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Visniauskas B, Ogola BO, Kilanowski-Doroh I, Harris NR, Diaz ZT, Horton AC, Blessinger SA, McNally AB, Zimmerman MA, Arnold AC, Lindsey SH. Hypertension disrupts the vascular clock in both sexes. Am J Physiol Heart Circ Physiol 2024; 327:H765-H777. [PMID: 39058434 DOI: 10.1152/ajpheart.00131.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 07/16/2024] [Accepted: 07/22/2024] [Indexed: 07/28/2024]
Abstract
Blood pressure (BP) displays a circadian rhythm and disruptions in this pattern elevate cardiovascular risk. Although both central and peripheral clock genes are implicated in these processes, the importance of vascular clock genes is not fully understood. BP, vascular reactivity, and the renin-angiotensin-aldosterone system display overt sex differences, but whether changes in circadian patterns underlie these differences is unknown. Therefore, we hypothesized that circadian rhythms and vascular clock genes would differ across sex and would be blunted by angiotensin II (ANG II)-induced hypertension. ANG II infusion elevated BP and disrupted circadian patterns similarly in both males and females. In females, an impact on heart rate (HR) and locomotor activity was revealed, whereas in males hypertension suppressed baroreflex sensitivity (BRS). A marked disruption in the vascular expression patterns of period circadian regulator 1 (Per1) and brain and muscle aryl hydrocarbon receptor nuclear translocator like protein 1 (Bmal1) was noted in both sexes. Vascular expression of the G protein-coupled estrogen receptor (Gper1) also showed diurnal synchronization in both sexes that was similar to that of Per1 and Per2 and disrupted by hypertension. In contrast, vascular expression of estrogen receptor 1 (Esr1) showed a diurnal rhythm and hypertension-induced disruption only in females. This study shows a strikingly similar impact of hypertension on BP rhythmicity, vascular clock genes, and vascular estrogen receptor expression in both sexes. We identified a greater impact of hypertension on locomotor activity and heart rate in females and on baroreflex sensitivity in males and also revealed a diurnal regulation of vascular estrogen receptors. These insights highlight the intricate ties between circadian biology, sex differences, and cardiovascular regulation.NEW & NOTEWORTHY This study reveals that ANG II-induced hypertension disrupts the circadian rhythm of blood pressure in both male and female mice, with parallel effects on vascular clock gene and estrogen receptor diurnal patterns. Notably, sex-specific responses to hypertension in terms of locomotor activity, heart rate, and baroreflex sensitivity are revealed. These findings pave the way for chronotherapeutic strategies tailored to mitigate cardiovascular risks associated with disrupted circadian rhythms in hypertension.
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Affiliation(s)
- Bruna Visniauskas
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, Louisiana, United States
| | - Benard O Ogola
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, Louisiana, United States
- Vascular Biology Center and Department of Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia, United States
| | - Isabella Kilanowski-Doroh
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, Louisiana, United States
| | - Nicholas R Harris
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, Louisiana, United States
| | - Zaidmara T Diaz
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, Louisiana, United States
| | - Alec C Horton
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, Louisiana, United States
| | - Sophia A Blessinger
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, Louisiana, United States
| | - Alexandra B McNally
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, Louisiana, United States
| | - Margaret A Zimmerman
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, Louisiana, United States
| | - Amy C Arnold
- Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, United States
| | - Sarah H Lindsey
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, Louisiana, United States
- Tulane Center of Excellence in Sex-Based Biology and Medicine, Tulane University, New Orleans, Louisiana, United States
- Tulane Brain Institute, Tulane University, New Orleans, Louisiana, United States
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2
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Triki L, Gammoudi N, Chtourou L, Gallas S, Tahri N, Zouari HG. Dysfunction of the autonomic nervous system in gastro-esophageal reflux disease: Consequences for the cardiovascular system. Neurophysiol Clin 2024; 54:103009. [PMID: 39244825 DOI: 10.1016/j.neucli.2024.103009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 08/16/2024] [Accepted: 08/16/2024] [Indexed: 09/10/2024] Open
Abstract
OBJECTIVE The pathophysiology of gastro esophageal reflux disease (GERD) implicates autonomic dysregulation of the lower esophageal sphincter tone. Our goal is to investigate whether this dysregulation of the autonomic nervous system (ANS) function observed in isolated GERD cases can affect other systems, such as cardiovascular regulation. METHODS Twenty-five participants were included in the study, 11 patients with isolated GERD and 14 controls. All patients and 7 controls responded to a COMposite Autonomic Symptoms Score 31 (COMPASS 31) questionnaire and underwent functional explorations including EMLA test, sympathetic skin response (SSR), 24-hour heart rate recording and ambulatory blood pressure measurement (ABPM). Seven additional controls underwent a 24-hour heart rate recording only. RESULTS GERD patients (Age: mean 36.81±7.82; SR= 0.22) showed high clinically dysautonomic scores (COMPASS 31) (p = 0.015), increased Heart rate variability (HRV) parameters (daytime, nighttime, 24-hour SDNN (standard deviation of the RR interval (NN)), respectively p = 0.003, p < 0.001, p = 0.001; daytime and nighttime very low frequencies (VLF) respectively p = 0.03 and p = 0.007), impaired nocturnal dipping of blood pressure (3/11 patients) and high positivity of EMLA test (7/11, p = 0.037). These outcomes were strongly correlated with clinical dysautonomic assessment. No difference was observed between patients and controls regarding SSR. CONCLUSION Our data suggests a high parasympathetic tone amongst patients with GERD and a dysregulation of parasympathetic and sympathetic balance in the cardiovascular system with an impairment of the peripheral sympathetic fibers of cutaneous microcirculation, assessed by the EMLA test. GERD may be an inaugural symptom of autonomic neuropathy. Further functional exploration of peripheral small fibers seems to be necessary.
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Affiliation(s)
- Leila Triki
- Functional Explorations Department, Habib Bourguiba Hospital, Sfax Tunisia; LR19ES15, Medical School, University of Sfax, Tunisia
| | - Nouha Gammoudi
- Functional Explorations Department, Sahloul Hospital, Sousse Tunisia; Medical School, University of Monastir, Tunisia
| | - Lassaad Chtourou
- Gastrointestinal Department, Hedi Chaker Hospital, Sfax Tunisia; Medical School, University of Sfax, Tunisia
| | - Syrine Gallas
- Functional Explorations Department, Sahloul Hospital, Sousse Tunisia; Medical School, University of Monastir, Tunisia
| | - Nabil Tahri
- Gastrointestinal Department, Hedi Chaker Hospital, Sfax Tunisia; Medical School, University of Sfax, Tunisia
| | - Hela G Zouari
- Functional Explorations Department, Habib Bourguiba Hospital, Sfax Tunisia; LR19ES15, Medical School, University of Sfax, Tunisia.
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Juraschek SP, Cortez MM, Flack JM, Ghazi L, Kenny RA, Rahman M, Spikes T, Shibao CA, Biaggioni I. Orthostatic Hypotension in Adults With Hypertension: A Scientific Statement From the American Heart Association. Hypertension 2024; 81:e16-e30. [PMID: 38205630 PMCID: PMC11067441 DOI: 10.1161/hyp.0000000000000236] [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] [Indexed: 01/12/2024]
Abstract
Although orthostatic hypotension (OH) has long been recognized as a manifestation of autonomic dysfunction, a growing body of literature has identified OH as a common comorbidity of hypertension. This connection is complex, related to pathophysiology in blood pressure regulation and the manner by which OH is derived as the difference between 2 blood pressure measurements. While traditional therapeutic approaches to OH among patients with neurodegenerative disorders focus on increasing upright blood pressure to prevent cerebral hypoperfusion, the management of OH among patients with hypertension is more nuanced; resting hypertension is itself associated with adverse outcomes among these patients. Although there is substantial evidence that intensive blood pressure treatment does not cause OH in the majority of patients with essential hypertension, some classes of antihypertensive agents may unmask OH in patients with an underlying autonomic impairment. Practical steps to manage OH among adults with hypertension start with (1) a thorough characterization of its patterns, triggers, and cause; (2) review and removal of aggravating factors (often pharmacological agents not related to hypertension treatment); (3) optimization of an antihypertensive regimen; and (4) adoption of a tailored treatment strategy that avoids exacerbating hypertension. These strategies include countermaneuvers and short-acting vasoactive agents (midodrine, droxidopa). Ultimately, further research is needed on the epidemiology of OH, the impact of hypertension treatment on OH, approaches to the screening and diagnosis of OH, and OH treatment among adults with hypertension to improve the care of these patients and their complex blood pressure pathophysiology.
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Patel H, Berglund F, Laffin L, Ruthmann N. Should Antihypertensive Medications Be Routinely Administered in the Nighttime Instead of Daytime? Am J Med 2023; 136:975-978. [PMID: 37451389 DOI: 10.1016/j.amjmed.2023.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/22/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
The optimal timing for administering antihypertensive medications remains a topic of debate. This review examines the effectiveness of nighttime vs daytime administration of antihypertensive medications in controlling blood pressure (BP). The MAPEC and Hygia trials suggest that nighttime dosing achieves better BP control and significantly lowers cardiovascular events. However, concerns about methodology and generalizability have been raised. In contrast, the HARMONY and TIME trials found no significant difference in BP control nor cardiovascular outcomes between daytime and nighttime dosing. Current research suggests that the timing of antihypertensive medication administration may not be a crucial factor. Therefore, the decision about the timing of antihypertensive medications administration should be individualized, taking into account patient preference and clinical context, in order to promote consistent compliance.
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Affiliation(s)
| | | | - Luke Laffin
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio
| | - Nicholas Ruthmann
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio
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Okamoto LE, Celedonio JE, Smith EC, Paranjape SY, Black BK, Wahba A, Park JW, Shibao CA, Diedrich A, Biaggioni I. Continuous Positive Airway Pressure for the Treatment of Supine Hypertension and Orthostatic Hypotension in Autonomic Failure. Hypertension 2023; 80:650-658. [PMID: 36601916 PMCID: PMC10128890 DOI: 10.1161/hypertensionaha.122.20081] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 12/14/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Supine hypertension affects most patients with orthostatic hypotension (OH) due to autonomic failure, but it is often untreated for fear of worsening OH. We hypothesized that increasing intrathoracic pressure with continuous positive airway pressure (CPAP) had a Valsalva-like blood-pressure-lowering effect that could be used to treat nocturnal supine hypertension in these patients, while reducing nocturnal pressure diuresis and improving daytime OH. METHODS In Protocol 1, we determined the acute hemodynamic effects of increasing levels of CPAP (0, 4, 8, 12, and 16 cm H2O, 3 minutes each) in 26 patients with autonomic failure and supine hypertension studied while awake and supine. In Protocol 2 (n=11), we compared the effects of overnight therapy with CPAP (8-12 cm H2O for 8 hours) versus placebo on nocturnal supine hypertension, nocturnal diuresis and daytime OH in a 2-night crossover study. RESULTS In Protocol 1, acute CPAP (4-16 cm H2O) decreased systolic blood pressure in a dose-dependent manner (maximal drop 22±4 mmHg with CPAP 16) due to reductions in stroke volume (-16+3%) and cardiac output (-14±3%). Systemic vascular resistance and heart rate remained unchanged. In Protocol 2, overnight CPAP lowered nighttime systolic blood pressure (maximal change -23±5 versus placebo -1±7 mmHg; P=0.023) and was associated with lower nighttime diuresis (609±84 versus placebo 1004±160 mL; P=0.004) and improved morning orthostatic tolerance (AUC upright SBP 642±121 versus placebo 410±109 mmHg*min; P=0.014). CONCLUSIONS CPAP is a novel nonpharmacologic approach to treat the supine hypertension of autonomic failure while improving nocturia and daytime OH. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03312556.
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Affiliation(s)
- Luis E. Okamoto
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jorge E. Celedonio
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Emily C. Smith
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sachin Y. Paranjape
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bonnie K. Black
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amr Wahba
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jin-Woo Park
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cyndya A. Shibao
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - André Diedrich
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Italo Biaggioni
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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6
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Jones L, Blair J, Hawcutt DB, Lip GYH, Shantsila A. Hypertension in Turner syndrome: a review of proposed mechanisms, management and new directions. J Hypertens 2023; 41:203-211. [PMID: 36583347 DOI: 10.1097/hjh.0000000000003321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Acquired cardiovascular diseases account for much of the increased risk of premature death in patients with Turner syndrome (TS). Hypertension is a major modifiable cardiovascular risk factor. It has a high prevalence in TS developing at an early age and thus leading to prolonged exposure to high blood pressure. The aetiology for hypertension in TS is largely unknown. It is likely multifactorial, and recent hypotheses include altered sympathetic tone, vasculopathy and endocrine factors. In this review article we aim to provide a comprehensive review of data on mechanisms of hypertension in TS and their implication for diagnostics and optimal choice of antihypertensive treatments. Ultimately this knowledge should help prevent hypertension-related complications, and improve quality of life and life expectancy for patients with TS.
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Affiliation(s)
- Lily Jones
- Department of Women's and Children's Health, University of Liverpool
| | - Joanne Blair
- Department of Endocrinology, Alder Hey Children's NHS Foundation Trust
| | - Daniel B Hawcutt
- Department of Women's and Children's Health, University of Liverpool
- NIHR Alder Hey Clinical Research Facility, Alder Hey Children's NHS Foundation Trust
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Alena Shantsila
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
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7
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Wallbach M, Born E, Schäfer A, Koziolek MJ. Effect of baroreflex activation therapy on dipping pattern in patients with resistant hypertension. J Clin Hypertens (Greenwich) 2022; 25:22-29. [PMID: 36545753 PMCID: PMC9832236 DOI: 10.1111/jch.14620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/21/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
A relevant number of patients with resistant hypertension do not achieve blood pressure (BP) dipping during nighttime. This inadequate nocturnal BP reduction is associated with elevated cardiovascular risks. The aim of this study was to evaluate whether a nighttime intensification of BAT might improve nocturnal BP dipping. In this prospective observational study, non-dippers treated with BAT for at least 6 months were included. BAT programming was modified in a two-step intensification of nighttime stimulation at baseline and week 6. Twenty-four hours ambulatory BP (ABP) was measured at inclusion and after 3 months. A number of 24 patients with non- or inverted dipping pattern, treated with BAT for a median of 44 months (IQR 25-52) were included. At baseline of the study, patients were 66 ± 9 years old, had a BMI of 33 ± 6 kg/m2 , showed an office BP of 135 ± 22/72 ± 10 mmHg, and took a median number of antihypertensives of 6 (IQR 4-9). Nighttime stimulation of BAT was adapted by an intensification of pulse width from 237 ± 161 to 267 ± 170 μs (p = .003) while frequency (p = .10) and amplitude (p = .95) remained unchanged. Uptitration of BAT programming resulted in an increase of systolic dipping from 2 ± 6 to 6 ± 8% (p = .03) accompanied with a significant improvement of dipping pattern (p = .02). Twenty four hours ABP, day- and nighttime ABP remained unchanged. Programming of an intensified nighttime BAT interval improved dipping profile in patients treated with BAT, while the overall 24 h ABP did not change. Whether the improved dipping response contributes to a reduction of cardiovascular risk beyond the BP-lowering effects of BAT, however, remains to be shown.
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Affiliation(s)
- Manuel Wallbach
- Department of Nephrology and RheumatologyUniversity Medical Center GöttingenGermany,German Center for Cardiovascular Research (DZHK)Partner Site GöttingenGermany
| | - Ellen Born
- Department of Nephrology and RheumatologyUniversity Medical Center GöttingenGermany
| | - Ann‐Kathrin Schäfer
- Department of Nephrology and RheumatologyUniversity Medical Center GöttingenGermany
| | - Michael J. Koziolek
- Department of Nephrology and RheumatologyUniversity Medical Center GöttingenGermany,German Center for Cardiovascular Research (DZHK)Partner Site GöttingenGermany
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8
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Concurrent Aerobic Plus Resistance Training Elicits Different Effects on Short-Term Blood Pressure Variability of Hypertensive Patients in Relation to Their Nocturnal Blood Pressure Pattern. Medicina (B Aires) 2022; 58:medicina58111682. [DOI: 10.3390/medicina58111682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/16/2022] [Accepted: 11/18/2022] [Indexed: 11/22/2022] Open
Abstract
Background and Objectives: The purpose of this study was to investigate the effects of a 12-week concurrent training (CT) (i.e., aerobic plus resistance exercise) on short–term blood pressure variability (BPV) and BP values in hypertensive patients with non-dippper BP nocturnal pattern and underlying coronary artery disease. Material and Methods: The study included 72 consecutive patients who were divided into two groups according to the nocturnal BP pattern: dipping pattern (33 pts) and non-dipping (39 pts). Before starting CT and at 12 weeks, patients underwent the six minute walk test, ergometric test, assessment of 1-repetiton maximum (1 RM), and 24/h BP monitoring (24-h ABPM). Results: After CT, exercise capacity increased in both groups in a similar fashion. Twenty-four/h systolic BPV and daytime systolic BPV decreased significantly in the dipping group while they were unchanged in the non-dipping group (between groups changes: −1.0 ± 0.4 mmHg and −1.3 ± 0.9 mmHg; p = 0.02 and p = 0.006, respectively). Twenty-four/h systolic BP and daytime systolic BP decreased significantly in the dipping group while they were unchanged in the non-dipping group (between groups changes: −7.1 ± 2.6 mmHg and −7.8 ± 2.4 mmHg; p = 0.004 and p = 0.002, respectively). Nighttime systolic BP and BPV was unchanged in both groups. Twenty-four/h diastolic BP presented small but not significant changes in both groups. Conclusions: The effects of CT on BPV and BP were blunted in hypertensive subjects with a non-dipping BP pattern.
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9
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Advances in the Pathophysiology and Management of Supine Hypertension in Patients with Neurogenic Orthostatic Hypotension. Curr Hypertens Rep 2022; 24:45-54. [PMID: 35230654 PMCID: PMC9553128 DOI: 10.1007/s11906-022-01168-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Patients with neurogenic orthostatic hypotension (OH) frequently have hypertension in the supine position (sHTN). We review the controversies surrounding the need and safety of treating sHTN in patients with OH. RECENT FINDINGS The presence of sHTN complicates the management of OH because treatment of one can worsen the other. New approaches have been developed to treat OH without worsening sHTN by preferentially improving standing blood pressure, such as medications that harness the patient's residual sympathetic tone like pyridostigmine and atomoxetine, and devices such as an automated abdominal binder that targets the inappropriate splanchnic venous pooling causing OH. There is a reluctance to treat sHTN for fear of increasing the risks of falls and syncope associated with OH, thought to be more immediate and dangerous than the late complications of organ damage associated with sHTN. This, however, does not take into account that nighttime sHTN induces natriuresis, volume loss, and begets daytime orthostatic hypotension. It is possible to treat sHTN in ways that reduce the risk of worsening OH. Furthermore, novel approaches, such as the use of local heat can control nighttime sHTN, reduce nocturia, and improve OH. Although continued progress is needed, recent findings offer hope that we can treat nocturnal sHTN and at the same time improve daytime OH, lessening the controversy whether to treat or not sHTN.
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Newman L, O'Connor JD, Romero-Ortuno R, Reilly RB, Kenny RA. Supine Hypertension Is Associated With an Impaired Cerebral Oxygenation Response to Orthostasis: Finding From The Irish Longitudinal Study on Ageing. Hypertension 2021; 78:210-219. [PMID: 34058851 DOI: 10.1161/hypertensionaha.121.17111] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Louise Newman
- The Irish Longitudinal Study on Ageing (L.N., J.D.O., R.R.-O., R.A.K.), Trinity College Dublin, Ireland
| | - John D O'Connor
- The Irish Longitudinal Study on Ageing (L.N., J.D.O., R.R.-O., R.A.K.), Trinity College Dublin, Ireland
| | - Roman Romero-Ortuno
- The Irish Longitudinal Study on Ageing (L.N., J.D.O., R.R.-O., R.A.K.), Trinity College Dublin, Ireland.,Discipline of Medical Gerontology, School of Medicine (R.R.-O., R.B.R., R.A.K.), Trinity College Dublin, Ireland.,Mercer's Institute for Successful Ageing, St. James' Hospital, Dublin, Ireland (R.R.-O., R.A.K.)
| | - Richard B Reilly
- Trinity Centre for Biomedical Engineering (R.B.R.), Trinity College Dublin, Ireland.,Discipline of Medical Gerontology, School of Medicine (R.R.-O., R.B.R., R.A.K.), Trinity College Dublin, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing (L.N., J.D.O., R.R.-O., R.A.K.), Trinity College Dublin, Ireland.,Discipline of Medical Gerontology, School of Medicine (R.R.-O., R.B.R., R.A.K.), Trinity College Dublin, Ireland.,Mercer's Institute for Successful Ageing, St. James' Hospital, Dublin, Ireland (R.R.-O., R.A.K.)
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11
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Bassam A, Thacker J, Walter LM, Davey MJ, Nixon GM, Horne RS. Nocturnal dipping of heart rate is impaired in children with Down syndrome and sleep disordered breathing. Sleep Med 2021; 81:466-473. [PMID: 33872947 DOI: 10.1016/j.sleep.2021.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/10/2021] [Accepted: 03/16/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Children with Down syndrome (DS) are at increased risk for sleep disordered breathing (SDB), which can have adverse effects on the cardiovascular system. In adults with SDB, nocturnal dipping of heart rate (HR) and blood pressure (BP) is reduced, and this is associated with an increased risk of future cardiovascular events. We aimed to compare nocturnal dipping of HR and pulse transit time (PTT) (a surrogate inverse measure of BP change) in children with DS and SDB to those of typically developing (TD) children with and without SDB. METHODS 19 children with DS (3-18 years) were age and sex matched with 19 TD children without SDB (TD-) and with 19 TD children with matched severity of SDB (TD+). Nocturnal dipping was assessed as the percentage change in HR and PTT from wake before sleep onset to total sleep, N2, N3 and REM sleep across the night and to the first cycle of sleep. RESULTS Children with DS exhibited reduced nocturnal dipping of HR during total sleep, N2, N3 and REM sleep and increased PTT (reduced BP dipping) in N2 sleep. Fewer children with DS exhibited a greater than 10% fall in HR between wake and N2 or REM sleep compared to TD+ children. CONCLUSIONS Our findings demonstrate significantly reduced nocturnal dipping of HR in children with DS compared to TD children matched for SDB severity, suggesting SDB has a greater cardiovascular effect in these children. Further studies are required to fully understand the mechanisms involved and to assess if treatment of SDB improves nocturnal dipping.
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Affiliation(s)
- Ahmad Bassam
- Department of Paediatrics, Monash University, The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Julie Thacker
- Department of Paediatrics, Monash University, The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Lisa M Walter
- Department of Paediatrics, Monash University, The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Margot J Davey
- Department of Paediatrics, Monash University, The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne Children's Sleep Centre, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Gillian M Nixon
- Department of Paediatrics, Monash University, The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne Children's Sleep Centre, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Rosemary Sc Horne
- Department of Paediatrics, Monash University, The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.
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12
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Isaacson SH, Dashtipour K, Mehdirad AA, Peltier AC. Management Strategies for Comorbid Supine Hypertension in Patients with Neurogenic Orthostatic Hypotension. Curr Neurol Neurosci Rep 2021; 21:18. [PMID: 33687577 PMCID: PMC7943503 DOI: 10.1007/s11910-021-01104-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW In autonomic failure, neurogenic orthostatic hypotension (nOH) and neurogenic supine hypertension (nSH) are interrelated conditions characterized by postural blood pressure (BP) dysregulation. nOH results in a sustained BP drop upon standing, which can lead to symptoms that include lightheadedness, orthostatic dizziness, presyncope, and syncope. nSH is characterized by elevated BP when supine and, although often asymptomatic, may increase long-term cardiovascular and cerebrovascular risk. This article reviews the pathophysiology and clinical characteristics of nOH and nSH, and describes the management of patients with both nOH and nSH. RECENT FINDINGS Pressor medications required to treat the symptoms of nOH also increase the risk of nSH. Because nOH and nSH are hemodynamically opposed, therapies to treat one condition may exacerbate the other. The management of patients with nOH who also have nSH can be challenging and requires an individualized approach to balance the short- and long-term risks associated with these conditions. Approaches to manage neurogenic BP dysregulation include nonpharmacologic approaches and pharmacologic treatments. A stepwise treatment approach is presented to help guide neurologists in managing patients with both nOH and nSH.
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Affiliation(s)
- Stuart H Isaacson
- Parkinson's Disease and Movement Disorders Center of Boca Raton, 951 NW 13th Street, Bldg. 5-E, Boca Raton, FL, USA.
| | - Khashayar Dashtipour
- Division of Movement Disorders, Department of Neurology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Ali A Mehdirad
- Wright State University, Dayton VA Medical Center, Dayton, OH, USA
| | - Amanda C Peltier
- Department of Neurology and Medicine, Vanderbilt University, Nashville, TN, USA
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13
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Biological pathways underlying the association between habitual long-sleep and elevated cardiovascular risk in adults. Sleep Med 2020; 78:135-140. [PMID: 33429289 DOI: 10.1016/j.sleep.2020.12.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/02/2020] [Accepted: 12/11/2020] [Indexed: 12/16/2022]
Abstract
Cardiovascular disease is the leading cause of death in the world. In addition to non-modifiable factors such as age and sex, cardiovascular risk is also driven by behavioral, and therefore somewhat modifiable, factors such as physical activity, diet, and sleep. It is well established that sleep duration has a U-shaped association with mortality and cardiovascular disease, with recent evidence suggesting that this association is observed even while controlling for the effects of comorbid conditions. Whereas several biological mechanisms mediating the association between chronic short sleep duration and cardiovascular risk have been established, the biological mechanisms underlying the relationship between habitual long sleep (≥9 h) duration and cardiovascular risk, in the absence of other chronic diseases, are not well understood. This review will focus on summarizing the literature investigating the mechanisms underlying the association between habitual long sleep duration and cardiovascular risk. We will also propose the mechanistic pathways, distinct from the ones for short sleep, by which habitual long sleep can increase cardiovascular disease.
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Abstract
Cardiovascular disorders, such as orthostatic hypotension and supine hypertension, are common in patients with neurodegenerative synucleinopathies such as Parkinson disease (PD), and may also occur in other conditions, such as peripheral neuropathies, that result in autonomic nervous system (ANS) dysfunction. Dysfunction and degeneration of the ANS are implicated in the development of orthostatic and postprandial hypotension and impaired thermoregulation. Neurogenic orthostatic hypotension (nOH) results from sympathetic failure and is a common autonomic disorder in PD. Supine hypertension may also occur as a result of both sympathetic and parasympathetic dysfunction in conjunction with nOH in the majority of patients with PD. Management of supine hypertension in the setting of nOH can be counterintuitive and challenging. Additionally, the presence of other noncardiovascular comorbidities, such as diabetes mellitus and peripheral edema, may further contribute to the burden of disease. ANS dysfunction thus presents major healthcare implications and challenges for neurology and cardiovascular practices, necessitating an integrated neurology and cardiology management approach.
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15
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Shibao CA, Biaggioni I. Management of Orthostatic Hypotension, Postprandial Hypotension, and Supine Hypertension. Semin Neurol 2020; 40:515-522. [PMID: 33058087 DOI: 10.1055/s-0040-1713886] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This review provides recommendations for the treatment of neurogenic orthostatic hypotension (nOH), postprandial hypotension, and supine hypertension. It focuses on novel treatment strategies and new insights into the mechanism underlying these conditions. Our goal is to provide practical advice for clinicians on how to screen, diagnose, and treat these conditions with nonpharmacological and pharmacological approaches. For each disorder, we offered a stepwise recommendation on how to apply these new concepts to successfully ameliorate the symptoms associated with OH to prevent syncope and falls. The management of OH in patients who also have supine hypertension requires special considerations and pharmacotherapy. It is noteworthy that there are few therapeutic options for OH and only two Food and Drug Administration-approved drugs for the treatment of OH and nOH based on randomized clinical trials. We will use these studies to develop evidence-based guidelines for OH. The research is limited for postprandial hypotension and supine hypertension, and therefore the recommendations will be based on small studies, clinical expertise, and, above all, an understanding of the underlying pathophysiology.
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Affiliation(s)
- Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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16
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Management of supine hypertension in patients with neurogenic orthostatic hypotension: scientific statement of the American Autonomic Society, European Federation of Autonomic Societies, and the European Society of Hypertension. J Hypertens 2020; 37:1541-1546. [PMID: 30882602 DOI: 10.1097/hjh.0000000000002078] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Supine hypertension commonly occurs in patients with neurogenic orthostatic hypotension due to autonomic failure. Supine hypertension promotes nocturnal sodium excretion and orthostatic hypotension, thus, interfering with quality of life. Perusal of the literature on essential hypertension and smaller scale investigations in autonomic failure patients also suggest that supine hypertension may predispose to cardiovascular and renal disease. These reasons provide a rationale for treating supine hypertension. Yet, treatment of supine hypertension, be it through nonpharmacological or pharmacological approaches, may exacerbate orthostatic hypotension when patients get up during the night. Fall-related complications may occur. More research is needed to define the magnitude of the deleterious effects of supine hypertension on cardiovascular, cerebrovascular, and renal morbidity and mortality. Integration of more precise cardiovascular risk assessment, efficacy, and safety data, and the prognosis of the underlying condition causing autonomic failure is required for individualized management recommendations.
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Lodhi HA, Peri-Okonny PA, Schesing K, Phelps K, Ngo C, Evans H, Arbique D, Price AL, Vernino S, Phillips L, Mitchell JH, Smith SA, Yano Y, Das SR, Wang T, Vongpatanasin W. Usefulness of Blood Pressure Variability Indices Derived From 24-Hour Ambulatory Blood Pressure Monitoring in Detecting Autonomic Failure. J Am Heart Assoc 2020; 8:e010161. [PMID: 30905258 PMCID: PMC6509738 DOI: 10.1161/jaha.118.010161] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Increased blood pressure ( BP ) variability and nondipping status seen on 24-hour ambulatory BP monitoring are often observed in autonomic failure ( ATF ). Methods and Results We assessed BP variability and nocturnal BP dipping in 273 patients undergoing ambulatory BP monitoring at Southwestern Medical Center between 2010 and 2017. SD , average real variability, and variation independent of mean were calculated from ambulatory BP monitoring. Patients were divided into a discovery cohort (n=201) and a validation cohort (n=72). ATF was confirmed by formal autonomic function test. In the discovery cohort, 24-hour and nighttime average real variability, SD , and variation independent of mean did not differ significantly between ATF (n=25) and controls (n=176, all P>0.05). However, daytime SD, daytime coefficient of variation, and daytime variation independent of mean of systolic BP ( SBP ) were all significantly higher in patients with ATF than in controls in both discovery and validation cohorts. Nocturnal BP dipping was more blunted in ATF patients than controls in both cohorts (both P<0.01). Using the threshold of 16 mm Hg, daytime SD SBP yielded a sensitivity of 77% and specificity of 82% in detecting ATF in the validation cohort, whereas nondipping status had a sensitivity of 80% and specificity of 44%. The area under the receiver operator characteristic of daytime SD SBP was greater than the area under the receiver operator characteristic of nocturnal SBP dipping (0.79 [0.66-0.91] versus 0.73 [0.58-0.87], respectively). Conclusions Daytime SD of SBP is a better screening tool than nondipping status in detecting autonomic dysfunction.
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Affiliation(s)
- Hamza A Lodhi
- 1 Hypertension Section University of Texas Southwestern Medical Center Dallas TX
| | - Poghni A Peri-Okonny
- 1 Hypertension Section University of Texas Southwestern Medical Center Dallas TX
| | - Kevin Schesing
- 2 Internal Medicine Department University of Texas Southwestern Medical Center Dallas TX
| | - Kamal Phelps
- 1 Hypertension Section University of Texas Southwestern Medical Center Dallas TX
| | - Christian Ngo
- 2 Internal Medicine Department University of Texas Southwestern Medical Center Dallas TX
| | - Hillary Evans
- 2 Internal Medicine Department University of Texas Southwestern Medical Center Dallas TX
| | - Debbie Arbique
- 1 Hypertension Section University of Texas Southwestern Medical Center Dallas TX
| | - Angela L Price
- 1 Hypertension Section University of Texas Southwestern Medical Center Dallas TX
| | - Steven Vernino
- 3 Department of Neurology and Neurotherapeutics University of Texas Southwestern Medical Center Dallas TX
| | - Lauren Phillips
- 3 Department of Neurology and Neurotherapeutics University of Texas Southwestern Medical Center Dallas TX
| | - Jere H Mitchell
- 4 Cardiology Division University of Texas Southwestern Medical Center Dallas TX
| | - Scott A Smith
- 5 Department of Health Care Sciences University of Texas Southwestern Medical Center Dallas TX
| | - Yuichiro Yano
- 6 Department of Community and Family Medicine Duke University Durham NC
| | - Sandeep R Das
- 4 Cardiology Division University of Texas Southwestern Medical Center Dallas TX
| | - Tao Wang
- 7 Quantitative Biomedical Research Center University of Texas Southwestern Medical Center Dallas TX.,8 Center for the Genetics of Host Defense University of Texas Southwestern Medical Center Dallas TX
| | - Wanpen Vongpatanasin
- 1 Hypertension Section University of Texas Southwestern Medical Center Dallas TX.,4 Cardiology Division University of Texas Southwestern Medical Center Dallas TX
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Aung AT, Chan SP, Kyaing TT, Lee CH. Diabetes mellitus is associated with high sleep-time systolic blood pressure and non-dipping pattern. Postgrad Med 2020; 132:346-351. [PMID: 32208051 DOI: 10.1080/00325481.2020.1745537] [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: 10/24/2022]
Abstract
INTRODUCTION Compared to clinic blood pressure (BP), sleep-time BP and non-dipping BP pattern are better predictors of target organ damage and cardiovascular sequalae. AIM In a retrospective study, we determined whether diabetes mellitus (DM) status is associated with high sleep-time BP and non-dipping pattern. METHODS We analyzed 1092 patients who underwent ambulatory BP monitoring between 2015 and 2017 in a tertiary cardiology institution. During a 24-hour period, BP was automatically measured every 15 minutes between 7:00 AM and 11:59 PM and every 30 minutes thereafter. RESULTS Compared with the non-DM group (n = 910), the DM group (n = 182) had a higher 24-hour systolic BP (137 ± 17 vs. non-DM, 132 ± 14 mmHg, p < 0.001) and sleep-time systolic BP (132 ± 20 vs. 123 ± 16 mmHg, p < 0.001), and was more likely to exhibit non-dipping (63% vs 42%, p˂0.001). The DM group was also less likely to meet the guideline-recommended target of 120/70 mmHg for the sleep-time BP measured via ambulatory monitoring (22% vs. 34%, p = 0.002). After adjusting for the effects of age, sex, body mass index, smoking, urea, eGFR, previous myocardial infarction, previous percutaneous coronary intervention, previous coronary artery bypass surgery, and previous stroke, DM remained a significant independent predictor of a higher 24-hour systolic BP (coefficient: 2.8, 95% confidence interval: 0.1-5.5, p = 0.042) and higher sleep-time systolic BP (coefficient: 4.2, 95% confidence interval: 1.1-7.3, p = 0.008). There was a trend toward more sleep-time non-dipping BP pattern (odds ratio: 1.4, 95% confidence interval: 1.0-2.0, p = 0.087) in the DM group. CONCLUSION DM is independently associated with suboptimal 24-hour BP control. This association is mainly attributed to a high sleep-time systolic BP.
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Affiliation(s)
- Aye Thandar Aung
- Yong Loo Lin School of Medicine, National University of Singapore , Singapore, Singapore
| | - Siew-Pang Chan
- Department of Cardiology, National University Heart Centre Singapore , Singapore, Singapore.,Cardiovascular Research Institute, National University of Singapore , Singapore, Singapore
| | - Than-Than Kyaing
- Department of Cardiovascular Medicine, Mandalay General Hospital , Mandalay, Myanmar
| | - Chi-Hang Lee
- Yong Loo Lin School of Medicine, National University of Singapore , Singapore, Singapore.,Cardiovascular Research Institute, National University of Singapore , Singapore, Singapore
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Abstract
PURPOSE OF REVIEW Patients with severe orthostatic hypotension due to autonomic failure may be hypertensive in the supine position. Until recently, there were no internationally recognized diagnostic criteria for supine hypertension. This review covers diagnostic criteria, mechanisms, and management of supine hypertension in autonomic failure patients. RECENT FINDINGS Recently, an international consensus group defined supine hypertension in patients with neurogenic orthostatic hypotension as brachial SBP at least 140 mmHg and/or DBP at least 90 mmHg while supine. Using these criteria, a large proportion of patients with orthostatic hypotension is diagnosed with supine hypertension. Recent research supports the concept that the hypertension can be mediated through residual sympathetic nervous system function and independently from sympathetic activity, for example via mineralocorticoid receptor activation. SUMMARY The clear definition of supine hypertension is an important step that will hopefully foster clinical research in this area. Supine hypertension promotes renal sodium excretion, thus, worsening orthostatic hypotension the next morning. Supine hypertension may promote cardiovascular and renal disease. Yet, long-term benefits of treating supine hypertension be it through non pharmacological or pharmacological means have not been proven by sufficiently large clinical trials.
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20
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Abstract
Parkinson disease (PD) is associated with a variety of motor and non-motor clinical manifestations, including cardiovascular autonomic dysfunction. Neurogenic orthostatic hypotension (nOH) is a potentially serious manifestation of cardiovascular sympathetic failure that occurs in approximately 30% of patients with PD. Here we review the pathophysiology and effects of the condition as well as treatment considerations for patients with PD and nOH. Screening for nOH using orthostatic symptom questionnaires, orthostatic blood pressure measurements, and specialized autonomic testing is beneficial for the identification of symptomatic and asymptomatic cases because cardiac sympathetic denervation and nOH can occur even at early (premotor) stages of PD. Symptoms of nOH, such as orthostatic lightheadedness, in patients with PD, have been shown to adversely affect patient safety (with increased risk of falls) and quality of life and should prompt treatment with non-pharmacologic and, occasionally, pharmacologic measures. Patients with nOH are also at increased risk of supine hypertension, which requires balancing various management strategies. FUNDING: Lundbeck (Deerfield, IL).
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Affiliation(s)
| | - Phillip A Low
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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21
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Abstract
We found that orders and initial doses of treatment in the hospital were strongly influenced by time of day, regardless of drug type, diagnosis, or care unit. As the first large-scale account of 24-h rhythms in hospital medicine, this study identifies a potential operational barrier to best clinical care. Clinical decisions should be made around the clock; pain, infection, hypertensive crisis, and other conditions do not occur selectively in the morning. Systemic bias in the timing of medicine may also conflict with circadian biology, which can influence when certain treatments are most effective or safe. Our findings suggest that time of day in hospital operations deserves further consideration. Hospitals operate 24 h a day, and it is assumed that important clinical decisions occur continuously around the clock. However, many aspects of hospital operation occur at specific times of day, including medical team rounding and shift changes. It is unclear whether this impacts patient care, as no studies have addressed this. We analyzed the daily distribution of ∼500,000 doses of 12 separate drugs in 1,546 inpatients at a major children’s hospital in the United States from 2010 to 2017. We tracked both order time (when a care provider places an electronic request for a drug) and dosing time (when the patient receives the drug). Order times were time-of-day−dependent, marked by distinct morning-time surges and overnight lulls. Nearly one-third of all 103,847 orders for treatment were placed between 8:00 AM and 12:00 PM. First doses from each order were also rhythmic but shifted by 2 h. These 24-h rhythms in orders and first doses were remarkably consistent across drugs, diagnosis, and hospital units. This rhythm in hospital medicine coincided with medical team rounding time, not necessarily immediate medical need. Lastly, we show that the clinical response to hydralazine, an acute antihypertensive, is dosing time-dependent and greatest at night, when the fewest doses were administered. The prevailing dogma is that hospital treatment is administered as needed regardless of time of day. Our findings challenge this notion and reveal a potential operational barrier to best clinical care.
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22
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Senkus KE, Crowe-White KM. Influence of mouth rinse use on the enterosalivary pathway and blood pressure regulation: A systematic review. Crit Rev Food Sci Nutr 2019; 60:2874-2886. [DOI: 10.1080/10408398.2019.1665495] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Katelyn E. Senkus
- Department of Human Nutrition, The University of Alabama, Tuscaloosa, Alabama, USA
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23
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The association between orthostatic blood pressure changes and subclinical target organ damage in subjects over 60 years old. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2019; 16:387-394. [PMID: 31217791 PMCID: PMC6558572 DOI: 10.11909/j.issn.1671-5411.2019.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Although recent studies have indicated that both orthostatic hypotension and orthostatic hypertension independently predict cardiovascular events, the underlying mechanisms are still controversial. The aim of the study was to investigate the relationships between orthostatic changes and organ damage in subjects over 60 years old. Methods This is a prospective observational cohort study. One thousand nine hundred and ninety-seven subjects over 60 years old were enrolled. Participants were grouped according to whether they had a drop ≥ 20 mmHg in systolic or ≥ 10 mmHg in diastolic BP (orthostatic hypotension), an increase in mean orthostatic systolic blood pressure ≥ 20 mm Hg (orthostatic hypertension), or normal changes within 3 min of orthostatism. Multiple regression modeling was used to investigate the relationship between orthostatic hypotension, orthostatic hypertension and subclinical organ damage with adjustment for confounders. Results Orthostatic hypotension and orthostatic hypertension were found in 461 (23.1%) and 189 (9.5%) participants, respectively. Measurement of carotid intima-media thickness (IMT), brachial-ankle pulse wave velocity (baPWV), clearance of creatinine, and microalbuminuria were associated with orthostatic hypotension; measurement of IMT and baPWV were associated with orthostatic hypertension in a cruse model. After adjustment, IMT [odds ratio (OR), 95% confidence interval (CI) per one-SD increment: 1.385, 1.052–1.823; P = 0.02], baPWV (OR = 1.627, 95% CI: 1.041–2.544; P = 0.033) and microalbuminuria (OR = 1.401, 95% CI: 1.002–1.958; P = 0.049) were still associated with orthostatic hypotension, while orthostatic hypertension was only associated with IMT (OR = 1.730, 95% CI: 1.143–2.618; P = 0.009). Conclusions Orthostatic hypotension seems to be independently correlated with increased carotid atherosclerosis, arterial stiffness and renal damage in subjects over 60 years old. Orthostatic hypertension correlates with carotid atherosclerosis only.
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24
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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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25
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Douma LG, Solocinski K, Holzworth MR, Crislip GR, Masten SH, Miller AH, Cheng KY, Lynch IJ, Cain BD, Wingo CS, Gumz ML. Female C57BL/6J mice lacking the circadian clock protein PER1 are protected from nondipping hypertension. Am J Physiol Regul Integr Comp Physiol 2018; 316:R50-R58. [PMID: 30427705 DOI: 10.1152/ajpregu.00381.2017] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The circadian clock is integral to the maintenance of daily rhythms of many physiological outputs, including blood pressure. Our laboratory has previously demonstrated the importance of the clock protein period 1 (PER1) in blood pressure regulation in male mice. Briefly, a high-salt diet (HS; 4% NaCl) plus injection with the long-acting mineralocorticoid deoxycorticosterone pivalate (DOCP) resulted in nondipping hypertension [<10% difference between night and day blood pressure (BP) in Per1-knockout (KO) mice but not in wild-type (WT) mice]. To date, there have been no studies that have examined the effect of a core circadian gene KO on BP rhythms in female mice. The goal of the present study was to determine whether female Per1-KO mice develop nondipping hypertension in response to HS/DOCP treatment. For the first time, we demonstrate that loss of the circadian clock protein PER1 in female mice does not significantly change mean arterial pressure (MAP) or the BP rhythm relative to female C57BL/6 WT control mice. Both WT and Per1-KO female mice experienced a significant increase in MAP in response to HS/DOCP. Importantly, however, both genotypes maintained a >10% dip in BP on HS/DOCP. This effect is distinct from the nondipping hypertension seen in male Per1-KO mice, demonstrating that the female sex appears to be protective against PER1-mediated nondipping hypertension in response to HS/DOCP. Together, these data suggest that PER1 acts in a sex-dependent manner in the regulation of cardiovascular rhythms.
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Affiliation(s)
- Lauren G Douma
- Department of Medicine, University of Florida , Gainesville, Florida.,Department of Biochemistry and Molecular Biology, University of Florida , Gainesville, Florida
| | - Kristen Solocinski
- Department of Medicine, University of Florida , Gainesville, Florida.,Department of Biochemistry and Molecular Biology, University of Florida , Gainesville, Florida
| | | | - G Ryan Crislip
- Department of Medicine, University of Florida , Gainesville, Florida.,Department of Physiology and Functional Genomics, University of Florida , Gainesville, Florida
| | - Sarah H Masten
- Department of Medicine, University of Florida , Gainesville, Florida
| | - Amber H Miller
- Department of Medicine, University of Florida , Gainesville, Florida
| | - Kit-Yan Cheng
- Department of Medicine, University of Florida , Gainesville, Florida
| | - I Jeanette Lynch
- Department of Medicine, University of Florida , Gainesville, Florida.,Department of Physiology and Functional Genomics, University of Florida , Gainesville, Florida
| | - Brian D Cain
- Department of Biochemistry and Molecular Biology, University of Florida , Gainesville, Florida
| | - Charles S Wingo
- Department of Medicine, University of Florida , Gainesville, Florida.,Department of Physiology and Functional Genomics, University of Florida , Gainesville, Florida.,Research, North Florida/South Georgia Veterans Health System, Gainesville, Florida
| | - Michelle L Gumz
- Department of Medicine, University of Florida , Gainesville, Florida.,Department of Biochemistry and Molecular Biology, University of Florida , Gainesville, Florida.,Department of Physiology and Functional Genomics, University of Florida , Gainesville, Florida
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26
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Goldberg L, Bar-Aluma BE, Krauthammer A, Efrati O, Sharabi Y. Ambulatory blood pressure profiles in familial dysautonomia. Clin Auton Res 2018; 28:385-390. [PMID: 29435868 DOI: 10.1007/s10286-018-0507-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 01/23/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Familial dysautonomia (FD) is a rare genetic disease that involves extreme blood pressure fluctuations secondary to afferent baroreflex failure. The diurnal blood pressure profile, including the average, variability, and day-night difference, may have implications for long-term end organ damage. The purpose of this study was to describe the circadian pattern of blood pressure in the FD population and relationships with renal and pulmonary function, use of medications, and overall disability. METHODS We analyzed 24-h ambulatory blood pressure monitoring recordings in 22 patients with FD. Information about medications, disease severity, renal function (estimated glomerular filtration, eGFR), pulmonary function (forced expiratory volume in 1 s, FEV1) and an index of blood pressure variability (standard deviation of systolic pressure) were analyzed. RESULTS The mean (± SEM) 24-h blood pressure was 115 ± 5.6/72 ± 2.0 mmHg. The diurnal blood pressure variability was high (daytime systolic pressure standard deviation 22.4 ± 1.5 mmHg, nighttime 17.2 ± 1.6), with a high frequency of a non-dipping pattern (16 patients, 73%). eGFR, use of medications, FEV1, and disability scores were unrelated to the degree of blood pressure variability or to dipping status. INTERPRETATION This FD cohort had normal average 24-h blood pressure, fluctuating blood pressure, and a high frequency of non-dippers. Although there was evidence of renal dysfunction based on eGFR and proteinuria, the ABPM profile was unrelated to the measures of end organ dysfunction or to reported disability.
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Affiliation(s)
- Lior Goldberg
- Pediatric Pulmonary Unit and The National Center for Familial Dysautonomia, Edmond and Lily Safra Children's Pediatric Hospital, Chaim Sheba Medical Center, Tel-HaShomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Bat-El Bar-Aluma
- Pediatric Pulmonary Unit and The National Center for Familial Dysautonomia, Edmond and Lily Safra Children's Pediatric Hospital, Chaim Sheba Medical Center, Tel-HaShomer, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Alex Krauthammer
- Pediatric Pulmonary Unit and The National Center for Familial Dysautonomia, Edmond and Lily Safra Children's Pediatric Hospital, Chaim Sheba Medical Center, Tel-HaShomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Efrati
- Pediatric Pulmonary Unit and The National Center for Familial Dysautonomia, Edmond and Lily Safra Children's Pediatric Hospital, Chaim Sheba Medical Center, Tel-HaShomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yehonatan Sharabi
- Hypertension Unit, Chaim Sheba Medical Center, Tel-HaShomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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27
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Arnold AC, Ng J, Lei L, Raj SR. Autonomic Dysfunction in Cardiology: Pathophysiology, Investigation, and Management. Can J Cardiol 2017; 33:1524-1534. [PMID: 29102451 PMCID: PMC5705288 DOI: 10.1016/j.cjca.2017.09.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 08/19/2017] [Accepted: 09/06/2017] [Indexed: 12/24/2022] Open
Abstract
Presyncope and syncope are common medical findings, with a > 40% estimated lifetime prevalence. These conditions are often elicited by postural stress and can be recurrent and accompanied by debilitating symptoms of cerebral hypoperfusion. Therefore, it is critical for physicians to become familiar with the diagnosis and treatment of common underlying causes of presyncope and syncope. In some patients, altered postural hemodynamic responses result from a failure of compensatory autonomic nervous system reflex mechanisms. The most common presentations of presyncope and syncope secondary to this autonomic dysfunction include vasovagal syncope, neurogenic orthostatic hypotension, and postural tachycardia syndrome. The most sensitive method for diagnosis is a detailed initial evaluation with medical history, physical examination, and resting electrocardiogram to rule out cardiac syncope. Physical examination should include measurement of supine and standing blood pressure and heart rate to identify the pattern of hemodynamic regulation during orthostatic stress. Additional testing may be required in patients without a clear diagnosis after the initial evaluation. Management of patients should focus on improving symptoms and functional status and not targeting arbitrary hemodynamic values. An individualized structured and stepwise approach should be taken for treatment, starting with patient education, lifestyle modifications, and use of physical counter-pressure manoeuvres and devices to improve venous return. Pharmacologic interventions should be added only when conservative approaches are insufficient to improve symptoms. There are no gold standard approaches for pharmacologic treatment in these conditions, with medications often used off label and with limited long-term data for effectiveness.
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Affiliation(s)
- Amy C Arnold
- Department of Neural and Behavioral Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jessica Ng
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Lucy Lei
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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Havakuk O, Zukerman N, Flint N, Sadeh B, Margolis G, Konigstein M, Keren G, Aviram G, Shmilovich H. Shift Work and the Risk of Coronary Artery Disease: A Cardiac Computed Tomography Angiography Study. Cardiology 2017; 139:11-16. [PMID: 29130963 DOI: 10.1159/000481088] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 08/30/2017] [Indexed: 11/19/2022]
Abstract
AIMS Shift work disrupts the normal circadian rhythm and is associated with risk factors for coronary artery disease (CAD) and a higher incidence of CAD morbidity and mortality. Cardiac computed tomography angiography (CCTA) is a robust noninvasive modality for assessing the presence, extent, and severity of CAD. We sought to investigate whether shift workers are prone to a higher burden of CAD compared to non-shift workers. METHODS We conducted a historically prospective study in consecutive patients who underwent CCTA and answered a telephonic questionnaire. Due to significant differences in age and gender, we compared 89 well-matched pairs of shift workers and non-shift workers with the use of propensity scores. RESULTS Our cohort consisted of 349 participants, of whom 94 (26.9%) were shift workers. The mean age was 50.7 years, and 62.5% were males. After pairing, we showed that shift workers had a higher prevalence of CAD than non-shift workers (74.2 vs. 53.9%, respectively, p = 0.01), and a lower prevalence of coronary calcium scores of zero (46.8 vs. 63.4%, respectively, p = 0.034). Stenosis >50% was more prevalent in shift workers than in non-shift workers (20.2 vs. 11.2%, respectively, p = 0.006), and the extent of CAD (defined as the presence of ≥1-vessel disease) tended to be higher in shift workers than in non-shift workers (25.8 vs. 13.5%, respectively, p = 0.06). CONCLUSIONS In this CCTA study, we showed in a well-matched cohort of consecutive patients that shift workers had a higher prevalence and extent of CAD than non-shift workers.
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Affiliation(s)
- Ofer Havakuk
- Department of Cardiology, Tel Aviv Medical Center, affiliated to Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abstract
Cardiovascular autonomic dysfunctions, including neurogenic orthostatic hypotension, supine hypertension and post-prandial hypotension, are relatively common in patients with Parkinson disease. Recent evidence suggests that early autonomic impairment such as cardiac autonomic denervation and even neurogenic orthostatic hypotension occur prior to the appearance of the typical motor deficits associated with the disease. When neurogenic orthostatic hypotension develops, patients with Parkinson disease have an increased risk of mortality, falls, and trauma-related to falls. Neurogenic orthostatic hypotension reduces quality of life and contributes to cognitive decline and physical deconditioning. The co-existence of supine hypertension complicates the treatment of neurogenic orthostatic hypotension because it involves the use of drugs with opposing effects. Furthermore, treatment of neurogenic orthostatic hypotension is challenging because of few therapeutic options; in the past 20 years, the US Food and Drug Administration approved only two drugs for the treatment of this condition. Small, open-label or randomized studies using acute doses of different pharmacologic probes suggest benefit of other drugs as well, which could be used in individual patients under close monitoring. This review describes the pathophysiology of neurogenic orthostatic hypotension and supine hypertension in Parkinson disease. We discuss the mode of action and therapeutic efficacy of different pharmacologic agents used in the treatment of patients with cardiovascular autonomic failure.
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Affiliation(s)
- Cyndya A. Shibao
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt Autonomic Dysfunction Center, Vanderbilt University Medical Center, Nashville, TN
| | - Horacio Kaufmann
- Department of Neurology, NYU Langone Medical Center, Dysautonomia Center, 530 1st Avenue, New York, NY, USA.
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Klimczak D, Kuch M, Pilecki T, Żochowska D, Wirkowska A, Pączek L. Plasma microRNA-155-5p is increased among patients with chronic kidney disease and nocturnal hypertension. ACTA ACUST UNITED AC 2017; 11:831-841.e4. [PMID: 29146158 DOI: 10.1016/j.jash.2017.10.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 10/17/2017] [Accepted: 10/23/2017] [Indexed: 12/13/2022]
Abstract
MicroRNAs play multiple roles in the regulation of blood pressure (BP). Nevertheless, to date, no study has assessed the association between microRNA plasma expression and BP control in chronic kidney disease (CKD) patients. Given this background, we evaluated the plasma expression of miR-155-5p, a translational inhibitor of angiotensin receptor type I, in CKD patients, to determine the association between miR-155-5p level and BP control. In this single-center cross-sectional study, we analyzed the miR-155-5p concentration by quantitative reverse transcriptase polymerase chain reaction using the U6 snRNA as a reference gene and 24-hour ambulatory blood pressure monitoring in CKD patients (stage ≥2) in relation to a control group of healthy age-matched and gender-matched individuals, with normal BP proven by the ambulatory blood pressure monitoring. We enrolled a total of 105 patients with CKD (stages 2-5, including 33 kidney renal transplant recipients), aged 59 ± 14 years; 47% males and 26 healthy volunteers (aged 55 ± 13, 50% male). Within the study group, a total of 36 patients (40%) presented with an average 24-hour systolic BP (SBP) ≥130 mm Hg and 41 patients (45%) presented nocturnal hypertension (NHT; SBP ≥120 mm Hg or diastolic BP ≥ 70 mm Hg). miRNA-155-5p was increased in plasma of CKD patients with median expression relative to control subjects equal to 2.92 (1.34-5.58). Interestingly, the plasma miRNA-155-5p expression was significantly higher in patients with NHT: 4.04 (2.92-10.8) versus 2.01 (1.21-3.07), P = .001 and its expression maintained an independent association with the average nocturnal SBP (coefficient B = 4.368, P = .047) by a multivariate regression analysis adjusted for confounders. The miR-155-5p was increased among CKD patients and further increased among subjects presenting with NHT. Further studies are warranted to determine the role of this non-coding RNA as a potential novel biomarker and therapeutic target in the non-dipping CKD individuals, characterized by increased cardiovascular risk.
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Affiliation(s)
- Dominika Klimczak
- Department of Immunology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland; Department of Heart Failure and Cardiac Rehabilitation, Second Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Marek Kuch
- Department of Cardiology, Hypertension and Internal Medicine, Second Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Pilecki
- Department of Immunology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Dorota Żochowska
- Department of Immunology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Agnieszka Wirkowska
- Department of Immunology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Leszek Pączek
- Department of Immunology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland.
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Biaggioni I. The Pharmacology of Autonomic Failure: From Hypotension to Hypertension. Pharmacol Rev 2017; 69:53-62. [PMID: 28011746 DOI: 10.1124/pr.115.012161] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Primary neurodegenerative autonomic disorders are characterized clinically by loss of autonomic regulation of blood pressure. The clinical picture is dominated by orthostatic hypotension, but supine hypertension is also a significant problem. Autonomic failure can result from impairment of central autonomic pathways (multiple system atrophy) or neurodegeneration of peripheral postganglionic autonomic fibers (pure autonomic failure, Parkinson's disease). Pharmacologic probes such as the ganglionic blocker trimethaphan can help us in the understanding of the underlying pathophysiology and diagnosis of these disorders. Conversely, understanding the pathophysiology is crucial in the development of effective pharmacotherapy for these patients. Autonomic failure patients provide us with an unfortunate but unique research model characterized by loss of baroreflex buffering. This greatly magnifies the effect of stimuli that would not be apparent in normal subjects. An example of this is the discovery of the osmopressor reflex: ingestion of water increases blood pressure by 30-40 mm Hg in autonomic failure patients. Animal studies indicate that the trigger of this reflex is related to hypo-osmolality in the portal circulation involving transient receptor potential vanilloid 4 receptors. Studies in autonomic failure patients have also revealed that angiotensin II can be generated through noncanonical pathways independent of plasma renin activity to contribute to hypertension. Similarly, the mineralocorticoid receptor antagonist eplerenone produces acute hypotensive effects, highlighting the presence of non-nuclear mineralocorticoid receptor pathways. These are examples of careful clinical research that integrates pathophysiology and pharmacology to advance our knowledge of human disease.
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Affiliation(s)
- Italo Biaggioni
- Division of Clinical Pharmacology, Departments of Medicine and Pharmacology, Vanderbilt University, Nashville, Tennessee
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Espay AJ, LeWitt PA, Hauser RA, Merola A, Masellis M, Lang AE. Neurogenic orthostatic hypotension and supine hypertension in Parkinson's disease and related synucleinopathies: prioritisation of treatment targets. Lancet Neurol 2017; 15:954-966. [PMID: 27478953 DOI: 10.1016/s1474-4422(16)30079-5] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 03/21/2016] [Accepted: 05/12/2016] [Indexed: 12/18/2022]
Abstract
Neurogenic orthostatic hypotension and supine hypertension are common manifestations of cardiovascular dysautonomia in Parkinson's disease and related synucleinopathies. Because these disorders are haemodynamic opposites, improvement in one might be achieved at the expense of worsening of the other. Thus, management decisions necessitate assessment of the individual risks for patients with coexistent neurogenic orthostatic hypotension and supine hypertension. Whereas neurogenic orthostatic hypotension poses risks for falls and can be associated with cognitive impairment in the short term, chronic supine hypertension can be associated with stroke and myocardial infarction in the long term. Because few clinical trial data exist for outcomes in patients with coexistent neurogenic orthostatic hypotension and supine hypertension, clinicians need to balance, on the basis of comorbidities and disease staging, the potential immediate benefits of treatment for neurogenic orthostatic hypotension and the long-term risks of supine hypertension treatment in each patient. Future research needs to focus on ascertaining a safe degree of supine hypertension when treating neurogenic orthostatic hypotension; the effectiveness of nocturnal antihypertensive therapy in patients with coexistent neurogenic orthostatic hypotension and supine hypertension; and the prevalence, scope, and therapeutic requirements for managing neurogenic orthostatic hypotension that manifests with falls or cognitive impairment, but without postural lightheadedness or near syncope.
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Affiliation(s)
- Alberto J Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA.
| | - Peter A LeWitt
- Parkinson's Disease and Movement Disorders Program, Henry Ford Hospital, West Bloomfield, MI, USA; Department of Neurology, Wayne State University School of Medicine, West Bloomfield, MI, USA
| | - Robert A Hauser
- USF Health Byrd NPF Parkinson's Disease and Movement Disorders Center of Excellence, Tampa, FL, USA
| | - Aristide Merola
- Department of Neuroscience, University of Torino, Torino, Italy
| | - Mario Masellis
- Cognitive & Movement Disorders Clinic, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Anthony E Lang
- Movement Disorders Clinic and the Edmond J Safra Program in Parkinson's Disease, University Health Network, University of Toronto, Toronto, ON, Canada
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Wang F, Zhao H, Yang C, Kong G, Song L, Li C, Wang Y, Chen S, Wang J, Wu S. Association of blood pressure in the supine position with target organ damage in subjects over 60 years old. J Int Med Res 2017; 45:123-133. [PMID: 28222633 PMCID: PMC5536603 DOI: 10.1177/0300060516677175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective Toexplore the correlation between blood pressure in the supine position and target organ damage in subjects over 60 years of age. Methods In 2444 individuals, we investigated the association of systolic blood pressure (SBP) in the supine position with the target organ damage indices microalbuminuria (ALBU), brachial-ankle pulse wave velocity (baPWV), and carotid intima-media thickness (IMT). Supine hypertension (SH) is defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. Subjects were assigned to either the SH group (1275 cases) or the non-SH group (1169 cases). Results The levels of ALBU, baPWV, and IMT, as well as the percentage of participants with ALBU > 30 mg/L, baPWV ≥ 1400 cm/s, and IMT ≥ 1 mm, were significantly higher in the SH group than in the non-SH group. Multivariate logistic regression analysis showed that SH was an independent risk factor for baPWV and IMT, but the relationship with ALBU was not statistically significant after correction for confounding factors. Conclusions SH is a risk factor for target organ damage, as expressed by the indices baPWV and IMT. The association of SH with kidney damage requires further study.
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Affiliation(s)
- Feng Wang
- 1 Sixth Hospital of Peking University, Beijing, China
| | - Hualing Zhao
- 2 North China University of Science and Technology, Tangshan, China
| | - Chao Yang
- 3 Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
| | - Guilan Kong
- 4 Medical Informatics Center, Peking University, Beijing, China
| | - Lu Song
- 2 North China University of Science and Technology, Tangshan, China
| | - Chunhui Li
- 2 North China University of Science and Technology, Tangshan, China
| | - Yiming Wang
- 2 North China University of Science and Technology, Tangshan, China
| | - Shuohua Chen
- 5 Cardiology Department of Hebei United University, Affiliated Kailuan General Hospital, Tangshan, China
| | - Jing Wang
- 4 Medical Informatics Center, Peking University, Beijing, China
| | - Shouling Wu
- 5 Cardiology Department of Hebei United University, Affiliated Kailuan General Hospital, Tangshan, China
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Franzen K, Fliegen S, Koester J, Martin RC, Deuschl G, Reppel M, Mortensen K, Schneider SA. Central hemodynamics and arterial stiffness in idiopathic and multiple system atrophy. J Neurol 2016; 264:327-332. [DOI: 10.1007/s00415-016-8352-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 11/16/2016] [Accepted: 11/18/2016] [Indexed: 10/20/2022]
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Batla A, Phé V, De Min L, Panicker JN. Nocturia in Parkinson's Disease: Why Does It Occur and How to Manage? Mov Disord Clin Pract 2016; 3:443-451. [PMID: 30363512 PMCID: PMC6178648 DOI: 10.1002/mdc3.12374] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/18/2016] [Accepted: 03/11/2016] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Nocturia is one of the commonest nonmotor symptoms in Parkinson's disease (PD) and has a significant impact on quality of life both for patients and their carers. There exists a relation between nocturia and poor sleep quality, falls, and institutionalization. Nocturia may manifest as a result of reduced functional bladder capacity or nocturnal polyuria; however, most often the cause is multifactorial. Disorders of circadian rhythm regulation are known to occur with sleep disturbances in PD may also contribute to nocturia. METHODS AND RESULTS In this review, an overview of the assessment and management of nocturia in patients with PD is presented. History taking, medication review, and a bladder diary form the cornerstone of the evaluation. Urinalysis, ultrasonography, and urodynamic studies help to assess the cause for lower urinary tract symptoms and exclude concomitant pathologies, such as bladder outlet obstruction. Antimuscarinic medications are the first-line treatment for the overactive bladder; however, caution is needed when using these medications in individuals predisposed to cognitive impairment. Desmopressin is effective for managing nocturnal polyuria. CONCLUSIONS An individualized approach is recommended to optimize the management of nocturia in PD.
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Affiliation(s)
- Amit Batla
- Department of Motor neuroscience and Movement DisordersUCL Institute of NeurologyLondonUnited Kingdom
| | - Véronique Phé
- Department of Uro‐NeurologyThe National Hospital for Neurology and Neurosurgery and UCL Institute of NeurologyLondonUnited Kingdom
- Pitié‐Salpêtrière Academic HospitalDepartment of UrologyAssistance Publique‐Hôpitaux de ParisPierre and Marie Curie Medical School, Paris 6 UniversityParisFrance
| | - Lorenzo De Min
- Department of Uro‐NeurologyThe National Hospital for Neurology and Neurosurgery and UCL Institute of NeurologyLondonUnited Kingdom
| | - Jalesh N. Panicker
- Department of Uro‐NeurologyThe National Hospital for Neurology and Neurosurgery and UCL Institute of NeurologyLondonUnited Kingdom
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Dietary sodium and nocturnal blood pressure dipping in normotensive men and women. J Hum Hypertens 2016; 31:145-150. [PMID: 27511475 PMCID: PMC5214254 DOI: 10.1038/jhh.2016.53] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 06/17/2016] [Accepted: 07/05/2016] [Indexed: 12/20/2022]
Abstract
Impaired nocturnal blood pressure (BP) dipping (i.e., <10% decline in nocturnal BP) is associated with an increased risk of cerebrovascular and cardiovascular diseases. Excess sodium has been shown to impair BP regulation and increase cardiovascular disease risk, yet few studies have assessed the influence of dietary sodium on nocturnal dipping in normotensive adults. The purpose of this study was to determine the effects of dietary sodium on BP dipping in normotensive men and women. Eighty healthy normotensive adults participated in a controlled feeding study (men: n=39, 34±2 yrs; women: n=41, 41±2 yrs). Participants consumed a standardized run-in 100 mmol sodium·day−1 diet for 7 days, followed by 7 days of low sodium (LS; 20 mmol·day−1) and high sodium (HS; 300 mmol·day−1) diets in random order. On the final day of each diet, subjects wore a 24h ambulatory BP monitor, collected a 24h urine sample, and provided a blood sample. During the run-in diet, 24h urinary sodium excretion was 79.4±5.1 mmol·24h−1 in men and 85.3±5.5 mmol·24h−1 in women (p>0.05). Systolic BP dipping was not different between men (11.4±1.0%) and women (11.2±0.9%) (p>0.05). During the HS diet, 24h urinary sodium excretion increased compared to the LS diet in men (LS=31.7±4.6 mmol·24h−1 vs. HS=235.0±13.9 mmol·24h−1, p<0.01) and women (LS=25.8±2.2 mmol·24h−1 vs. HS=234.7±13.8 mmol·24h−1, p<0.01). Despite this large increase in sodium intake and excretion, systolic BP dipping was not blunted in men (LS=8.9±1.0% vs. HS=9.4±1.2%, p>0.05) or women (LS=10.3±0.8% vs. HS=10.5±0.8%, p>0.05). Among normotensive men and women, HS does not blunt nocturnal BP dipping.
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Goh MY, Millard MS, Wong ECK, Brown DJ, Frauman AG, O’Callaghan CJ. Diurnal blood pressure and urine production in acute spinal cord injury compared with controls. Spinal Cord 2016; 55:39-46. [DOI: 10.1038/sc.2016.100] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 05/22/2016] [Accepted: 05/28/2016] [Indexed: 01/26/2023]
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Choi J, Kook MS. Systemic and Ocular Hemodynamic Risk Factors in Glaucoma. BIOMED RESEARCH INTERNATIONAL 2015; 2015:141905. [PMID: 26557650 PMCID: PMC4628774 DOI: 10.1155/2015/141905] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 08/03/2015] [Indexed: 01/31/2023]
Abstract
Primary open angle glaucoma (POAG) is a multifactorial disease characterized by progressive retinal ganglion cell death and visual field loss. It is known that alterations in intraocular pressure (IOP), blood pressure (BP), and ocular perfusion pressure (OPP) can play a significant role in the pathogenesis of the disease. Impaired autoregulatory capacity of ocular blood vessels may render tissues vulnerable to OPP changes and potentially harmful tissue ischemia-reperfusion damage. Vascular risk factors should be considered more important in a subgroup of patients with POAG, and especially in patients with normal tension glaucoma (NTG) with evidence of unphysiological BP response. For example, reduction of BP during the nighttime has an influence on OPP, and increased circadian OPP fluctuation, which might stand for unstable ocular blood flow, has been found to be the consistent risk factor for NTG development and progression. Central visual field may be affected more severely than peripheral visual field in NTG patients with higher 24-hour fluctuation of OPP. This review will discuss the current understanding of allegedly major systemic and ocular hemodynamic risk factors for glaucoma including systemic hypertension, arterial stiffness, antihypertensive medication, exaggerated nocturnal hypotension, OPP, and autonomic dysregulation.
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Affiliation(s)
- Jaewan Choi
- Central Seoul Eye Center, 224 Ichon-ro, Yongsan-gu, Seoul 04427, Republic of Korea
| | - Michael S. Kook
- Department of Ophthalmology, University of Ulsan, Asan Medical Center, Seoul 05505, Republic of Korea
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Milazzo V, Maule S, Di Stefano C, Tosello F, Totaro S, Veglio F, Milan A. Cardiac Organ Damage and Arterial Stiffness in Autonomic Failure: Comparison With Essential Hypertension. Hypertension 2015; 66:1168-75. [PMID: 26459422 DOI: 10.1161/hypertensionaha.115.05913] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Accepted: 09/12/2015] [Indexed: 11/16/2022]
Abstract
Autonomic failure (AF) is characterized by orthostatic hypotension, supine hypertension, and increased blood pressure (BP) variability. AF patients develop cardiac organ damage, similarly to essential hypertension (EH), and have higher arterial stiffness than healthy controls. Determinants of cardiovascular organ damage in AF are not well known: both BP variability and mean BP values may be involved. The aim of the study was to evaluate cardiac organ damage, arterial stiffness, and central hemodynamics in AF, compared with EH subjects with similar 24-hour BP and a group of healthy controls, and to evaluate determinants of target organ damage in patients with AF. Twenty-seven patients with primary AF were studied (mean age, 65.7±11.2 years) using transthoracic echocardiography, carotid-femoral pulse wave velocity, central hemodynamics, and 24-hour ambulatory BP monitoring. They were compared with 27 EH subjects matched for age, sex, and 24-hour mean BP and with 27 healthy controls. AF and EH had similar left ventricular mass (101.6±33.3 versus 97.7±28.1 g/m(2), P=0.59) and carotid-femoral pulse wave velocity (9.3±1.8 versus 9.2±3.0 m/s, P=0.93); both parameters were significantly lower in healthy controls (P<0.01). Compared with EH, AF patients had higher augmentation index (31.0±7.6% versus 26.1±9.2%, P=0.04) and central BP values. Nighttime systolic BP and 24-hour systolic BP predicted organ damage, independent of BP variability. AF patients develop hypertensive heart disease and increased arterial stiffness, similar to EH with comparable mean BP values. Twenty-four-hour and nighttime systolic BP were determinants of cardiovascular damage, independent of BP variability.
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Affiliation(s)
- Valeria Milazzo
- From the Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy.
| | - Simona Maule
- From the Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Cristina Di Stefano
- From the Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Francesco Tosello
- From the Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Silvia Totaro
- From the Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Franco Veglio
- From the Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Alberto Milan
- From the Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
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Celedonio JE, Arnold AC, Dupont WD, Ramirez CE, Diedrich A, Okamoto LE, Raj SR, Robertson D, Peltier AC, Biaggioni I, Shibao CA. Residual sympathetic tone is associated with reduced insulin sensitivity in patients with autonomic failure. Clin Auton Res 2015; 25:309-15. [PMID: 26359268 DOI: 10.1007/s10286-015-0307-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 06/18/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE Parkinson disease, an α-synucleinopathy, is associated with reduced insulin sensitivity, impaired glucose tolerance, and diabetes mellitus. Importantly, these metabolic alterations have been shown to contribute to disease progression. The purpose of this study was to determine if reduced insulin sensitivity is also present in other α-synucleinopathies associated with autonomic failure. METHODS We studied 19 patients with multiple system atrophy and 26 patients with pure autonomic failure. For comparison, we studied 8 healthy controls matched for body mass index. Insulin sensitivity and beta cell function were calculated using fasting glucose and insulin levels according to the homeostatic model assessment 2. A multiple linear regression model was performed to determine factors that predict insulin sensitivity in autonomic failure. RESULTS There was a significant difference in insulin sensitivity among groups (P = 0.048). This difference was due to lower insulin sensitivity in multiple system atrophy patients: 64% [interquartile range (IQR), 43 to 117] compared to healthy controls 139% (IQR, 83 to 212), P = 0.032. The main factor that contributed to the reduced insulin sensitivity was the presence of supine hypertension and residual sympathetic tone. CONCLUSIONS Multiple system atrophy patients have reduced insulin sensitivity that is associated with residual sympathetic activation and supine hypertension. These patients may therefore be at high risk for development of impaired glucose tolerance and diabetes mellitus.
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Affiliation(s)
- Jorge E Celedonio
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - Amy C Arnold
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - William D Dupont
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, USA
| | - Claudia E Ramirez
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - André Diedrich
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - Luis E Okamoto
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - Satish R Raj
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - David Robertson
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - Amanda C Peltier
- Department of Neurology, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, USA
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA.
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Tuohy ST, Kyvelou SMG, Gleeson PJ, Daniels FB, Ryan LA, Lappin DW, O'Donnell MJ, Sharif F. The effect of renal sympathetic denervation on nocturnal dipping in patients with resistant hypertension; observational data from a tertiary referral centre in the Republic of Ireland. Ir J Med Sci 2015; 185:635-641. [PMID: 26089291 DOI: 10.1007/s11845-015-1324-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 05/30/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Renal sympathetic denervation (RSD) is an emerging device based treatment for patients with resistant hypertension. Nocturnal dipping (ND) is defined as a decrease in BP of 10-20 % during sleep, and has been shown to be protective against cardiovascular disease. This study examined the effect of RSD on the 24 h BP profile of patients with resistant hypertension. METHODS AND RESULTS The first 23 consecutive patients with resistant hypertension scheduled for renal denervation in a single centre were included. 24 h ambulatory blood pressure monitors (ABPM) were given to patients pre-procedure and 9 months post-procedure. RSD led to a statistically non-significant reduction in overall 24 h ABPM BP (150/85 ± 12/9 vs. 143/84 ± 15/11 mmHg; P > 0.05) despite a reduction in the number of antihypertensive medications (4.9 ± 1.2 vs. 4.3 ± 1.2; P = 0.001). There were improvements in systolic ND 1.7 ± 8 vs. 5.2 ± 8 %; P < 0.05), diastolic ND (5.2 ± 8 vs. 10.2 ± 9 %; P < 0.05) and mean arterial pressure (MAP) ND (4.2 ± 8 vs. 8.0 ± 8 %; P < 0.05). Non-significant changes in ND status were observed in systolic (17 vs. 43 % of participants; P > 0.05), diastolic (30 vs. 43 % of participants; P > 0.05) and MAP (22 vs. 39 % of participants; P > 0.05) measurements. CONCLUSIONS These data suggest that RSD may lead to an improvement in nocturnal dipping in selected patients with resistant hypertension. This may have cardiovascular benefits even if reduction in BP is not achieved with RSD.
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Affiliation(s)
- S T Tuohy
- Department of Cardiology, Galway University Hospital, Galway, Republic of Ireland.
| | - S-M G Kyvelou
- Department of Cardiology, Galway University Hospital, Galway, Republic of Ireland
| | - P J Gleeson
- Department of Cardiology, Galway University Hospital, Galway, Republic of Ireland
| | - F B Daniels
- Department of Cardiology, Galway University Hospital, Galway, Republic of Ireland
| | - L A Ryan
- Department of Cardiology, Galway University Hospital, Galway, Republic of Ireland
| | - D W Lappin
- Department of Nephrology, Galway University Hospital, Galway, Republic of Ireland
| | - M J O'Donnell
- Department of Cardiology, Galway University Hospital, Galway, Republic of Ireland.,Clinical Research Facility, National University of Ireland, Galway, Republic of Ireland
| | - F Sharif
- Department of Cardiology, Galway University Hospital, Galway, Republic of Ireland.,Clinical Research Facility, National University of Ireland, Galway, Republic of Ireland
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Abstract
Hypertension is widely encountered in family medicine. Despite its prevalence, many patients have uncontrolled or difficult-to-control blood pressure. Resistant hypertension is defined as hypertension that is poorly responsive to treatment and requires the use of multiple medications to achieve acceptable blood pressure ranges. It may be a consequence of secondary hypertension or have no identifiable cause. Resistant hypertension is important to recognise because it places patients at risk of end-organ damage. Primary care physicians should be aware of the therapeutic approach for hypertension when traditional therapy fails. This article aims to familiarise readers with the evaluation and management of resistant hypertension by outlining the most recent evidence-based treatment options.
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Affiliation(s)
- Julian P Yaxley
- Department of Medicine, Redcliffe Hospital, Queensland, Australia
| | - Sam V Thambar
- Department of Medicine, Gold Coast University Hospital, Queensland, Australia
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Milazzo V, Di Stefano C, Milan A, Ravera A, Sobrero G, Sabia L, Veglio F, Maule S. Cardiovascular complications in patients with autonomic failure. Clin Auton Res 2015; 25:133-40. [PMID: 25791260 DOI: 10.1007/s10286-015-0275-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 11/11/2014] [Indexed: 12/31/2022]
Abstract
Patients with autonomic failure are characterized by orthostatic hypotension, supine hypertension, high blood pressure variability, blunted heart rate variability, and often have a "non-dipping" or "reverse dipping" pattern on 24-h ambulatory blood pressure monitoring. These alterations may lead to cardiovascular and cerebrovascular changes, similar to the target organ damage found in hypertension. Often patients with autonomic failure are on treatment with anti-hypotensive drugs, which may worsen supine hypertension. The aim of this review is to summarize the evidence for cardiac, vascular, renal, and cerebrovascular damage in patients with autonomic failure.
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Affiliation(s)
- Valeria Milazzo
- Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy,
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Sufiun A, Rafiq K, Fujisawa Y, Rahman A, Mori H, Nakano D, Kobori H, Ohmori K, Masaki T, Kohno M, Nishiyama A. Effect of dipeptidyl peptidase-4 inhibition on circadian blood pressure during the development of salt-dependent hypertension in rats. Hypertens Res 2015; 38:237-43. [PMID: 25588850 DOI: 10.1038/hr.2014.173] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/17/2014] [Accepted: 09/20/2014] [Indexed: 01/02/2023]
Abstract
A growing body of evidence has indicated that dipeptidyl peptidase-4 (DPP-4) inhibitors have antihypertensive effects. Here, we aim to examine the effect of vildagliptin, a DPP-4-specific inhibitor, on blood pressure and its circadian-dipping pattern during the development of salt-dependent hypertension in Dahl salt-sensitive (DSS) rats. DSS rats were treated with a high-salt diet (8% NaCl) plus vehicle or vildagliptin (3 or 10 mg kg(-1) twice daily by oral gavage) for 7 days. Blood pressure was measured by the telemetry system. High-salt diet for 7 days significantly increased the mean arterial pressure (MAP), systolic blood pressure (SBP) and were also associated with an extreme dipping pattern of blood pressure in DSS rats. Treatment with vildagliptin dose-dependently decreased plasma DPP-4 activity, increased plasma glucagon-like peptide 1 (GLP-1) levels and attenuated the development of salt-induced hypertension. Furthermore, vildagliptin significantly increased urine sodium excretion and normalized the dipping pattern of blood pressure. In contrast, intracerebroventricular infusion of vildagliptin (50, 500 or 2500 μg) did not alter MAP and heart rate in DSS rats. These data suggest that salt-dependent hypertension initially develops with an extreme blood pressure dipping pattern. The DPP-4 inhibitor, vildagliptin, may elicit beneficial antihypertensive effects, including the improvement of abnormal circadian blood pressure pattern, by enhancing urinary sodium excretion.
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Affiliation(s)
- Abu Sufiun
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Kazi Rafiq
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Yoshihide Fujisawa
- Life Science Research Center, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Asadur Rahman
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Hirohito Mori
- Department of Gastroenterology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Daisuke Nakano
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Hiroyuki Kobori
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Koji Ohmori
- Cardiorenal and Cerebrovascular Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tsutomu Masaki
- Department of Gastroenterology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Masakazu Kohno
- Cardiorenal and Cerebrovascular Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Akira Nishiyama
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Kagawa, Japan
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A retrospective review of the ambulatory blood pressure patterns and diurnal urine production in subgroups of spinal cord injured patients. Spinal Cord 2014; 53:49-53. [PMID: 25384400 DOI: 10.1038/sc.2014.192] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 10/06/2014] [Accepted: 10/06/2014] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVES To quantify diurnal blood pressure (BP) patterns and nocturnal hypertension and to measure diurnal urine production in spinal cord injury (SCI) patients with clinically significant disorders of BP control. SETTING A specialist state-based spinal cord service in Victoria, Australia. METHODS Medical records of patients with traumatic SCI who were referred to a specialist service for management of a BP disorder were examined. Ambulatory BP and nocturnal urine production were compared between groups of patients classified according to level, completeness and chronicity of SCI. Patients with night:day systolic BP <90% were classified as dippers, 90-100% as non-dippers and >100% as reversed dippers. RESULTS Patients (44 tetraplegic, 10 paraplegic) were predominantly males (92.6%) aged 41±2.5 years (mean±s.e.m.). Referral was for orthostatic intolerance (n=37), autonomic dysreflexia (n=6), nocturnal polyuria (n=4), elevated BP (n=1) and peripheral oedema (n=1). The average BP was 111.1±1.4/65.0±1.2 mm Hg. In 56% of patients (n=30), BP at night was higher than during the day and another 37% (n=20) were non-dippers. Nocturnal hypertension was present in 31% (n=17) of the patients. In the tetraplegic patients, urine flow rate was greater during the night than day (121±9.5 ml h(-1) vs 89±8.2 ml h(-1), P=0.025). CONCLUSION Ambulatory BP monitoring in patients with SCI and clinically significant BP disorders detected a high incidence of reversed dipping and nocturnal hypertension. We postulate elevated nocturnal BP may contribute to nocturnal diuresis that might cause relative volume depletion and thereby contribute to daytime orthostatic hypotension.
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García-Ortiz L, de Cabo-Laso A, Rodriguez-Martín C, Recio-Rodríguez J, Garcia Garcia A, Rodriguez-Sanchez E, Agudo-Conde C, Gomez-Marcos M. Monitorización ambulatoria de la presión arterial y actividad física en pacientes hipertensos. HIPERTENSION Y RIESGO VASCULAR 2014. [DOI: 10.1016/j.hipert.2014.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Kadoya M, Koyama H, Kanzaki A, Kurajoh M, Hatayama M, Shiraishi J, Okazaki H, Shoji T, Moriwaki Y, Yamamoto T, Inaba M, Namba M. Plasma brain-derived neurotrophic factor and reverse dipping pattern of nocturnal blood pressure in patients with cardiovascular risk factors. PLoS One 2014; 9:e105977. [PMID: 25153796 PMCID: PMC4143316 DOI: 10.1371/journal.pone.0105977] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 07/25/2014] [Indexed: 01/09/2023] Open
Abstract
CONTEXT Basic studies have shown that brain-derived neurotrophic factor (BDNF) has critical roles in the survival, growth, maintenance, and death of central and peripheral neurons, while it is also involved in regulation of the autonomic nervous system. Furthermore, recent clinical studies have suggested potential role of plasma BDNF in the circulatory system. OBJECTIVE We investigated the mutual relationships among plasma BDNF, patterns of nocturnal blood pressure changes (dippers, non-dippers, extra-dippers, and reverse-dippers), and cardiac autonomic function as determined by heart rate variability (HRV). DESIGN This was a cross-sectional study of patients registered in the Hyogo Sleep Cardio-Autonomic Atherosclerosis (HSCAA) Study from October 2010 to November 2012. PATIENTS Two-hundred fifty patients with 1 or more cardiovascular risk factor(s) (obesity, smoking, presence of cardiovascular event history, hypertension, dyslipidemia, diabetes mellitus, chronic kidney disease) were enrolled. RESULTS Plasma BDNF levels (natural logarithm transformed) were significantly (p = 0.001) lower in reverse-dipper patients (7.18±0.69 pg/ml, mean ± SD, n = 36) as compared to dippers (7.86±0.86 pg/ml, n = 100). Multiple logistic regression analysis showed that BDNF (odds ratios: 0.417, 95% confidence interval: 0.228-0.762, P = 0.004) was the sole factor significantly and independently associated with the reverse-dippers as compared with dippers. Furthermore, plasma BDNF level was significantly and positively correlated with the time-domain (SDNN, SDANN5, CVRR) and frequency-domain (LF) of HRV parameters. Finally, multiple logistic regression analyses showed that the relationship between plasma BDNF and the reverse-dippers was weakened, yet remained significant or borderline significant even after adjusting for HRV parameters. CONCLUSIONS Low plasma BDNF was independently associated with patients showing a reverse-dipper pattern of nocturnal blood pressure, in which an imbalance of cardiac autonomic function may be partly involved.
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Affiliation(s)
- Manabu Kadoya
- Department of Internal Medicine, Division of Diabetes, Endocrinology and Metabolism, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hidenori Koyama
- Department of Internal Medicine, Division of Diabetes, Endocrinology and Metabolism, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
- * E-mail:
| | - Akinori Kanzaki
- Department of Internal Medicine, Division of Diabetes, Endocrinology and Metabolism, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Masafumi Kurajoh
- Department of Internal Medicine, Division of Diabetes, Endocrinology and Metabolism, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Miki Hatayama
- Department of Internal Medicine, Division of Diabetes, Endocrinology and Metabolism, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Jun Shiraishi
- Department of Internal Medicine, Division of Diabetes, Endocrinology and Metabolism, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hirokazu Okazaki
- Department of Internal Medicine, Division of Diabetes, Endocrinology and Metabolism, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Takuhito Shoji
- Department of Internal Medicine, Division of Diabetes, Endocrinology and Metabolism, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yuji Moriwaki
- Department of Internal Medicine, Division of Diabetes, Endocrinology and Metabolism, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Tetsuya Yamamoto
- Department of Internal Medicine, Division of Diabetes, Endocrinology and Metabolism, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Masaaki Inaba
- Department of Endocrinology, Metabolism and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Mitsuyoshi Namba
- Department of Internal Medicine, Division of Diabetes, Endocrinology and Metabolism, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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Kaufmann H, Freeman R, Biaggioni I, Low P, Pedder S, Hewitt LA, Mauney J, Feirtag M, Mathias CJ. Droxidopa for neurogenic orthostatic hypotension: a randomized, placebo-controlled, phase 3 trial. Neurology 2014; 83:328-35. [PMID: 24944260 PMCID: PMC4115605 DOI: 10.1212/wnl.0000000000000615] [Citation(s) in RCA: 186] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether droxidopa, an oral norepinephrine precursor, improves symptomatic neurogenic orthostatic hypotension (nOH). METHODS Patients with symptomatic nOH due to Parkinson disease, multiple system atrophy, pure autonomic failure, or nondiabetic autonomic neuropathy underwent open-label droxidopa dose optimization (100-600 mg 3 times daily), followed, in responders, by 7-day washout and then a 7-day double-blind trial of droxidopa vs placebo. Outcome measures included patient self-ratings on the Orthostatic Hypotension Questionnaire (OHQ), a validated, nOH-specific tool that assesses symptom severity and symptom impact on daily activities. RESULTS From randomization to endpoint (n = 162), improvement in mean OHQ composite score favored droxidopa over placebo by 0.90 units (p = 0.003). Improvement in OHQ symptom subscore favored droxidopa by 0.73 units (p = 0.010), with maximum change in "dizziness/lightheadedness." Improvement in symptom-impact subscore favored droxidopa by 1.06 units (p = 0.003), with maximum change for "standing a long time." Mean standing systolic blood pressure (BP) increased by 11.2 vs 3.9 mm Hg (p < 0.001), and mean supine systolic BP by 7.6 vs 0.8 mm Hg (p < 0.001). At endpoint, supine systolic BP >180 mm Hg was observed in 4.9% of droxidopa and 2.5% of placebo recipients. Adverse events reported in ≥ 3% of double-blind droxidopa recipients were headache (7.4%) and dizziness (3.7%). No patients discontinued double-blind treatment because of adverse events. CONCLUSIONS In patients with symptomatic nOH, droxidopa improved symptoms and symptom impact on daily activities, with an associated increase in standing systolic BP, and was generally well tolerated. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that in patients with symptomatic nOH who respond to open-label droxidopa, droxidopa improves subjective and objective manifestation of nOH at 7 days.
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Affiliation(s)
- Horacio Kaufmann
- From the Department of Neurology (H.K.), NYU Medical Center, New York; Department of Neurology (R.F.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Medicine (I.B.), Vanderbilt University Medical Center, Nashville, TN; Department of Neurology (P.L.), Mayo Clinic, Rochester, MN; Chelsea Therapeutics, Inc. (S.P., L.A.H.), Charlotte, NC; Chiltern (J.M.), Wilmington, NC; The Curry Rockefeller Group, LLC (M.F.), Tarrytown, NY; Autonomic and Neurovascular Medicine Departments (C.J.M.), Imperial College London; and Institute of Neurology (C.J.M.), University College London, UK.
| | - Roy Freeman
- From the Department of Neurology (H.K.), NYU Medical Center, New York; Department of Neurology (R.F.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Medicine (I.B.), Vanderbilt University Medical Center, Nashville, TN; Department of Neurology (P.L.), Mayo Clinic, Rochester, MN; Chelsea Therapeutics, Inc. (S.P., L.A.H.), Charlotte, NC; Chiltern (J.M.), Wilmington, NC; The Curry Rockefeller Group, LLC (M.F.), Tarrytown, NY; Autonomic and Neurovascular Medicine Departments (C.J.M.), Imperial College London; and Institute of Neurology (C.J.M.), University College London, UK
| | - Italo Biaggioni
- From the Department of Neurology (H.K.), NYU Medical Center, New York; Department of Neurology (R.F.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Medicine (I.B.), Vanderbilt University Medical Center, Nashville, TN; Department of Neurology (P.L.), Mayo Clinic, Rochester, MN; Chelsea Therapeutics, Inc. (S.P., L.A.H.), Charlotte, NC; Chiltern (J.M.), Wilmington, NC; The Curry Rockefeller Group, LLC (M.F.), Tarrytown, NY; Autonomic and Neurovascular Medicine Departments (C.J.M.), Imperial College London; and Institute of Neurology (C.J.M.), University College London, UK
| | - Phillip Low
- From the Department of Neurology (H.K.), NYU Medical Center, New York; Department of Neurology (R.F.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Medicine (I.B.), Vanderbilt University Medical Center, Nashville, TN; Department of Neurology (P.L.), Mayo Clinic, Rochester, MN; Chelsea Therapeutics, Inc. (S.P., L.A.H.), Charlotte, NC; Chiltern (J.M.), Wilmington, NC; The Curry Rockefeller Group, LLC (M.F.), Tarrytown, NY; Autonomic and Neurovascular Medicine Departments (C.J.M.), Imperial College London; and Institute of Neurology (C.J.M.), University College London, UK
| | - Simon Pedder
- From the Department of Neurology (H.K.), NYU Medical Center, New York; Department of Neurology (R.F.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Medicine (I.B.), Vanderbilt University Medical Center, Nashville, TN; Department of Neurology (P.L.), Mayo Clinic, Rochester, MN; Chelsea Therapeutics, Inc. (S.P., L.A.H.), Charlotte, NC; Chiltern (J.M.), Wilmington, NC; The Curry Rockefeller Group, LLC (M.F.), Tarrytown, NY; Autonomic and Neurovascular Medicine Departments (C.J.M.), Imperial College London; and Institute of Neurology (C.J.M.), University College London, UK
| | - L Arthur Hewitt
- From the Department of Neurology (H.K.), NYU Medical Center, New York; Department of Neurology (R.F.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Medicine (I.B.), Vanderbilt University Medical Center, Nashville, TN; Department of Neurology (P.L.), Mayo Clinic, Rochester, MN; Chelsea Therapeutics, Inc. (S.P., L.A.H.), Charlotte, NC; Chiltern (J.M.), Wilmington, NC; The Curry Rockefeller Group, LLC (M.F.), Tarrytown, NY; Autonomic and Neurovascular Medicine Departments (C.J.M.), Imperial College London; and Institute of Neurology (C.J.M.), University College London, UK
| | - Joe Mauney
- From the Department of Neurology (H.K.), NYU Medical Center, New York; Department of Neurology (R.F.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Medicine (I.B.), Vanderbilt University Medical Center, Nashville, TN; Department of Neurology (P.L.), Mayo Clinic, Rochester, MN; Chelsea Therapeutics, Inc. (S.P., L.A.H.), Charlotte, NC; Chiltern (J.M.), Wilmington, NC; The Curry Rockefeller Group, LLC (M.F.), Tarrytown, NY; Autonomic and Neurovascular Medicine Departments (C.J.M.), Imperial College London; and Institute of Neurology (C.J.M.), University College London, UK
| | - Michael Feirtag
- From the Department of Neurology (H.K.), NYU Medical Center, New York; Department of Neurology (R.F.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Medicine (I.B.), Vanderbilt University Medical Center, Nashville, TN; Department of Neurology (P.L.), Mayo Clinic, Rochester, MN; Chelsea Therapeutics, Inc. (S.P., L.A.H.), Charlotte, NC; Chiltern (J.M.), Wilmington, NC; The Curry Rockefeller Group, LLC (M.F.), Tarrytown, NY; Autonomic and Neurovascular Medicine Departments (C.J.M.), Imperial College London; and Institute of Neurology (C.J.M.), University College London, UK
| | - Christopher J Mathias
- From the Department of Neurology (H.K.), NYU Medical Center, New York; Department of Neurology (R.F.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Medicine (I.B.), Vanderbilt University Medical Center, Nashville, TN; Department of Neurology (P.L.), Mayo Clinic, Rochester, MN; Chelsea Therapeutics, Inc. (S.P., L.A.H.), Charlotte, NC; Chiltern (J.M.), Wilmington, NC; The Curry Rockefeller Group, LLC (M.F.), Tarrytown, NY; Autonomic and Neurovascular Medicine Departments (C.J.M.), Imperial College London; and Institute of Neurology (C.J.M.), University College London, UK
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García-Ortiz L, Recio-Rodríguez JI, Puig-Ribera A, Lema-Bartolomé J, Ibáñez-Jalón E, González-Viejo N, Guenaga-Saenz N, Agudo-Conde C, Patino-Alonso MC, Gomez-Marcos MA. Blood pressure circadian pattern and physical exercise assessment by accelerometer and 7-day physical activity recall scale. Am J Hypertens 2014; 27:665-73. [PMID: 23975330 DOI: 10.1093/ajh/hpt159] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The relationship between regular physical activity, measured objectively and by self-report, and the circadian pattern of 24-hour ambulatory arterial blood pressure (BP) has not been clarified. METHODS We performed a cross-sectional study in a cohort of healthy patients. We included 1,345 patients from the EVIDENT study (mean age 55 ± 14 years; 59.3% women). Physical activity was assessed using the 7-day physical activity recall (PAR) questionnaire (metabolic equivalents (MET)/hour/week) and the Actigraph GT3X accelerometer (counts/minute) for 7 days; ambulatory arterial BP was measured with a radial tonometer (B-pro device). RESULTS The dipper-pattern patients showed a higher level of activity than nondipper patients, as assessed by accelerometer and 7-day PAR. Physical activity measures correlated positively with the percent drop in systolic BP (SBP; ρ = 0.19 to 0.11; P < 0.01) and negatively with the systolic and diastolic sleep to wake ratios (ρ = -0.10 to -0.18; P < 0.01) and heart rate (ρ = -0.13; P < 0.01). In logistic regression, considering the circadian pattern (1, dipper; 0, nondipper) as the dependent variable, the odds ratio of the third tertile of counts/minute was 1.79 (95% confidence interval [CI], 1.35-2.38; P < 0.01) and of MET/hour/week was 1.33 (95% CI, 1.01-1.75; P = 0.04) after adjustment for confounding variables. CONCLUSIONS Physical activity, as evaluated by both the accelerometer and the 7-day PAR, was associated with a more marked nocturnal BP dip and, accordingly, a lower SBP and diastolic BP sleep to wake ratio. CLINICAL TRIAL REGISTRATION Clinical Trials.gov Identifier: NCT01083082.
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Affiliation(s)
- Luis García-Ortiz
- Alamedilla Health Center, Castilla y León Health Service (SACYL), Instituto de Investigación Biosanitario de Salamanca (IBSAL), Salamanca, Spain
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50
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Fanciulli A, Strano S, Ndayisaba JP, Goebel G, Gioffrè L, Rizzo M, Colosimo C, Caltagirone C, Poewe W, Wenning GK, Pontieri FE. Detecting nocturnal hypertension in Parkinson’s disease and multiple system atrophy: proposal of a decision-support algorithm. J Neurol 2014; 261:1291-9. [DOI: 10.1007/s00415-014-7339-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 04/02/2014] [Accepted: 04/02/2014] [Indexed: 11/28/2022]
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