1
|
Carvalho LB, Kaffenberger T, Chambers B, Borschmann K, Levi C, Churilov L, Thijs V, Bernhardt J. Cerebral hemodynamic response to upright position in acute ischemic stroke. Front Neurol 2024; 15:1392773. [PMID: 39055319 PMCID: PMC11269199 DOI: 10.3389/fneur.2024.1392773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/24/2024] [Indexed: 07/27/2024] Open
Abstract
Introduction Concerns exist that a potential mechanism for harm from upright activity (sitting, standing, and walking) early after an acute ischaemic stroke could be the reduction of cerebral perfusion during this critical phase. We aimed to estimate the effects of upright positions (sitting and standing) on cerebral hemodynamics within 48 h and later, 3-7 days post-stroke, in patients with strokes with and without occlusive disease and in controls. Methods We investigated MCAv using transcranial Doppler in 0° head position, then at 30°, 70°, 90° sitting, and 90° standing, at <48 h post-stroke, and later at 3-7 days post-stroke. Mixed-effect linear regression modeling was used to estimate differences in MCAv between the 0° and other positions and to compare MCAv changes across groups. Results A total of 42 stroke participants (anterior and posterior circulation) (13 with occlusive disease, 29 without) and 22 controls were recruited. Affected hemisphere MCAv decreased in strokes with occlusive disease (<48 h post-stroke): from 0° to 90° sitting (-9.9 cm/s, 95% CI[-16.4, -3.4]) and from 0° to 90° standing (-7.1 cm/s, 95%CI[-14.3, -0.01]). Affected hemisphere MCAv also decreased in strokes without occlusive disease: from 0° to 90° sitting (-3.3 cm/s, 95%CI[-5.6, -1.1]) and from 0° to 90° standing (-3.6 cm/s, 95%CI [-5.9, -1.3]) (p-value interaction stroke with vs. without occlusive disease = 0.07). A decrease in MCAv when upright was also observed in controls: from 0° to 90° sitting (-3.8 cm/s, 95%CI[-6.0, -1.63]) and from 0° to 90° standing (-3 cm/s, 95%CI[-5.2, -0.81]) (p-value interaction stroke vs. controls = 0.85). Subgroup analysis of anterior circulation stroke showed similar patterns of change in MCAv in the affected hemisphere, with a significant interaction between those with occlusive disease (n = 11) and those without (n = 26) (p = 0.02). Changes in MCAv from 0° to upright at <48 h post-stroke were similar to 3-7 days. No association between changes in MCAv at <48 h and the 30-day modified Rankin Scale was found. Discussion Moving to more upright positions <2 days post-stroke does reduce MCAv in the affected hemisphere; however, these changes were not significantly different for stroke participants (anterior and posterior circulation) with and without occlusive disease, nor for controls. The decrease in MCAv in anterior circulation stroke with occlusive disease significantly differed from without occlusive disease. However, the sample size was small, and more research is warranted to confirm these findings.
Collapse
Affiliation(s)
- Lilian B. Carvalho
- Stroke Theme, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
| | - Tina Kaffenberger
- Stroke Theme, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
| | - Brian Chambers
- Neurology Department, Austin Health, Melbourne, VIC, Australia
| | - Karen Borschmann
- Stroke Theme, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
- Allied Health, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Christopher Levi
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Leonid Churilov
- Department of Medicine (Austin Health) and Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Vincent Thijs
- Stroke Theme, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
- Neurology Department, Austin Health, Melbourne, VIC, Australia
| | - Julie Bernhardt
- Stroke Theme, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
| |
Collapse
|
2
|
Shali RK, Setarehdan SK, Seifi B. Functional near-infrared spectroscopy based blood pressure variations and hemodynamic activity of brain monitoring following postural changes: A systematic review. Physiol Behav 2024; 281:114574. [PMID: 38697274 DOI: 10.1016/j.physbeh.2024.114574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/03/2024] [Accepted: 04/26/2024] [Indexed: 05/04/2024]
Abstract
Postural change from supine or sitting to standing up leads to displacement of 300 to 1000 mL of blood from the central parts of the body to the lower limb, which causes a decrease in venous return to the heart, hence decrease in cardiac output, causing a drop in blood pressure. This may lead to falling down, syncope, and in general reducing the quality of daily activities, especially in the elderly and anyone suffering from nervous system disorders such as Parkinson's or orthostatic hypotension (OH). Among different modalities to study brain function, functional near-infrared spectroscopy (fNIRS) is a neuroimaging method that optically measures the hemodynamic response in brain tissue. Concentration changes in oxygenated hemoglobin (HbO2) and deoxygenated hemoglobin (HHb) are associated with brain neural activity. fNIRS is significantly more tolerant to motion artifacts compared to fMRI, PET, and EEG. At the same time, it is portable, has a simple structure and usage, is safer, and much more economical. In this article, we systematically reviewed the literature to examine the history of using fNIRS in monitoring brain oxygenation changes caused by sudden changes in body position and its relationship with the blood pressure changes. First, the theory behind brain hemodynamics monitoring using fNIRS and its advantages and disadvantages are presented. Then, a study of blood pressure variations as a result of postural changes using fNIRS is described. It is observed that only 58 % of the references concluded a positive correlation between brain oxygenation changes and blood pressure changes. At the same time, 3 % showed a negative correlation, and 39 % did not show any correlation between them.
Collapse
Affiliation(s)
- Roya Kheyrkhah Shali
- School of Electrical and Computer Engineering, College of Engineering, University of Tehran, Tehran, Iran.
| | - Seyed Kamaledin Setarehdan
- School of Electrical and Computer Engineering, College of Engineering, University of Tehran, Tehran, Iran
| | - Behjat Seifi
- Faculty of Medical Science, University of Tehran, Tehran, Iran
| |
Collapse
|
3
|
Mitsuyama S, Sakamoto T, Nagasawa T, Kario K, Ozawa S. A pilot study to assess the origin of the spectral power increases of heart rate variability associated with transient changes in the R-R interval. Physiol Rep 2024; 12:e15907. [PMID: 38226411 PMCID: PMC10790152 DOI: 10.14814/phy2.15907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/17/2024] Open
Abstract
Spectral analysis of heart rate variability (HRV) is used to assess cardiovascular autonomic function. In the power density spectrum calculated from a time series of the R-R interval (RRI), three main components are distinguished: very-low-frequency (VLF; 0.003-0.04 Hz), low-frequency (LF; 0.04-0.15 Hz), and high-frequency (HF; 0.15-0.4 Hz) components. However, the physiological correlates of these frequency components have yet to be determined. In this study, we conducted spectral analysis of data segments of various lengths (5, 30, 100, and 200 s) of the RRI time series during active standing. Because of the trade-off relationship between time and frequency resolution, the analysis of the RRI data segment shorter than 30 s was needed to identify the temporal relationships between individual transient increases in RRI and the resulting spectral power changes. In contrast, the segment of 200 s was needed to properly evaluate the magnitude of the increase in the VLF power. The results showed that a transient increase in the RRI was tightly associated with simultaneous increases in the powers of the VLF, LF, and HF components. We further found that the simultaneous power increases in these three components were caused by the arterial baroreceptor reflex responding to rapid blood pressure rise.
Collapse
Affiliation(s)
- Satoshi Mitsuyama
- Department of Healthcare InformaticsTakasaki University of Health and WelfareTakasakiGunmaJapan
| | - Teruhiko Sakamoto
- Department of Healthcare InformaticsTakasaki University of Health and WelfareTakasakiGunmaJapan
| | - Toru Nagasawa
- Department of Healthcare InformaticsTakasaki University of Health and WelfareTakasakiGunmaJapan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of MedicineJichi Medical University School of MedicineTochigiJapan
| | - Seiji Ozawa
- Department of Healthcare InformaticsTakasaki University of Health and WelfareTakasakiGunmaJapan
| |
Collapse
|
4
|
James A, Bruce D, Tetlow N, Patel AB, Black E, Whitehead N, Ratcliff A, Jamie Humphreys A, MacDonald N, McDonnell G, Raobaikady R, Thirugnanasambanthar J, Ravindran JI, Whitehead N, Minto G, Abbott TE, Jhanji S, Milliken D, Ackland GL. Heart rate recovery after orthostatic challenge and cardiopulmonary exercise testing in older individuals: prospective multicentre observational cohort study. BJA OPEN 2023; 8:100238. [PMID: 38026081 PMCID: PMC10654531 DOI: 10.1016/j.bjao.2023.100238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 09/12/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023]
Abstract
Background Impaired vagal function in older individuals, quantified by the 'gold standard' delayed heart rate recovery after maximal exercise (HRRexercise), is an independent predictor of cardiorespiratory capacity and mortality (particularly when HRR ≤12 beats min-1). Heart rate also often declines after orthostatic challenge (HRRorthostatic), but the mechanism remains unclear. We tested whether HRRorthostatic reflects similar vagal autonomic characteristics as HRRexercise. Methods Prospective multicentre cohort study of subjects scheduled for cardiopulmonary exercise testing (CPET) as part of routine care. Before undergoing CPET, heart rate was measured with participants seated for 3 min, before standing for 3 min (HRRorthostatic). HRRexercise 1 min after the end of CPET was recorded. The primary outcome was the correlation between mean heart rate change every 10 s for 1 min after peak heart rate was attained on standing and after exercise for each participant. Secondary outcomes were HRRorthostatic and peak VO2 compared between individuals with HRRexercise <12 beats min-1. Results A total of 87 participants (mean age: 64 yr [95%CI: 61-66]; 48 (55%) females) completed both tests. Mean heart rate change every 10 s for 1 min after peak heart rate after standing and exercise was significantly correlated (R2=0.81; P<0.0001). HRRorthostatic was unchanged in individuals with HRRexercise ≤12 beats min-1 (n=27), but was lower when HRRexercise >12 beats min-1 (n=60; mean difference: 3 beats min-1 [95% confidence interval 1-5 beats min-1]; P<0.0001). Slower HRRorthostatic was associated with lower peak VO2 (mean difference: 3.7 ml kg-1 min-1 [95% confidence interval 0.7-6.8 ml kg-1 min-1]; P=0.039). Conclusion Prognostically significant heart rate recovery after exhaustive exercise is characterised by quantitative differences in heart rate recovery after orthostatic challenge. These data suggest that orthostatic challenge is a valid, simple test indicating vagal impairment. Clinical trial registration researchregistry6550.
Collapse
Affiliation(s)
- Aaron James
- Department of Anaesthesia, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - David Bruce
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden Hospital, London, UK
| | - Nicholas Tetlow
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden Hospital, London, UK
| | - Amour B.U. Patel
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary, University of London, UK
| | - Ethel Black
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden Hospital, London, UK
| | - Nicole Whitehead
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden Hospital, London, UK
| | - Anna Ratcliff
- Department of Anaesthesia, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - Neil MacDonald
- Department of Anaesthesia and Perioperative Medicine, Royal London Hospital, London, UK
| | - Gayle McDonnell
- Department of Anaesthesia and Perioperative Medicine, Royal London Hospital, London, UK
| | - Ravishankar Raobaikady
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary, University of London, UK
| | | | - Jeuela I. Ravindran
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary, University of London, UK
| | - Nicole Whitehead
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden Hospital, London, UK
| | - Gary Minto
- Department of Anaesthesia, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Tom E.F. Abbott
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary, University of London, UK
- Department of Anaesthesia and Perioperative Medicine, Royal London Hospital, London, UK
| | - Shaman Jhanji
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden Hospital, London, UK
| | - Don Milliken
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden Hospital, London, UK
| | - Gareth L. Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary, University of London, UK
- Department of Anaesthesia and Perioperative Medicine, Royal London Hospital, London, UK
| |
Collapse
|
5
|
Duggan E, Murphy CH, Knight SP, Davis JRC, O'Halloran AM, Kenny RA, Romero-Ortuno R. Differential Associations Between Two Markers of Probable Sarcopenia and Continuous Orthostatic Hemodynamics in The Irish Longitudinal Study on Ageing. J Gerontol A Biol Sci Med Sci 2023; 78:1376-1382. [PMID: 36480700 PMCID: PMC10395558 DOI: 10.1093/gerona/glac243] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Sarcopenia and orthostatic hypotension are growing age-related health burdens associated with adverse outcomes, including falls. Despite a possible pathophysiological link, the association between the 2 disorders is not well elucidated. We sought to investigate this relationship in The Irish Longitudinal Study on Ageing (TILDA). METHODS Data from 2 858 participants at wave 3 of TILDA were analyzed. Probable sarcopenia was defined as per the European Working Group on Sarcopenia in Older People revised definition cutoffs (hand grip strength [HGS] <27 kg in men, <16 kg in women, and/or 5-chair stand test [5CST] time >15 seconds). Participants underwent an active stand orthostatic test with continuous blood pressure (BP) monitoring. Multilevel mixed-effects models, controlling for possible confounders, were used to assess the effect of probable sarcopenia by HGS and 5CST criteria on the change in BP after standing. RESULTS HGS- and 5CST-defined probable sarcopenia were independently associated with an attenuated BP recovery at 10-20 seconds poststand (systolic BP: β -0.54, p < .001; β -0.25, p < .001). On average, those meeting HGS probable sarcopenia criteria had a significantly lower BP at 20, 30, and 40 seconds (differences in systolic BP: -5.01 mmHg, -3.68 mmHg, -2.32 mmHg, p < .05 for all). Those meeting 5CST probable sarcopenia criteria had a significant difference in systolic BP at 20 seconds (-1.94 mmHg, p = .002) but not at 30 or 40 seconds. CONCLUSION Probable sarcopenia had a significant association with delayed orthostatic BP recovery, with HGS-defined probable sarcopenia having a stronger association than 5CST-defined probable sarcopenia. Results support a modest but significant pathophysiological link between probable sarcopenia and orthostatic hypotension.
Collapse
Affiliation(s)
- Eoin Duggan
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, Dublin, Ireland
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Caoileann H Murphy
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, Dublin, Ireland
- Teagasc, Food Research Centre, Ashtown, Dublin, Ireland
| | - Silvin P Knight
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, Dublin, Ireland
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - James R C Davis
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, Dublin, Ireland
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Aisling M O'Halloran
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, Dublin, Ireland
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, Dublin, Ireland
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Roman Romero-Ortuno
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, Dublin, Ireland
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| |
Collapse
|
6
|
Värri E, Suojanen L, Koskela JK, Choudhary MK, Tikkakoski A, Kähönen M, Nevalainen PI, Mustonen J, Pörsti I. Ambulatory daytime blood pressure versus tonometric blood pressure measurements in the laboratory: effect of posture. Blood Press Monit 2023; 28:199-207. [PMID: 37318783 PMCID: PMC10309093 DOI: 10.1097/mbp.0000000000000651] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 02/23/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To compare blood pressure (BP) in tonometric radial artery recordings during passive head-up tilt with ambulatory recordings and evaluate possible laboratory cutoff values for hypertension. METHODS Laboratory BP and ambulatory BP were recorded in normotensive (n = 69), unmedicated hypertensive (n = 190), and medicated hypertensive (n = 151) subjects. RESULTS Mean age was 50.2 years, BMI 27.7 kg/m 2 , ambulatory daytime BP 139/87 mmHg, and 276 were male (65%). As supine-to-upright changes in SBP ranged from -52 to +30 mmHg, and in DBP from -21 to +32 mmHg, the mean values of BP supine and upright measurements were compared with ambulatory BP. The mean(supine+upright) systolic laboratory BP was corresponding to ambulatory level (difference +1 mmHg), while mean(supine+upright) DBP was 4 mmHg lower ( P < 0.05) than ambulatory value. Correlograms indicated that laboratory 136/82 mmHg corresponded to ambulatory 135/85 mmHg. When compared with ambulatory 135/85 mmHg, the sensitivity and specificity of laboratory 136/82 mmHg to define hypertension were 71.5% and 77.3% for SBP, and 71.7% and 72.8%, for DBP, respectively. The laboratory cutoff 136/82 mmHg classified 311/410 subjects similarly to ambulatory BP as normotensive or hypertensive, 68 were hypertensive only in ambulatory, while 31 were hypertensive only in laboratory measurements. CONCLUSION BP responses to upright posture were variable. When compared with ambulatory BP, mean(supine+upright) laboratory cutoff 136/82 mmHg classified 76% of subjects similarly as normotensive or hypertensive. In the remaining 24% the discordant results may be attributed to white-coat or masked hypertension, or higher physical activity during out-of-office recordings.
Collapse
Affiliation(s)
- Emmi Värri
- Faculty of Medicine and Health Technology, Tampere University, Departments of
| | - Lauri Suojanen
- Faculty of Medicine and Health Technology, Tampere University, Departments of
- Internal Medicine
| | - Jenni K. Koskela
- Faculty of Medicine and Health Technology, Tampere University, Departments of
- Internal Medicine
| | - Manoj K. Choudhary
- Faculty of Medicine and Health Technology, Tampere University, Departments of
| | - Antti Tikkakoski
- Clinical Physiology, Tampere University Hospital, Tampere, Finland
| | - Mika Kähönen
- Faculty of Medicine and Health Technology, Tampere University, Departments of
- Clinical Physiology, Tampere University Hospital, Tampere, Finland
| | | | - Jukka Mustonen
- Faculty of Medicine and Health Technology, Tampere University, Departments of
- Internal Medicine
| | - Ilkka Pörsti
- Faculty of Medicine and Health Technology, Tampere University, Departments of
- Internal Medicine
| |
Collapse
|
7
|
Duggan E, Knight SP, Romero-Ortuno R. Relationship between sarcopenia and orthostatic blood pressure recovery in older falls clinic attendees. Eur Geriatr Med 2023:10.1007/s41999-023-00775-0. [PMID: 37029293 DOI: 10.1007/s41999-023-00775-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/23/2023] [Indexed: 04/09/2023]
Abstract
PURPOSE Sarcopenia and delayed orthostatic blood pressure (BP) recovery are two disorders increasingly associated with adverse clinical outcomes in older adults. There may exist a pathophysiological link between the two via the skeletal muscle pump of the lower limbs. Previously in a large population-based study, we found an association between probable sarcopenia and orthostatic BP recovery. Here, we sought to determine the association between confirmed sarcopenia and orthostatic BP recovery in falls clinic attendees aged 50 years or over. METHODS One hundred and nine recruited patients (mean age 70 years, 58% women) underwent an active stand with non-invasive beat-to-beat haemodynamic monitoring. Hand grip strength and five-chair stands time were measured, and bioelectrical impedance analysis was performed. They were then classified as robust, probable sarcopenic or sarcopenic as per the European Working Group on Sarcopenia in Older People guidelines. Mixed effects models with linear splines were used to model the effect of sarcopenia status on orthostatic BP recovery, whilst controlling for potential confounders. RESULTS Probable sarcopenia was identified in 32% of the sample and sarcopenia in 15%. Both probable and confirmed sarcopenia were independently associated with an attenuated rate of recovery of both systolic and diastolic BP in the 10-20 s period after standing. Attenuation was larger for confirmed than probable sarcopenia (systolic BP β - 0.85 and - 0.59, respectively, P < 0.01; diastolic BP β - 0.65, - 0.45, P < 0.001). CONCLUSION Sarcopenia was independently associated with slower BP recovery during the early post-stand period. The potentially modifiable effect of the skeletal muscle pump in orthostatic haemodynamics requires further study.
Collapse
Affiliation(s)
- Eoin Duggan
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland.
- Falls and Syncope Unit (FASU), Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland.
| | - Silvin P Knight
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Roman Romero-Ortuno
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
- Falls and Syncope Unit (FASU), Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland
| |
Collapse
|
8
|
Bennett AJ, Levine BD. The argument against tilt table testing in the geriatric population. J Am Geriatr Soc 2022; 70:3293-3295. [PMID: 36254345 DOI: 10.1111/jgs.18053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 12/30/2021] [Accepted: 01/01/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Ari J Bennett
- Cardiology Division, The University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Cardiology Division, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Benjamin D Levine
- Cardiology Division, The University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Exercise Physiology, Institute for Exercise and Environmental Medicine, Dallas, Texas, USA
| |
Collapse
|
9
|
Personalised physiological medicine: Orthostatic hypotension. Med Hypotheses 2022. [DOI: 10.1016/j.mehy.2022.110928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
10
|
Wieling W, Kaufmann H, Claydon VE, van Wijnen VK, Harms MPM, Juraschek SP, Thijs RD. Diagnosis and treatment of orthostatic hypotension. Lancet Neurol 2022; 21:735-746. [PMID: 35841911 PMCID: PMC10024337 DOI: 10.1016/s1474-4422(22)00169-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 01/24/2023]
Abstract
Orthostatic hypotension is an unusually large decrease in blood pressure on standing that increases the risk of adverse outcomes even when asymptomatic. Improvements in haemodynamic profiling with continuous blood pressure measurements have uncovered four major subtypes: initial orthostatic hypotension, delayed blood pressure recovery, classic orthostatic hypotension, and delayed orthostatic hypotension. Clinical presentations are varied and range from cognitive slowing with hypotensive unawareness or unexplained falls to classic presyncope and syncope. Establishing whether symptoms are due to orthostatic hypotension requires careful history taking, a thorough physical examination, and supine and upright blood pressure measurements. Management and prognosis vary according to the underlying cause, with the main distinction being whether orthostatic hypotension is neurogenic or non-neurogenic. Neurogenic orthostatic hypotension might be the earliest clinical manifestation of Parkinson's disease or related synucleinopathies, and often coincides with supine hypertension. The emerging variety of clinical presentations advocates a stepwise, individualised, and primarily non-pharmacological approach to the management of orthostatic hypotension. Such an approach could include the cessation of blood pressure lowering drugs, adoption of lifestyle measures (eg, counterpressure manoeuvres), and treatment with pharmacological agents in selected cases.
Collapse
Affiliation(s)
- Wouter Wieling
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Horacio Kaufmann
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Victoria E Claydon
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
| | - Veera K van Wijnen
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Mark P M Harms
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stephen P Juraschek
- Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands; UCL Queen Square Institute of Neurology, University College London, London, UK; Stichting Epilepsie Instellingen Nederland, Heemstede, Netherlands.
| |
Collapse
|
11
|
Heinrich T, Sehner S, Wageringel I, Ehmke H, Schwoerer AP. The baroreceptor reflex brought to life outside the classroom - an e-learning based asynchronous laboratory class using a non-supervised modified Active Standing Test. BMC MEDICAL EDUCATION 2022; 22:515. [PMID: 35778720 PMCID: PMC9250187 DOI: 10.1186/s12909-022-03573-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 06/21/2022] [Indexed: 06/15/2023]
Abstract
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.
Collapse
Affiliation(s)
- Tobias Heinrich
- Department of Cellular and Integrative Physiology, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Susanne Sehner
- Department of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Isabel Wageringel
- Department of Cellular and Integrative Physiology, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Heimo Ehmke
- Department of Cellular and Integrative Physiology, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Alexander Peter Schwoerer
- Department of Cellular and Integrative Physiology, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| |
Collapse
|
12
|
Diagnostic criteria for initial orthostatic hypotension: a narrative review. Clin Auton Res 2021; 31:685-698. [PMID: 34677720 DOI: 10.1007/s10286-021-00833-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/13/2021] [Indexed: 12/20/2022]
Abstract
Abnormalities in orthostatic blood pressure changes upon active standing are associated with morbidity, mortality, and reduced quality of life. However, over the last decade, several population-based cohort studies have reported a remarkably high prevalence (between 25 and 70%) of initial orthostatic hypotension (IOH) among elderly individuals. This has raised the question as to whether the orthostatic blood pressure patterns in these community-dwelling elderly should truly be considered as pathological. If not, redefining of the systolic cutoff values for IOH (i.e., a value ≥ 40 mmHg in systolic blood pressure in the first 15 s after standing up) might be necessary to differ between normal aging and true pathology. Therefore, in this narrative review, we provide a critical analysis of the current reference values for the changes in systolic BP in the first 60 s after standing up and discuss how these values should be applied to large population studies. We will address factors that influence the magnitude of the systolic blood pressure changes following active standing and the importance of standardization of the stand-up test, which is a prerequisite for quantitative, between-subject comparisons of the postural hemodynamic response.
Collapse
|
13
|
Tran J, Hillebrand SL, Meskers CGM, Iseli RK, Maier AB. Prevalence of initial orthostatic hypotension in older adults: a systematic review and meta-analysis. Age Ageing 2021; 50:1520-1528. [PMID: 34260686 PMCID: PMC8437071 DOI: 10.1093/ageing/afab090] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Indexed: 12/05/2022] Open
Abstract
Background Initial orthostatic hypotension (OH) is a clinical syndrome of exaggerated transient orthostasis associated with higher risks of falls, frailty and syncope in older adults. Objective To provide a prevalence estimate of initial OH in adults aged 65 years or older. Methods Literature search of MEDLINE (from 1946), Embase (from 1947) and Cochrane Central Register of Controlled Trials was performed until 6 December 2019, using the terms ‘initial orthostatic hypotension’, ‘postural hypotension’ and ‘older adults’. Articles were included if published in English and participants were 65 years or older. Random effects models were used for pooled analysis. Results Of 5,136 articles screened, 13 articles (10 cross-sectional; 3 longitudinal) reporting data of 5,465 individuals (54.5% female) from the general (n = 4,157), geriatric outpatient (n = 1,136), institutionalised (n = 55) and mixed (n = 117) population were included. Blood pressure was measured continuously and intermittently in 11 and 2 studies, respectively. Pooled prevalence of continuously measured initial OH was 29.0% (95% CI: 22.1–36.9%, I2 = 94.6%); 27.8% in the general population (95% CI: 17.9–40.5%, I2 = 96.1%), 35.2% in geriatric outpatients (95% CI: 24.2–48.1%, I2 = 95.3%), 10.0% in institutionalised individuals (95% CI: 2.4–33.1%, I2 = 0%) and 21.4% in the mixed population (95% CI: 7.0–49.6, I2 = 0%). Pooled prevalence of intermittently measured initial OH was 5.6% (95% CI: 1.5–18.9%, I2 = 81.1%); 1.0% in the general population (95% CI: 0.0–23.9%, I2 = 0%) and 7.7% in geriatric outpatients (95% CI: 1.8–27.0%, I2 = 86.7%). Conclusion The prevalence of initial OH is high in older adults, especially in geriatric outpatients. Proper assessment of initial OH requires continuous blood pressure measurements.
Collapse
Affiliation(s)
- Jennifer Tran
- Department of Medicine and Aged Care, @AgeMelbourne, The University of Melbourne, The Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
| | - Sarah L Hillebrand
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Carel G M Meskers
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Rebecca K Iseli
- Department of Medicine and Aged Care, @AgeMelbourne, The University of Melbourne, The Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
| | - Andrea B Maier
- Department of Medicine and Aged Care, @AgeMelbourne, The University of Melbourne, The Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Healthy Longevity Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Centre for Healthy Longevity, @AgeSingapore, National University Health System, Singapore
| |
Collapse
|
14
|
Individual changes of central blood pressure in response to upright posture: different hemodynamic phenotypes. J Hypertens 2021; 39:2403-2412. [PMID: 34269331 DOI: 10.1097/hjh.0000000000002965] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Most studies about upright regulation of blood pressure have focused on orthostatic hypotension despite the diverse hemodynamic changes induced by orthostatic challenge. We investigated the effect of passive head-up tilt on aortic blood pressure. METHODS Noninvasive peripheral and central hemodynamics in 613 volunteers without cardiovascular morbidities or medications were examined using pulse wave analysis, whole-body impedance cardiography and heart rate variability analysis. RESULTS In all participants, mean aortic SBP decreased by -4 (-5 to -3) mmHg [mean (95% confidence intervals)] and DBP increased by 6 (5--6) mmHg in response to upright posture. When divided into tertiles according to the supine-to-upright change in aortic SBP, two tertiles presented with a decrease [-15 (-14 to -16) and -4 (-3 to -4) mmHg, respectively] whereas one tertile presented with an increase [+7 (7-- 8) mmHg] in aortic SBP. There were no major differences in demographic characteristics between the tertiles. In regression analysis, the strongest explanatory factors for upright changes in aortic SBP were the supine values of, and upright changes in systemic vascular resistance and cardiac output, and supine aortic SBP. CONCLUSION In participants without cardiovascular disease, the changes in central SBP during orthostatic challenge are not uniform. One-third presented with higher upright than supine aortic SBP with underlying differences in the regulation of systemic vascular resistance and cardiac output. These findings emphasize that resting blood pressure measurements give only limited information about the blood pressure status.
Collapse
|
15
|
Hillebrand SL, Reijnierse EM, Meskers CGM, Maier AB. Orthostatic hypotension assessed by active standing is associated with worse cognition in geriatric rehabilitation inpatients, RESORT. Arch Gerontol Geriatr 2021; 96:104482. [PMID: 34284300 DOI: 10.1016/j.archger.2021.104482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/04/2021] [Accepted: 07/06/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE Geriatric rehabilitation inpatients who suffer from acute and chronic diseases that aggravate blood pressure (BP) dysregulation, may be particularly susceptible to orthostatic hypotension (OH). OH may increase the risk of cerebral small vessel disease and subsequent white matter hyperintensities inducing cognitive impairment (CI). This study investigates the association between OH and cognition in geriatric rehabilitation inpatients. MATERIALS AND METHODS Geriatric rehabilitation inpatients of the observational, longitudinal REStORing health of acutely unwell adulTs (RESORT) cohort in Melbourne, Australia, underwent intermittent BP measurements during active standing or partial postural change to sitting (when unable to stand). OH was defined as a systolic BP drop ≥20 mmHg and/or diastolic BP drop ≥10 mmHg within three minutes after postural change. CI included dementia diagnosis, Mini-Mental State Examination (MMSE) score <24 points (categorized as 18-23 (mild CI) and <18 points (severe CI)), Montreal Cognitive Assessment score <26 points or Rowland Universal Dementia Assessment Scale score <23 points. RESULTS In geriatric rehabilitation inpatients (n=1232, mean age 82.3 years (SD 8.2), 57.5% female), OH, CI and dementia prevalence was 20.0%, 61.0% and 20.4% respectively. MMSE was scored 18-23 in 32.6% and <18 points in 27.8% of patients (n=1033). In standing patients (51.7%), OH was associated with CI (p=0.045) and dementia (p=0.021), with a trend for MMSE scores <18 points (p=0.080), but not for MMSE scores 18-23 points (p=0.528). No association was found between seated OH and cognition. CONCLUSION OH assessed by active standing using intermittent BP measurements was associated with worse cognition in geriatric rehabilitation inpatients.
Collapse
Affiliation(s)
- Sarah L Hillebrand
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands
| | - Esmee M Reijnierse
- Department of Medicine and Aged Care, @AgeMelbourne, The University of Melbourne, The Royal Melbourne Hospital, City Campus, Level 6 North, 300 Grattan Street, Parkville, Victoria 3050, Australia; Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, de Boelelaan 1117, 1081 HZ Amsterdam, the Netherlands
| | - Carel G M Meskers
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, de Boelelaan 1117, 1081 HZ Amsterdam, the Netherlands
| | - Andrea B Maier
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands; Department of Medicine and Aged Care, @AgeMelbourne, The University of Melbourne, The Royal Melbourne Hospital, City Campus, Level 6 North, 300 Grattan Street, Parkville, Victoria 3050, Australia; Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Centre for Healthy Longevity, @AgeSingapore, National University Health System, Singapore.
| |
Collapse
|
16
|
Thijs RD, Brignole M, Falup-Pecurariu C, Fanciulli A, Freeman R, Guaraldi P, Jordan J, Habek M, Hilz M, Traon APL, Stankovic I, Struhal W, Sutton R, Wenning G, Van Dijk JG. Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness : Consensus statement of the European Federation of Autonomic Societies (EFAS) endorsed by the American Autonomic Society (AAS) and the European Academy of Neurology (EAN). Clin Auton Res 2021; 31:369-384. [PMID: 33740206 PMCID: PMC8184725 DOI: 10.1007/s10286-020-00738-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 10/12/2020] [Indexed: 12/17/2022]
Abstract
An expert committee was formed to reach consensus on the use of tilt table testing (TTT) in the diagnosis of disorders that may cause transient loss of consciousness (TLOC) and to outline when other provocative cardiovascular autonomic tests are needed. While TTT adds to history taking, it cannot be a substitute for it. An abnormal TTT result is most meaningful if the provoked event is recognised by patients or eyewitnesses as similar to spontaneous events. The minimum requirements to perform TTT are a tilt table, a continuous beat-to-beat blood pressure monitor, at least one ECG lead, protocols for the indications stated below and trained staff. This basic equipment lends itself to the performance of (1) additional provocation tests, such as the active standing test, carotid sinus massage and autonomic function tests; (2) additional measurements, such as video, EEG, transcranial Doppler, NIRS, end-tidal CO2 or neuro-endocrine tests; and (3) tailor-made provocation procedures in those with a specific and consistent trigger of TLOC. TTT and other provocative cardiovascular autonomic tests are indicated if the initial evaluation does not yield a definite or highly likely diagnosis, but raises a suspicion of (1) reflex syncope, (2) the three forms of orthostatic hypotension (OH), i.e. initial, classic and delayed OH, as well as delayed orthostatic blood pressure recovery, (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT is to teach patients with reflex syncope and OH to recognise hypotensive symptoms and to perform physical counter manoeuvres.
Collapse
Affiliation(s)
- Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands.
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands.
| | - Michele Brignole
- Faint and Fall Programme, Department of Cardiology, Ospedale San Luca, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Cardiology and Arrhythmologic Centre, Ospedali del Tigullio, 16033, Lavagna, Italy
| | - Cristian Falup-Pecurariu
- Department of Neurology, County Emergency Clinic Hospital, Transilvania University, Brasov, Romania
| | | | - Roy Freeman
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Pietro Guaraldi
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Jens Jordan
- German Aerospace Center (DLR), Institute of Aerospace Medicine, Cologne, Germany
- Chair of Aerospace Medicine, University of Cologne, Cologne, Germany
- University Hypertension Center, Cologne, Germany
| | - Mario Habek
- Referral Center for Autonomic Nervous System, Department of Neurology, School of Medicine, University Hospital Center Zagreb, University of Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia
| | - Max Hilz
- Department of Neurology, University Erlangen-Nuremberg, Erlangen, Germany
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anne Pavy-Le Traon
- Neurology Department, French Reference Center for MSA, University Hospital of Toulouse and INSERM U 1048, Toulouse, France
| | - Iva Stankovic
- Clinical Center of Serbia, Neurology Clinic, University of Belgrade, Belgrade, Serbia
| | - Walter Struhal
- Department of Neurology, University Clinic Tulln, Karl Landsteiner University of Health Sciences, Tulln, Austria
| | - Richard Sutton
- Department of Cardiology, National Heart and Lung Institute, Hammersmith Hospital, Ducane Road, London, W12 0NN, UK
| | - Gregor Wenning
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Gert Van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| |
Collapse
|
17
|
Thijs RD, Brignole M, Falup-Pecurariu C, Fanciulli A, Freeman R, Guaraldi P, Jordan J, Habek M, Hilz M, Pavy-LeTraon A, Stankovic I, Struhal W, Sutton R, Wenning G, van Dijk JG. Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness : Consensus statement of the European Federation of Autonomic Societies (EFAS) endorsed by the American Autonomic Society (AAS) and the European Academy of Neurology (EAN). Auton Neurosci 2021; 233:102792. [PMID: 33752997 DOI: 10.1016/j.autneu.2021.102792] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
An expert committee was formed to reach consensus on the use of Tilt Table Testing (TTT) in the diagnosis of disorders that may cause transient loss of consciousness (TLOC) and to outline when other provocative cardiovascular autonomic tests are needed. While TTT adds to history taking, it cannot be a substitute for it. An abnormal TTT result is most meaningful if the provoked event is recognised by patients or eyewitnesses as similar to spontaneous ones. The minimum requirements to perform TTT are a tilt table, a continuous beat-to-beat blood pressure monitor, at least one ECG lead, protocols for the indications stated below and trained staff. This basic equipment lends itself to perform (1) additional provocation tests, such as the active standing test carotid sinus massage and autonomic function tests; (2) additional measurements, such as video, EEG, transcranial Doppler, NIRS, end-tidal CO2 or neuro-endocrine tests; (3) tailor-made provocation procedures in those with a specific and consistent trigger of TLOC. TTT and other provocative cardiovascular autonomic tests are indicated if the initial evaluation does not yield a definite or highly likely diagnosis, but raises a suspicion of (1) reflex syncope, (2) the three forms of orthostatic hypotension (OH), i.e. initial, classic and delayed OH, as well as delayed orthostatic blood pressure recovery, (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT is to teach patients with reflex syncope and OH to recognise hypotensive symptoms and to perform physical counter manoeuvres.
Collapse
Affiliation(s)
- Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands.
| | - Michele Brignole
- Faint & Fall Programme, Department of Cardiology, Ospedale San Luca, IRCCS Istituto Auxologico Italiano, Milan, Italy; Department of Cardiology and Arrhythmologic Centre, Ospedali del Tigullio, 16033 Lavagna, Italy
| | - Cristian Falup-Pecurariu
- Department of Neurology, County Emergency Clinic Hospital, Transilvania University, Brasov, Romania
| | | | - Roy Freeman
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Pietro Guaraldi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Jens Jordan
- German Aerospace Center (DLR), Institute of Aerospace Medicine, Cologne, Germany; Chair of Aerospace Medicine, University of Cologne, Cologne, Germany; University Hypertension Center, Cologne, Germany
| | - Mario Habek
- Referral Center for Autonomic Nervous System, Department of Neurology, University Hospital Center Zagreb, University of Zagreb, School of Medicine, Kispaticeva 12, HR-10000 Zagreb, Croatia
| | - Max Hilz
- Department of Neurology, University Erlangen-Nuremberg, Germany; Dept. of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anne Pavy-LeTraon
- French reference center for MSA, Neurology department, University Hospital of Toulouse and INSERM U 1048, Toulouse, France
| | - Iva Stankovic
- Neurology Clinic, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Walter Struhal
- Department of Neurology, University Clinic Tulln, Karl Landsteiner University of Health Sciences, Tulln, Austria
| | - Richard Sutton
- Department of Cardiology, National Heart & Lung Institute, Hammersmith Hospital, Ducane Road, London W12 0NN, UK
| | - Gregor Wenning
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| |
Collapse
|
18
|
Harms MPM, Finucane C, Pérez-Denia L, Juraschek SP, van Wijnen VK, Lipsitz LA, van Lieshout JJ, Wieling W. Systemic and cerebral circulatory adjustment within the first 60 s after active standing: An integrative physiological view. Auton Neurosci 2021; 231:102756. [PMID: 33385733 PMCID: PMC8103784 DOI: 10.1016/j.autneu.2020.102756] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/30/2020] [Accepted: 11/22/2020] [Indexed: 02/07/2023]
Abstract
Transient cardiovascular and cerebrovascular responses within the first minute of active standing provide the means to assess autonomic, cardiovascular and cerebrovascular regulation using a real-world everyday stimulus. Traditionally, these responses have been used to detect autonomic dysfunction, and to identify the hemodynamic correlates of patient symptoms and attributable causes of (pre)syncope and falls. This review addresses the physiology of systemic and cerebrovascular adjustment within the first 60 s after active standing. Mechanical factors induced by standing up cause a temporal mismatch between cardiac output and vascular conductance which leads to an initial blood pressure drops with a nadir around 10 s. The arterial baroreflex counteracts these initial blood pressure drops, but needs 2-3 s to be initiated with a maximal effect occurring at 10 s after standing while, in parallel, cerebral autoregulation buffers these changes within 10 s to maintain adequate cerebral perfusion. Interestingly, both the magnitude of the initial drop and these compensatory mechanisms are thought to be quite well-preserved in healthy aging. It is hoped that the present review serves as a reference for future pathophysiological investigations and epidemiological studies. Further experimental research is needed to unravel the causal mechanisms underlying the emergence of symptoms and relationship with aging and adverse outcomes in variants of orthostatic hypotension.
Collapse
Affiliation(s)
- Mark P M Harms
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ciáran Finucane
- Department of Medical Physics & Bioengineering, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland; Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Ireland
| | - Laura Pérez-Denia
- Department of Medical Physics & Bioengineering, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland; Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Ireland
| | - Stephen P Juraschek
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Veera K van Wijnen
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Lewis A Lipsitz
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA; Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Boston, MA, USA
| | - Johannes J van Lieshout
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; School of Life Sciences, The Medical School, MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research, Queen's Medical Centre, Nottingham, United Kingdom
| | - Wouter Wieling
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
| |
Collapse
|
19
|
de Heus RAA, de Jong DLK, Rijpma A, Lawlor BA, Olde Rikkert MGM, Claassen JAHR. Orthostatic Blood Pressure Recovery Is Associated With the Rate of Cognitive Decline and Mortality in Clinical Alzheimer's Disease. J Gerontol A Biol Sci Med Sci 2021; 75:2169-2176. [PMID: 32449919 PMCID: PMC7566323 DOI: 10.1093/gerona/glaa129] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Indexed: 01/08/2023] Open
Abstract
Background Impaired recovery of blood pressure (BP) after standing has been shown to be related to cognitive function and mortality in people without dementia, but its role in people with Alzheimer’s disease (AD) is unknown. The aim of this study was to investigate the association of the orthostatic BP response with cognitive decline and mortality in AD. Methods In this post hoc analysis of a randomized controlled trial (Nilvad), we measured the beat-to-beat response of BP upon active standing in mild-to-moderate AD. This included the initial drop (nadir within 40 seconds) and recovery after 1 minute, both expressed relative to resting values. We examined the relationship between a small or large initial drop (median split) and unimpaired (≥100%) or impaired recovery (<100%) with 1.5-year change in Alzheimer’s Disease Assessment—cognitive subscale (ADAS-cog) scores and all-cause mortality. Results We included 55 participants (age 73.1 ± 6.2 years). Impaired BP recovery was associated with higher increases in ADAS-cog scores (systolic: β [95% confidence interval] = 5.6 [0.4–10.8], p = .035; diastolic: 7.6 [2.3–13.0], p = .006). During a median follow-up time of 49 months, 20 participants died. Impaired BP recovery was associated with increased mortality (systolic: HR [95% confidence interval] = 2.9 [1.1–7.8], p = .039; diastolic: HR [95% confidence interval] = 5.5 [1.9–16.1], p = .002). The initial BP drop was not associated with any outcome. Results were adjusted for age, sex, and intervention group. Conclusions Failure to fully recover BP after 1 minute of standing is associated with cognitive decline and mortality in AD. As such, BP recovery can be regarded as an easily obtained marker of progression rate of AD.
Collapse
Affiliation(s)
- Rianne A A de Heus
- Department of Geriatric Medicine, Radboudumc Alzheimer Center, Radboud University Medical Center, Donders Institute for Brain Cognition and Behaviour, Nijmegen, The Netherlands
| | - Daan L K de Jong
- Department of Geriatric Medicine, Radboudumc Alzheimer Center, Radboud University Medical Center, Donders Institute for Brain Cognition and Behaviour, Nijmegen, The Netherlands
| | - Anne Rijpma
- Department of Geriatric Medicine, Radboudumc Alzheimer Center, Radboud University Medical Center, Donders Institute for Brain Cognition and Behaviour, Nijmegen, The Netherlands
| | - Brian A Lawlor
- Mercer's Institute for Research on Ageing, St. James's Hospital, Dublin, Ireland.,Department of Medical Gerontology, Trinity College Institute of Neuroscience, Dublin, Ireland
| | - Marcel G M Olde Rikkert
- Department of Geriatric Medicine, Radboudumc Alzheimer Center, Radboud University Medical Center, Donders Institute for Brain Cognition and Behaviour, Nijmegen, The Netherlands
| | - Jurgen A H R Claassen
- Department of Geriatric Medicine, Radboudumc Alzheimer Center, Radboud University Medical Center, Donders Institute for Brain Cognition and Behaviour, Nijmegen, The Netherlands
| |
Collapse
|
20
|
Webb AJS, Lawson A, Mazzucco S, Li L, Rothwell PM. Body Mass Index and Arterial Stiffness Are Associated With Greater Beat-to-Beat Blood Pressure Variability After Transient Ischemic Attack or Minor Stroke. Stroke 2021; 52:1330-1338. [PMID: 33588593 DOI: 10.1161/strokeaha.120.031179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
[Figure: see text].
Collapse
Affiliation(s)
- Alastair J S Webb
- Wolfson Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Amy Lawson
- Wolfson Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Sara Mazzucco
- Wolfson Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Linxin Li
- Wolfson Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | | |
Collapse
|
21
|
Juraschek SP, Hu JR, Cluett JL, Ishak A, Mita C, Lipsitz LA, Appel LJ, Beckett NS, Coleman RL, Cushman WC, Davis BR, Grandits G, Holman RR, Miller ER, Peters R, Staessen JA, Taylor AA, Thijs L, Wright JT, Mukamal KJ. Effects of Intensive Blood Pressure Treatment on Orthostatic Hypotension : A Systematic Review and Individual Participant-based Meta-analysis. Ann Intern Med 2021; 174:58-68. [PMID: 32909814 PMCID: PMC7855528 DOI: 10.7326/m20-4298] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Although intensive blood pressure (BP)-lowering treatment reduces risk for cardiovascular disease, there are concerns that it might cause orthostatic hypotension (OH). PURPOSE To examine the effects of intensive BP-lowering treatment on OH in hypertensive adults. DATA SOURCES MEDLINE, EMBASE, and Cochrane CENTRAL from inception through 7 October 2019, without language restrictions. STUDY SELECTION Randomized trials of BP pharmacologic treatment (more intensive BP goal or active agent) that involved more than 500 adults with hypertension or elevated BP and that were 6 months or longer in duration. Trial comparisons were groups assigned to either less intensive BP goals or placebo, and the outcome was measured OH, defined as a decrease of 20 mm Hg or more in systolic BP or 10 mm Hg or more in diastolic BP after changing position from seated to standing. DATA EXTRACTION 2 investigators independently abstracted articles and rated risk of bias. DATA SYNTHESIS 5 trials examined BP treatment goals, and 4 examined active agents versus placebo. Trials examining BP treatment goals included 18 466 participants with 127 882 follow-up visits. Trials were open-label, with minimal heterogeneity of effects across trials. Intensive BP treatment lowered risk for OH (odds ratio, 0.93 [95% CI, 0.86 to 0.99]). Effects did not differ by prerandomization OH (P for interaction = 0.80). In sensitivity analyses that included 4 additional placebo-controlled trials, overall and subgroup findings were unchanged. LIMITATIONS Assessments of OH were done while participants were seated (not supine) and did not include the first minute after standing. Data on falls and syncope were not available. CONCLUSION Intensive BP-lowering treatment decreases risk for OH. Orthostatic hypotension, before or in the setting of more intensive BP treatment, should not be viewed as a reason to avoid or de-escalate treatment for hypertension. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute, National Institutes of Health. (PROSPERO: CRD42020153753).
Collapse
Affiliation(s)
- Stephen P Juraschek
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (S.P.J., J.L.C., K.J.M.)
| | - Jiun-Ruey Hu
- Vanderbilt University Medical Center, Nashville, Tennessee (J.H.)
| | - Jennifer L Cluett
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (S.P.J., J.L.C., K.J.M.)
| | - Anthony Ishak
- Healthcare Associates, Beth Israel-Lahey Health System, Boston, Massachusetts (A.I.)
| | - Carol Mita
- Countway Library, Harvard University, Boston, Massachusetts (C.M.)
| | - Lewis A Lipsitz
- Beth Israel Deaconess Medical Center, Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, and Harvard Medical School, Boston, Massachusetts (L.A.L.)
| | | | - Nigel S Beckett
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (N.S.B.)
| | - Ruth L Coleman
- Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom (R.L.C., R.R.H.)
| | - William C Cushman
- University of Tennessee Health Science Center, Memphis, Tennessee (W.C.C.)
| | - Barry R Davis
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, Texas (B.R.D.)
| | - Greg Grandits
- School of Public Health, University of Minnesota, Minneapolis, Minnesota (G.G.)
| | - Rury R Holman
- Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom (R.L.C., R.R.H.)
| | - Edgar R Miller
- Johns Hopkins University, Baltimore, Maryland (L.J.A., E.R.M.)
| | - Ruth Peters
- University of New South Wales, Sydney, and Neuroscience Research Australia, Randwick, New South Wales, Australia (R.P.)
| | - Jan A Staessen
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, University of Leuven, Leuven, and NPA Alliance for the Promotion of Preventive Medicine (APPREMED), Mechelen, Belgium (J.A.S.)
| | - Addison A Taylor
- Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas (A.A.T.)
| | - Lutgarde Thijs
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, University of Leuven, Leuven, Belgium (L.T.)
| | - Jackson T Wright
- Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio (J.T.W.)
| | - Kenneth J Mukamal
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (S.P.J., J.L.C., K.J.M.)
| |
Collapse
|
22
|
Zanotto T, Hernandez ME, Medrano CN, Wilund KR, Sosnoff JJ. Cardiovascular Autonomic Dysfunction and Falls in People With Multiple Sclerosis: Is There a Link? An Opinion Article. Front Neurosci 2020; 14:610917. [PMID: 33364920 PMCID: PMC7750464 DOI: 10.3389/fnins.2020.610917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/18/2020] [Indexed: 12/20/2022] Open
Affiliation(s)
- Tobia Zanotto
- Motor Control Research Laboratory, Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL, United States.,Illinois Multiple Sclerosis Research Collaborative, University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | - Manuel E Hernandez
- Illinois Multiple Sclerosis Research Collaborative, University of Illinois at Urbana-Champaign, Urbana, IL, United States.,Mobility and Fall Prevention Research Laboratory, Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | - Cristina N Medrano
- McKinley Health Center, University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | - Kenneth R Wilund
- Renal and Cardiovascular Disease Research Laboratory, Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | - Jacob J Sosnoff
- Motor Control Research Laboratory, Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL, United States.,Illinois Multiple Sclerosis Research Collaborative, University of Illinois at Urbana-Champaign, Urbana, IL, United States
| |
Collapse
|
23
|
Webb AJ, Lawson A, Mazzucco S, Li L, Rothwell PM. Age and sex distribution of beat-to-beat blood pressure variability after transient ischemic attack and minor stroke: A population-based study. Int J Stroke 2020; 16:683-691. [PMID: 33167788 PMCID: PMC8366176 DOI: 10.1177/1747493020971905] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Beat-to-beat blood pressure variability is associated with increased stroke risk but its importance at different ages is unclear. Aims To determine the age-sex distribution of blood pressure variability in patients with transient ischemic stroke or minor stroke. Methods In consecutive patients within six weeks of transient ischemic stroke or non-disabling stroke (Oxford Vascular Study), non-invasive blood pressure was measured beat-to-beat over five minutes (Finometer). The age-sex distribution of blood pressure variability (residual coefficient of variation) was determined for systolic blood pressure and diastolic blood pressure. The risk of top-decile blood pressure variability was estimated (logistic regression), unadjusted, and adjusted for age, sex, and cardiovascular risk factors. Results In 908 of 1013 patients, excluding 54 in atrial fibrillation and 51 with low quality recordings, residual coefficient of variation was positively skewed with a median systolic residual coefficient of variation of 4.2% (IQR 3.2–5.5) and diastolic residual coefficient of variation of 3.9% (3.0–5.5), with 90th centile thresholds of 7.2 and 7.3%. Median systolic residual coefficient of variation was higher in patients under 50 years (4.5 and 3.0–5.3) compared to 60–70 years (4.1 and 3.2–5.2), but rose to 4.5% (3.5–6.9) above 80 years, with an increasingly positive skew. The proportion of patients with markedly elevated blood pressure variability in the top-decile increased significantly per decade (OR 1.72, p < 0.001), after adjustment for sex and risk factors. Conclusions Median beat-to-beat blood pressure variability fell in midlife, reflecting loss of physiological, organized blood pressure variability. However, rates of markedly elevated blood pressure variability significantly increased with greater age, suggesting that blood pressure variability may be particularly important in older patients.
Collapse
Affiliation(s)
- Alastair Js Webb
- Wolfson Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK
| | - Amy Lawson
- Wolfson Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK
| | - Sara Mazzucco
- Wolfson Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK
| | - Linxin Li
- Wolfson Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK
| |
Collapse
|
24
|
Fanciulli A, Campese N, Goebel G, Ndayisaba JP, Eschlboeck S, Kaindlstorfer C, Raccagni C, Granata R, Bonuccelli U, Ceravolo R, Seppi K, Poewe W, Wenning GK. Association of transient orthostatic hypotension with falls and syncope in patients with Parkinson disease. Neurology 2020; 95:e2854-e2865. [PMID: 32938788 DOI: 10.1212/wnl.0000000000010749] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 06/25/2020] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES To assess the frequency of transient orthostatic hypotension (tOH) and its clinical impact in Parkinson disease (PD), we retrospectively studied 173 patients with PD and 173 age- and sex-matched controls with orthostatic intolerance, who underwent cardiovascular autonomic function testing under continuous noninvasive blood pressure (BP) monitoring. METHODS We screened for tOH (systolic BP fall ≥20 mm Hg or diastolic ≥10 mm Hg resolving within the first minute upon standing) and classic OH (cOH, sustained systolic BP fall ≥20 mm Hg or diastolic ≥10 mm Hg within 3 minutes upon standing). In patients with PD, we reviewed the medical records of the 6 months preceding and following autonomic testing for history of falls, syncope, and orthostatic intolerance. RESULTS tOH occurred in 24% of patients with PD and 21% of controls, cOH in 19% of patients with PD and in none of the controls, independently of any clinical-demographic or PD-specific characteristic. Forty percent of patients with PD had a history of falls, in 29% of cases due to syncope. Patients with PD with history of orthostatic intolerance and syncope had a more severe systolic BP fall and lower diastolic BP rise upon standing, most pronounced in the first 30-60 seconds. CONCLUSIONS tOH is an age-dependent phenomenon, which is at least as common as cOH in PD. Transient BP falls when changing to the upright position may be overlooked with bedside BP measurements, but contribute to orthostatic intolerance and syncope in PD. Continuous noninvasive BP monitoring upon standing may help identify a modifiable risk factor for syncope-related falls in parkinsonian patients.
Collapse
Affiliation(s)
- Alessandra Fanciulli
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy.
| | - Nicole Campese
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Georg Goebel
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Jean Pierre Ndayisaba
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Sabine Eschlboeck
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Christine Kaindlstorfer
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Cecilia Raccagni
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Roberta Granata
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Ubaldo Bonuccelli
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Roberto Ceravolo
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Klaus Seppi
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Werner Poewe
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Gregor K Wenning
- From the Departments of Neurology (A.F., N.C., J.P.N., S.E., C.K., C.R., R.G., K.S., W.P., G.K.W.) and Medical Statistics, Informatics and Health Economics (G.G.), Medical University of Innsbruck, Austria; and Neurology Unit (N.C., U.B., R.C.), Department of Clinical and Experimental Medicine, University of Pisa, Italy
| |
Collapse
|
25
|
Stewart JM, Kota A, O'Donnell-Smith MB, Visintainer P, Terilli C, Medow MS. The preponderance of initial orthostatic hypotension in postural tachycardia syndrome. J Appl Physiol (1985) 2020; 129:459-466. [PMID: 32702262 DOI: 10.1152/japplphysiol.00540.2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Reduced systolic/diastolic blood pressure (BP) by >40/20 mmHg defines initial orthostatic hypotension (IOH). Rapid resolution of hypotension and lightheadedness follows, but tachycardia may be prolonged. We aimed to examine IOH in controls and patients with postural tachycardia syndrome (POTS) using indices of spontaneous fluctuations of heart rate (HR) and systolic BP as measures of cardiac baroreflex differences. We recruited otherwise healthy IOH patients without POTS (n = 20, 16 ± 3 yr), healthy volunteers (n = 32, 17 ± 3 yr), and POTS patients (n = 39, 17 ± 4 yr). Subjects were instrumented for electrocardiography and beat-to-beat BP. After 10 min supine, subjects stood for 5 min. Following supine recovery, subjects underwent 70° head-up tilt for 10 min to test for POTS. BP, HR, and time, referenced to standing, were measured at events during standing: minimum BP, BP recovery, peak HR, HR minimum, and steady state. Baseline HR and BP were higher in POTS compared with healthy groups. IOH occurred in 13% of controls and 51% of POTS patients. The BP minimum was lower in POTS. Parasympathetic modulation of cardiac baroreflex was decreased in all POTS and control-IOH subjects. Sympathetic indices were increased. Events following BP minimum occurred progressively later in all POTS and control-IOH subjects compared with non-IOH controls. IOH is more frequent in POTS than in controls with a lower minimum BP. POTS has markedly reduced heart rate variability and baroreflex, indicating reduced HR buffering of BP. POTS-IOH and control-IOH subjects had similar peak HR despite decreased minimum BP in POTS. IOH data indicate modest parasympathetic and cardiovagal baroreflex deficits in control-IOH subjects. Parasympathetic deficits are more severe in all POTS patients.NEW & NOTEWORTHY Significant initial orthostatic hypotension (IOH) occurs in ~50% of postural tachycardia syndrome (POTS) patients and 13% of controls. Heart rate and blood pressure recovery are prolonged in IOH sustaining lightheadedness; IOH is more prevalent and severe in POTS. Altered cerebral blood flow and cardiorespiratory regulation are more prevalent in POTS. Altered heart rate variability and baroreflex gain may cause nearly instantaneous lightheadedness in POTS. IOH alone fails to confer a strong probability of POTS.
Collapse
Affiliation(s)
- Julian M Stewart
- Department of Pediatric, New York Medical College, Valhalla, New York.,Department of Physiology, New York Medical College, Valhalla, New York
| | - Archana Kota
- Department of Pediatric, New York Medical College, Valhalla, New York
| | | | - Paul Visintainer
- Baystate Medical Center, University of Massachusetts School of Medicine, Springfield, Massachusetts
| | - Courtney Terilli
- Department of Pediatric, New York Medical College, Valhalla, New York
| | - Marvin S Medow
- Department of Pediatric, New York Medical College, Valhalla, New York.,Department of Physiology, New York Medical College, Valhalla, New York
| |
Collapse
|
26
|
Orthostatic blood pressure recovery associates with physical performance, frailty and number of falls in geriatric outpatients. J Hypertens 2020; 39:101-106. [PMID: 32773650 PMCID: PMC7752240 DOI: 10.1097/hjh.0000000000002617] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Blood pressure (BP) recovery after orthostatic hypotension might be important to prevent cerebral hypoperfusion episodes in older adults, and be related to better clinical outcome. The objective was to study the relationship between BP recovery and clinical outcome, that is physical and cognitive performance, frailty and falls, in geriatric outpatients.
Collapse
|
27
|
O'Connor JD, O'Connell MDL, Romero-Ortuno R, Hernández B, Newman L, Reilly RB, Kenny RA, Knight SP. Functional Analysis of Continuous, High-Resolution Measures in Aging Research: A Demonstration Using Cerebral Oxygenation Data From the Irish Longitudinal Study on Aging. Front Hum Neurosci 2020; 14:261. [PMID: 32765238 PMCID: PMC7379867 DOI: 10.3389/fnhum.2020.00261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 06/12/2020] [Indexed: 12/16/2022] Open
Abstract
Background: A shift towards the dynamic measurement of physiologic resilience and improved technology incorporated into experimental paradigms in aging research is producing high-resolution data. Identifying the most appropriate analysis method for this type of data is a challenge. In this work, the functional principal component analysis (fPCA) was employed to demonstrate a data-driven approach to the analysis of high-resolution data in aging research. Methods: Cerebral oxygenation during standing was measured in a large cohort [The Irish Longitudinal Study on Aging (TILDA)]. FPCA was performed on tissue saturation index (TSI) data. A regression analysis was then conducted with the functional principal component (fPC) scores as the explanatory variables and transition time as the response. Results: The mean ± SD age of the analysis sample was 64 ± 8 years. Females made up 54% of the sample and overall, 43% had tertiary education. The first PC explained 96% of the variance in cerebral oxygenation upon standing and was related to a baseline shift. Subsequent components described the recovery to before-stand levels (fPC2), drop magnitude and initial recovery (fPC3 and fPC4) as well as a temporal shift in the location of the minimum TSI value (fPC5). Transition time was associated with components describing the magnitude and timing of the nadir. Conclusions: Application of fPCA showed utility in reducing a large amount of data to a small number of parameters which summarize the inter-participant variation in TSI upon standing. A demonstration of principal component regression was provided to allow for continued use and development of data-driven approaches to high-resolution data analysis in aging research.
Collapse
Affiliation(s)
- John D O'Connor
- The Irish Longitudinal Study on Aging, Trinity College, The University of Dublin, Dublin, Ireland
| | - Matthew D L O'Connell
- The Irish Longitudinal Study on Aging, Trinity College, The University of Dublin, Dublin, Ireland.,Department of Population Health Sciences, King's College London, London, United Kingdom
| | - Roman Romero-Ortuno
- The Irish Longitudinal Study on Aging, Trinity College, The University of Dublin, Dublin, Ireland.,The Global Brain Health Institute, Trinity College, The University of Dublin, Dublin, Ireland
| | - Belinda Hernández
- The Irish Longitudinal Study on Aging, Trinity College, The University of Dublin, Dublin, Ireland
| | - Louise Newman
- The Irish Longitudinal Study on Aging, Trinity College, The University of Dublin, Dublin, Ireland
| | - Richard B Reilly
- Trinity Centre for Biomedical Engineering, Trinity College, The University of Dublin, Dublin, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Aging, Trinity College, The University of Dublin, Dublin, Ireland
| | - Silvin P Knight
- The Irish Longitudinal Study on Aging, Trinity College, The University of Dublin, Dublin, Ireland
| |
Collapse
|
28
|
van Wijnen VK, Gans ROB, Wieling W, Ter Maaten JC, Harms MPM. Diagnostic accuracy of evaluation of suspected syncope in the emergency department: usual practice vs. ESC guidelines. BMC Emerg Med 2020; 20:59. [PMID: 32746777 PMCID: PMC7397639 DOI: 10.1186/s12873-020-00344-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 06/03/2020] [Indexed: 11/17/2022] Open
Abstract
Background Syncope is a frequent reason for referral to the emergency department. After excluding a potentially life-threatening condition, the second objective is to find the cause of syncope. The objective of this study was to assess the diagnostic accuracy of the treating physician in usual practice and to compare this to the diagnostic accuracy of a standardised evaluation, consisting of thorough history taking and physical examination by a research physician. Methods This prospective cohort study included suspected (pre) syncope patients without an identified serious underlying condition who were assessed in the emergency department. Patients were initially seen by the initial treating physician and the usual evaluation was performed. A research physician, blinded to the findings of the initial treating physician, then performed a standardised evaluation according to the ESC syncope guidelines. Diagnostic accuracy (proportion of correct diagnoses) was determined by expert consensus after long-term follow-up. Results One hundred and one suspected (pre) syncope patients were included (mean age 59 ± 20 years). The usual practice of the initial treating physicians did not in most cases follow ESC syncope guidelines, with orthostatic blood pressure measurements made in only 40% of the patients. Diagnostic accuracy by the initial treating physicians was 65% (95% CI 56–74%), while standardised evaluation resulted in a diagnostic accuracy of 80% (95% CI 71–87%; p = 0.009). No life-threatening causes were missed. Conclusions Usual practice of the initial treating physician resulted in a diagnostic accuracy of 65%, while standardised practice, with an emphasis on thorough history taking, increased diagnostic accuracy to 80%. Results suggest that the availability of additional resources does not result in a higher diagnostic accuracy than standardised evaluation, and that history taking is the most important diagnostic test in suspected syncope patients. Netherlands Trial Registration: NTR5651. Registered 29 January 2016,https://www.trialregister.nl/trial/5532
Collapse
Affiliation(s)
- Veera K van Wijnen
- Department of Internal and Emergency Medicine, University of Groningen, University Medical Center Groningen, PO BOX 30001, 9700 RB, Groningen, the Netherlands
| | - Reinold O B Gans
- Department of Internal and Emergency Medicine, University of Groningen, University Medical Center Groningen, PO BOX 30001, 9700 RB, Groningen, the Netherlands
| | - Wouter Wieling
- Department of Internal Medicine, University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
| | - Jan C Ter Maaten
- Department of Internal and Emergency Medicine, University of Groningen, University Medical Center Groningen, PO BOX 30001, 9700 RB, Groningen, the Netherlands
| | - Mark P M Harms
- Department of Internal and Emergency Medicine, University of Groningen, University Medical Center Groningen, PO BOX 30001, 9700 RB, Groningen, the Netherlands.
| |
Collapse
|
29
|
The relative importance of frailty, physical and cardiovascular function as exercise-modifiable predictors of falls in haemodialysis patients: a prospective cohort study. BMC Nephrol 2020; 21:99. [PMID: 32169050 PMCID: PMC7071740 DOI: 10.1186/s12882-020-01759-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 03/05/2020] [Indexed: 02/07/2023] Open
Abstract
Background Stage 5 chronic kidney disease (CKD-5) patients on haemodialysis (HD) are at high risk of accidental falls. Previous research has shown that frailty is one of the primary contributors to the increased risk of falling in this clinical population. However, HD patients often present with abnormalities of cardiovascular function such as baroreflex impairment and orthostatic dysregulation of blood pressure (BP) which may also be implicated in the aetiology of falling. Therefore, we aimed to explore the relative importance of frailty and cardiovascular function as potential exercise-modifiable predictors of falls in these patients. Methods Ninety-three prevalent CKD-5 patients on HD from three Renal Units were recruited for this prospective cohort study, which was conducted between October 2015 and August 2018. At baseline, frailty status was assessed using the Fried’s frailty phenotype, while physical function was evaluated through timed up and go (TUG), five repetitions chair sit-to-stand (CSTS-5), objectively measured physical activity, and maximal voluntary isometric strength. Baroreflex and haemodynamic function at rest and in response to a 60° head-up tilt test (HUT-60°) were also assessed by means of the Task Force Monitor. The number of falls experienced was recorded once a month during 12 months of follow-up. Results In univariate negative binomial regression analysis, frailty (RR: 4.10, 95%CI: 1.60–10.51, p = 0.003) and other physical function determinants were associated with a higher number of falls. In multivariate analysis however, only worse baroreflex function (RR: 0.96, 95%CI: 0.94–0.99, p = 0.004), and orthostatic decrements of BP to HUT-60° (RR: 0.93, 95%CI: 0.87–0.99, p = 0.033) remained significantly associated with a greater number of falls. Eighty falls were recorded during the study period and the majority of them (41.3%) were precipitated by dizziness symptoms, as reported by participants. Conclusions This prospective study indicates that cardiovascular mechanisms implicated in the short-term regulation of BP showed a greater relative importance than frailty in predicting falls in CKD-5 patients on HD. A high number of falls appeared to be mediated by a degree of cardiovascular dysregulation, as evidenced by the predominance of self-reported dizziness symptoms. Trial registration ClinicalTrials.gov (trial registration ID: NCT02392299; date of registration: March 18, 2015).
Collapse
|
30
|
Tzur I, Barchel D, Khateb Z, Swarka M, Izhakian S, Gorelik O. Delayed versus classic orthostatic hypotension: clinical and prognostic implications. Blood Press 2020; 29:209-219. [PMID: 32131615 DOI: 10.1080/08037051.2020.1733389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Purpose: Orthostatic hypotension (OH) is a common disorder, especially among hospitalised patients. Classic OH is defined as occurring 3 or less minutes of orthostatic stress, and delayed OH as occurring after 3 min of stress. We aimed to compare clinical characteristics and prognosis between inpatients with classic vs. delayed OH.Methods: We performed a retrospective analysis of data from 358 inpatients, aged ≥60 years, who were evaluated for the occurrence of OH at the initial phase of ambulation in four previous prospective studies in our department. Demographic, clinical and prognostic data were compared between patients with (n = 191) vs. without (n = 167) OH, classic (n = 138) vs. delayed (n = 53) OH and seated (n = 115) vs. standing (n = 76) OH.Results: Demographic characteristics, duration of bed rest, the main reasons for admission and the use of offending medications were comparable between the delayed and classic OH groups. Mean maximal postural diastolic (p < .001) and systolic (p = .063) blood pressure falls were higher among patients with classic v. delayed OH. No statistically significant difference between the patients with classic and delayed OH were observed in the occurrence of OH-related symptoms (62.3 vs. 69.8%, p = .42). During a median follow-up of 5.5 years, no statistically significant differences in survival were observed between patients with vs. without OH (p = .14), classic vs. delayed OH (p = .68) and seated vs. standing OH (p = .067). On multivariate analysis, these variables remained not significantly associated with decreased survival.Conclusions: Among inpatients, delayed OH is associated with a lesser magnitude of orthostatic blood pressure fall than classic OH. However, rates of symptomatic OH and long-term mortality were comparable between the groups. Thus, among hospitalised patients, delayed OH should be considered as posing the same severity as classic OH.
Collapse
Affiliation(s)
- Irma Tzur
- Department of Internal Medicine "F", Yitzhak Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Dana Barchel
- Department of Internal Medicine "F", Yitzhak Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Zaki Khateb
- Department of Internal Medicine "F", Yitzhak Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Muhareb Swarka
- Department of Internal Medicine "F", Yitzhak Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Shimon Izhakian
- Department of Internal Medicine "F", Yitzhak Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Oleg Gorelik
- Department of Internal Medicine "F", Yitzhak Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| |
Collapse
|
31
|
Mol A, Maier AB, van Wezel RJA, Meskers CGM. Multimodal Monitoring of Cardiovascular Responses to Postural Changes. Front Physiol 2020; 11:168. [PMID: 32194438 PMCID: PMC7063121 DOI: 10.3389/fphys.2020.00168] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 02/13/2020] [Indexed: 12/13/2022] Open
Abstract
Background In the poorly understood relationship between orthostatic hypotension and falls, next to blood pressure (BP), baroreflex sensitivity (BRS) and cerebral autoregulation (CAR) may be key measures. The posture- and movement dependency of orthostatic hypotension requires continuous and unobtrusive monitoring. This may be possible using simultaneous photoplethysmography (PPG), electrocardiography (ECG), and near-infrared spectroscopy (NIRS) signal recordings, from which pulse wave velocity (PWV; potentially useful for BP estimation), BRS and CAR can be derived. The PPG, NIRS and PWV signal correlation with BP and BRS/CAR reliability and validity need to be addressed. Methods In 34 healthy adults (mean age 25 years, inter quartile range 22–45; 10 female), wrist and finger PPG, ECG, bifrontal NIRS (oxygenated and deoxygenated hemoglobin) and continuous BP were recorded during sit to stand and supine to stand movements. Sixteen participants performed slow and rapid supine to stand movements; eighteen other participants performed a 1-min squat movement. Pulse wave velocity (PWV) was defined as the inverse of the ECG R-peak to PPG pulse delay; PPG, NIRS and PWV signal correlation with BP as their Pearson correlations with mean arterial pressure (MAP) within 30 s after the postural changes; BRS as inter beat interval drop divided by systolic BP (SBP) drop during the postural changes; CAR as oxygenated hemoglobin drop divided by MAP drop. BRS and CAR were separately computed using measured and estimated (linear regression) BP. BRS/CAR reliability was defined by the intra class correlation between repeats of the same postural change; validity as the Pearson correlation between BRS/CAR values based on measured and estimated BP. Results The highest correlation with MAP was found for finger PPG and oxygenated hemoglobin, ranging from 0.75–0.79 (sit to stand), 0.66–0.88 (supine to stand), and 0.82–0.94 (1-min squat). BRS and CAR reliability was highest during the different supine to stand movements, ranging from 0.17 – 0.49 (BRS) and 0.42-0.75 (CAR); validity was highest during rapid supine to stand movements, 0.54 and 0.79 respectively. Conclusion PPG-ECG-NIRS recordings showed high correlation with BP and enabled computation of reliable and valid BRS and CAR estimates, suggesting their potential for continuous unobtrusive monitoring of orthostatic hypotension key measures.
Collapse
Affiliation(s)
- Arjen Mol
- Department of Human Movement Sciences @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Andrea B Maier
- Department of Human Movement Sciences @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Department of Medicine and Aged Care @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Richard J A van Wezel
- Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands.,Department of Biomedical Signals and Systems, Technical Medical Centre, University of Twente, Enschede, Netherlands
| | - Carel G M Meskers
- Department of Human Movement Sciences @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Department of Rehabilitation Medicine, Amsterdam UMC, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, Netherlands
| |
Collapse
|
32
|
Juraschek SP, Taylor AA, Wright JT, Evans GW, Miller ER, Plante TB, Cushman WC, Gure TR, Haley WE, Moinuddin I, Nord J, Oparil S, Pedley C, Roumie CL, Whittle J, Wiggers A, Finucane C, Anne Kenny R, Appel LJ, Townsend RR. Orthostatic Hypotension, Cardiovascular Outcomes, and Adverse Events: Results From SPRINT. Hypertension 2020; 75:660-667. [PMID: 31983312 PMCID: PMC7261502 DOI: 10.1161/hypertensionaha.119.14309] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 12/06/2019] [Indexed: 11/16/2022]
Abstract
Orthostatic hypotension (OH) is frequently observed with hypertension treatment, but its contribution to adverse outcomes is unknown. The SPRINT (Systolic Blood Pressure Intervention Trial) was a randomized trial of adults, age ≥50 years at high risk for cardiovascular disease with a seated systolic blood pressure (BP) of 130 to 180 mm Hg and a standing systolic BP ≥110 mm Hg. Participants were randomized to a systolic BP treatment goal of either <120 or <140 mm Hg. OH was defined as a drop in systolic BP ≥20 or diastolic BP ≥10 mm Hg 1 minute after standing from a seated position. We used Cox models to examine the association of OH with cardiovascular disease or adverse study events by randomized BP goal. During the follow-up period (median 3years), there were 1170 (5.7%) instances of OH among those assigned a standard BP goal and 1057 (5.0%) among those assigned the intensive BP goal. OH was not associated with higher risk of cardiovascular disease events (primary outcome: hazard ratio 1.06 [95% CI, 0.78-1.44]). Moreover, OH was not associated with syncope, electrolyte abnormalities, injurious falls, or acute renal failure. OH was associated with hypotension-related hospitalizations or emergency department visits (hazard ratio, 1.77 [95% CI, 1.11-2.82]) and bradycardia (hazard ratio, 1.94 [95% CI, 1.19-3.15]), but these associations did not differ by BP treatment goal. OH was not associated with a higher risk of cardiovascular disease events, and BP treatment goal had no effect on OH's association with hypotension and bradycardia. Symptomless OH during hypertension treatment should not be viewed as a reason to down-titrate therapy even in the setting of a lower BP goal. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT01206062.
Collapse
Affiliation(s)
- Stephen P Juraschek
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (S.P.J.)
| | - Addison A Taylor
- Michael E. DeBakey Veterans Affairs Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX (A.A.T.)
| | - Jackson T Wright
- Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH (J.T.W.)
| | - Gregory W Evans
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC (G.W.E.)
| | - Edgar R Miller
- The Johns Hopkins University School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Welch Center for Prevention, Epidemiology and Clinical Research, Baltimore, MD (E.R.M., L.J.A.)
| | - Timothy B Plante
- Larner College of Medicine at The University of Vermont, Burlington (T.B.P.)
| | - William C Cushman
- Preventive Medicine Section, Memphis VA Medical Center, Memphis, TN (W.C.C.)
| | - Tanya R Gure
- Division of General Internal Medicine and Geriatrics, Department of Internal Medicine, The Ohio State University, Columbus (T.R.G.)
| | - William E Haley
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL (W.E.H.)
| | - Imran Moinuddin
- Department of Medicine, University of Illinois at Chicago, College of Medicine, IL (I.M.)
| | - John Nord
- Department of Internal Medicine; Salt Lake City VA Medical Center, UT (J.N.)
| | - Suzanne Oparil
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham (S.O.)
| | - Carolyn Pedley
- Department of Internal Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.P.)
| | - Christianne L Roumie
- Institute for Medicine and Public Health, Vanderbilt University Medical Center, VA Geriatric Research Education and Clinical Center, Nashville, TN (C.L.R.)
| | - Jeff Whittle
- Clement J. Zablocki VA Medical Center, Milwaukee, WI (J.W.)
| | - Alan Wiggers
- Department of Primary Care, Ohio University Heritage College of Osteopathic Medicine, Cleveland (A.W.)
| | - Ciarán Finucane
- Department of Medical Physics, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland (C.F.)
- Department of Medical Gerontology, Trinity College, Dublin, Ireland (C.F., R.A.K.)
| | - Rose Anne Kenny
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland (R.A.K.)
| | - Lawrence J Appel
- The Johns Hopkins University School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Welch Center for Prevention, Epidemiology and Clinical Research, Baltimore, MD (E.R.M., L.J.A.)
| | - Raymond R Townsend
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania (R.R.T.)
| |
Collapse
|
33
|
van Twist DJL, Mostard GJM, Sipers WMWH. Delayed recovery from initial orthostatic hypotension: an expression of frailty in the elderly. Clin Auton Res 2020; 30:105-106. [PMID: 31993807 DOI: 10.1007/s10286-019-00664-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 12/26/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Daan J L van Twist
- Department of Internal Medicine, Subdivision of Vascular Medicine, Zuyderland Medical Centre, PO Box 5500, 6130 MB, Sittard/Heerlen, The Netherlands.
| | - Guy J M Mostard
- Department of Internal Medicine, Subdivision of Vascular Medicine, Zuyderland Medical Centre, PO Box 5500, 6130 MB, Sittard/Heerlen, The Netherlands
| | - Walther M W H Sipers
- Department of Geriatric Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| |
Collapse
|
34
|
O'Connor JD, O'Connell MDL, Nolan H, Newman L, Knight SP, Kenny RA. Impact of Standing Speed on the Peripheral and Central Hemodynamic Response to Orthostasis: Evidence From the Irish Longitudinal Study on Ageing. Hypertension 2019; 75:524-531. [PMID: 31838912 DOI: 10.1161/hypertensionaha.119.14040] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Assessment of the cerebrovascular and cardiovascular response to standing has prognostic value for a range of outcomes in the older adult population. Studies generally attempt to control for standing speed differences by asking participants to stand in a specified time but little is known about the range of transition times observed. This study aimed to characterize how standing speed associates with cardiovascular and cerebrovascular measures following transition from supine to standing. Continuous cerebral oxygenation, heart rate, systolic and diastolic blood pressure were monitored for 3 minutes after transitioning from supine to standing. An algorithm was used to calculate the time taken to transition from existing Finometer data (from the height correction unit). Linear mixed-effects models were used to assess the influence of transition time on each of the signals while adjusting for covariates. Transition time ranged from 2 to 27 s with 17% of participants taking >10 s to stand. Faster transition was associated with a more extreme decrease 10 s after standing but improved recovery at 20 s for cerebral oxygenation and blood pressure. Standing faster was associated with an elevated heart rate on initiation of stand and a quicker recovery 10 to 20 s after standing. The speed of transitioning from supine to standing position is associated with cardiovascular and cerebrovascular response in the early period after standing (<40 s). Care should be taken in the interpretation of findings which may be confounded by standing speed and statistical adjustment for standing time should be applied where appropriate.
Collapse
Affiliation(s)
- John D O'Connor
- From Department of Medical Gerontology, The Irish Longitudinal Study on Ageing, Trinity College, University of Dublin, Ireland (J.D.O., H.N., L.N., S.P.K., R.A.K.)
| | | | - Hugh Nolan
- From Department of Medical Gerontology, The Irish Longitudinal Study on Ageing, Trinity College, University of Dublin, Ireland (J.D.O., H.N., L.N., S.P.K., R.A.K.)
| | - Louise Newman
- From Department of Medical Gerontology, The Irish Longitudinal Study on Ageing, Trinity College, University of Dublin, Ireland (J.D.O., H.N., L.N., S.P.K., R.A.K.)
| | - Silvin P Knight
- From Department of Medical Gerontology, The Irish Longitudinal Study on Ageing, Trinity College, University of Dublin, Ireland (J.D.O., H.N., L.N., S.P.K., R.A.K.)
| | - Rose Anne Kenny
- From Department of Medical Gerontology, The Irish Longitudinal Study on Ageing, Trinity College, University of Dublin, Ireland (J.D.O., H.N., L.N., S.P.K., R.A.K.)
| |
Collapse
|
35
|
Mol A, Reijnierse EM, Trappenburg MC, van Wezel RJA, Maier AB, Meskers CGM. Rapid Systolic Blood Pressure Changes After Standing Up Associate With Impaired Physical Performance in Geriatric Outpatients. J Am Heart Assoc 2019; 7:e010060. [PMID: 30608209 PMCID: PMC6404215 DOI: 10.1161/jaha.118.010060] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Orthostatic hypotension is a prevalent condition in older adults and is associated with impaired physical performance and falls. The ability of older adults to compensate for rapid changes in systolic blood pressure (SBP; ie, SBP decline rate and SBP variability) may be important for physical performance. This study investigates the association of rapid SBP changes after standing up with physical performance. Methods and Results Consecutive patients who visited the Center of Geriatrics Amsterdam in 2014 and 2015 were included. The following SBP parameters were computed in 2 intervals (0–15 and 15–180 seconds) after standing up: steepness of steepest SBP decline; ratio of standing/supine SBP variability; and magnitude of largest SBP decline. Physical performance was assessed using the following measures: chair stand time, timed up and go time, walking speed, handgrip strength, and tandem stance performance. A total of 109 patients (45% men; age, mean, 81.7 years [standard deviation, 7.0 years]) were included. Steepness of steepest SBP decline (0–15 seconds) was associated with slower chair stand time (P<0.001), timed up and go time (P=0.022), and walking speed (P=0.024). Ratio of standing/supine SBP variability (0–15 seconds) was associated with slower chair stand time (P=0.005). Magnitude of largest SBP decline was not associated with physical performance. Conclusions SBP parameters reflecting rapid SBP changes were more strongly associated with physical performance compared with SBP decline magnitude in geriatric outpatients. These results support the hypothesis of an inadequate cerebral autoregulation during rapid SBP changes and advocate the use of continuous blood pressure measurements.
Collapse
Affiliation(s)
- Arjen Mol
- 1 Department of Human Movement Sciences @AgeAmsterdam Amsterdam Movement Sciences Vrije Universiteit Amsterdam Amsterdam the Netherlands.,2 Department of Biophysics Donders Institute for Brain, Cognition and Behaviour Radboud University Nijmegen the Netherlands
| | - Esmee M Reijnierse
- 3 Department of Medicine and Aged Care @AgeMelbourne The Royal Melbourne Hospital The University of Melbourne Australia
| | - Marijke C Trappenburg
- 4 Section of Gerontology and Geriatrics Department of Internal Medicine VU University Medical Center Amsterdam Amsterdam the Netherlands.,5 Department of Internal Medicine Amstelland Hospital Amstelveen the Netherlands
| | - Richard J A van Wezel
- 2 Department of Biophysics Donders Institute for Brain, Cognition and Behaviour Radboud University Nijmegen the Netherlands.,6 Biomedical Signals and Systems Technical Medical Centre, University of Twente Enschede the Netherlands
| | - Andrea B Maier
- 1 Department of Human Movement Sciences @AgeAmsterdam Amsterdam Movement Sciences Vrije Universiteit Amsterdam Amsterdam the Netherlands.,3 Department of Medicine and Aged Care @AgeMelbourne The Royal Melbourne Hospital The University of Melbourne Australia
| | - Carel G M Meskers
- 1 Department of Human Movement Sciences @AgeAmsterdam Amsterdam Movement Sciences Vrije Universiteit Amsterdam Amsterdam the Netherlands.,7 Department of Rehabilitation Medicine VU University Medical Center Amsterdam Amsterdam the Netherlands
| |
Collapse
|
36
|
Saedon NI, Frith J, Goh CH, Ahmad WAW, Khor HM, Tan KM, Chin AV, Kamaruzzaman SB, Tan MP. Orthostatic blood pressure changes and physical, functional and cognitive performance: the MELoR study. Clin Auton Res 2019; 30:129-137. [DOI: 10.1007/s10286-019-00647-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 10/23/2019] [Indexed: 12/22/2022]
|
37
|
Fitzgibbon-Collins LK, Noguchi M, Heckman GA, Hughson RL, Robertson AD. Acute reduction in cerebral blood velocity on supine-to-stand transition increases postural instability in young adults. Am J Physiol Heart Circ Physiol 2019; 317:H1342-H1353. [PMID: 31674810 DOI: 10.1152/ajpheart.00360.2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We tested the hypothesis that transient deficits in cerebral blood flow are associated with postural sway. In 19 young, healthy adults, we examined the association between the drop in cerebral blood flow during supine-to-stand transitions, indexed by transcranial Doppler ultrasound [middle cerebral artery blood velocity at diastole (MCAdv)] and near-infrared spectroscopy [tissue saturation index (TSI)] and the center of pressure displacement while standing. Participants performed transitions under three conditions aimed at progressively increasing the drop in MCAdv, in a randomized order: 1) a control transition (Con); 2) a transition that coincided with deflation of bilateral thigh cuffs; and 3) a transition that coincided with both thigh-cuff deflation and 90 s of prior hyperventilation (HTC). The deficit in diastolic blood velocity (MCAdv deficit) was quantified as the difference between MCAdv and its preceding baseline value, summed over 10 s, beginning at the MCAdv nadir. Compared with Con, HTC led to greater drops in MCAdv (P = 0.003) and TSI (P < 0.001) at nadir. The MCAdv deficit was positively associated with the center of pressure displacement vector-average using repeated-measures correlation (repeated-measures correlation coefficient = 0.56, P < 0.001). An a posteriori analysis identified a sub-group of participants that showed an exaggerated increase in MCAdv deficit and greater postural instability in both the anterior-posterior (P = 0.002) and medial-lateral (P = 0.021) directions in response to the interventions. These findings support the theory that individuals who experience greater initial cerebral hypoperfusion on standing may be at a greater risk for falls.NEW & NOTEWORTHY Dizziness and risk for falls after standing might link directly to reduced delivery of oxygen to the brain. By introducing challenges that increased the drop in brain blood flow in healthy young adults, we have shown for the first time a direct link to greater postural instability. These results point to a need to measure cerebral blood flow and/or oxygenation after postural transitions in populations, such as older adults, to assist in fall risk assessment.
Collapse
Affiliation(s)
| | | | - George A Heckman
- Schlegel-University of Waterloo Research Institute for Aging, Waterloo, Ontario, Canada
| | - Richard L Hughson
- Schlegel-University of Waterloo Research Institute for Aging, Waterloo, Ontario, Canada
| | - Andrew D Robertson
- Schlegel-University of Waterloo Research Institute for Aging, Waterloo, Ontario, Canada
| |
Collapse
|
38
|
Finucane C, van Wijnen VK, Fan CW, Soraghan C, Byrne L, Westerhof BE, Freeman R, Fedorowski A, Harms MPM, Wieling W, Kenny R. A practical guide to active stand testing and analysis using continuous beat-to-beat non-invasive blood pressure monitoring. Clin Auton Res 2019; 29:427-441. [PMID: 31076939 DOI: 10.1007/s10286-019-00606-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 04/02/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE The average adult stands approximately 50-60 times per day. Cardiovascular responses evoked during the first 3 min of active standing provide a simple means to clinically assess short-term neural and cardiovascular function across the lifespan. Clinically, this response is used to identify the haemodynamic correlates of patient symptoms and attributable causes of (pre-)syncope, and to detect autonomic dysfunction, variants of orthostatic hypotension, postural orthostatic tachycardia syndrome and orthostatic hypertension. METHODS This paper provides a set of experience/expertise-based recommendations detailing current state-of-the-art measurement and analysis approaches for the active stand test, focusing on beat-to-beat BP technologies. This information is targeted at those interested in performing and interpreting the active stand test to current international standards. RESULTS This paper presents a practical step-by-step guide on (1) how to perform active stand measurements using beat-to-beat continuous blood pressure measurement technologies, (2) how to conduct an analysis of the active stand response and (3) how to identify the spectrum of abnormal blood pressure and heart rate responses which are of clinical interest. CONCLUSION Impairments in neurocardiovascular control are an attributable cause of falls and syncope across the lifespan. The simple active stand test provides the clinician with a powerful tool for assessing individuals at risk of such common disorders. However, its simplicity belies the complexity of its interpretation. Care must therefore be taken in administering and interpreting the test in order to maximise its clinical benefit and minimise its misinterpretation.
Collapse
Affiliation(s)
- Ciarán Finucane
- Department of Medical Physics and Bioengineering, Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin 8, Ireland.
- Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin 8, Ireland.
- Department of Medical Gerontology, Trinity College Dublin, The Irish Longitudinal Study on Ageing (TILDA), Dublin, Ireland.
| | - V K van Wijnen
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - C W Fan
- Department of Gerontology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - C Soraghan
- Department of Medical Physics and Bioengineering, Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin 8, Ireland
- Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin 8, Ireland
| | - L Byrne
- Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin 8, Ireland
| | - B E Westerhof
- Amsterdam UMC, Vrije Universiteit Amsterdam, Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
- Amsterdam UMC, University of Amsterdam, Medical Biology, Section of Systems Physiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - R Freeman
- Neurology Department, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, USA
| | - A Fedorowski
- Department of Clinical Sciences, Clinical Research Center, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - M P M Harms
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - W Wieling
- Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - R Kenny
- Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin 8, Ireland
- Department of Medical Gerontology, Trinity College Dublin, The Irish Longitudinal Study on Ageing (TILDA), Dublin, Ireland
| |
Collapse
|
39
|
Tzur I, Izhakian S, Gorelik O. Orthostatic hypotension: definition, classification and evaluation. Blood Press 2019; 28:146-156. [DOI: 10.1080/08037051.2019.1604067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Irma Tzur
- Department of Internal Medicine "F", Assaf Harofeh Medical Center, Zerifin, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Shimon Izhakian
- Department of Internal Medicine "F", Assaf Harofeh Medical Center, Zerifin, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Oleg Gorelik
- Department of Internal Medicine "F", Assaf Harofeh Medical Center, Zerifin, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| |
Collapse
|
40
|
Mol A, Woltering JHH, Colier WNJM, Maier AB, Meskers CGM, van Wezel RJA. Sensitivity and reliability of cerebral oxygenation responses to postural changes measured with near-infrared spectroscopy. Eur J Appl Physiol 2019; 119:1117-1125. [PMID: 30771059 PMCID: PMC6469633 DOI: 10.1007/s00421-019-04101-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 02/11/2019] [Indexed: 11/26/2022]
Abstract
Purpose Cerebral oxygenation as measured by near-infrared spectroscopy (NIRS) might be useful to discriminate between physiological and pathological responses after standing up in individuals with orthostatic hypotension. This study addressed the physiological sensitivity of the cerebral oxygenation responses as measured by NIRS to different types and speeds of postural changes in healthy adults and assessed the reliability of these responses. Methods Cerebral oxygenated hemoglobin (O2Hb), deoxygenated hemoglobin (HHb) and tissue saturation index (TSI) were measured bilaterally on the forehead of 15 healthy individuals (12 male, age range 18–27) using NIRS. Participants performed three repeats of sit to stand, and slow and rapid supine to stand movements. Responses were defined as the difference between mean, minimum and maximum O2Hb, HHb and TSI values after standing up and baseline. Test–retest, interobserver and intersensor reliabilities were addressed using intraclass correlation coefficients (ICCs). Results The minimum O2Hb response was most sensitive to postural changes and showed significant differences (− 4.09 µmol/L, p < 0.001) between standing up from sitting and supine position, but not between standing up at different speeds (− 0.31 µmol/L, p = 0.70). The minimum O2Hb response was the most reliable parameter (ICC > 0.6). Conclusions In healthy individuals, NIRS-based cerebral oxygenation parameters are sensitive to postural change and discriminate between standing up from supine and sitting position with minimum O2Hb response as the most sensitive and reliable parameter. The results underpin the potential value for future clinical use of NIRS in individuals with orthostatic hypotension. Electronic supplementary material The online version of this article (10.1007/s00421-019-04101-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Arjen Mol
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorstraat 9, 1081 BT, Amsterdam, The Netherlands.
- Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Heijendaalseweg 135, 6525 AJ, Nijmegen, The Netherlands.
| | - Jeffrey H H Woltering
- Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Heijendaalseweg 135, 6525 AJ, Nijmegen, The Netherlands
| | | | - Andrea B Maier
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorstraat 9, 1081 BT, Amsterdam, The Netherlands
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, City Campus, Level 6 North, 300 Grattan Street, Parkville, VIC, 3050, Australia
| | - Carel G M Meskers
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorstraat 9, 1081 BT, Amsterdam, The Netherlands
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Richard J A van Wezel
- Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Heijendaalseweg 135, 6525 AJ, Nijmegen, The Netherlands
- Biomedical Signals and Systems, Technical Medical Centre, University of Twente, Zuidhorst Building, P.O. Box 217, 7500 AE, Enschede, The Netherlands
| |
Collapse
|
41
|
van Wijnen VK, Harms MPM, Wieling W. Orthostatic Hypotension in the First Minute After Standing Up: What Is the Clinical Relevance and Do Symptoms Matter? Hypertension 2019; 71:816-818. [PMID: 29632100 DOI: 10.1161/hypertensionaha.118.10609] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Veera K van Wijnen
- From the Department of Internal and Emergency Medicine, University Medical Center Groningen, University of Groningen, The Netherlands (V.K.v.W., M.P.M.H.); and Department of Internal Medicine, Academic Medical Center, University of Amsterdam, The Netherlands (W.W.)
| | - Mark P M Harms
- From the Department of Internal and Emergency Medicine, University Medical Center Groningen, University of Groningen, The Netherlands (V.K.v.W., M.P.M.H.); and Department of Internal Medicine, Academic Medical Center, University of Amsterdam, The Netherlands (W.W.)
| | - Wouter Wieling
- From the Department of Internal and Emergency Medicine, University Medical Center Groningen, University of Groningen, The Netherlands (V.K.v.W., M.P.M.H.); and Department of Internal Medicine, Academic Medical Center, University of Amsterdam, The Netherlands (W.W.).
| |
Collapse
|
42
|
Luiting S, Jansen S, Seppälä LJ, Daams JG, van der Velde N. Effectiveness of Cardiovascular Evaluations and Interventions on Fall Risk: A Scoping Review. J Nutr Health Aging 2019; 23:330-337. [PMID: 30932131 PMCID: PMC6507528 DOI: 10.1007/s12603-019-1165-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/12/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Cardiovascular abnormalities are consistently associated with fall risk in older people. However, little research has been done to assess the effect of cardiovascular interventions on fall risk. The aim of this scoping review is to explore the current literature on the effectiveness of cardiovascular evaluations and interventions in reducing fall risk in older people. DESIGN Scoping review. DATA SOURCES Medline, Cochrane Library, and WHO ICTRP Search Portal were systematically searched. SELECTION CRITERIA Randomized controlled trials (RCTs) and intervention studies of community-dwelling adults aged ≥50 years or with a mean age of >60 years that assessed the effect of a cardiovascular assessment and interventions in reducing fall risk. Key search concepts were "falls" and "aged", and terms for different cardiovascular evaluations and interventions were included. The Cochrane Checklist for risk of bias and the ROBINS-I tool were used to assess the quality of the studies. RESULTS Seven studies were included. The majority showed a reduction in falls after cardiovascular evaluation and intervention. Two out of four studies that focused on carotid sinus hypersensitivity (CSH) as a modifiable cardiovascular risk factor for falls, showed a significant reduction in falls after pacemaker implantation. Two studies that looked at sinus node dysfunction (SND) both showed a significant reduction in falls after pacemaker implantation. One study showed that 33% of the patients experienced a fall after cardiovascular evaluation and intervention, whereas all patients fell before assessment. CONCLUSIONS The majority of the included studies showed a reduction in falls after the intervention. However, the number of published papers regarding the effect of cardiovascular assessment and interventions on falls is small. A standardized assessment of cardiovascular risk factors may be essential in preventing falls in older adults and could consequently reduce injuries, loss of quality of life, deaths, and fall-related expenditures.
Collapse
Affiliation(s)
- S Luiting
- Nathalie van der Velde, PhD, Amsterdam University Medical Center, Department of Internal Medicine, Section of Geriatric Medicine, Meibergdreef 9, Amsterdam 1105AZ, the Netherlands, Tel. nr: +31 20-5665991, e-mail:
| | | | | | | | | |
Collapse
|
43
|
Robertson AD, Udow SJ, Espay AJ, Merola A, Camicioli R, Lang AE, Masellis M. Orthostatic hypotension and dementia incidence: links and implications. Neuropsychiatr Dis Treat 2019; 15:2181-2194. [PMID: 31447560 PMCID: PMC6683958 DOI: 10.2147/ndt.s182123] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/09/2019] [Indexed: 12/14/2022] Open
Abstract
Orthostatic hypotension (OH) is a common condition, particularly in patients with α-synucleinopathies such as Parkinson's disease, and has a significant impact on activities of daily living and quality of life. Recent data suggest an association with cognitive impairment. Herein, we review the evidence that OH increases the odds of incident mild cognitive impairment and dementia. Potential mechanisms underlying the putative relationship are discussed, including cerebral hypoperfusion, supine hypertension, white matter hyperintensities, and neurodegeneration. Finally, we highlight the challenges with respect to treatment and the negative impact on the quality of life and long-term prognosis presented by the coexistence of OH and dementia. Large population-based studies have reported that OH is associated with about a 20% increased risk of dementia in the general population, while smaller cohort studies suggest an even greater effect in patients with α-synucleinopathies (3- to 7-fold higher than controls). Ultimately, OH exposure is difficult to quantify, predominantly limited to pressure regulation during a one-time orthostatic challenge, and the causative association with dementia may turn out to be bidirectional, especially in α-synucleinopathies. Early diagnosis and treatment of OH may improve long-term prognosis.
Collapse
Affiliation(s)
- Andrew D Robertson
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, ON, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - Sean J Udow
- Division of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Alberto J Espay
- Department of Neurology, James and Joan Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, Cincinnati, OH, USA
| | - Aristide Merola
- Department of Neurology, James and Joan Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, Cincinnati, OH, USA
| | - Richard Camicioli
- Department of Medicine (Neurology), University of Alberta, Edmonton, AB, Canada
| | - Anthony E Lang
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, University Health Network, Toronto, ON, Canada.,Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Mario Masellis
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada.,Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Cognitive and Movement Disorders Clinic, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| |
Collapse
|
44
|
Bai R. Initial orthostatic hypotension: A common cause of syncope but uncommonly overlooked. Int J Cardiol 2018; 271:293-294. [PMID: 30049490 DOI: 10.1016/j.ijcard.2018.07.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 07/03/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Rong Bai
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA.
| |
Collapse
|
45
|
van Wijnen VK, Hove DT, Finucane C, Wieling W, van Roon AM, Ter Maaten JC, Harms MP. Hemodynamic Mechanisms Underlying Initial Orthostatic Hypotension, Delayed Recovery and Orthostatic Hypotension. J Am Med Dir Assoc 2018; 19:786-792. [DOI: 10.1016/j.jamda.2018.05.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 04/24/2018] [Accepted: 05/05/2018] [Indexed: 01/18/2023]
|
46
|
Different patterns of orthostatic hypotension in older patients with unexplained falls or syncope: orthostatic hypotension patterns in older people. Eur Geriatr Med 2018; 9:485-492. [DOI: 10.1007/s41999-018-0063-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 04/30/2018] [Indexed: 11/26/2022]
|
47
|
Briggs R, Carey D, Kennelly SP, Kenny RA. Longitudinal Association Between Orthostatic Hypotension at 30 Seconds Post-Standing and Late-Life Depression. Hypertension 2018; 71:946-954. [DOI: 10.1161/hypertensionaha.117.10542] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 11/09/2017] [Accepted: 01/18/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Robert Briggs
- From the Irish Longitudinal Study on Ageing, Trinity College Dublin, Ireland (R.B., D.C., R.A.K.); Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin, Ireland (R.B., R.A.K.); and Age-Related Health Care, Tallaght Hospital, Dublin, Ireland (R.B., S.P.K.)
| | - Daniel Carey
- From the Irish Longitudinal Study on Ageing, Trinity College Dublin, Ireland (R.B., D.C., R.A.K.); Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin, Ireland (R.B., R.A.K.); and Age-Related Health Care, Tallaght Hospital, Dublin, Ireland (R.B., S.P.K.)
| | - Sean P. Kennelly
- From the Irish Longitudinal Study on Ageing, Trinity College Dublin, Ireland (R.B., D.C., R.A.K.); Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin, Ireland (R.B., R.A.K.); and Age-Related Health Care, Tallaght Hospital, Dublin, Ireland (R.B., S.P.K.)
| | - Rose Anne Kenny
- From the Irish Longitudinal Study on Ageing, Trinity College Dublin, Ireland (R.B., D.C., R.A.K.); Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin, Ireland (R.B., R.A.K.); and Age-Related Health Care, Tallaght Hospital, Dublin, Ireland (R.B., S.P.K.)
| |
Collapse
|
48
|
Modeling human orthostatic responses on the Moon and on Mars. Clin Auton Res 2018; 28:325-332. [PMID: 29700646 DOI: 10.1007/s10286-018-0527-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE Since manned missions to the Moon and Mars are planned, we conducted active standing tests with lunar, Martian, terrestrial, and 1.8 loads of inertial resistance (+Gz) modeled through defined parabolic flight maneuvers. We hypothesized that the cardiovascular response to active standing is proportional to the +Gz load. METHODS During partial-+Gz parabolic flights, 14 healthy test subjects performed active stand-up maneuvers under 1 +Gz, lunar (0.16 +Gz), Martian (0.38 +Gz), and hyper inertial resistance (1.8 +Gz) while heart rate and finger blood pressure were continuously monitored. We quantified amplitudes and timing of orthostatic response immediately following standing up. RESULTS The maximum early heart rate increase was 21 (SD ± 10) bpm with lunar, 23 (± 11) bpm with Martian, 34 (± 17) bpm with terrestrial +Gz, and 40 (± 11) bpm hyper +Gz. The time to maximum heart rate increased gradually with increasing loads of inertial resistance. The transient blood pressure reduction was most pronounced with hyper +Gz but did not differ significantly between lunar and Martian +Gz. The mean arterial pressure nadir was reached significantly later with Martian and lunar compared to 1 +Gz. Paradoxically, the time for blood pressure to recover was shortest with terrestrial +Gz. CONCLUSION While load of inertial resistance directly affects the magnitude of the transient blood pressure reduction and heart rate response to active standing, blood pressure stabilization is most rapidly attained during terrestrial +Gz. The observation might suggest that the human cardiovascular system is tuned to cope with orthostatic stress on earth.
Collapse
|
49
|
van Wijnen VK, Ten Hove D, Gans ROB, Nieuwland W, van Roon AM, Ter Maaten JC, Harms MPM. Orthostatic blood pressure recovery patterns in suspected syncope in the emergency department. Emerg Med J 2018; 35:226-230. [PMID: 29367218 PMCID: PMC5868292 DOI: 10.1136/emermed-2017-207207] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 12/22/2017] [Indexed: 11/20/2022]
Abstract
Introduction Orthostasis is a frequent trigger for (pre)syncope but some forms of orthostatic (pre)syncope have a worse prognosis than others. Routine assessment of orthostatic BP in the ED can detect classic orthostatic hypotension, but often misses these other forms of orthostatic (pre)syncope. This study aimed to determine the frequency of abnormal orthostatic BP recovery patterns in patients with (pre)syncope by using continuous non-invasive BP monitoring. Methods We performed a prospective cohort study in suspected patients with (pre)syncope in the ED of a tertiary care teaching hospital between January and August 2014. Orthostatic BP was measured during the active lying-to-standing test with Nexfin, a continuous non-invasive finger arterial pressure measurement device. Orthostatic BP recovery patterns were defined as normal BP recovery, initial orthostatic hypotension, delayed BP recovery, classic orthostatic hypotension and reflex-mediated hypotension. Results Of 116 patients recruited, measurements in 111 patients (age 63 years, 51% male) were suitable for analysis. Classic orthostatic hypotension was the most prevalent abnormal BP pattern (19%), but only half of the patients received a final diagnosis of orthostatic hypotension. Initial orthostatic hypotension and delayed BP recovery were present in 20% of the patients with (pre)syncope of whom 45% were diagnosed as unexplained syncope. Reflex-mediated hypotension was present in 4% of the patients. Conclusion Continuous non-invasive BP measurement can potentially identify more specific and concerning causes of orthostatic (pre)syncope. Correct classification is important because of different short-term and long-term clinical implications.
Collapse
Affiliation(s)
- Veera K van Wijnen
- Department of Internal, Emergency and Vascular Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dik Ten Hove
- Department of Internal, Emergency and Vascular Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Reinold O B Gans
- Department of Internal, Emergency and Vascular Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wybe Nieuwland
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Arie M van Roon
- Department of Internal, Emergency and Vascular Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan C Ter Maaten
- Department of Internal, Emergency and Vascular Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mark P M Harms
- Department of Internal, Emergency and Vascular Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|