Orthostatic hypotension associated with baroreceptor dysfunction: treatment approaches

12. Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

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.

12. Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Renovascular Hypertension with Superimposed Aortic Arch Baroreceptor Failure: Case Report and Review of Literature

Background. Atherosclerotic renal artery diseases are among the most common causes of secondary hypertension. Baroreceptors, as carotid and aortic, are important regulatory mechanisms of blood pressure; their disruption can lead to labile blood pressure due to sympathetic overactivity: an entity called neurogenic hypertension. A disease such as aortic dissection can lead to a challenging combined etiology of secondary hypertension. It can affect both or one of the renal arteries leading to a renovascular pathology that can cause hypertension through RAAS activation. Also, surgical repair of the dissected aortic arch can disrupt baroreceptors leading to neurogenic hypertension. Case Report. We report a case of an 83-year-old female patient investigated for recurrent episodes of aphasia. She has a history of hypertension and coronary artery disease. Surgical history is significant for aortic valve replacement complicated by type A aortic dissection requiring surgical repair. Following surgery, the patient developed difficult-to-control and labile blood pressure. Workup included a CT angiogram of the abdominal aorta that showed an infrarenal dominant abdominal aortic aneurysm with juxtarenal aortic dissection; these findings were similar to previous findings. A diagnosis of aortic baroreceptor failure following aortic dissection repair was established, which lead to labile hypertension with superimposed renovascular pathology due to unilateral compromised renal artery blood flow following aortic dissection and thrombosis. Conclusions. This report highlights the importance of accurate diagnosis of secondary hypertension and its underlying mechanisms, as this has a huge impact on the choice of therapy to avoid undertreatment or overtreatment of hypertension.

12. Retinopathy, Neuropathy, and Foot Care: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Long-term complications of type 1 diabetes: what do we know and what do we need to understand?

Long-term complications of type 1 diabetes (T1D) include microvascular complications and macrovascular disease. Despite the important advances in the treatment of T1D of the last decades, these complications still represent the leading cause of morbidity and mortality in patients with T1D. Extensive evidence indicates that structural and functional alterations of the kidney, retina, nerves and large arteries occur already in the first years after the onset of diabetes. We performed a comprehensive review of the available evidence on screening, diagnosis, prevention and treatment of vascular complications of T1D. In particular, we focused on three major challenges related to long-term complications of T1D: 1) finding of new biomarkers and diagnostic methods able to identify early signs of complications; 2) identifying specific risk factors for the development of these complications; 3) identifying and implementing new therapeutic strategies able to prevent the development and progression of vascular complications.

Hyponatremia accompanying volatile hypertension caused by baroreflex failure after neck surgery: case report and literature review

: The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is the most common cause of euvolemic hyponatremia, and many disorders have been associated with it. Baroreflex failure is a rare disorder characterized by extreme blood pressure (BP) fluctuations, most frequently caused by neck or head trauma and irradiation. We report a case of a 48-year-old patient referred to our department for asymptomatic hyponatremia and volatile hypertension. His past medical history included nasopharyngeal carcinoma treated with surgery and bilateral neck radiation. Following the diagnostic algorithm for hyponatremia, the diagnosis of SIADH was made. Ambulatory BP monitoring revealed highly variable BP; extensive autonomic nervous system function testing suggested baroreflex-cardiovagal failure. We propose the hypothesis that not only labile hypertension because of baroreflex failure but also hyponatremia can develop as a late consequence of neck trauma and irradiation.

11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Value of ambulatory blood pressure measurement in diagnosing hypotension in hypertensive diabetic patients with medication-controlled BP

Background

Hypotension is a common clinical finding in diabetic patients on anti-hypertensive medications. In the absence of clearly defined and documented hypotensive episodes, clinicians are faced with the challenge of modifying antihypertensive medication in potentially symptomatic diabetic patients.

Objective

To determine the value of ambulatory blood pressure monitor (ABPM) in diagnosing hypotensive episodes in hypertensive diabetic patients with medication-controlled blood pressure.

Patients and methods

The records of all hypertensive diabetic patients with medication-controlled were obtained between 2017 and 2018. Patients' demographic data, comorbid conditions, hypotensive symptoms and echocardiography results were obtained and compared to office-based blood pressure and ABPM.

Results

Of 926 patients screened in the department of medicine outpatient clinics, 231 patients had diabetes and hypertension and were taking antihypertension medications, so only 86 patients were recruited. Using 24 h ABPM, hypotensive events were documented in 65 (75.6%) patients without correlated hypotensive symptoms in the patient sheet. Patients who had hypotensive episodes recorded by ABPM tended to have these between 5 and 10 a.m. and were significantly older - 60.71 versus 58.76 (P = .022) - and more likely to have lower ejection fractions by echocardiography 46.31 versus 62.85 (EF) (P < .001).

Conclusion

In treated hypertensive diabetic patients with antihypertensive medication, ABPM may be beneficial in capturing bouts of asymptomatic (silent) hypotension readings that occur in the out-of-hospital setting. Diabetic patients with controlled hypertension based on office reading showed a significant number of asymptomatic hypotensive readings detected with ambulatory BP monitoring that can have a role in following up such patients.

Late side effects of radiation treatment for head and neck cancer

Patients undergoing radiation therapy for head and neck cancer (HNC) experience significant early and long-term side effects. The likelihood and severity of complications depends on a number of factors, including the total dose of radiation delivered, over what time it was delivered and what parts of the head and neck received radiation. Late side effects include: permanent loss of saliva; osteoradionecrosis; radiation recall myositis, pharyngoesophageal stenosis; dental caries; oral cavity necrosis; fibrosis; impaired wound healing; skin changes and skin cancer; lymphedema; hypothyroidism, hyperparathyroidism, lightheadedness, dizziness and headaches; secondary cancer; and eye, ear, neurological and neck structures damage. Patients who undergo radiotherapy for nasopharyngeal carcinoma tend to suffer from chronic sinusitis. These side effects present difficult challenges to the patients and their caregivers and require life-long strategies to alleviate their deleterious effect on basic life functions and on the quality of life. This review presents these side effects and their management.

11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Clinical Conditions and Predictive Markers of Non-Dipper Profile in Hypertensive Patients

Hypertension remains one of the primary causes of premature cardiovascular mortality representing a major independent risk factor.

The importance of ambulatory blood pressure monitoring in clinical evaluation of hypertensive patients, beyond diagnosis, is the identification of circadian dipping/non-dipping profile. The non-dipper pattern in hypertensive and normotensive patients is associated with significant target organ damage and worse outcomes, as an increased cardiovascular risk condition. Non-dipping pattern has been found to be associated with specific clinical conditions. Obesity, diabetes mellitus, metabolic syndrome, obstructive sleep apnea syndrome, chronic kidney disease, autonomic and baroreflex dysfunctions, salt sensitivity, hormonal changes, gender and age were extensively studied. Research efforts are focused on recognizing and exploring predictive markers of abnormal blood pressure circadian pattern. Previous studies acknowledge that red cell distribution width, mean platelet volume, fibrinogen level, C-reactive protein, serum uric acid and gamma-glutamyltransferase, are independently significant and positive associated to non-dipping pattern. Moreover, research on new biomarkers are conducted: Chitinase 3-Like-Protein 1, atrial and B-type natriuretic peptide, brain-derived neurotrophic factor, chemerin, sphingomyelin and the G972R polymorphism of the insulin receptor substrate-1 gene. This review summarizes the current knowledge of different clinical conditions and biomarkers associated with the non-dipper profile in hypertensive patients.

Hydration health literacy in the elderly

BACKGROUND

Inadequate hydration in the elderly is associated with increased morbidity and mortality. However, few studies have addressed the knowledge of elderly individuals regarding hydration in health and disease. Gaps in health literacy have been identified as a critical component in health maintenance, and promoting health literacy should improve outcomes related to hydration associated illnesses in the elderly.

METHODS

We administered an anonymous survey to community-dwelling elderly (n = 170) to gauge their hydration knowledge.

RESULTS

About 56% of respondents reported consuming >6 glasses of fluid/day, whereas 9% reported drinking ≤3 glasses. About 60% of respondents overestimated the amount of fluid loss at which moderately severe dehydration symptoms occur, and 60% did not know fever can cause dehydration. Roughly 1/3 were not aware that fluid overload occurs in heart failure (35%) or kidney failure (32%). A majority of respondents were not aware that improper hydration or changes in hydration status can result in confusion, seizures, or death.

CONCLUSIONS

Overall, our study demonstrated that there were significant deficiencies in hydration health literacy among elderly. Appropriate education and attention to hydration may improve quality of life, reduce hospitalizations and the economic burden related to hydration-associated morbidity and mortality.

Syncope from radiation-induced baroreceptor failure

Orthostatic hypotension has a vast differential that has been previously described throughout the literature. However, baroreceptor failure as a sequela of head and neck radiation is not often recognised as an important cause of dramatic haemodynamic variability. As a result, individuals suffering from baroreceptor failure likely have been undertreated. Herein, we report a case of a patient with a history of radiation to the neck for squamous cell carcinoma of the tongue and resultant baroreceptor failure resulting in syncope.

Clinically significant hemodynamic alterations after propacetamol injection in the emergency department: prevalence and risk factors

Propacetamol, a water-soluble prodrug form of paracetamol, is hydrolyzed by esterase to generate paracetamol in the blood. Each gram of propacetamol is equal to 0.5 g of paracetamol. It has been reported to cause hypotension in critically ill patients with a fever. We aimed to investigate the hemodynamic effects of propacetamol for the control of fever in patients with diverse severities of illness who were managed in the emergency department (ED). We also aimed to identify clinical factors related to significant hemodynamic alterations in ED patients. This was a retrospective study of 1507 ED patients who received propacetamol. Significant hemodynamic alterations were defined as systolic blood pressure (SBP) <90 mmHg or diastolic blood pressure (DBP) <60 mmHg, or a drop in SBP >30 mmHg, which required treatments with a bolus of fluid or vasopressor administration. Postinfusion SBP and DBP were significantly lower than the preinfusion SBP and DBP. A clinically significant drop in BP occurred in 162 (10.7 %) patients, and interventions were necessary. Among the predictors assessed, congestive heart failure (OR 6.21, 95 % CI 2.67-14.45) and chills (OR 3.10, 95 % CI 2.04-4.70) were independent factors for a significant hemodynamic change. Administration of propacetamol can provoke a reduction in BP in ED patients. This reduction was clinically significant for 10 % of infusions. Clinicians should be aware of this potential deleterious effect, especially in patients with congestive heart failure or who experience chills prior to the administration of propacetamol.

[Orthostatic hypotension; that great unknown]

Orthostatic hypotension is an anomaly of growing interest in scientific research. Although certain neurogenic diseases are associated with this phenomenon, it can also be associated with non-neurological causes. Although orthostatic hypotension is defined by consensus as a decrease in the systolic blood pressure of at least 20mmHg, or a decrease in diastolic blood pressure of at least 10mmHg, within 3min of standing, the studies differ on how to diagnose it. Orthostatic hypotension is associated with certain cardiovascular risk factors and with drug treatment, but the results are contradictory. The purpose of this review is to update the knowledge about orthostatic hypotension and its treatment, as well as to propose a method to standardise its diagnosis.

Orthostatic changes in systolic blood pressure among SPRINT participants at baseline

Orthostatic changes in systolic blood pressure (SBP) impact cardiovascular outcomes. In this study, we aimed to determine the pattern of orthostatic systolic pressure changes in participants enrolled in the SBP Intervention Trial (SPRINT) at their baseline visit before randomization and sought to understand clinical factors predictive of these changes. Of the 9323 participants enrolled in SPRINT, 8662 had complete data for these analyses. The SBP after 1 minute of standing was subtracted from the mean value of the three preceding seated SBP values. At the baseline visit, medical history, medications, anthropometric measures, and standard laboratory testing were undertaken. The mean age of SPRINT participants was 68 years, two-thirds were male, with 30% black, 11% Hispanic, and 55% Caucasian. The spectrum of SBP changes on standing demonstrated that increases in SBP were as common as declines, and about 5% of participants had an increase, and 5% had a decrease of >20 mm Hg in SBP upon standing. Female sex, taller height, more advanced kidney disease, current smoking, and several drug classes were associated with larger declines in BP upon standing, while black race, higher blood levels of glucose and sodium, and heavier weight were associated with more positive values of the change in BP upon standing. Our cross-sectional results show a significant spectrum of orthostatic SBP changes, reflecting known (eg, age) and less well-known (eg, kidney function) relationships that may be important considerations in determining the optimal target blood pressure in long-term outcomes of older hypertensive patients.