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Shibao CA, Harrison DG, Biaggioni I. David Herlie Robertson, MD. Hypertension 2024; 81:e44-e46. [PMID: 38630798 DOI: 10.1161/hypertensionaha.124.22755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Affiliation(s)
- Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - David G Harrison
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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2
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Biaggioni I, Arnold AC, Black B, Diedrich A, Furlan R, Gamboa A, Garland E, Jacob G, Jordan J, Okamoto LE, Raj SR, Sato K, Shannon J, Tank J, Peltier A, Shibao CA. In memoriam: a celebration of the autonomic contributions of David Robertson (1947-2024). Clin Auton Res 2024; 34:5-7. [PMID: 38436914 DOI: 10.1007/s10286-024-01025-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 03/05/2024]
Affiliation(s)
- Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
| | - Amy C Arnold
- Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Bonnie Black
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Andre Diedrich
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Raffaello Furlan
- Internal Medicine and Syncope Unit, Humanitas Research Hospital, Humanitas University, Rozzano, Italy
| | - Alfredo Gamboa
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Emily Garland
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Giris Jacob
- Deparment of Internal Medicine, Recanati Autonomic Dysfunction Center, Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jens Jordan
- Institute of Aerospace Medicine, German Aerospace Center and Medical Faculty, University of Cologne, Cologne, Germany
| | - Luis E Okamoto
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Satish R Raj
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
- Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | - Kyoko Sato
- Adachi Medical Center, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Jens Tank
- Institute of Aerospace Medicine, German Aerospace Center and Medical Faculty, University of Cologne, Cologne, Germany
| | - Amanda Peltier
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
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3
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Belna H, Fortrat JO, Augusto JF, Brilland B. Post-traumatic hypertension: when nerves break down. J Nephrol 2023; 36:2629-2632. [PMID: 37308776 DOI: 10.1007/s40620-023-01662-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 04/28/2023] [Indexed: 06/14/2023]
Affiliation(s)
- Hugo Belna
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, 4 rue Larrey, 49033, Angers CEDEX 09, France
| | - Jacques-Olivier Fortrat
- Service de Médecine Vasculaire, Mitovasc UMR INSERM 1083-CNRS 6015, CHU Angers, Angers, France
| | - Jean-François Augusto
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, 4 rue Larrey, 49033, Angers CEDEX 09, France
- Université d'Angers Inserm, CNRS, Nantes Université, CRCI2NA, Angers, France
| | - Benoit Brilland
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, 4 rue Larrey, 49033, Angers CEDEX 09, France.
- Université d'Angers Inserm, CNRS, Nantes Université, CRCI2NA, Angers, France.
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Lamotte G, Coon EA, Suarez MD, Sandroni P, Benarroch E, Cutsforth-Gregory JK, Mauermann ML, Berini SE, Shouman K, Sletten D, Goodman BP, Low PA, Singer W. Standardized Autonomic Testing in Patients With Probable Radiation-Induced Afferent Baroreflex Failure. Hypertension 2022; 79:50-56. [PMID: 34739766 PMCID: PMC8665095 DOI: 10.1161/hypertensionaha.121.17805] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Injury of the afferent limb of the baroreflex from neck radiation causes radiation-induced afferent baroreflex failure (R-ABF). Identification and management of R-ABF is challenging. We aimed to investigate the pattern of autonomic dysfunction on standardized autonomic testing in patients with probable R-ABF. We retrospectively analyzed all autonomic reflex screens performed at Mayo Clinic in Rochester, MN, between 2000 and 2020 in patients with probable R-ABF. Additional tests reviewed included ambulatory blood pressure monitoring, plasma norepinephrine, and thermoregulatory sweat test. We identified 90 patients with probable R-ABF. Median total composite autonomic severity score (range, 0-10) was 7 (interquartile range, 6-7). Cardiovascular adrenergic impairment was seen in 85 patients (94.4%), increased blood pressure recovery time after Valsalva maneuver in 71 patients (78.9%; median 17.4 seconds), and orthostatic hypotension in 68 patients (75.6%). Cardiovagal impairment was demonstrated by abnormal heart rate responses to deep breathing (79.5%), Valsalva ratio (87.2%), and vagal baroreflex sensitivity (57.9%). Plasma norepinephrine was elevated and rose appropriately upon standing (722-1207 pg/mL). Ambulatory blood pressure monitoring revealed hypertension, postural hypotension, hypertensive surges, tachycardia, and absence of nocturnal dipping. Blood pressure lability correlated with impaired vagal baroreflex function. Postganglionic sympathetic sudomotor function was normal in most cases; the most frequent thermoregulatory sweat test finding was focal neck anhidrosis (78.9%). Standardized autonomic testing in R-ABF demonstrates cardiovascular adrenergic impairment with orthostatic hypotension, blood pressure lability, and elevated plasma norepinephrine. Cardiovagal impairment is common, while sudomotor deficits are limited to direct radiation effects.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Wolfgang Singer
- Department of Neurology, Mayo Clinic, Rochester, MN,,Corresponding author: Wolfgang Singer, MD, Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA, , Phone: 507-284-3375
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Hyponatremia accompanying volatile hypertension caused by baroreflex failure after neck surgery: case report and literature review. J Hypertens 2021; 38:1617-1624. [PMID: 32371768 DOI: 10.1097/hjh.0000000000002436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is the most common cause of euvolemic hyponatremia, and many disorders have been associated with it. Baroreflex failure is a rare disorder characterized by extreme blood pressure (BP) fluctuations, most frequently caused by neck or head trauma and irradiation. We report a case of a 48-year-old patient referred to our department for asymptomatic hyponatremia and volatile hypertension. His past medical history included nasopharyngeal carcinoma treated with surgery and bilateral neck radiation. Following the diagnostic algorithm for hyponatremia, the diagnosis of SIADH was made. Ambulatory BP monitoring revealed highly variable BP; extensive autonomic nervous system function testing suggested baroreflex-cardiovagal failure. We propose the hypothesis that not only labile hypertension because of baroreflex failure but also hyponatremia can develop as a late consequence of neck trauma and irradiation.
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Lamotte G, Coon EA, Suarez MD, Sandroni P, Benarroch EE, Cutsforth-Gregory JK, Mauermann ML, Berini SE, Shouman K, Sletten D, Goodman BP, Low PA, Singer W. Natural History of Afferent Baroreflex Failure in Adults. Neurology 2021; 97:e136-e144. [PMID: 33947784 DOI: 10.1212/wnl.0000000000012149] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/29/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To describe the natural history of afferent baroreflex failure (ABF) based on systematic review of clinical and laboratory data in patients with a diagnosis of ABF at Mayo Clinic Rochester. METHODS We performed a retrospective chart review of all patients who underwent standardized autonomic reflex testing between 2000 and 2020 and had confirmation of the diagnosis of ABF by an autonomic disorders specialist. Patients were identified using a data repository of medical records. Variables included demographic, all-cause mortality, medications, ABF manifestations, comorbidities, and laboratory (autonomic testing, blood pressure monitoring, echocardiogram, brain imaging, plasma catecholamines, serum sodium level, and kidney function tests). RESULTS A total of 104 patients with ABF were identified. Head and neck radiation was the most common etiology (86.5%), followed by neck surgery (5.8%) and other causes (7.7%). The most common findings were hypertension (87.5%), fluctuating blood pressure (78.8%), orthostatic hypotension (91.3%), syncope (58.6%), headache (22.1%), and tachycardia (20.2%). Patients commonly received antihypertensives (66.3%), pressor agents (41.3%), or a combination of both (19.2%). The median latency from completion of radiation to ABF was longer compared to the latency in the surgery group (p < 0.0001). Comorbidities, including complications from neck radiation, were frequently seen and all-cause mortality was 39.4% over a 20-year period. CONCLUSIONS ABF should be suspected in patients with prior head and neck cancer treated by radiation or surgery who present with labile hypertension and orthostatic hypotension. Management may require both antihypertensive and pressor medications. The morbidity and mortality in ABF are high.
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Affiliation(s)
- Guillaume Lamotte
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Elizabeth A Coon
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Mariana D Suarez
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Paola Sandroni
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Eduardo E Benarroch
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Jeremy K Cutsforth-Gregory
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Michelle L Mauermann
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Sarah E Berini
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Kamal Shouman
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - David Sletten
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Brent P Goodman
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Phillip A Low
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Wolfgang Singer
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ.
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Rahman M, Pradhan N, Chen Z, Kanthety R, Townsend RR, Tatsuoka C, Wright JT. Orthostatic Hypertension and Intensive Blood Pressure Control; Post-Hoc Analyses of SPRINT. Hypertension 2020; 77:49-58. [PMID: 33161773 DOI: 10.1161/hypertensionaha.120.15887] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We evaluated the association between orthostatic hypertension and cardiovascular outcomes and the effect of intensive blood pressure (BP) control on cardiovascular outcomes in patients with orthostatic hypertension. Post hoc analyses of the SPRINT (Systolic Blood Pressure Intervention Trial) data were conducted; orthostatic hypertension was defined as increase in systolic BP≥20 mm Hg or increase in diastolic BP≥10 mm Hg with standing. Of 9329 participants, 1986 (21.2%) had orthostatic hypertension at baseline. Within the intensive treatment group, participants with orthostatic hypertension were at higher risk of developing the composite cardiovascular outcome (hazard ratio, 1.44 [95% CI, 1.1-1.87], P=0.007) compared with participants without orthostatic hypertension. Within the standard treatment group, there were no significant differences in cardiovascular outcome between participants with and without orthostatic hypertension. In participants with orthostatic hypertension, there was no statistically significant difference in risk of the composite cardiovascular outcome between the intensive and the standard BP treatment group (hazard ratio, 1.07 [95% CI, 0.78-1.47], P=0.68). In participants without orthostatic hypertension at baseline, the intensive treatment group was associated with a lower risk of the composite cardiovascular outcome (hazard ratio, 0.67 [95% CI, 0.56-0.79], P<0.0001). Orthostatic hypertension was associated with a higher risk of cardiovascular outcomes in the intensive and not in the standard treatment group; intensive treatment of BP did not reduce the risk of cardiovascular outcomes compared with standard treatment in patients with orthostatic hypertension. These post hoc analyses are hypothesis generating and will need to be confirmed in future studies.
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Affiliation(s)
- Mahboob Rahman
- From the Division of Nephrology and Hypertension (M.R., N.P., R.K., J.T.W.)
| | | | | | - Radhika Kanthety
- From the Division of Nephrology and Hypertension (M.R., N.P., R.K., J.T.W.)
| | - Raymond R Townsend
- University Hospitals Cleveland Medical Center, Case Western Reserve University, OH and University of Pennsylvania Perelman School of Medicine, Philadelphia (R.R.T.)
| | | | - Jackson T Wright
- From the Division of Nephrology and Hypertension (M.R., N.P., R.K., J.T.W.)
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Norcliffe-Kaufmann L, Millar Vernetti P, Palma JA, Balgobin BJ, Kaufmann H. Afferent Baroreflex Dysfunction: Decreased or Excessive Signaling Results in Distinct Phenotypes. Semin Neurol 2020; 40:540-549. [PMID: 32906172 DOI: 10.1055/s-0040-1713892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Head and neck tumors can affect afferent baroreceptor neurons and either interrupt or intermittently increase their signaling, causing blood pressure to become erratic. When the afferent fibers of the baroreflex are injured by surgery or radiotherapy or fail to develop as in familial dysautonomia, their sensory information is no longer present to regulate arterial blood pressure, resulting in afferent baroreflex failure. When the baroreflex afferents are abnormally activated, such as by paragangliomas in the neck, presumably by direct compression, they trigger acute hypotension and bradycardia and frequently syncope, by a mechanism similar to the carotid sinus syndrome. We describe our observations in a large series of 23 patients with afferent baroreflex dysfunction and the cardiovascular autonomic features that arise when the sensory baroreceptor neurons are injured or compressed. The management of afferent baroreceptor dysfunction is limited, but pharmacological strategies can mitigate blood pressure swings, improve symptoms, and may reduce hypertensive organ damage. Although rare, the prevalence of afferent baroreflex dysfunction appears to be increasing in middle-aged men due to human papillomavirus related oropharyngeal cancer.
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Affiliation(s)
| | | | - Jose-Alberto Palma
- Department of Neurology, New York University School of Medicine, New York, New York
| | - Bhumika J Balgobin
- Department of Neurology, New York University School of Medicine, New York, New York
| | - Horacio Kaufmann
- Department of Neurology, New York University School of Medicine, New York, New York
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9
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Barboi A, Pocica S. Somatic and autonomic findings in cancer-related base of the skull syndromes. Clin Auton Res 2020; 30:343-346. [PMID: 32594278 DOI: 10.1007/s10286-020-00706-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/18/2020] [Indexed: 01/30/2023]
Affiliation(s)
- Alexandru Barboi
- Department of Neurology, NorthShore University HealthSystem, Evanston, IL, USA.
| | - Sylwia Pocica
- Department of Neurology, NorthShore University HealthSystem, Evanston, IL, USA
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10
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Biaggioni I, Shibao CA, Diedrich A, Muldowney JAS, Laffer CL, Jordan J. Blood Pressure Management in Afferent Baroreflex Failure: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 74:2939-2947. [PMID: 31806138 DOI: 10.1016/j.jacc.2019.10.027] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/18/2019] [Accepted: 10/21/2019] [Indexed: 12/14/2022]
Abstract
Afferent baroreflex failure is most often due to damage of the carotid sinus nerve because of neck surgery or radiation. The clinical picture is characterized by extreme blood pressure lability with severe hypertensive crises, hypotensive episodes, and orthostatic hypotension, making it the most difficult form of hypertension to manage. There is little evidence-based data to guide treatment. Recommendations rely on understanding the underlying pathophysiology, relevant clinical pharmacology, and anecdotal experience. The goal of treatment should be improving quality of life rather than normalization of blood pressure, which is rarely achievable. Long-acting central sympatholytic drugs are the mainstay of treatment, used at the lowest doses that prevent the largest hypertensive surges. Short-acting clonidine should be avoided because of rebound hypertension, but can be added to control residual hypertensive episodes, often triggered by mental stress or exertion. Hypotensive episodes can be managed with countermeasures and short-acting pressor agents if necessary.
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Affiliation(s)
- Italo Biaggioni
- Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt Autonomic Dysfunction Center, Nashville, Tennessee.
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt Autonomic Dysfunction Center, Nashville, Tennessee
| | - André Diedrich
- Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt Autonomic Dysfunction Center, Nashville, Tennessee
| | - James A S Muldowney
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt Autonomic Dysfunction Center, Nashville, Tennessee; Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cheryl L Laffer
- Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jens Jordan
- Institute of Aerospace Medicine, German Aerospace Center, Cologne, Germany; Aerospace Medicine, University of Cologne, Cologne, Germany
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11
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Jordan J, Ricci F, Hoffmann F, Hamrefors V, Fedorowski A. Orthostatic Hypertension: Critical Appraisal of an Overlooked Condition. Hypertension 2020; 75:1151-1158. [PMID: 32223382 DOI: 10.1161/hypertensionaha.120.14340] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Orthostatic hypertension, which appears to be mediated through excess neurohumoral activation while standing, is a common blood pressure trait among patients with and without arterial hypertension. However, lack of consensus regarding the definition of orthostatic hypertension makes it difficult to assess the true prevalence of this condition. Orthostatic hypertension appears to predict the risk for progression to arterial hypertension in younger and risk of cardiovascular morbidity and mortality in older persons. Yet, the risk may differ between populations. Whether orthostatic hypertension indicates a generally increased risk of death, constitutes an intermediate variable in the causal pathway of cardiovascular risk factors, a simple measure of disease severity, or an independently acting mechanism is not known. Since both orthostatic hypotension and orthostatic hypertension herald increased risk of cardiovascular disease, it appears reasonable to screen the patients for abnormal orthostatic blood pressure responses using simple orthostatic testing. However, how presence of orthostatic hypertension may affect clinical management decisions such as the choice of antihypertensive drugs is currently difficult to ascertain. Clearly, this issue deserves more attention.
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Affiliation(s)
- Jens Jordan
- From the Institute of Aerospace Medicine, German Aerospace Center (DLR) and Chair of Aerospace Medicine (J.J., F.H.), University of Cologne, Germany.,University Hypertension Center (J.J., F.H.), University of Cologne, Germany
| | - Fabrizio Ricci
- Department of Clinical Sciences, Lund University, Malmö, Sweden (F.R., V.H., A.F.).,Department of Neuroscience, Imaging and Clinical Sciences, "G.d'Annunzio" University, Chieti-Pescara, Italy (F.R.)
| | - Fabian Hoffmann
- From the Institute of Aerospace Medicine, German Aerospace Center (DLR) and Chair of Aerospace Medicine (J.J., F.H.), University of Cologne, Germany.,University Hypertension Center (J.J., F.H.), University of Cologne, Germany
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden (F.R., V.H., A.F.).,Department of Internal Medicine (V.H.), Skåne University Hospital, Malmö, Sweden
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden (F.R., V.H., A.F.).,Department of Cardiology (A.F.), Skåne University Hospital, Malmö, Sweden
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12
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Cardiac and Vascular Sympathetic Baroreflex Control during Orthostatic Pre-Syncope. J Clin Med 2019; 8:jcm8091434. [PMID: 31510103 PMCID: PMC6781174 DOI: 10.3390/jcm8091434] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 11/17/2022] Open
Abstract
We hypothesized that sympathetic baroreflex mediated uncoupling between neural sympathetic discharge pattern and arterial pressure (AP) fluctuations at 0.1 Hz during baroreceptor unloading might promote orthostatic pre-syncope. Ten volunteers (32 ± 6 years) underwent electrocardiogram, beat-to-beat AP, respiratory activity and muscle sympathetic nerve activity (MSNA) recordings while supine (REST) and during 80° head-up tilt (HUT) followed by -10 mmHg stepwise increase of lower body negative pressure until pre-syncope. Cardiac and sympathetic baroreflex sensitivity were quantified. Spectrum analysis of systolic and diastolic AP (SAP and DAP) and calibrated MSNA (cMSNA) variability assessed the low frequency fluctuations (LF, ~0.1 Hz) of SAP, DAP and cMSNA variability. The squared coherence function (K2) quantified the coupling between cMSNA and DAP in the LF band. Analyses were performed while supine, during asymptomatic HUT (T1) and at pre-syncope onset (T2). During T2 we found that: (1) sympathetic baroreceptor modulation was virtually abolished compared to T1; (2) a progressive decrease in AP was accompanied by a persistent but chaotic sympathetic firing; (3) coupling between cMSNA and AP series at 0.1 Hz was reduced compared to T1. A negligible sympathetic baroreceptor modulation during pre-syncope might disrupt sympathetic discharge pattern impairing the capability of vessels to constrict and promote pre-syncope.
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13
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Vallelonga F, Maule S. Diagnostic and therapeutical management of supine hypertension in autonomic failure. J Hypertens 2019; 37:1102-1111. [DOI: 10.1097/hjh.0000000000002008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Burke SD, Jordan J, Harrison DG, Karumanchi SA. Solving Baroreceptor Mystery: Role of PIEZO Ion Channels. J Am Soc Nephrol 2019; 30:911-913. [PMID: 31043433 DOI: 10.1681/asn.2019020160] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Suzanne D Burke
- Center for Vascular Biology Research and Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Jens Jordan
- Institute of Aerospace Medicine, German Aerospace Center and Department of Aerospace Medicine, University of Cologne, Cologne, Germany
| | - David G Harrison
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee; and
| | - S Ananth Karumanchi
- Center for Vascular Biology Research and Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; .,Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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15
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Hampel KG, Elger CE, Surges R. Impaired Baroreflex Sensitivity after Bilateral Convulsive Seizures in Patients with Focal Epilepsy. Front Neurol 2017; 8:210. [PMID: 28572789 PMCID: PMC5435824 DOI: 10.3389/fneur.2017.00210] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/01/2017] [Indexed: 11/29/2022] Open
Abstract
Background Sudden unexpected death in epilepsy (SUDEP) is probably due to an autonomic failure in the early postictal phase after bilateral convulsive seizures (BCS) in the majority of cases. The baroreflex sensitivity (BRS) is an established and reliable biomarker of autonomic function and sudden cardiac death. Objective To investigate whether postictal BRS depends on seizure type. Methods Beat-to-beat systemic blood pressure and heart rate were continuously and non-invasively recorded with the ccNexfin® device in patients with focal epilepsy undergoing video-EEG monitoring. BRS was calculated using the sequence as well as the spectral method. A random mixed linear model was applied to analyze the influence of seizure type on BRS during three different time periods of 15-min length each (interictal, preictal, and postictal). In addition, the possible effects of other factors (hypertension, hemispheric lateralization of ictal activity, epilepsy type, body position, vigilance state) were explored. Data are given as median with interquartile range. Results A total of 26 seizures of 26 patients were analyzed. In BCS (n = 7), BRS significantly dropped from a preictal value of 15.0 ms/mm Hg (13.0–19.4) and an interictal value of 15.6 ms/mm Hg (12.0–20.4) to 3.1 ms/mm Hg (2.7–10.5) during the postictal period (p < 0.0001) according to the sequence method. This finding was replicated with the spectral method. In contrast, focal seizures (n = 19) did not lead to significant alterations of BRS in the postictal phase. Conclusion Postictal BRS depends on the seizure type and is markedly impaired after BCS. The present study provides further evidence for a disturbed autonomic function following BCS. These findings might be related to cardiovascular failure in the context of SUDEP.
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Affiliation(s)
- Kevin G Hampel
- Department of Epileptology, University Hospital Bonn, Bonn, Germany.,Multidisciplinary Epilepsy Unit, Neurology Service, University Hospital La Fe, Valencia, Spain
| | | | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
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16
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Abuzinadah AR, Sinn DI, Freeman R, Gibbons CH. Blood pressure oscillations in baroreflex failure. Clin Auton Res 2016; 26:465-466. [PMID: 27541037 DOI: 10.1007/s10286-016-0374-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 07/24/2016] [Indexed: 11/29/2022]
Abstract
A 67-year-old man presented with labile hypertension and orthostatic hypotension after radical neck dissection and radiotherapy for squamus cell carcinoma. Baroreflex failure is clearly evident on autonomic testing.
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Affiliation(s)
- Ahmad Rida Abuzinadah
- Neurology department, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 111, Boston, MA, 02215, USA.,Neurology Division, Internal Medicine Department, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Dong In Sinn
- Neurology department, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 111, Boston, MA, 02215, USA
| | - Roy Freeman
- Neurology department, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 111, Boston, MA, 02215, USA
| | - Christopher H Gibbons
- Neurology department, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 111, Boston, MA, 02215, USA.
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17
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Abstract
GOALS To analyze the neurochemical profile during the recurrent attacks of nausea and vomiting in patients with Riley-day syndrome. BACKGROUND One of the most disabling features of patients with Riley-day syndrome are recurrent attacks of severe nausea/retching/vomiting accompanied by hypertension, tachycardia, and skin flushing, usually triggered by emotional or other stresses. STUDY We monitored blood pressure and heart rate and measured plasma catecholamines during typical dysautonomic crises triggered by emotionally charged situations. For comparison, measurements were repeated at follow-up after the symptoms had resolved and the patients were feeling calm and well. RESULTS During a typical attack, patients were hypertensive and tachycardic. In all patients, circulating levels of norepinephrine (P < 0.002) and dopamine (P < 0.007) increased significantly. CONCLUSIONS Activation of dopamine receptors in the chemoreceptor trigger zone may explain the cyclic nausea/retching/vomiting of patients with Riley-day syndrome.
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18
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Metzler M, Duerr S, Granata R, Krismer F, Robertson D, Wenning GK. Neurogenic orthostatic hypotension: pathophysiology, evaluation, and management. J Neurol 2012. [PMID: 23180176 PMCID: PMC3764319 DOI: 10.1007/s00415-012-6736-7] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Neurogenic orthostatic hypotension is a distinctive and treatable sign of cardiovascular autonomic dysfunction. It is caused by failure of noradrenergic neurotransmission that is associated with a range of primary or secondary autonomic disorders, including pure autonomic failure, Parkinson’s disease with autonomic failure, multiple system atrophy as well as diabetic and nondiabetic autonomic neuropathies. Neurogenic orthostatic hypotension is commonly accompanied by autonomic dysregulation involving other organ systems such as the bowel and the bladder. In the present review, we provide an overview of the clinical presentation, pathophysiology, epidemiology, evaluation and management of neurogenic orthostatic hypotension focusing on neurodegenerative disorders.
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Affiliation(s)
- Manuela Metzler
- Autonomic Function Laboratory, Division of Neurobiology, Department of Neurology, Innsbruck Medical University, Anichstrasse 35, Innsbruck, Austria
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19
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20
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Younas F, Janjua M, Badshah A, DeGregorio M, Patel KC, Cotant JF. Transient complete heart block and isolated ventricular asystole with nitroglycerin. J Cardiovasc Med (Hagerstown) 2012; 13:533-5. [DOI: 10.2459/jcm.0b013e3283416b8b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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21
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An Unusual Case of Asystole following Penetrating Neck Trauma and Anoxic Brain Injury. Case Rep Cardiol 2011; 2011:579805. [PMID: 24826224 PMCID: PMC4008474 DOI: 10.1155/2011/579805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 06/30/2011] [Indexed: 11/17/2022] Open
Abstract
Bradycardia and transient asystole are well-described sequelae of a myriad of neurologic insults, ranging from focal to generalized injuries. Increased vagal tone also predisposes many individuals, particularly adolescents, to transient neurally mediated bradyarrhythmia. However, prolonged periods of sinus arrest without junctional or ventricular escape are quite rare, even after significant neurologic injury. We describe the case of a 17-year-old man who presented with anoxic brain injury secondary to hemorrhagic shock from a stab wound to the neck. His recovery was complicated by prolonged periods of sinus arrest and asystole, lasting over 60 seconds per episode. This case illustrates that sustained asystolic episodes may occur following significant neurologic injury, and may continue to recur even months after an initial insult. Pacemaker implantation for such patients should be strongly considered.
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22
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Flack JM, Ferdinand KC, Nasser SA, Rossi NF. Hypertension in special populations: chronic kidney disease, organ transplant recipients, pregnancy, autonomic dysfunction, racial and ethnic populations. Cardiol Clin 2010; 28:623-38. [PMID: 20937446 DOI: 10.1016/j.ccl.2010.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The benefits of appropriate blood pressure (BP) control include reductions in proteinuria and possibly a slowing of the progressive loss of kidney function. Overall, medication therapy to lower BP during pregnancy should be used mainly for maternal safety because of the lack of data to support an improvement in fetal outcome. The major goal of hypertension treatment in those with baroreceptor dysfunction is to avoid the precipitous, severe BP elevations that characteristically occur during emotional stimulation. The treatment of hypertension in African Americans optimally consists of comprehensive lifestyle modifications along with pharmacologic treatments, most often with combination, not single-drug, therapy.
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Affiliation(s)
- John M Flack
- Department of Medicine, Wayne State University, Detroit Medical Center, MI 48201, USA.
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23
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Components of arterial systolic pressure and RR-interval oscillation spectra in a case of baroreflex failure, a human open-loop model of vascular control. J Hum Hypertens 2009; 24:417-26. [PMID: 19907435 DOI: 10.1038/jhh.2009.79] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The baroreflex control of circulation is always operating and modulates blood pressure and heart rate oscillations. Thus, the study of cardiovascular variability in humans is performed in a closed-loop model and the physiology of post-sinoaortic denervation is completely unknown in humans. We dissected for the first time the different components of systolic arterial pressure (SAP) and RR-interval spectra in a patient with 'baroreflex failure' (due to mixed cranial nerve neuroma) who represents a human model to investigate the cardiovascular regulation in an open-loop condition. Interactions among cardiovascular variability signals and respiratory influences were described using the multivariate parametric ARXAR model with the following findings: (1) rhythms unrelated to respiration were detected only at frequencies lower than classical low frequency (LF; Slow-LF, around 0.02 Hz) both in SAP an RR spectra, (2) small high-frequency (HF) modulation is present and related with respiration at rest and in tilt (but for SAP only) and (3) the Slow-LF fluctuations detected both in SAP and RR oscillate independently as the multivariate model shows no relationships between SAP and RR, and these oscillations are not phase related. Thus, we showed that in a patient with impaired baroreflex arc integrity the Slow-LF rhythms for RR have a central origin that dictates fluctuations on RR at the same rhythm but unrelated to the oscillation of SAP (which may be related with both peripheral activity and central rhythms). The synchronization in LF band is a hallmark of integrity of baroreflex arc whose impairment unmasks lower frequency rhythms in SAP and RR whose fluctuations oscillate independently.
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24
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Julien C, Parkes MJ, Tzeng SYC, Sin PYW, Ainslie PN, van de Borne P, Fortrat JO, Custaud MA, Gharib C, Porta A, Vallais F, Baselli G, Pagani M, Lucini D, Hughson RL, Taylor JA, Tan CO, Baekey DM, Dick TE, Paton JFR, Taha B. Comments on point:counterpoint: respiratory sinus arrhythmia is due to a central mechanism vs. respiratory sinus arrhythmia is due to the baroreflex mechanism. J Appl Physiol (1985) 2009; 106:1745-9. [PMID: 19414628 DOI: 10.1152/japplphysiol.00196.2009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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25
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Montano N, Furlan R, Guzzetti S, McAllen RM, Julien C. Analysis of sympathetic neural discharge in rats and humans. PHILOSOPHICAL TRANSACTIONS. SERIES A, MATHEMATICAL, PHYSICAL, AND ENGINEERING SCIENCES 2009; 367:1265-1282. [PMID: 19324708 DOI: 10.1098/rsta.2008.0285] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Neural signals convey information through two different modalities: intensity and discharge pattern. The intensity code is based on the number of action potentials per unit time, which is then easily translated into neurotransmitter release. This kind of information may be assessed simply by counting the number of spikes or bursts over a time unit. However, the discharge pattern is a further, efficient means of neural information transfer. Rhythmic patterns (i.e. oscillations) can support highly structured, temporal codes based on correlation and synchronization. It is therefore clear that applying frequency domain analysis to sympathetic activity recorded in animals and humans may provide additional information about the neural control of the circulation. Over the last century, data obtained by the analysis of sympathetic activity in experimental animals, and recently also in humans, have provided fundamental contributions to our understanding of the physiological mechanisms involved in the neural control of circulation, as well as how these are altered in cardiovascular and non-cardiovascular diseases. The aim of this paper is to address some aspects related to the recording, analysis and interpretation of sympathetic activity in rats and humans, with special emphasis on analysis in the frequency domain.
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Affiliation(s)
- Nicola Montano
- Internal Medicine II, Department of Clinical Sciences, L. Sacco Hospital, University of Milan, 20157 Milano, Italy.
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26
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Abstract
We describe the case of a 75-year-old man presenting with labile hypertension and symptomatic postural hypotension 13 months following radiotherapy for squamous cell carcinoma of his external auditory canal. Magnetic resonance image (MRI) scan demonstrated scarring and a probable recurrence of his tumour. He underwent autonomic testing, including muscle sympathetic nerve activity (MSNA), heart rate (HR) and blood pressure (BP) responses to a variety of stimuli. Results were consistent with baroreflex failure. Urinary catecholamine levels were within the high normal range. We postulate that baroreflex failure was caused by vagal and glossopharyngeal nerve damage secondary to radiotherapy and tumour recurrence. This diagnosis is rare, but should be considered with pure autonomic failure and phaeochromocytoma in the presence of labile hypertension, especially in patients with a history of radiotherapy to the neck and high-normal catecholamine levels.
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27
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Skrapari I, Tentolouris N, Perrea D, Bakoyiannis C, Papazafiropoulou A, Katsilambros N. Baroreflex sensitivity in obesity: relationship with cardiac autonomic nervous system activity. Obesity (Silver Spring) 2007; 15:1685-93. [PMID: 17636086 DOI: 10.1038/oby.2007.201] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The aim of this study was to test the hypothesis that baroreflex sensitivity (BRS), assessed by indirect measurement of aortic pressure, is blunted in obesity. Additionally, the potential effect of cardiac autonomic nervous system (ANS) activity, aortic compliance, and metabolic parameters on BRS of obese subjects was investigated. RESEARCH METHODS AND PROCEDURES A group of 30 women with BMI>30 kg/m2 and a group of 30 controls with BMI<25 kg/m2 were examined. BRS was estimated by the sequence technique, cardiac ANS activity by short-term spectral analysis of heart rate variability (HRV), and aortic compliance by the method of applanation tonometry. RESULTS BRS was lower in obese women (9.18+/-3.77 vs. 19.63+/-9.16 ms/mm Hg, p<0.001). The median values (interquartile range) of the power of both the high-frequency and low-frequency components of the HRV were higher in the lean than in the obese participants [1079.2 (202.7 to 1716.9) vs. 224.1 (72.7 to 539.6) msec2, p=0.001 and 411.8 (199.3 to 798.0) vs. 235.8 (99.4 to 424.5) msec2, p=0.01 respectively]. Low-to-high-frequency ratio values were higher in the obese subjects [0.82 (0.47 to 2.1) vs. 0.57 (0.28 to 0.89), p=0.02]. Aortic augmentation values were not significantly different between lean and obese subjects. Multivariate analysis demonstrated a significant and independent association between BRS and age (p=0.003), BMI (p<0.001), and high-frequency power of HRV (p<0.001). These variables explained 72% of the variation of BRS values. DISCUSSION BRS is severely reduced in obese subjects. BMI, age, and the parasympathetic nervous system activity are the main determinants of BRS. Baroreflex behavior is of clinical relevance because an attenuated BRS represents a negative prognostic factor in cardiovascular diseases, which are common in obesity.
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Affiliation(s)
- Ioanna Skrapari
- First Department of Propaedeutic Medicine, Athens University Medical School, Laiko General Hospital, Greece.
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28
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Ma RCW, Yiu KH, Wong EHC, Liu KH, Chan JYS, Chow CC, Cockram CS. A man with labile blood pressure. PLoS Med 2007; 4:e111. [PMID: 17455986 PMCID: PMC1855694 DOI: 10.1371/journal.pmed.0040111] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2006] [Accepted: 01/31/2007] [Indexed: 12/02/2022] Open
Abstract
Ronald Ma and colleagues discuss the differential diagnosis and management of a patient who presented with recurrent episodes of chest discomfort, palpitations, and labile blood pressure.
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Affiliation(s)
- Ronald C W Ma
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.
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29
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Fessel J, Robertson D. Orthostatic hypertension: when pressor reflexes overcompensate. ACTA ACUST UNITED AC 2006; 2:424-31. [PMID: 16932477 DOI: 10.1038/ncpneph0228] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2005] [Accepted: 03/31/2006] [Indexed: 11/08/2022]
Abstract
Orthostatic hypertension--a rise in blood pressure upon assuming upright posture-is an underappreciated and understudied clinical phenomenon. There is currently no widely agreed-upon definition of clinical orthostatic hypertension, the current definitions being operational within the context of particular studies. The underlying pathophysiology is thought to involve activation of the sympathetic nervous system, but the actual etiology is poorly understood. Orthostatic hypertension is observed in association with a variety of other clinical conditions, including essential hypertension, dysautonomias, and type 2 diabetes mellitus. Orthostatic hypertension has been associated with increased occurrence of silent cerebrovascular ischemia and possibly with neuropathy in type 2 diabetes. So, appreciation of the true incidence of orthostatic hypertension, elucidation of the underlying pathophysiology, and an understanding of potentially effective treatment approaches and their associated risks and benefits might all have major clinical significance. Orthostatic hypertension is an aspect of hypertension that is in need of further focused investigation.
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Affiliation(s)
- Joshua Fessel
- Department of Medicine at Vanderbilt University, Nashville, TN 37232-2195, USA
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31
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Timmers HJLM, Wieling W, Karemaker JM, Lenders JWM. Denervation of carotid baro- and chemoreceptors in humans. J Physiol 2003; 553:3-11. [PMID: 14528027 PMCID: PMC2343492 DOI: 10.1113/jphysiol.2003.052415] [Citation(s) in RCA: 127] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2003] [Accepted: 09/30/2003] [Indexed: 01/11/2023] Open
Abstract
Experimental denervation in animals has shown that carotid baro- and chemoreceptors play an eminent role in maintaining blood pressure and blood gas homeostasis. Denervation of carotid sinus baro- and chemoreceptors in humans may occur as a complication of invasive interventions on the neck or after experimental surgical treatment in asthma. In this topical review, the short- and long-term effects of carotid baro- and chemoreceptor denervation on the control of circulation and ventilation in humans are discussed. Carotid baroreceptor denervation in humans causes a persistent decrease in vagal and sympathetic baroreflex sensitivity and an increase in blood pressure variability; however, carotid denervation does not lead to chronic hypertension. Therefore, although carotid baroreceptors contribute to short-term blood pressure control, other receptors are able to maintain normal chronic blood pressure levels in the absence of carotid baroreceptors. Conversely, carotid chemoreceptor denervation leads to permanent abolition of normocapnic ventilatory responses to hypoxia and reduced ventilatory responses to hypercapnia.
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Affiliation(s)
- Henri J L M Timmers
- Department of Internal Medicine, University Medical Centre Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
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Timmers HJLM, Karemaker JM, Wieling W, Marres HAM, Folgering HTM, Lenders JWM. Baroreflex and chemoreflex function after bilateral carotid body tumor resection. J Hypertens 2003; 21:591-9. [PMID: 12640254 DOI: 10.1097/00004872-200303000-00026] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate whether bilateral carotid body tumor resection invariably and chronically affects arterial baroreflex or peripheral chemoreflex function. METHODS We studied eight consecutive patients (two men and six women; ages 48.1 +/- 11.8 years), a median time of 3.4 years (range 1.3-20.6 years) after bilateral carotid body tumor resection, and 12 healthy control individuals (eight men and four women; ages 53.7 +/- 10.1 years). Baroreflex sensitivity (phenylephrine), blood pressure and its variability (24 h Spacelabs and 5 h Portapres recordings), responses to standard cardiovascular reflex tests and the ventilatory responses to normocapnic and hypercapnic hypoxia were assessed. RESULTS Baroreflex sensitivity was lower in patients (6.4 +/- 7.2 ms/mmHg) than in controls (14.7 +/- 6.6 ms/mmHg; P +/- 0.011). Mean office blood pressure and heart rate were normal in patients (123.3 +/- 11.9/79.0 +/- 7.3 mmHg and 67.5 +/- 9.4 beats/min, respectively) and controls (117.8 +/- 10.6/74.0 +/- 6.8 mmHg and 61.1 +/- 9.2 beats/min, respectively). Blood pressure variability was increased during ambulatory measurements. Three patients exhibited orthostatic hypotension. The Valsalva ratio, an index of baroreflex-mediated cardiovagal innervation, was lower in patients (1.4 +/- 0.2) than in controls (1.8 +/- 0.5; P +/- 0.008). The normocapnic ventilatory response to hypoxia was absent in all patients, whereas a small residual response to hypoxia was observed under hypercapnic conditions in two patients. CONCLUSIONS Bilateral carotid body tumor resection results in heterogeneous expression of arterial baroreflex dysfunction, whereas the normocapnic hypoxic drive is invariably abolished as a result of peripheral chemoreflex failure.
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Affiliation(s)
- Henri J L M Timmers
- Department of General Internal Medicine (541), Department of Otorhinolaryngology, University Medical Center St Radboud, Geert Grooteplein Zuid 8, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
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Biaggioni I. Sympathetic control of the circulation in hypertension: lessons from autonomic disorders. Curr Opin Nephrol Hypertens 2003; 12:175-80. [PMID: 12589178 DOI: 10.1097/00041552-200303000-00008] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF THE REVIEW Inappropriate sympathetic overactivity is consistently observed in patients with essential hypertension. The present review summarizes the recent advances that have been made in our understanding of the role of the sympathetic nervous system in hypertension. RECENT FINDINGS Studies in patients with autonomic disorders underscore the role of the sympathetic nervous system in the long-term maintenance of hypertension. Abnormalities in the afferent limb of the sympathetic nervous system, in the regulation of central neurons where sympathetic outflow originates, and in the modulation of efferent sympathetic function, can all produce autonomic disorders that are associated with hypertension. More subtle dysfunctions in any of these components have been described in essential hypertension and can contribute to its pathogenesis. These include impaired buffering capacity of arterial baroreflexes, increased central sympathetic outflow, and enhanced norepinephrine release (or decrease reuptake) from sympathetic nerve terminals. Whether genetic polymorphisms of adrenoreceptors are associated with essential hypertension is an area of active research. SUMMARY Increased sympathetic activity can contribute to sustained hypertension not only because of its hemodynamic effects (increased cardiac output and vascular resistance), but also by altering renal and water handling by the kidney, and by inducing cardiac and vascular remodeling. Antihypertensive agents that directly or indirectly target this sympathetic overactivity may be particularly useful in long-term treatment of essential hypertension.
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Affiliation(s)
- Italo Biaggioni
- Department of Medicine and Pharmacology, Division of Clinical Pharmacology, Vanderbilt University, Nashville, Tennessee 37212, USA.
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Timmers HJLM, Karemaker JM, Wieling W, Kaanders JHAM, Folgering HTM, Marres HAM, Lenders JWM. Arterial baroreflex and peripheral chemoreflex function after radiotherapy for laryngeal or pharyngeal cancer. Int J Radiat Oncol Biol Phys 2002; 53:1203-10. [PMID: 12128121 DOI: 10.1016/s0360-3016(02)02827-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE Denervation of the carotid sinus causes baroreflex and chemoreflex failure, resulting in labile hypertension and loss of hypoxic responsiveness. We investigated whether radiation therapy for laryngeal or pharyngeal cancer affects baroreflex and chemoreflex function. METHODS AND MATERIALS Twelve patients were studied after radiation therapy for locally advanced laryngeal or pharyngeal cancer (11 male, 1 female, age: 56.0 +/- 7.9 years), 3.3 years (median; range 1.0-4.7) after radiotherapy and 15 healthy controls (11 male, 4 female, 53.4 +/- 9.2 years). We measured baroreflex sensitivity (phenylephrine), blood pressure level and variability (24-h Spacelabs and 5-h Portapres recordings), responses to cardiovascular reflex tests, and the ventilatory responses to normocapnic and hypercapnic hypoxia. RESULTS Baroreflex sensitivity was lower in patients (9.7 +/- 7.8 ms/mm Hg) than in controls (17.5 +/- 10.3 ms/mm Hg, p = 0.011). Mean office blood pressure was significantly higher in patients (141.5 +/- 27.8/89.2 +/- 10.6 mm Hg, 63.3 +/- 12.3 bpm) than in controls (117.3 +/- 10.1/75.1 +/- 6.8 mm Hg, 61.8 +/- 10.8 bpm). Blood pressure variability was not different between groups, nor were the responses to reflex tests. The normo/hypercapnic ventilatory response to hypoxia was similar in patients (0.21 +/- 0.10/1.37 +/- 0.60 L/min/%) and controls (0.22 +/- 0.16/1.19 +/- 0.78 L/min/%). CONCLUSIONS Radiation therapy for laryngeal or pharyngeal carcinoma does not affect chemoreflex function, but results in an attenuated baroreflex sensitivity. Clinically relevant blood pressure lability is absent however.
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Affiliation(s)
- Henri J L M Timmers
- Department of Internal Medicine, University Medical Center, Nijmegen, The Netherlands.
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Jordan J, Biaggioni I. Diagnosis and treatment of supine hypertension in autonomic failure patients with orthostatic hypotension. J Clin Hypertens (Greenwich) 2002; 4:139-45. [PMID: 11927799 PMCID: PMC8099208 DOI: 10.1111/j.1524-6175.2001.00516.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Orthostatic hypotension is seen in various medical conditions. It can be secondary to medications or volume depletion. It can also be due to autonomic neuropathy secondary to other diseases, such as diabetes mellitus, or to primary degenerative processes of the autonomic nervous system. Orthostatic hypotension dominates the clinical picture of patients suffering from autonomic failure. Paradoxically, about one half of these patients also suffer from supine hypertension, which induces pressure natriuresis, worsening orthostatic hypotension. It also complicates the treatment of orthostatic hypotension. Supine hypertension is mediated by an increase in peripheral vascular resistance. This is due to residual sympathetic tone in patients with multiple system atrophy (Shy-Drager syndrome), but the cause is not known in patients with pure autonomic failure, who have increased vascular resistance despite very low levels or plasma norepinephrine and renin activity. The recent observation that patients with supine hypertension develop left ventricular hypertrophy suggests they should be treated. During the day, avoiding the supine position is often all that is required. Short-acting vasodilators (e.g., transdermal nitroglycerin) can be used during the night.
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Affiliation(s)
- Jens Jordan
- From the Hypotension and Syncope Unit, Clinical Research Center, Franz Volhard Clinic, Medical Faculty of the Charité, Humboldt University, Berlin, Germany; and the Division of Clinical Pharmacology, Department of Medicine and Pharmacology, and the Autonomic Dysfunction Center, Vanderbilt University, Nashville, TN
| | - Italo Biaggioni
- From the Hypotension and Syncope Unit, Clinical Research Center, Franz Volhard Clinic, Medical Faculty of the Charité, Humboldt University, Berlin, Germany; and the Division of Clinical Pharmacology, Department of Medicine and Pharmacology, and the Autonomic Dysfunction Center, Vanderbilt University, Nashville, TN
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Abstract
Nonpharmacologic and pharmacologic treatment can significantly attenuate the symptoms of orthostatic hypotension. Some of the interventions that are used to treat orthostatic hypotension have been known for decades. However, several new treatment strategies have been developed in recent years. New knowledge about the pathophysiology of orthostatic syndromes has been gathered that will strongly influence the way treatments are tailored to individual patients. For example, patients with and without residual autonomic function exhibit differential responses to certain treatments. A large subgroup of patients with severe autonomic failure show a profound pressor response to water drinking. This simple effect can be exploited to treat orthostatic and postprandial hypotension in some patients. New bioengineering technologies that attempt to replicate normal baroreflex mechanisms may become available for selected patients with central autonomic dysfunction.
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Affiliation(s)
- J Jordan
- Franz-Volhard-Clinic, Haus 129, Humboldt University, Wiltbergstr. 50, 13125 Berlin, Germany.
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De Toma G, Nicolanti V, Plocco M, Cavallaro G, Letizia C, Piccirillo G, Cavallaro A. Baroreflex failure syndrome after bilateral excision of carotid body tumors: an underestimated problem. J Vasc Surg 2000; 31:806-10. [PMID: 10753291 DOI: 10.1067/mva.2000.103789] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Carotid body tumors (CBTs) are relatively rare paragangliomas that develop from neural crest cells at the bifurcation of the common carotid artery. They are generally slow growing and benign. Excision is currently considered the treatment of choice, although vascular and especially neural injuries are still relatively frequent in patients with large or bilaterally resected tumors. The baroreflex failure syndrome (BFS) has recently been identified as a severe, rarely recognized, and certainly underestimated complication after the bilateral excision of CBTs. The present report describes a case of a bilateral CBT followed by BFS and reviews the experiences reported in the literature. In light of the low incidence of malignancy of these tumors, their biologic behavior, their very high rate of cranial nerve palsy, and the occurrence of BFS in bilaterally resected paragangliomas, the current practice of bilaterally removing these tumors is questioned.
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Affiliation(s)
- G De Toma
- First Department of Surgery, University of Rome La Sapienza, Italy
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Jardine DL, Melton IC, Bennett SI, Crozier IG, Donaldson IM, Ikram H. Baroreceptor denervation presenting as part of a vagal mononeuropathy. Clin Auton Res 2000; 10:69-75. [PMID: 10823338 DOI: 10.1007/bf02279894] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A 48-year-old woman presented with a history of progressive cough, dysphonia, dysphagia, and postural symptoms. Subsequent neurological investigations were consistent with a bilateral vagal mononeuropathy, and neurosarcoidosis was diagnosed after scalene node biopsy. Autonomic investigations including microneurography, neurohormones, and heart rate variability demonstrated arterial and cardiopulmonary baroreflex failure. In addition, parasympathetic control of heart rate was absent and consistent with a bilateral, nonselective lesion in the proximal vagus.
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Affiliation(s)
- D L Jardine
- Cardiology Department, Christchurch Hospital, New Zealand.
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Ali YS, Daamen N, Jacob G, Jordan J, Shannon JR, Biaggioni I, Robertson D. Orthostatic intolerance: a disorder of young women. Obstet Gynecol Surv 2000; 55:251-9. [PMID: 10758621 DOI: 10.1097/00006254-200004000-00025] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Orthostatic intolerance (OI) is a cause of significant disability in otherwise healthy women seen by gynecologists. Orthostatic tachycardia is often the most obvious hemodynamic abnormality found in OI patients, but symptoms may include dizziness, visual changes, discomfort in the head or neck, poor concentration, fatigue, palpitations, tremulousness, anxiety, and, in some cases, fainting (syncope). It is the most common disorder of blood pressure regulation after essential hypertension, and patients with OI are traditionally women of childbearing age. Estimates suggest that at least 500,000 Americans suffer from some form of OI, and such patients comprise the largest group referred to centers specialized in autonomic disorders. This article reviews recent advances made in the understanding of this condition, potential pathophysiological mechanisms contributing to orthostatic intolerance, and therapeutic alternatives currently available for the management of these patients.
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Affiliation(s)
- Y S Ali
- Vanderbilt University, Nashville, Tennessee 37232-2195, USA
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Jordan J, Shannon JR, Jacob G, Pohar B, Robertson D. Interaction of genetic predisposition and environmental factors in the pathogenesis of idiopathic orthostatic intolerance. Am J Med Sci 1999; 318:298-303. [PMID: 10555091 DOI: 10.1097/00000441-199911000-00003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The hemodynamic and autonomic abnormalities in idiopathic orthostatic intolerance (IOI) have been studied extensively. However, the mechanisms underlying these abnormalities are not understood. If genetic predisposition were important in the pathogenesis of IOI, monozygotic twins of patients with IOI should have similar hemodynamic and autonomic abnormalities. METHODS We studied two patients with IOI and their identical twins. Both siblings in the first twin pair had orthostatic symptoms, significant orthostatic tachycardia, increased plasma norepinephrine levels with standing, and a greater than normal decrease in systolic blood pressure with trimethaphan infusion. RESULTS Both siblings had a normal response of plasma renin activity to upright posture. In the second twin pair, only one sibling had symptoms of orthostatic intolerance, an orthostatic tachycardia, and raised plasma catecholamines with standing. The affected sibling had inappropriately low plasma renin activity with standing and was 8-fold more sensitive to the pressor effect of phenylephrine than the unaffected sibling. CONCLUSIONS We conclude that in some patients, IOI seems to be strongly influenced by genetic factors. In others, however, IOI may be mainly caused by nongenetic factors. These findings suggest that IOI is heterogenous, and that both genetic and environmental factors contribute individually or collectively to create the IOI phenotype.
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Affiliation(s)
- J Jordan
- Clinical Research Center, Franz Volhard Clinic at the Max Delbrueck Centrum, Berlin, Germany
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Jordan J, Shannon JR, Jacob G, Pohar B, Robertson D. Interaction of Genetic Predisposition and Environmental Factors in the Pathogenesis of Idiopathic Orthostatic Intolerance. Am J Med Sci 1999. [DOI: 10.1016/s0002-9629(15)40642-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Affiliation(s)
- D Robertson
- Clinical Research Center, Vanderbilt University, Nashville, Tennessee 37232-2195, USA.
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Robertson RM, Medina E, Shah N, Furlan R, Mosqueda-Garcia R. Neurally mediated syncope: pathophysiology and implications for treatment. Am J Med Sci 1999; 317:102-9. [PMID: 10037113 DOI: 10.1097/00000441-199902000-00004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Neurally mediated syncope may occur in patients whose hemodynamic picture does not fit the characteristics of orthostatic intolerance as described elsewhere in this issue. Nonetheless, patients who suffer from neurocardiogenic or vasovagal syncope may be seriously incapacitated by their episodes of syncope or presyncope. Although it has been assumed that vagal activation as a result of stimulation of ventricular mechanoreceptors is essential to the production of these episodes, several critical observations are presented that suggest that other mechanisms may also be operative in some patient subsets. In addition, evidence is presented that the sympathetic responses of many of these patients may be reduced rather than increased and that abnormal baroreflex responsiveness may also play an causative role. These findings suggest new avenues for therapy in this field in which carefully controlled, randomized, double-blind trials are scarce.
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Affiliation(s)
- R M Robertson
- Autonomic Dysfunction Center, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.
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Jordan J, Shannon JR, Pohar B, Paranjape SY, Robertson D, Robertson RM, Biaggioni I. Contrasting effects of vasodilators on blood pressure and sodium balance in the hypertension of autonomic failure. J Am Soc Nephrol 1999; 10:35-42. [PMID: 9890307 DOI: 10.1681/asn.v10135] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Supine hypertension, which is very common in patients with autonomic failure, limits the use of pressor agents and induces nighttime natriuresis. In 13 patients with severe orthostatic hypotension due to autonomic failure (7 women, 6 men, 72 +/- 3 yr) and supine hypertension, the effect of 30 mg nifedipine (n = 10) and 0.025 to 0.2 mg/h nitroglycerin patch (n = 11) on supine BP, renal sodium handling, and orthostatic tolerance was determined. Medications were given at 8 p.m.; patients stood up at 8 a.m. Nitroglycerin was removed at 6 a.m. Compared with placebo, nifedipine and nitroglycerin decreased systolic BP during the night by a maximum of 37 +/- 9 and 36 +/- 10 mmHg, respectively (P < 0.01). At 8 a.m., supine systolic BP was 23 +/- 7 mmHg lower with nifedipine than with placebo (P < 0.05), but was similar with nitroglycerin and placebo. Sodium excretion during the night was not reduced with nitroglycerin (0.13 +/- 0.02 mmol/mg creatinine [Cr] versus 0.15 +/- 0.03 mmol/mg Cr with placebo), but it was increased with nifedipine (0.35 +/- 0.06 mmol/mg Cr versus 0.13 +/- 0.02 mmol/mg Cr with placebo, P < 0.05). Nifedipine but not nitroglycerin worsened orthostatic hypotension in the morning. It is concluded that nifedipine and transdermal nitroglycerin are effective in controlling supine hypertension in patients with autonomic failure. However, nifedipine has a prolonged depressor effect and worsens orthostatic hypotension in the morning. The decrease in pressure natriuresis that would be expected with the substantial decrease in BP obtained with nitroglycerin and nifedipine may be offset by a direct effect of both drugs on renal sodium handling.
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Affiliation(s)
- J Jordan
- Clinical Research Center, Franz Volhard Clinic, Berlin, Germany
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