptoms as a possible complication of COVID-19 disease that may persist in the post-acute period.

Orthostatic Hypotension is a Risk Factor for Falls Among Older Adults: 3-Year Follow-Up

OBJECTIVES

To assess the prevalence of orthostatic hypotension (OH) and the association of OH with the risk of falls among community-dwelling older adults with a previous fall.

DESIGN

Longitudinal study.

SETTING AND PARTICIPANTS

The subjects (n = 561) were participants in fall prevention conducted in western Finland.

METHODS

Blood pressure (BP) was measured in supine position and at 30 seconds and 3 minutes after standing. The participants were divided according to the consensus definition to an OH group (OHG) and a non-OH group (non-OHG). Falls were recorded by fall diaries during 12 months. Falls requiring treatment were gathered from health center and hospital registers during 12 and 36 months.

RESULTS

The prevalence of OH was 23.4% (30 seconds) and 7.3% (3 minutes). The 30-second measurement showed that the incidence of falls and that of falls requiring treatment were significantly higher in OHG compared with non-OHG during 12 months. After adjustments, the incidence of falls remained higher in all 5 adjusted models whereas that of falls requiring treatment remained higher only after adjustment for functional balance. The 3-minute measurement showed that the incidence of falls was higher in OHG compared with non-OHG during 12 months and remained higher after adjustments for functional balance and for age and functional balance. During the 36-month follow-up, OH measured at 30 seconds or 3 minutes after standing was not associated with the occurrence of falls leading to treatment.

CONCLUSIONS AND IMPLICATIONS

OH at 30 seconds or 3 minutes after standing is associated with a greater risk for falling within 12 months in older adults. The 30-second blood pressure measurement is more reliable to detect the risk than the 3-minute measurement. The results support the usability of 30-second measurement in determining OH and the risk for falling among older persons.

Orthostatic hypotension in patients with Alzheimer's disease: a meta-analysis of prospective studies

BACKGROUND

Orthostatic hypotension (OH) is a clinical sign associated with severe adverse health outcomes in older adults. It has been reported to be common in patients with Alzheimer's disease (AD). The present meta-analysis aimed to investigate the prevalence and risk of OH in AD patients.

METHODS

English-language articles published from January 1990 to August 2020 were searched in PubMed, ScienceDirect, Cochrane, and Web of Science with the keywords "Alzheimer" and "autonomic dysfunction" or "dysautonomia" or "postural hypotension" or "orthostatic hypotension." All prospective clinical studies (case-control, cohort, and cross-sectional studies, and randomized controlled trials) that were regarded as pertinent were included in this study. For quality assessment, the Newcastle-Ottawa Scale was used. Odds ratios (OR) and risk ratios (RR) were extracted with 95% confidence intervals (CI) and combined using the random effects model after logarithmic transformation. The prevalence in the AD patients was also combined using the random effects model.

RESULTS

The meta-analysis involved 11 studies (7 case-control and 4 case series) to assess the risk of OH in AD. It was found that AD increased the risk of OH with an RR of 1.98 (95% CI: 0.97-4.04) and an OR of 2.53 (95% CI:1.10-5.86) compared to healthy controls, and OH was present in 28% (95% CI: 0.17-0.40) of 500 AD patients.

CONCLUSION

There is an elevated risk of OH in AD by nearly 2.5-fold. Therefore, the evaluation of postural blood pressure changes should definitely be among the follow-up and treatment goals of AD.

Screening indexes for cardiovascular autonomic failure in Parkinson's disease

Autonomic failure (AF) is a common source of orthostatic hypotension (OH) in Parkinson's disease (PD). The diagnosis of AF is difficult on clinical grounds alone. We used autonomic testing and 24-h BP monitoring (ABPM) in 122 PD patients to evaluate the diagnostic accuracy of AF by (1) the reduced heart rate increase to fall in blood pressure (BP) ratio (ΔHR/ΔSBP), (2) reverse dipping (RD), and (3) increased diurnal systolic BP standard deviation (SD-SBP). Among patients with OH, ΔHR/ΔSBP yielded the best accuracy (85%), with excellent sensitivity (92%) and acceptable specificity (67%). RD and, to a lesser extent, SD-SBP had high specificity (93% and 73%, respectively) but low sensitivity, resulting in overall moderate accuracy (66% and 55%, respectively). In patients with OH, the addition of ABPM indexes to ΔHR/ΔSBP did not result in a significant improvement of accuracy. In patients without OH, RD and SD-SBP may be useful showing an accuracy of 72% and 81%, respectively, with high negative predictive value when both RD and increased SD-SBP are absent. The integration of bedside (∆HR/∆SBP) and ABPM-derived indexes can assist the clinician in screening PD patients for AF and guide referral to autonomic testing.

Association of Orthostatic Hypotension With Cerebral Atrophy in Patients With Lewy Body Disorders

OBJECTIVE

To evaluate whether orthostatic hypotension (OH) or supine hypertension (SH) is associated with brain atrophy and white matter hyperintensities (WMH), we analyzed clinical and radiologic data from a large multicenter consortium of patients with Parkinson disease (PD) and dementia with Lewy bodies (DLB).

METHODS

Supine and orthostatic blood pressure (BP) and structural MRI data were extracted from patients with PD and DLB evaluated at 8 tertiary-referral centers in the United States, Canada, Italy, and Japan. OH was defined as a systolic/diastolic BP fall ≥20/10 mm Hg within 3 minutes of standing from the supine position (severe ≥30/15 mm Hg) and SH as a BP ≥140/90 mm Hg with normal sitting BP. Diagnosis-, age-, sex-, and disease duration-adjusted differences in global and regional cerebral atrophy and WMH were appraised with validated semiquantitative rating scales.

RESULTS

A total of 384 patients (310 with PD, 74 with DLB) met eligibility criteria, of whom 44.3% (n = 170) had OH, including 24.7% (n = 42) with severe OH and 41.7% (n = 71) with SH. OH was associated with global brain atrophy (p = 0.004) and regional atrophy involving the anterior-temporal (p = 0.001) and mediotemporal (p = 0.001) regions, greater in severe vs nonsevere OH (p = 0.001). The WMH burden was similar in those with and without OH (p = 0.49). SH was not associated with brain atrophy (p = 0.59) or WMH (p = 0.72).

CONCLUSIONS

OH, but not SH, was associated with cerebral atrophy in Lewy body disorders, with prominent temporal region involvement. Neither OH nor SH was associated with WMH.

Orthostatic hypotension in older people: considerations, diagnosis and management

Orthostatic hypotension (OH) is very common in older people and is encountered daily in emergency departments and medical admissions units. It is associated with a higher risk of falls, fractures, dementia and death, so prompt recognition and treatment are essential. In this review article, we describe the physiology of standing (orthostasis) and the pathophysiology of orthostatic hypotension. We focus particularly on aspects pertinent to older people. We review the evidence and consensus management guidelines for all aspects of management. We also tackle the challenge of concomitant orthostatic hypotension and supine hypertension, providing a treatment overview as well as practical suggestions for management. In summary, orthostatic hypotension (and associated supine hypertension) are common, dangerous and disabling, but adherence to simple structures management strategies can result in major improvements.

Plasma NfL, clinical subtypes and motor progression in Parkinson's disease

INTRODUCTION

neurofilament light chain (NfL) levels have been proposed as reliable biomarkers of neurodegeneration in Parkinson's disease (PD) but the relationship between plasma NfL, clinical subtypes of PD and motor progression is still debated.

METHODS

plasma NfL concentration was measured in 45 healthy controls and consecutive 92 PD patients who underwent an extensive motor and non-motor assessment at baseline and after 2 years of follow-up. PD malignant phenotype was defined as the combination of at least two out of cognitive impairment, orthostatic hypotension and REM sleep behavior disorder. PD patients were divided according to the age-adjusted cut-offs of plasma NfL levels into high and normal NfL (H-NfL and N-NfL, respectively). A multivariable linear regression model was used to assess the value of plasma NfL as predictor of 2-years progression in PD.

RESULTS

NfL was higher in PD patients than in controls (p = 0.037). H-NfL (n = 16) group exhibited more severe motor and non-motor symptoms, higher prevalence of malignant phenotype and worse motor progression (MDS-UPDRS-III 11.3 vs 0.7 points, p = 0.003) compared to N-NfL group (n = 76). In linear regression analyses plasma NfL emerged as the best predictor of 2-year motor progression compared to age, sex, disease duration, baseline motor/non-motor variables.

CONCLUSION

increased plasma NfL concentration is associated with malignant PD phenotype and faster motor progression. These findings support the role of NfL assessment as a useful measure for stratifying patients with different baseline slopes of decline in future clinical trials of putative disease-modifying treatments.

Premotor Parkinson's disease: Overview of clinical symptoms and current diagnostic methods

Parkinson's disease (PD) is characterized by typical motor symptoms. However, recent studies show several non-motor features that may precede the development of the motor symptoms of PD. The best known premotor symptoms include hyposmia, REM sleep behavior disorder (RBD), constipation, and depression; other symptoms are excessive daytime somnolence, orthostatic hypotension and symptomatic hypotension, erectile or urinary dysfunction, musculoskeletal symptoms, pain, and global cognitive deficit. In this review, we summarize currently available diagnostic methods for these symptoms. We also briefly summarize neuroimaging, polyneuropathy, peripheral markers, and cerebrospinal fluid biomarkers that may be used in the early diagnosis of PD.