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Tsuruya K, Yoshida H. Cognitive Impairment and Brain Atrophy in Patients with Chronic Kidney Disease. J Clin Med 2024; 13:1401. [PMID: 38592226 PMCID: PMC10931800 DOI: 10.3390/jcm13051401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/19/2024] [Accepted: 02/27/2024] [Indexed: 04/10/2024] Open
Abstract
In Japan, the aging of the population is rapidly accelerating, with an increase in patients with chronic kidney disease (CKD) and those undergoing dialysis. As a result, the number of individuals with cognitive impairment (CI) is rising, and addressing this issue has become an urgent problem. A notable feature of dementia in CKD patients is the high frequency of vascular dementia, making its prevention through the management of classical risk factors such as hypertension, diabetes mellitus, dyslipidemia, smoking, etc., associated with atherosclerosis and arteriosclerosis. Other effective measures, including the use of renin-angiotensin system inhibitors, addressing anemia, exercise therapy, and lifestyle improvements, have been reported. The incidence and progression of CI may also be influenced by the type of kidney replacement therapy, with reports suggesting that long-duration dialysis, low-temperature hemodialysis, peritoneal dialysis, and kidney transplantation can have a preferable effect on the preservation of cognitive function. In conclusion, patients with CKD are at a higher risk of developing CI, with brain atrophy being a contributing factor. Despite the identification of various preventive measures, the evidence substantiating their efficacy remains limited across all studies. Future expectations lie in large-scale randomized controlled trials.
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Affiliation(s)
- Kazuhiko Tsuruya
- Department of Nephrology, Nara Medical University, Kashihara 634-8521, Nara, Japan
| | - Hisako Yoshida
- Department of Medical Statistics, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Osaka, Japan;
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Hamrahian SM, Vilayet S, Herberth J, Fülöp T. Prevention of Intradialytic Hypotension in Hemodialysis Patients: Current Challenges and Future Prospects. Int J Nephrol Renovasc Dis 2023; 16:173-181. [PMID: 37547077 PMCID: PMC10404053 DOI: 10.2147/ijnrd.s245621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 07/25/2023] [Indexed: 08/08/2023] Open
Abstract
Intradialytic hypotension, defined as rapid decrease in systolic blood pressure of greater than or equal to 20 mmHg or in mean arterial pressure of greater than or equal to 10 mmHg that results in end-organ ischemia and requires countermeasures such as ultrafiltration reduction or saline infusion to increase blood pressure to improve patient's symptoms, is a known complication of hemodialysis and is associated with several potential adverse outcomes. Its pathogenesis is complex and involves both patient-related factors such as age and comorbidities, as well as factors related to the dialysis prescription itself. Key factors include the need for volume removal during hemodialysis and a suboptimal vascular response which compromises the ability to compensate for acute intravascular volume loss. Inadequate vascular refill, incorrect assessment or unaccounted changes of target weight, acute illnesses and medication interference are further potential contributors. Intradialytic hypotension can lead to compromised tissue perfusion and end-organ damage, both acutely and over time, resulting in repetitive injuries. To address these problems, a careful assessment of subjective symptoms, minimizing interdialytic weight gains, individualizing dialysis prescription and adjusting the dialysis procedure based on patients' risk factors can mitigate negative outcomes.
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Affiliation(s)
| | - Salem Vilayet
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
| | - Johann Herberth
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
- Medicine Services, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Tibor Fülöp
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
- Medicine Services, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
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Besnier F, Gagnon C, Monnet M, Dupuy O, Nigam A, Juneau M, Bherer L, Gayda M. Acute Effects of a Maximal Cardiopulmonary Exercise Test on Cardiac Hemodynamic and Cerebrovascular Response and Their Relationship with Cognitive Performance in Individuals with Type 2 Diabetes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20085552. [PMID: 37107835 PMCID: PMC10138481 DOI: 10.3390/ijerph20085552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/20/2023] [Accepted: 04/07/2023] [Indexed: 05/11/2023]
Abstract
Cardiovascular and cerebrovascular diseases are prevalent in individuals with type 2 diabetes (T2D). Among people with T2D aged over 70 years, up to 45% might have cognitive dysfunction. Cardiorespiratory fitness (V˙O2max) correlates with cognitive performances in healthy younger and older adults, and individuals with cardiovascular diseases (CVD). The relationship between cognitive performances, V˙O2max, cardiac output and cerebral oxygenation/perfusion responses during exercise has not been studied in patients with T2D. Studying cardiac hemodynamics and cerebrovascular responses during a maximal cardiopulmonary exercise test (CPET) and during the recovery phase, as well as studying their relationship with cognitive performances could be useful to detect patients at greater risk of future cognitive impairment. Purposes: (1) to compare cerebral oxygenation/perfusion during a CPET and during its post-exercise period (recovery); (2) to compare cognitive performances in patients with T2D to those in healthy controls; and (3) to examine if V˙O2max, maximal cardiac output and cerebral oxygenation/perfusion are associated with cognitive function in individuals with T2D and healthy controls. Nineteen patients with T2D (61.9 ± 7 years old) and 22 healthy controls (HC) (61.8 ± 10 years old) were evaluated on the following: a CPET test with impedance cardiography and cerebral oxygenation/perfusion using a near-infrared spectroscopy. Prior to the CPET, the cognitive performance assessment was performed, targeting: short-term and working memory, processing speed, executive functions, and long-term verbal memory. Patients with T2D had lower V˙O2max values compared to HC (34.5 ± 5.6 vs. 46.4 ± 7.6 mL/kg fat free mass/min; p < 0.001). Compared to HC, patients with T2D showed lower maximal cardiac index (6.27 ± 2.09 vs. 8.70 ± 1.09 L/min/m2, p < 0.05) and higher values of systemic vascular resistance index (826.21 ± 308.21 vs. 583.35 ± 90.36 Dyn·s/cm5·m2) and systolic blood pressure at maximal exercise (204.94 ± 26.21 vs. 183.61 ± 19.09 mmHg, p = 0.005). Cerebral HHb during the 1st and 2nd min of recovery was significantly higher in HC compared to T2D (p < 0.05). Executive functions performance (Z score) was significantly lower in patients with T2D compared to HC (-0.18 ± 0.7 vs. -0.40 ± 0.60, p = 0.016). Processing speed, working and verbal memory performances were similar in both groups. Brain tHb during exercise and recovery (-0.50, -0.68, p < 0.05), and O2Hb during recovery (-0.68, p < 0.05) only negatively correlated with executive functions performance in patients with T2D (lower tHb values associated with longer response times, indicating a lower performance). In addition to reduced V˙O2max, cardiac index and elevated vascular resistance, patients with T2D showed reduced cerebral hemoglobin (O2Hb and HHb) during early recovery (0-2 min) after the CPET, and lower performances in executive functions compared to healthy controls. Cerebrovascular responses to the CPET and during the recovery phase could be a biological marker of cognitive impairment in T2D.
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Affiliation(s)
- Florent Besnier
- Research Centre and Centre ÉPIC, Montreal Heart Institute, Montreal, QC H1T 1N6, Canada
- Department of Medicine, Faculty of Medicine, Université de Montreal, Montreal, QC H3T 1J4, Canada
| | - Christine Gagnon
- Research Centre and Centre ÉPIC, Montreal Heart Institute, Montreal, QC H1T 1N6, Canada
| | - Meghann Monnet
- Laboratory MOVE (UR 20296), Faculty of Sport Sciences, Université de Poitiers, 86073 Poitiers, France
| | - Olivier Dupuy
- Laboratory MOVE (UR 20296), Faculty of Sport Sciences, Université de Poitiers, 86073 Poitiers, France
- School of Kinesiology and Physical Activity Sciences (EKSAP), Faculty of Medicine, Université de Montreal, Montreal, QC H3T 1J4, Canada
| | - Anil Nigam
- Research Centre and Centre ÉPIC, Montreal Heart Institute, Montreal, QC H1T 1N6, Canada
- Department of Medicine, Faculty of Medicine, Université de Montreal, Montreal, QC H3T 1J4, Canada
| | - Martin Juneau
- Research Centre and Centre ÉPIC, Montreal Heart Institute, Montreal, QC H1T 1N6, Canada
- Department of Medicine, Faculty of Medicine, Université de Montreal, Montreal, QC H3T 1J4, Canada
| | - Louis Bherer
- Research Centre and Centre ÉPIC, Montreal Heart Institute, Montreal, QC H1T 1N6, Canada
- Department of Medicine, Faculty of Medicine, Université de Montreal, Montreal, QC H3T 1J4, Canada
- Research Centre, Institut Universitaire de Gériatrie de Montréal, Montreal, QC H3W 1W5, Canada
| | - Mathieu Gayda
- Research Centre and Centre ÉPIC, Montreal Heart Institute, Montreal, QC H1T 1N6, Canada
- Department of Medicine, Faculty of Medicine, Université de Montreal, Montreal, QC H3T 1J4, Canada
- Correspondence:
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Shapiro ALB, Bellatorre A, Dabelea D, Stafford JM, D'Agostino R, Shah AS, Urbina EM, Barrett CE, Pihoker C, Marcovina S, Liese AD, Mottl AK, Jensen ET, Wilkening G. Diabetes complications and cognitive function in young adults with youth-onset type 1 or type 2 diabetes: the SEARCH for Diabetes in Youth Study. Pediatr Diabetes 2023; 2023:4860831. [PMID: 38706530 PMCID: PMC11068325 DOI: 10.1155/2023/4860831] [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] [Indexed: 05/07/2024] Open
Abstract
Aims/hypotheses People with type 1 (T1D) or type 2 diabetes (T2D) who also have diabetes complications can have pronounced cognitive deficits. It remains unknown, however, whether and how multiple diabetes complications co-occur with cognitive dysfunction, particularly in youth-onset diabetes. Methods Using data from the SEARCH for Diabetes in Youth study cohort, a prospective longitudinal cohort, we examined clustering of complications and their underlying clinical factors with performance on cognitive tests in young adults with youth-onset T1D or T2D. Cognition was assessed via the NIH Toolbox Cognition Battery. The main cognitive variables were age-corrected scores for composite fluid cognition and associated cognitive subdomains. Diabetes complications included retinopathy, microalbuminuria, and peripheral neuropathy (PN). Lipids, systolic blood pressure (SBP), hemoglobin A1c, and other clinical factors were included in the analyses. Clustering was applied separately to each group (T1D=646; T2D=165). A three-cluster(C) solution was identified for each diabetes type. Mean values and frequencies of all factors were compared between resulting clusters. Results The average age-corrected score for composite fluid cognition differed significantly across clusters for each group (p<0.001). People with T1D and the lowest average fluid cognition scores had the highest frequency of self-reporting at least one episode of hypoglycemia in the year preceding cognitive testing and the highest prevalence of PN. Persons with T2D and the lowest average fluid cognition scores had the highest SBP, the highest central systolic and diastolic blood pressures, and highest prevalence of PN. Conclusions/interpretations These findings highlight shared (PN) and unique factors (hypoglycemia in T1D; SBP in T2D) that could be targeted to potentially mitigate cognitive issues in young people with youth-onset diabetes.
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Affiliation(s)
- Allison L B Shapiro
- Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus
| | - Anna Bellatorre
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus
| | - Dana Dabelea
- Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus
| | | | - Ralph D'Agostino
- Department of Biostatistics and Data Science, Wake Forest University
| | - Amy S Shah
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati
| | - Elaine M Urbina
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati
| | - Catherine E Barrett
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention
| | | | - Santica Marcovina
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington
| | - Angela D Liese
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina
| | - Amy K Mottl
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill
| | - Elizabeth T Jensen
- Department of Epidemiology and Prevention, Public Health Sciences, Wake Forest University
| | - Greta Wilkening
- Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus
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van Rijssel AE, Stins BC, Beishon LC, Sanders ML, Quinn TJ, Claassen JA, de Heus RA. Effect of Antihypertensive Treatment on Cerebral Blood Flow in Older Adults: a Systematic Review and Meta-Analysis. Hypertension 2022; 79:1067-1078. [PMID: 35193363 PMCID: PMC8997667 DOI: 10.1161/hypertensionaha.121.18255] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 01/21/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND In older age, the benefits of antihypertensive treatment (AHT) become less evident, with greater associated risk. Of particular concern is compromising cerebral blood flow (CBF), especially in those with cognitive impairment. METHODS We created a synthesis of the published evidence by searching multiple electronic databases from 1970 to May 2021. Included studies had participants with mean age ≥50 years, hypertension or cognitive impairment, and assessed CBF before and after initiating AHT. Two authors independently determined eligibility and extracted data. Study quality was assessed using The Risk of Bias in Nonrandomized Studies of Interventions tool. We summarized study characteristics (qualitative synthesis) and performed random-effects meta-analyses (quantitative synthesis). RESULTS Thirty-two studies (total n=1306) were included, of which 23 were eligible for meta-analysis. In line with the qualitative synthesis, the meta-analysis indicated no effect of AHT initiation on CBF (standardized mean difference, 0.08 [95% CI, -0.07 to 0.22]; P=0.31, I2=42%). This was consistent across subgroups of acute versus chronic AHT, drug class, study design, and CBF measurement. Subgroups by age demonstrated an increase in CBF after AHT in those aged >70 years (standardized mean difference, 4.15 [95% CI, 0.16-8.15]; P=0.04, I2=42%), but not in those aged 50 to 65 and 65 to 70 years (standardized mean difference, 0.18 [95% CI,-2.02 to 2.38]; P=0.87, I2=49%; standardized mean difference, 1.22 [95% CI, -0.45 to 2.88]; P=0.15, I2=68%). Overall, risk of bias was moderate-to-high and quality of evidence (Grading of Recommendations Assessment, Development and Evaluation) was very low, reflecting the observational nature of the data. CONCLUSIONS Accepting the observed limitations, current evidence does not suggest a harmful effect of AHT on CBF. Concerns over CBF should not preclude treatment of hypertension.
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Affiliation(s)
- Anniek E. van Rijssel
- Radboud university medical center, Donders Institute for Brain Cognition and Behaviour, Department of Geriatric Medicine, Radboudumc Alzheimer Center, Nijmegen, the Netherlands (A.E.v.R., B.C.S., M.L.S., J.A.H.R.C., R.A.A.d.H.)
| | - Bram C. Stins
- Radboud university medical center, Donders Institute for Brain Cognition and Behaviour, Department of Geriatric Medicine, Radboudumc Alzheimer Center, Nijmegen, the Netherlands (A.E.v.R., B.C.S., M.L.S., J.A.H.R.C., R.A.A.d.H.)
| | - Lucy C. Beishon
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom (L.C.B.)
| | - Marit L. Sanders
- Radboud university medical center, Donders Institute for Brain Cognition and Behaviour, Department of Geriatric Medicine, Radboudumc Alzheimer Center, Nijmegen, the Netherlands (A.E.v.R., B.C.S., M.L.S., J.A.H.R.C., R.A.A.d.H.)
| | - Terence J. Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (T.J.Q.)
| | - Jurgen A.H.R. Claassen
- Radboud university medical center, Donders Institute for Brain Cognition and Behaviour, Department of Geriatric Medicine, Radboudumc Alzheimer Center, Nijmegen, the Netherlands (A.E.v.R., B.C.S., M.L.S., J.A.H.R.C., R.A.A.d.H.)
| | - Rianne A.A. de Heus
- Radboud university medical center, Donders Institute for Brain Cognition and Behaviour, Department of Geriatric Medicine, Radboudumc Alzheimer Center, Nijmegen, the Netherlands (A.E.v.R., B.C.S., M.L.S., J.A.H.R.C., R.A.A.d.H.)
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Vidyashree M, Deepeshwar S, Nagarathna R, Manjunath NK, Kaligal C, Kanthi A, Nagendra HR, Bathala L, Sharma VK. Transcranial Doppler studies in Type 2 diabetes mellitus: A systematic review. Diabetes Res Clin Pract 2022; 186:109808. [PMID: 35247526 DOI: 10.1016/j.diabres.2022.109808] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 02/15/2022] [Accepted: 02/28/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Type II Diabetes mellitus (T2DM) patients are at the risk of developing cerebrovascular diseases, often contributed by altered cerebral haemodynamics. We present a systematic review of studies on cerebral haemodynamics assessment using transcranial Doppler (TCD) in T2DM. REVIEW METHOD A systematic review of the published articles in the English language between 1991 to 2021. DATA SOURCES Articles were retrieved via Pubmed and Cochrane library. We included Cross-sectional, prospective, retrospective, randomized controlled, and cross-over studies for this review. RESULTS A total of 25 articles met the inclusion criteria, which provided data for 3212 patients. CONCLUSION Cerebral autoregulation is often impaired among patients with T2DM. The risk increased with the duration of T2DM, related complications and presence of comorbidities.
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Affiliation(s)
- Mahadevappa Vidyashree
- Yoga and Life Sciences, Swami Vivekananda Yoga Anusandana Samsthana(S-VYASA), Bangalore, India.
| | - Singh Deepeshwar
- Yoga and Life Sciences, Swami Vivekananda Yoga Anusandana Samsthana(S-VYASA), Bangalore, India.
| | - Raghuram Nagarathna
- Yoga and Life Sciences, Swami Vivekananda Yoga Anusandana Samsthana(S-VYASA), Bangalore, India
| | | | - Chidananda Kaligal
- Yoga and Life Sciences, Swami Vivekananda Yoga Anusandana Samsthana(S-VYASA), Bangalore, India
| | - Amit Kanthi
- Yoga and Life Sciences, Swami Vivekananda Yoga Anusandana Samsthana(S-VYASA), Bangalore, India
| | | | | | - Vijay K Sharma
- Yong Loo Lin School of Medicine, National University of Singapore and Division of Neurology, National University Hospital, Singapore
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Yan J, Zheng K, Liu A, Cheng W. The Impact of Cognitive Function on the Effectiveness and Safety of Intensive Blood Pressure Control for Patients With Hypertension: A post-hoc Analysis of SPRINT. Front Cardiovasc Med 2021; 8:777250. [PMID: 34901238 PMCID: PMC8655835 DOI: 10.3389/fcvm.2021.777250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Poor cognitive function can predict poor clinical outcomes. Intensive blood pressure control can reduce the risk of cardiovascular diseases and all-cause mortality. In this study, we assessed whether intensive blood pressure control in older patients can reduce the risk of stroke, composite cardiovascular outcomes and all-cause mortality for participants in the Systolic Blood Pressure Intervention Trial (SPRINT) with lower or higher cognitive function based on the Montreal Cognitive Assessment (MoCA) cut-off scores. Methods: The SPRINT evaluated the impact of intensive blood pressure control (systolic blood pressure <120 mmHg) compared with standard blood pressure control (systolic blood pressure <140 mmHg). We defined MoCA score below education specific 25th percentile as lower cognitive function. And SPRINT participants with a MoCA score below 21 (<12 years of education) or 22 (≥12 years of education) were having lower cognitive function, and all others were having higher cognitive function. The Cox proportional risk regression was used to investigate the association of treatment arms with clinical outcomes and serious adverse effects in different cognitive status. Additional interaction and stratified analyses were performed to evaluate the robustness of the association between treatment arm and stroke in patients with lower cognitive function. Results: Of the participants, 1,873 were having lower cognitive function at baseline. The median follow-up period was 3.26 years. After fully adjusting for age, sex, ethnicity, body mass index, smoking, systolic blood pressure, Framingham 10-year CVD risk score, aspirin use, statin use, previous cardiovascular disease, previous chronic kidney disease and frailty status, intensive blood pressure control increased the risk of stroke [hazard ratio (HR) = 1.93, 95% confidence interval (CI): 1.04–3.60, P = 0.038)] in patients with lower cognitive function. Intensive blood pressure control could not reduce the risk of composite cardiovascular outcomes (HR = 0.81, 95%CI: 0.59–1.12, P = 0.201) and all-cause mortality (HR = 0.93, 95%CI: 0.64–1.35, P = 0.710) in lower cognitive function group. In patients with higher cognitive function, intensive blood pressure control led to significant reduction in the risk of stroke (HR = 0.55, 95%CI: 0.35–0.85, P = 0.008), composite cardiovascular outcomes (HR = 0.68, 95%CI: 0.56–0.83, P < 0.001) and all-cause mortality (HR = 0.62, 95%CI: 0.48–0.80, P < 0.001) in the fully adjusted model. Additionally, after the full adjustment, intensive blood pressure control increased the risk of hypotension and syncope in patients with lower cognitive function. Rates of hypotension, electrolyte abnormality and acute kidney injury were increased in the higher cognitive function patients undergoing intensive blood pressure control. Conclusion: Intensive blood pressure control might not reduce the risk of stroke, composite cardiovascular outcomes and all-cause mortality in patients with lower cognitive function.
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Affiliation(s)
- Jiafu Yan
- Hypertension Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Keyang Zheng
- Hypertension Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Aoya Liu
- Hypertension Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wenli Cheng
- Hypertension Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Nogueira RC, Beishon L, Bor-Seng-Shu E, Panerai RB, Robinson TG. Cerebral Autoregulation in Ischemic Stroke: From Pathophysiology to Clinical Concepts. Brain Sci 2021; 11:511. [PMID: 33923721 PMCID: PMC8073938 DOI: 10.3390/brainsci11040511] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/02/2021] [Accepted: 04/09/2021] [Indexed: 11/17/2022] Open
Abstract
Ischemic stroke (IS) is one of the most impacting diseases in the world. In the last decades, new therapies have been introduced to improve outcomes after IS, most of them aiming for recanalization of the occluded vessel. However, despite this advance, there are still a large number of patients that remain disabled. One interesting possible therapeutic approach would be interventions guided by cerebral hemodynamic parameters such as dynamic cerebral autoregulation (dCA). Supportive hemodynamic therapies aiming to optimize perfusion in the ischemic area could protect the brain and may even extend the therapeutic window for reperfusion therapies. However, the knowledge of how to implement these therapies in the complex pathophysiology of brain ischemia is challenging and still not fully understood. This comprehensive review will focus on the state of the art in this promising area with emphasis on the following aspects: (1) pathophysiology of CA in the ischemic process; (2) methodology used to evaluate CA in IS; (3) CA studies in IS patients; (4) potential non-reperfusion therapies for IS patients based on the CA concept; and (5) the impact of common IS-associated comorbidities and phenotype on CA status. The review also points to the gaps existing in the current research to be further explored in future trials.
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Affiliation(s)
- Ricardo C. Nogueira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo 01246-904, Brazil;
- Department of Neurology, Hospital Nove de Julho, São Paulo 01409-002, Brazil
| | - Lucy Beishon
- Cerebral Haemodynamics in Ageing and Stroke Medicine Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK; (L.B.); (R.B.P.); (T.G.R.)
| | - Edson Bor-Seng-Shu
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo 01246-904, Brazil;
| | - Ronney B. Panerai
- Cerebral Haemodynamics in Ageing and Stroke Medicine Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK; (L.B.); (R.B.P.); (T.G.R.)
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, University of Leicester, Leicester LE5 4PW, UK
| | - Thompson G. Robinson
- Cerebral Haemodynamics in Ageing and Stroke Medicine Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK; (L.B.); (R.B.P.); (T.G.R.)
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, University of Leicester, Leicester LE5 4PW, UK
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9
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Kaufman CS, Bai SX, Eickmeyer SM, Billinger SA. Chronic hyperglycemia before acute ischemic stroke impairs the bilateral cerebrovascular response to exercise during the subacute recovery period. Brain Behav 2021; 11:e01990. [PMID: 33295148 PMCID: PMC7882183 DOI: 10.1002/brb3.1990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/17/2020] [Accepted: 11/20/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND PURPOSE Chronic hyperglycemia contributes to cerebrovascular dysfunction by damaging blood vessels. Poor glucose control has been tied to impairments in cerebral blood flow, which may be particularly detrimental for people recovering from major cerebrovascular events such as acute ischemic stroke. In this secondary analysis, we explore for the first time the connection between chronic hyperglycemia before acute stroke and the cerebrovascular response (CVR) to exercise 3 and 6 month into the subacute recovery period. METHODS We recorded middle cerebral artery velocity (MCAv) using transcranial Doppler ultrasound bilaterally at rest and during moderate-intensity exercise in stroke patients at 3 (n = 19) and 6 (n = 12) months post-stroke. We calculated CVR as the difference between MCAv during steady-state exercise and resting MCAv. We obtained hemoglobin A1c levels (HbA1c; a measure of blood glucose over the prior 3 months) from the electronic medical record (EMR) and divided participants by HbA1c greater or less than 7%. RESULTS Participants with high HbA1c (>7%) at the time of acute stroke had significantly lower CVR to exercise for both the stroke-affected (p = .009) and non-affected (p = .007) hemispheres at 3 months post-stroke. These differences remained significant at 6 months post-stroke (stroke-affected, p = .008; non-affected, p = .016). CONCLUSIONS Patients with chronic hyperglycemia before acute ischemic stroke demonstrated impaired cerebrovascular function during exercise months into the subacute recovery period. These findings highlight the importance of maintaining tight glucose control to reduce morbidity and improve recovery post-stroke and could have implications for understanding cerebrovascular pathophysiology.
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Affiliation(s)
- Carolyn S Kaufman
- Department of Molecular and Integrative Physiology, University of Kansas, Medical Center, Kansas City, KS, USA.,Department of Physical Therapy and Rehabilitation Science, University of Kansas, Medical Center, Kansas City, KS, USA
| | - Stephen X Bai
- Department of Physical Medicine and Rehabilitation, University of Kansas, Medical Center, Kansas City, KS, USA
| | - Sarah M Eickmeyer
- Department of Physical Medicine and Rehabilitation, University of Kansas, Medical Center, Kansas City, KS, USA
| | - Sandra A Billinger
- Department of Molecular and Integrative Physiology, University of Kansas, Medical Center, Kansas City, KS, USA.,Department of Physical Therapy and Rehabilitation Science, University of Kansas, Medical Center, Kansas City, KS, USA.,Department of Physical Medicine and Rehabilitation, University of Kansas, Medical Center, Kansas City, KS, USA.,Department of Neurology, University of Kansas, Medical Center, Kansas City, KS, USA
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10
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Kim YS, van der Ster BJP, Brassard P, Secher NH, van Lieshout JJ. Cerebral vs. Cardiovascular Responses to Exercise in Type 2 Diabetic Patients. Front Physiol 2021; 11:583155. [PMID: 33519500 PMCID: PMC7844205 DOI: 10.3389/fphys.2020.583155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/23/2020] [Indexed: 12/17/2022] Open
Abstract
The human brain is constantly active and even small limitations to cerebral blood flow (CBF) may be critical for preserving oxygen and substrate supply, e.g., during exercise and hypoxia. Exhaustive exercise evokes a competition for the supply of oxygenated blood between the brain and the working muscles, and inability to increase cardiac output sufficiently during exercise may jeopardize cerebral perfusion of relevance for diabetic patients. The challenge in diabetes care is to optimize metabolic control to slow progression of vascular disease, but likely because of a limited ability to increase cardiac output, these patients perceive aerobic exercise to be more strenuous than healthy subjects and that limits the possibility to apply physical activity as a preventive lifestyle intervention. In this review, we consider the effects of functional activation by exercise on the brain and how it contributes to understanding the control of CBF with the limited exercise tolerance experienced by type 2 diabetic patients. Whether a decline in cerebral oxygenation and thereby reduced neural drive to working muscles plays a role for "central" fatigue during exhaustive exercise is addressed in relation to brain's attenuated vascular response to exercise in type 2 diabetic subjects.
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Affiliation(s)
- Yu-Sok Kim
- Laboratory for Clinical Cardiovascular Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Department of Medical Biology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Department of Internal Medicine, Medisch Centrum Leeuwarden, Leeuwarden, Netherlands
| | - Björn J. P. van der Ster
- Laboratory for Clinical Cardiovascular Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, Research Center of the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Niels H. Secher
- Department of Anesthesia, The Copenhagen Muscle Research Center, University of Copenhagen, Copenhagen, Denmark
| | - Johannes J. van Lieshout
- Laboratory for Clinical Cardiovascular Physiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Department of Medical Biology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham Medical School, Queen’s Medical Centre, Nottingham, United Kingdom
- Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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11
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Chau ACM, Cheung EYW, Chan KH, Chow WS, Shea YF, Chiu PKC, Mak HKF. Impaired cerebral blood flow in type 2 diabetes mellitus - A comparative study with subjective cognitive decline, vascular dementia and Alzheimer's disease subjects. NEUROIMAGE-CLINICAL 2020; 27:102302. [PMID: 32521474 PMCID: PMC7284123 DOI: 10.1016/j.nicl.2020.102302] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 04/27/2020] [Accepted: 05/25/2020] [Indexed: 12/21/2022]
Abstract
CBF impairment is found in T2DM and SCD individuals, which might suggest a preclinical stage of dementia. Comparing to HC, lower CBF in T2DM was due to higher rate of multiple cerebrovascular risk factors. Unlike T2DM, CBF reduction in AD and VD was due to amyloid deposition and microangiopathy respectively. Significant negative correlation between adjusted CBF and HbA1c in all cortical regions in healthy control and T2DM.
The link between non-demented type 2 diabetes mellitus (T2DM) and different types of cognitive impairment is controversial. By controlling for co-morbidities such as cerebral macrovascular and microvascular changes, cerebral atrophy, amyloid burden, hypertension or hyperlipidemia, the current study investigated the cerebral blood flow of T2DM individuals as compared to cognitively impaired subjects recruited from a memory clinic. 15 healthy control (71.8 ± 6.1 years), 18 T2DM (62.5 ± 3.7 years), as well as 8 Subjective Cognitive Decline (69.5 ± 7.5 years), 12 Vascular Dementia (79.3 ± 4.2 years) and 17 Alzheimer’s Disease (75.1 ± 8.2 years) underwent multi-parametric MRI brain scanning. Subjects with T2DM and from the memory clinic also had 18-F Flutametamol PET-CT scanning to look for any amyloid burden. Pseudocontinuous Arterial Spin Labeling (PCASL), MR Angiography Head, 3D FLAIR and 3D T1-weighted sequences were used to quantify cerebral blood flow, cerebrovascular changes, white matter hyperintensities and brain atrophy respectively. Vascular risk factors were retrieved from the medical records. The 37 subjects from memory clinic were classified into subjective cognitive decline (SCD), vascular dementia (VD) and Alzheimer’s disease (AD) subgroups by a multi-disciplinary panel consisting of a neuroradiologist, and 2 geriatricians. Absolute cortical CBF in our cohort of T2DM, SCD, VD and AD was significantly decreased (p < 0.01) as compared to healthy controls (HC) in both whole brain and eight paired brain regions, after age, normalized grey matter volume and gender adjustment and Bonferroni correction. Subgroup analysis between T2DM, SCD, VD, and AD revealed that CBF of T2DM was not significantly different from AD, VD or SCD. By controlling for co-morbidities, impaired cortical CBF in T2DM was not related to microangiopathy or amyloid deposition, but to the interaction of triple risk factors (such as diabetes mellitus, hypertension, and hyperlipidemia). There was statistically significant negative correlation (p ≤ 0.05) between adjusted CBF and HbA1c in all brain regions of T2DM and HC (with partial correlation ranging from −0.30 to −0.46). Taken together, altered cerebral blood flow in T2DM might be related to disruption of cerebrovascular autoregulation related to vascular risk factors, and such oligemia occurred before clinical manifestation due to altered glycemic control.
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Affiliation(s)
- Anson C M Chau
- The University of Hong Kong (Shenzhen) Teaching Hospital Limited, The University of Hong Kong, Pokfulam Road, Hong Kong.
| | - Eva Y W Cheung
- Department of Diagnostic Radiology, LKS Faculty of Medicine, The University of Hong Kong, K406, Queen Mary Hospital, Pokfulam Road, Hong Kong
| | - K H Chan
- Department of Medicine, LKS Faculty of Medicine, The University of Hong Kong, 405B, Professorial Block, Queen Mary Hospital, Pokfulam Road, Hong Kong.
| | - W S Chow
- Department of Medicine, LKS Faculty of Medicine, The University of Hong Kong, 405B, Professorial Block, Queen Mary Hospital, Pokfulam Road, Hong Kong.
| | - Y F Shea
- Department of Medicine, LKS Faculty of Medicine, The University of Hong Kong, 405B, Professorial Block, Queen Mary Hospital, Pokfulam Road, Hong Kong
| | - Patrick K C Chiu
- Department of Medicine, LKS Faculty of Medicine, The University of Hong Kong, 405B, Professorial Block, Queen Mary Hospital, Pokfulam Road, Hong Kong
| | - Henry K F Mak
- Department of Diagnostic Radiology, LKS Faculty of Medicine, The University of Hong Kong, K406, Queen Mary Hospital, Pokfulam Road, Hong Kong; State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong; Alzheimer's Disease Research Network, The University of Hong Kong, Hong Kong.
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12
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Park B, Budzynska K, Almasri N, Islam S, Alyas F, Carolan RL, Abraham BE, Castro-Camero PA, Shreve ME, Rees DA, Lamerato L. Tight versus standard blood pressure control on the incidence of myocardial infarction and stroke: an observational retrospective cohort study in the general ambulatory setting. BMC FAMILY PRACTICE 2020; 21:91. [PMID: 32416722 PMCID: PMC7231410 DOI: 10.1186/s12875-020-01163-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 05/10/2020] [Indexed: 11/14/2022]
Abstract
Background The 2017 American College of Cardiology and American Heart Association guideline defined hypertension as blood pressure (BP) ≥ 130/80 mmHg compared to the traditional definition of ≥140/90 mmHg. This change raised much controversy. We conducted this study to compare the impact of tight (TBPC) versus standard BP control (SBPC) on the incidence of myocardial infarction (MI) and stroke. Methods We retrospectively identified all hypertensive patients in an ambulatory setting based on the diagnostic code for 1 year at our institution who were classified by the range of BP across 3 years into 2 groups of TBPC (< 130 mmHg) and SBPC (130–139 mmHg). We compared the incidence of new MI and stroke between the 2 groups across a 2-year follow-up. Multivariate analysis was done to identify independent predictors for the incidence of new MI and stroke. Results Of 5640 study patients, the TBPC group showed significantly less incidence of stroke compared to the SBPC group (1.5% vs. 2.7%, P < 0.010). No differences were found in MI incidence between the 2 groups (0.6% vs. 0.8%, P = 0.476). Multivariate analysis showed that increased age independently increased the incidence of both MI (OR 1.518, 95% CI 1.038–2.219) and stroke (OR 1.876, 95% CI 1.474–2.387), and TBPC independently decreased the incidence of stroke (OR 0.583, 95% CI 0.374–0.910) but not of MI. Conclusions Our observational study suggests that TBPC may be beneficial in less stroke incidence compared to SBPC but it didn’t seem to affect the incidence of MI. Our study is limited by its retrospective design with potential confounders.
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Affiliation(s)
- Bumsoo Park
- Departments of Family Medicine and Urology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Katarzyna Budzynska
- Department of Family Medicine, Henry Ford Health System, Wayne State University School of Medicine, 3370 E. Jefferson Ave. Detroit, Detroit, MI, 48207-4236, USA.
| | - Nada Almasri
- Department of Family Medicine, Henry Ford Health System, Wayne State University School of Medicine, 3370 E. Jefferson Ave. Detroit, Detroit, MI, 48207-4236, USA
| | - Sumaiya Islam
- Department of Family Medicine, Henry Ford Health System, Wayne State University School of Medicine, 3370 E. Jefferson Ave. Detroit, Detroit, MI, 48207-4236, USA
| | - Fanar Alyas
- Department of Family Medicine, ProMedica Physicians Family Medicine - Monroe, Monroe, MI, USA
| | - Rachel L Carolan
- Department of Family Medicine, Henry Ford Health System, Wayne State University School of Medicine, 3370 E. Jefferson Ave. Detroit, Detroit, MI, 48207-4236, USA
| | - Benjamin E Abraham
- Department of Family Medicine, Henry Ford Health System, Wayne State University School of Medicine, 3370 E. Jefferson Ave. Detroit, Detroit, MI, 48207-4236, USA
| | - Pamela A Castro-Camero
- Department of Family Medicine, Henry Ford Health System, Wayne State University School of Medicine, 3370 E. Jefferson Ave. Detroit, Detroit, MI, 48207-4236, USA
| | - Maria E Shreve
- Department of Family Medicine, Henry Ford Health System, Wayne State University School of Medicine, 3370 E. Jefferson Ave. Detroit, Detroit, MI, 48207-4236, USA
| | - Della A Rees
- Department of Family Medicine, Henry Ford Health System, Wayne State University School of Medicine, 3370 E. Jefferson Ave. Detroit, Detroit, MI, 48207-4236, USA
| | - Lois Lamerato
- Department of Public Health Sciences, Henry Ford Health System, Wayne State University School of Medicine, Detroit, MI, USA
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Wu W, Liu J, Li A, Li J, Yang Y, Ye X, Zheng J. Effect of Intensive Blood Pressure Control on Carotid Morphology and Hemodynamics in Chinese Patients with Hyperhomocysteinemia-Type Hypertension and High Risk of Stroke. Med Sci Monit 2019; 25:5717-5726. [PMID: 31369520 PMCID: PMC6688516 DOI: 10.12659/msm.914482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 03/21/2019] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Different blood pressure targets should be formulated for different groups of people. This study aimed to assess the effectiveness of intensive blood control in improving the carotid morphology and hemodynamics in Chinese patients with hyperhomocysteinemia-type hypertension and high risk of stroke. MATERIAL AND METHODS Chinese hypertensive patients with high risk of stroke were randomized to intensive (n=187) and standard (n=192; controls) blood pressure management groups. Systolic blood pressure (SBP) targets were 100< SBP ≤120 and 120< SBP ≤140 mmHg, respectively. All patients received folic acid 0.8 mg/d and atorvastatin 20 mg/d. Calcium antagonist was first used. If blood pressure was still uncontrolled, angiotensin-converting enzyme inhibitor or angiotensin receptor antagonist, ß-receptor blocker, and diuretics were added successively. Follow-up was 12 months. Carotid features, hemodynamics, and adverse events were examined. RESULTS There were no differences in sex, age, body mass index, blood lipids, baseline carotid parameters, and histories of smoking, diabetes, statin use, and stroke between the 2 groups. Carotid plaques after 12 months of treatment were 19.4±2.1 and 23.6±3.1 cm² for the intensive and control groups, respectively (P=0.038). Plaque scores were lower in the intensive group (1.75±0.52 vs. 2.45±0.47, P=0.023). Compared with controls, intensive management resulted in relatively higher Vd and significantly lower Vs/Vd, PI, and RI (all P<0.05). Major adverse events such as hypotension (n=5 (2.7%) vs. 3 (1.6%), P=0.020) and dizziness (n=20 (10.7%) vs. 16 (8.3%), P=0.041) were more frequent in the intensive group. CONCLUSIONS Intensive blood pressure management could be beneficial for Chinese patients with hyperhomocysteinemia-type hypertension and high risk of stroke.
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Affiliation(s)
- Wenjing Wu
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Jian Liu
- Department of Ultrasound Diagnosis, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Aili Li
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Jiahui Li
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Yiyun Yang
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Xiaojun Ye
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Jingang Zheng
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, P.R. China
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Shimoda H, Takahashi T. Perioperative management in a patient with type 1 diabetes mellitus who presented severe hypoglycemia during dental implant surgery: a case report. BMC Oral Health 2018; 18:204. [PMID: 30526578 PMCID: PMC6286565 DOI: 10.1186/s12903-018-0679-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 11/27/2018] [Indexed: 11/17/2022] Open
Abstract
Background Patients with type 1 diabetes mellitus (DM) have poor glycemic control owing to extreme impairments in glucose tolerance. There are few reports regarding dental implant surgery in patients with type 1 DM. We describe herein the perioperative glycemic management in an outpatient with type 1 DM who experienced a rare case of severe hypoglycemia during dental implant surgery. Only one such case has previously been reported. Case presentation A 60-year-old male patient diagnosed with type 1 DM was scheduled for dental implant primary surgery. Premedication with peroral antibiotics was carried out to prevent possible systemic infection as a complication of DM. The patient was treated to control intraoperative hypertension with diligent attention to cardiovascular conditions by using a bolus administration of nicardipine and diltiazem. During surgery, he abruptly complained of hypoglycemic symptoms and had a blood glucose level of 32 mg/dL. Following oral administration and electrolyte-combined infusion of glucose, he immediately recovered from the critical situation. The surgical procedure, involving a lower jaw implant fixture placement, was performed as planned and resulted in less invasion, limited to the area of implant fixture placement within the right mandibular region of the two molars, compared to implant surgery that spans the entire lower jaw. Conclusions The present case suggests that it is essential to promptly monitor possible signs of hypoglycemia-precipitated acute symptoms in patients with DM. In addition, it is also necessary to appropriately administer insulin with an electrolyte-combined infusion of glucose for deliberate glycemic control; this is particularly true in patients with type 1 DM undergoing relatively highly-invasive oral surgical manipulation such as commonly performed dental implant surgery spanning the entire jaw.
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Affiliation(s)
- Hajime Shimoda
- Division of Oral and Maxillofacial Surgery, Department of Oral Medicine and Surgery, Tohoku University Graduate School of Dentistry, 4-1 Seiryomachi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan.
| | - Tetsu Takahashi
- Division of Oral and Maxillofacial Surgery, Department of Oral Medicine and Surgery, Tohoku University Graduate School of Dentistry, 4-1 Seiryomachi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
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15
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Vianna LC, Fernandes IA, Barbosa TC, Amaral TG, Rocha NG, Secher NH, Nóbrega AC. Absent increase in vertebral artery blood flow during l-arginine infusion in hypertensive men. Am J Physiol Regul Integr Comp Physiol 2018; 315:R820-R824. [DOI: 10.1152/ajpregu.00088.2018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Endothelial dysfunction is observed in the peripheral vasculature of hypertensive patients, but it is unclear how the cerebral circulation is affected. More specifically, little is known about the impact of human hypertension on vertebral artery (VA) endothelial function. This study evaluated whether the endothelial function of the VA is impaired in hypertensive men. For 13 male hypertensive subjects (46 ± 3 yr) and eight age-matched male controls (46 ± 4 yr), blood pressure (BP; photoplethysmography), VA, and common carotid (CC) blood flow (duplex ultrasound) were determined at rest and during 30 min of intravenous l-arginine (30 g; a precursor of nitric oxide) or isotonic saline infusion. Controls and hypertensive subjects demonstrated a similar resting CC (601 ± 30 vs. controls 570 ± 43 ml/min; P = 0.529) and VA blood flow (119 ± 11 vs. controls 112 ± 9 ml/min; P = 0.878). During administration of l-arginine, CC blood flow increased similarly between groups (hypertensive 12 ± 3%, controls 13 ± 2%; P = 0.920). In contrast, the increase in VA blood flow was nonexistent in the hypertensive subjects (0.8 ± 3% vs. controls: 16 ± 4%; P = 0.015) with no significant change in BP. Both CC and VA flow returned to near-resting values within 30 min after the infusion, and for four hypertensive subjects and three controls, time-control experiments using 0.9% saline did not affect VA or CC blood flow significantly. The results demonstrate endothelial dysfunction in the posterior cerebral circulation of middle-aged hypertensive men.
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Affiliation(s)
- Lauro C. Vianna
- NeuroVASQ Integrative Physiology Laboratory, Faculty of Physical Education, University of Brasília, Brasília, Federal District, Brazil
- Department of Physiology and Pharmacology, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | - Igor A. Fernandes
- Department of Physiology and Pharmacology, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | - Thales C. Barbosa
- Department of Kinesiology, University of Texas at Arlington, Arlington, Texas
| | - Tatiana G. Amaral
- Department of Physiology and Pharmacology, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | - Natalia G. Rocha
- Department of Physiology and Pharmacology, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | - Niels H. Secher
- Department of Anaesthesiology, The Copenhagen Muscle Research Center, University of Copenhagen, Copenhagen, Denmark
| | - Antonio C. Nóbrega
- Department of Physiology and Pharmacology, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
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Abstract
PURPOSE OF REVIEW The extrinsic risk factors for postoperative cognitive disturbance have been a source of concern during the perioperative period, and these risk factors remain the subject of controversy. This review of recent studies focuses on the effect of these factors on postoperative cognitive disturbance during the perioperative period. RECENT FINDINGS Impairment of cerebral autoregulation may predispose patients to intraoperative cerebral malperfusion, which may subsequently induce postoperative cognitive disturbance. The neurotoxicity of several volatile anesthetics may contribute to cognitive functional decline, and the impact of intravenous anesthesia on cognitive function requires further exploration. Multimodal analgesia may not outperform traditional postoperative analgesia in preventing postoperative delirium. Furthermore, acute pain and chronic pain may exacerbate the cognitive functional decline of patients with preexisting cognitive impairment. The nuclear factor-kappa beta pathway is an important node in the neuroinflammatory network. SUMMARY Several intraoperative factors are associated with postoperative cognitive disturbance. However, if these factors are optimized in perioperative management, postoperative cognitive disturbance will improve.
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Affiliation(s)
- Huiqun Fu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Dewanjee S, Das S, Das AK, Bhattacharjee N, Dihingia A, Dua TK, Kalita J, Manna P. Molecular mechanism of diabetic neuropathy and its pharmacotherapeutic targets. Eur J Pharmacol 2018; 833:472-523. [DOI: 10.1016/j.ejphar.2018.06.034] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 06/15/2018] [Accepted: 06/26/2018] [Indexed: 02/07/2023]
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Tamura Y, Kimbara Y, Yamaoka T, Sato K, Tsuboi Y, Kodera R, Chiba Y, Mori S, Fujiwara Y, Tokumaru AM, Ito H, Sakurai T, Araki A. White Matter Hyperintensity in Elderly Patients with Diabetes Mellitus Is Associated with Cognitive Impairment, Functional Disability, and a High Glycoalbumin/Glycohemoglobin Ratio. Front Aging Neurosci 2017; 9:220. [PMID: 28729834 PMCID: PMC5498506 DOI: 10.3389/fnagi.2017.00220] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 06/23/2017] [Indexed: 01/07/2023] Open
Abstract
Aims: Although evidence has accumulated that white matter hyperintensity (WMH) is associated with the deterioration of cognitive function and impairment of activities of daily living (ADL), the clinical relevance of WMH in elderly patients with diabetes mellitus (DM) is not still clear. The aim of this study was to examine whether WMH volume is associated with ADL and cognitive function and whether glucose control and glucose variability can affect WMH volume in these patients. Methods: This cross-sectional study investigated the associations of WMH with cognitive function and instrumental ADL (IADL), as well as metabolic and vascular risk factors in a total of 178 elderly patients with diabetes. The study assessed WMH volumes and the functional status of cognition and IADL. WMH volumes were evaluated by obtaining axial T2-weighted and fluid-attenuated inversion recovery sequence images on brain magnetic resonance imaging and assessing the images using Software for Neuro-Image Processing in Experimental Research. Results: We found a significant association between WMH volumes and Mini-Mental State Examination (MMSE) scores (p = 0.039) and between WMH and IADL status (p = 0.006). Furthermore, we found significant relations of large WMH volumes with a high glycoalbumin/glycohemoglobin ratio (GA/HbA1c) (p < 0.001). Large WMH volumes were also found to be associated with a low body mass index (p = 0.014) and a low diastolic blood pressure (p = 0.024), but not with HbA1c. Multiple regression analysis showed that high GA/HbA1c, which reflects high glucose variability, was a significant determining factor for large WMH volumes. We also found that GA/HbA1c was negatively associated with both MMSE (p = 0.036) and IADL (p < 0.001). Conclusion: GA/HbA1c, which is a marker of glucose variability, was independently associated with WMH volumes, which could lead to the decline of cognition and IADL in elderly patients with DM.
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Affiliation(s)
- Yoshiaki Tamura
- Departments of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Geriatric HospitalTokyo, Japan
| | - Yoshiyuki Kimbara
- Departments of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Geriatric HospitalTokyo, Japan
| | - Takuya Yamaoka
- Departments of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Geriatric HospitalTokyo, Japan
| | - Ken Sato
- Departments of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Geriatric HospitalTokyo, Japan
| | - Yuki Tsuboi
- Departments of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Geriatric HospitalTokyo, Japan
| | - Remi Kodera
- Departments of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Geriatric HospitalTokyo, Japan
| | - Yuko Chiba
- Departments of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Geriatric HospitalTokyo, Japan
| | - Seijiro Mori
- Departments of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Geriatric HospitalTokyo, Japan
| | - Yoshinori Fujiwara
- Research Team for Social Participation and Community Health, Tokyo Metropolitan Institute of GerontologyTokyo, Japan
| | - Aya M Tokumaru
- Department of Diagnostic Radiology, Tokyo Metropolitan Geriatric HospitalTokyo, Japan
| | - Hideki Ito
- Departments of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Geriatric HospitalTokyo, Japan
| | - Takashi Sakurai
- Center for Comprehensive Care and Research on Memory Disorders, National Center for Geriatrics and GerontologyAichi, Japan
| | - Atsushi Araki
- Departments of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Geriatric HospitalTokyo, Japan
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Frosch OH, Yau PL, Osorio RS, Rusinek H, Storey P, Convit A. Insulin resistance among obese middle-aged is associated with decreased cerebrovascular reactivity. Neurology 2017; 89:249-255. [PMID: 28615420 DOI: 10.1212/wnl.0000000000004110] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 04/14/2017] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To evaluate differences in cerebrovascular reactivity (CVR) to mild hypercapnia in obese/overweight individuals with and without insulin resistance (IR) compared to comparable lean controls. METHODS A total of 60 cognitively normal participants (20 lean controls and 24 obese/overweight individuals with and 16 without IR) were evaluated using a high spatial resolution arterial spin labeling MRI technique at rest and during mild hypercapnia. We analyzed group differences in CVR in cerebral cortex and ascertained the relationships between CVR, IR, and body mass index (BMI). RESULTS Obese/overweight participants with and without IR had significantly lower CVR to hypercapnia than lean controls after controlling for age, sex, and the presence of hypertension (F2,53 = 5.578, p = 0.006 [Formula: see text] = 0.174). In the obese/overweight participants with IR, there was a significant correlation between higher CVR and a measure of insulin sensitivity, even after accounting for BMI (rp = 0.575, p = 0.004). In contrast, there was no relationship between CVR and BMI when controlling for IR. No such relationships existed for the other 2 groups. CONCLUSIONS IR is associated with impaired CVR; the relationship appears to be driven by the degree of IR and not by obesity. These rarely reported results suggest that early forms of cerebrovascular dysfunction exist among obese middle-aged individuals with significant IR but without type 2 diabetes mellitus. These functional vascular abnormalities may help explain the associations among IR, diabetes, and dementia, and suggest that interventions aiming to improve IR or CVR may help prevent cognitive decline later in life.
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Affiliation(s)
- Olivia H Frosch
- From the Departments of Psychiatry (O.H.F., P.L.Y., R.S.O., H.R., A.C.), Radiology (H.R., P.S., A.C.), and Medicine (A.C.), New York University School of Medicine, New York; and Nathan Kline Institute for Psychiatric Research (A.C.), Orangeburg, NY
| | - Po Lai Yau
- From the Departments of Psychiatry (O.H.F., P.L.Y., R.S.O., H.R., A.C.), Radiology (H.R., P.S., A.C.), and Medicine (A.C.), New York University School of Medicine, New York; and Nathan Kline Institute for Psychiatric Research (A.C.), Orangeburg, NY
| | - Ricardo S Osorio
- From the Departments of Psychiatry (O.H.F., P.L.Y., R.S.O., H.R., A.C.), Radiology (H.R., P.S., A.C.), and Medicine (A.C.), New York University School of Medicine, New York; and Nathan Kline Institute for Psychiatric Research (A.C.), Orangeburg, NY
| | - Henry Rusinek
- From the Departments of Psychiatry (O.H.F., P.L.Y., R.S.O., H.R., A.C.), Radiology (H.R., P.S., A.C.), and Medicine (A.C.), New York University School of Medicine, New York; and Nathan Kline Institute for Psychiatric Research (A.C.), Orangeburg, NY
| | - Pippa Storey
- From the Departments of Psychiatry (O.H.F., P.L.Y., R.S.O., H.R., A.C.), Radiology (H.R., P.S., A.C.), and Medicine (A.C.), New York University School of Medicine, New York; and Nathan Kline Institute for Psychiatric Research (A.C.), Orangeburg, NY
| | - Antonio Convit
- From the Departments of Psychiatry (O.H.F., P.L.Y., R.S.O., H.R., A.C.), Radiology (H.R., P.S., A.C.), and Medicine (A.C.), New York University School of Medicine, New York; and Nathan Kline Institute for Psychiatric Research (A.C.), Orangeburg, NY.
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Abd-Elrahman KS, Colinas O, Walsh EJ, Zhu HL, Campbell CM, Walsh MP, Cole WC. Abnormal myosin phosphatase targeting subunit 1 phosphorylation and actin polymerization contribute to impaired myogenic regulation of cerebral arterial diameter in the type 2 diabetic Goto-Kakizaki rat. J Cereb Blood Flow Metab 2017; 37:227-240. [PMID: 26721393 PMCID: PMC5363741 DOI: 10.1177/0271678x15622463] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 10/26/2015] [Accepted: 11/17/2015] [Indexed: 12/11/2022]
Abstract
The myogenic response of cerebral resistance arterial smooth muscle to intraluminal pressure elevation is a key physiological mechanism regulating blood flow to the brain. Rho-associated kinase plays a critical role in the myogenic response by activating Ca2+ sensitization mechanisms: (i) Rho-associated kinase inhibits myosin light chain phosphatase by phosphorylating its targeting subunit myosin phosphatase targeting subunit 1 (at T855), augmenting 20 kDa myosin regulatory light chain (LC20) phosphorylation and force generation; and (ii) Rho-associated kinase stimulates cytoskeletal actin polymerization, enhancing force transmission to the cell membrane. Here, we tested the hypothesis that abnormal Rho-associated kinase-mediated myosin light chain phosphatase regulation underlies the dysfunctional cerebral myogenic response of the Goto-Kakizaki rat model of type 2 diabetes. Basal levels of myogenic tone, LC20, and MYPT1-T855 phosphorylation were elevated and G-actin content was reduced in arteries of pre-diabetic 8-10 weeks Goto-Kakizaki rats with normal serum insulin and glucose levels. Pressure-dependent myogenic constriction, LC20, and myosin phosphatase targeting subunit 1 phosphorylation and actin polymerization were suppressed in both pre-diabetic Goto-Kakizaki and diabetic (18-20 weeks) Goto-Kakizaki rats, whereas RhoA, ROK2, and MYPT1 expression were unaffected. We conclude that abnormal Rho-associated kinase-mediated Ca2+ sensitization contributes to the dysfunctional cerebral myogenic response in the Goto-Kakizaki model of type 2 diabetes.
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Affiliation(s)
- Khaled S Abd-Elrahman
- The Smooth Muscle Research Group, Departments of Physiology & Pharmacology, Libin Cardiovascular Institute & Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Olaia Colinas
- The Smooth Muscle Research Group, Departments of Physiology & Pharmacology, Libin Cardiovascular Institute & Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Emma J Walsh
- The Smooth Muscle Research Group, Departments of Physiology & Pharmacology, Libin Cardiovascular Institute & Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Hai-Lei Zhu
- The Smooth Muscle Research Group, Departments of Physiology & Pharmacology, Libin Cardiovascular Institute & Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Christine M Campbell
- The Smooth Muscle Research Group, Departments of Physiology & Pharmacology, Libin Cardiovascular Institute & Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Michael P Walsh
- The Smooth Muscle Research Group, Department of Biochemistry & Molecular Biology, Libin Cardiovascular Institute & Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - William C Cole
- The Smooth Muscle Research Group, Departments of Physiology & Pharmacology, Libin Cardiovascular Institute & Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
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Tsuruya K, Fujisaki K. Cerebrovascular disease in end-stage kidney disease. RENAL REPLACEMENT THERAPY 2016. [DOI: 10.1186/s41100-016-0044-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Repeat remote ischaemic pre-conditioning for improved cardiovascular function in humans: A systematic review. IJC HEART & VASCULATURE 2016; 11:55-58. [PMID: 28616526 PMCID: PMC5441349 DOI: 10.1016/j.ijcha.2016.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 03/04/2016] [Indexed: 01/17/2023]
Abstract
BACKGROUND Single exposure to remote ischaemic pre-conditioning (RIPC) has been shown to be effective in reducing major adverse events during cardiac surgery. We evaluated the efficacy of repeated exposure RIPC to elicit improvements in cardiovascular function. METHODS A systematic search was conducted up until May 1st, 2015, using the following databases: EMBASE, PubMed (Medline), Web of Science and the Cochrane Central Registry of Controlled Trials (CENTRAL). Data was extracted and synthesized from published studies of repeat RIPC. RESULTS Data from seven studies showed evidence of improvements in vascular function and anti-hypertensive effects of systolic, diastolic and mean arterial blood pressure following repeat RIPC. Currently existing work justifies a systematic review but not data pooling of individual study data. Repeat RIPC has also produced evidence of improvements in endothelial dependent vasodilation, but not non-endothelial dependent vasodilation, cutaneous vascular conductance or cardiorespiratory fitness. CONCLUSION Repeated RIPC exposure has produced evidence of improvements in endothelial dependent vasodilation, ulcer healing and blood pressure but no benefit in non-endothelial dependent vasodilation, cutaneous vascular conductance or cardiorespiratory fitness. The optimal delivery of RIPC remains unclear, but at least 3 or preferably 4, 5 min exposures appears to be most beneficial, at least for reducing blood pressure. Aside from those undertaking cardiac surgery, other study populations with endothelial dysfunction may benefit from repeat exposure to RIPC.
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Prakash K, Chandran DS, Khadgawat R, Jaryal AK, Deepak KK. Correlations between endothelial function in the systemic and cerebral circulation and insulin resistance in type 2 diabetes mellitus. Diab Vasc Dis Res 2016; 13:49-55. [PMID: 26408643 DOI: 10.1177/1479164115604120] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Insulin resistance is associated with endothelial dysfunction in type 2 diabetes mellitus, which can lead to impaired vascular reactivities of both systemic and cerebral circulations. Appropriate 'correction' of vascular reactivity results for non-endothelium-dependent systemic effects avoids misinterpretation of endothelial function. Therefore, we 'corrected' vascular reactivity results and explored the potential correlations between systemic vascular reactivity, cerebrovascular reactivity and insulin resistance. In 34 patients, 'systemic vascular reactivity' was assessed by quantifying reactive hyperaemia. Cerebrovascular reactivity was assessed by quantifying changes in cerebral blood flow velocity during hypercapnia. To minimize the influence of non-endothelium-dependent systemic effects on vascular reactivity results, 'corrected systemic vascular reactivity' was calculated by normalizing systemic vascular reactivity using the measurements from the contralateral side; and cerebrovascular reactivity results were corrected by calculating percentage and absolute changes in cerebrovascular conductance index ('percent cerebrovascular conductance index' and 'delta cerebrovascular conductance index', respectively). Insulin resistance was estimated by homeostatic model assessment. Correlation between conventional cerebrovascular reactivity and systemic vascular reactivity was not significant. But correlations between 'corrected systemic vascular reactivity' and 'percent cerebrovascular conductance index' (r = 0.51; p = 0.002) and 'corrected systemic vascular reactivity' and 'delta cerebrovascular conductance index' (r = 0.50; p = 0.003) were significant. Among all vascular reactivity parameters, only 'delta cerebrovascular conductance index' was significantly correlated with homeostatic model assessment of insulin resistance (r = -0.38; p = 0.029). In conclusion, endothelial function in the systemic and cerebral circulations is moderately correlated, provided that vascular reactivity estimates are corrected for non-endothelium-dependent influences.
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Affiliation(s)
- Kiran Prakash
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India Department of Physiology, Government Medical College & Hospital, Chandigarh, India
| | - Dinu S Chandran
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Khadgawat
- Department of Endocrinology & Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Ashok Kumar Jaryal
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Kishore K Deepak
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
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van Veen TR, Panerai RB, Haeri S, van den Berg PP, Zeeman GG, Belfort MA. Cerebral autoregulation in pregnancies complicated by diabetes and overweight. Diab Vasc Dis Res 2015; 12:377-80. [PMID: 26092823 DOI: 10.1177/1479164115588547] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
AIM The aim of this study was to estimate the impact of diabetes and obesity on cerebral autoregulation in pregnancy. METHODS Cerebral autoregulation was evaluated in women with gestational diabetes, type 2 diabetes mellitus and/or overweight (body mass index ⩾ 25 kg m(-2)) and compared to a cohort of euglycaemic pregnant women. The autoregulation index was calculated using simultaneously recorded cerebral blood flow velocity in the middle cerebral artery and blood pressure. Autoregulation index values of 0 and 9 indicate absent and perfect autoregulation, respectively. RESULTS Autoregulation index in women with either diabetes (n = 33, 6.6 ± 1.1) or overweight (n = 21, 6.7 ± 0.6) was not significantly different to that in control patients (n = 23, 6.6 ± 0.8, p = 0.96). CONCLUSION Cerebral autoregulation is not impaired in pregnant women who have non-vasculopathic diabetes or overweight. This suggests that the increased risk of pre-eclampsia in diabetic and overweight women is not associated with early impaired cerebral autoregulation.
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Affiliation(s)
- Teelkien R van Veen
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK NIHR Biomedical Research Unit in Cardiovascular Sciences, Glenfield Hospital, Leicester, UK
| | - Sina Haeri
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA St. David's Women's Center of Texas, North Austin Maternal-Fetal Medicine, Austin, TX, USA
| | - Paul P van den Berg
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gerda G Zeeman
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
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Kim YS, Seifert T, Brassard P, Rasmussen P, Vaag A, Nielsen HB, Secher NH, van Lieshout JJ. Impaired cerebral blood flow and oxygenation during exercise in type 2 diabetic patients. Physiol Rep 2015; 3:3/6/e12430. [PMID: 26109188 PMCID: PMC4510631 DOI: 10.14814/phy2.12430] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Endothelial vascular function and capacity to increase cardiac output during exercise are impaired in patients with type 2 diabetes (T2DM). We tested the hypothesis that the increase in cerebral blood flow (CBF) during exercise is also blunted and, therefore, that cerebral oxygenation becomes affected and perceived exertion increased in T2DM patients. We quantified cerebrovascular besides systemic hemodynamic responses to incremental ergometer cycling exercise in eight male T2DM and seven control subjects. CBF was assessed from the Fick equation and by transcranial Doppler-determined middle cerebral artery blood flow velocity. Cerebral oxygenation and metabolism were evaluated from the arterial-to-venous differences for oxygen, glucose, and lactate. Blood pressure was comparable during exercise between the two groups. However, the partial pressure of arterial carbon dioxide was lower at higher workloads in T2DM patients and their work capacity and increase in cardiac output were only ~80% of that established in the control subjects. CBF and cerebral oxygenation were reduced during exercise in T2DM patients (P < 0.05), and they expressed a higher rating of perceived exertion (P < 0.05). In contrast, CBF increased ~20% during exercise in the control group while the brain uptake of lactate and glucose was similar in the two groups. In conclusion, these results suggest that impaired CBF and oxygenation responses to exercise in T2DM patients may relate to limited ability to increase cardiac output and to reduced vasodilatory capacity and could contribute to their high perceived exertion.
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Affiliation(s)
- Yu-Sok Kim
- Department of Internal Medicine, AMC Center for Heart Failure Research Academic Medical Center University of Amsterdam, Amsterdam, The Netherlands Department of Anatomy, Embryology & Physiology, AMC Center for Heart Failure Research Academic Medical Center University of Amsterdam, Amsterdam, The Netherlands Laboratory for Clinical Cardiovascular Physiology, AMC Center for Heart Failure Research Academic Medical Center University of Amsterdam, Amsterdam, The Netherlands
| | - Thomas Seifert
- Department of Anesthesia, The Copenhagen Muscle Research Center University of Copenhagen, Copenhagen, Denmark
| | - Patrice Brassard
- Department of Anesthesia, The Copenhagen Muscle Research Center University of Copenhagen, Copenhagen, Denmark
| | - Peter Rasmussen
- Department of Anesthesia, The Copenhagen Muscle Research Center University of Copenhagen, Copenhagen, Denmark
| | - Allan Vaag
- Department of Endocrinology, Rigshospitalet University of Copenhagen, Copenhagen, Denmark
| | - Henning B Nielsen
- Department of Anesthesia, The Copenhagen Muscle Research Center University of Copenhagen, Copenhagen, Denmark
| | - Niels H Secher
- Department of Anesthesia, The Copenhagen Muscle Research Center University of Copenhagen, Copenhagen, Denmark
| | - Johannes J van Lieshout
- Department of Internal Medicine, AMC Center for Heart Failure Research Academic Medical Center University of Amsterdam, Amsterdam, The Netherlands Department of Anatomy, Embryology & Physiology, AMC Center for Heart Failure Research Academic Medical Center University of Amsterdam, Amsterdam, The Netherlands Laboratory for Clinical Cardiovascular Physiology, AMC Center for Heart Failure Research Academic Medical Center University of Amsterdam, Amsterdam, The Netherlands MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research, School of Life Sciences University of Nottingham Medical School Queen's Medical Centre, Nottingham, UK
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Hemodynamic Control and Delirium. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-014-0096-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Hirsch J, DePalma G, Tsai TT, Sands LP, Leung JM. Impact of intraoperative hypotension and blood pressure fluctuations on early postoperative delirium after non-cardiac surgery. Br J Anaesth 2015; 115:418-26. [PMID: 25616677 DOI: 10.1093/bja/aeu458] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2014] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Postoperative delirium is common in older patients. Despite its prognostic significance, the pathophysiology is incompletely understood. Although many risk factors have been identified, no reversible factors, particularly ones potentially modifiable by anaesthetic management, have been identified. The goal of this prospective cohort study was to investigate whether intraoperative hypotension was associated with postoperative delirium in older patients undergoing major non-cardiac surgery. METHODS Study subjects were patients >65 years of age, undergoing major non-cardiac surgery, who were enrolled in an ongoing prospective observational study of the pathophysiology of postoperative delirium. Intraoperative blood pressure was measured and predefined criteria were used to define hypotension. Delirium was measured by the Confusion Assessment Method on the first two postoperative days. Data were analysed using t-tests, two-sample proportion tests and ordered logistic regression multivariable models, including correction for multiple comparisons. RESULTS Data from 594 patients with a mean age of 73.6 years (sd 6.2) were studied. Of these 178 (30%) developed delirium on day 1 and 176 (30%) on day 2. Patients developing delirium were older, more often female, had lower preoperative cognitive scores, and underwent longer operations. Relative hypotension (decreases by 20, 30, or 40%) or absolute hypotension [mean arterial pressure (MAP)<50 mm Hg] were not significantly associated with postoperative delirium, nor was the duration of hypotension (MAP<50 mm Hg). Conversely, intraoperative blood pressure variance was significantly associated with postoperative delirium. DISCUSSION These results showed that increased blood pressure fluctuation, not absolute or relative hypotension, was predictive of postoperative delirium.
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Affiliation(s)
- J Hirsch
- Department of Anesthesia and Perioperative Care, University of California, San Francisco 94143-0648, USA
| | - G DePalma
- Department of Statistics, Purdue University, West Lafayette, IN 47907-2069, USA
| | - T T Tsai
- Department of Anesthesia and Perioperative Care, University of California, San Francisco 94143-0648, USA
| | - L P Sands
- Department of Statistics, Purdue University, West Lafayette, IN 47907-2069, USA
| | - J M Leung
- Department of Anesthesia and Perioperative Care, University of California, San Francisco 94143-0648, USA
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Larsen SL, Lyngeraa TS, Maschmann CP, Van Lieshout JJ, Pott FC. Cardiovascular consequence of reclining vs. sitting beach-chair body position for induction of anesthesia. Front Physiol 2014; 5:187. [PMID: 24904427 PMCID: PMC4032912 DOI: 10.3389/fphys.2014.00187] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 04/26/2014] [Indexed: 11/13/2022] Open
Abstract
The sitting beach-chair position is regularly used for shoulder surgery and anesthesia may be induced in that position. We tested the hypothesis that the cardiovascular challenge induced by induction of anesthesia is attenuated if the patient is placed in a reclining beach-chair position. Anesthesia was induced with propofol in the sitting beach-chair (n = 15) or with the beach-chair tilted backwards to a reclining beach-chair position (n = 15). The last group was stepwise tilted to the sitting beach-chair position prior to surgery. Hypotension was treated with ephedrine. Continuous hemodynamic variables were recorded by photoplethysmography and frontal cerebral oxygenation (ScO2) by near infrared spectroscopy. Significant differences were only observed immediately after the induction when patients induced in a reclining beach-chair position had higher mean arterial pressure (MAP) (35 ± 12 vs. 45 ± 15 % reduction from baseline, p = 0.04) and ScO2 (7 ± 6 vs. 1 ± 8% increase from baseline, p = 0.02) and received less ephedrine (mean: 4 vs. 13 mg, p = 0.048). The higher blood pressure and lower need of vasopressor following induction of anesthesia in the reclining compared to the sitting beach-chair position indicate more stable hemodynamics with the clinical implication that anesthesia should not be induced with the patient in the sitting position.
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Affiliation(s)
- Søren L Larsen
- Department of Anesthesiology, Bispebjerg Hospital, University of Copenhagen Denmark
| | - Tobias S Lyngeraa
- Department of Anesthesiology, Bispebjerg Hospital, University of Copenhagen Denmark
| | | | - Johannes J Van Lieshout
- Acute Admissions Unit, Laboratory for Clinical Cardiovascular Physiology, Department of Internal Medicine, AMC Center for Heart Failure University of Amsterdam, Netherlands ; Queen's Medical Centre, School of Life Sciences, University of Nottingham Medical School Nottingham, UK
| | - Frank C Pott
- Department of Anesthesiology, Bispebjerg Hospital, University of Copenhagen Denmark
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Lastra G, Syed S, Kurukulasuriya LR, Manrique C, Sowers JR. Type 2 diabetes mellitus and hypertension: an update. Endocrinol Metab Clin North Am 2014; 43:103-22. [PMID: 24582094 PMCID: PMC3942662 DOI: 10.1016/j.ecl.2013.09.005] [Citation(s) in RCA: 181] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patients with hypertension and type 2 diabetes are at increased risk of cardiovascular and chronic renal disease. Factors involved in the pathogenesis of both hypertension and type 2 diabetes include inappropriate activation of the renin-angiotensin-aldosterone system, oxidative stress, inflammation, impaired insulin-mediated vasodilatation, augmented sympathetic nervous system activation, altered innate and adaptive immunity, and abnormal sodium processing by the kidney. The renin-angiotensin-aldosterone system blockade is a key therapeutic strategy in the treatment of hypertension in type 2 diabetes. Emerging therapies for resistant hypertension as often exists in patients with diabetes, include renal denervation and carotid body denervation.
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Affiliation(s)
- Guido Lastra
- Division of Endocrinology, Diabetes & Metabolism, Department of Internal Medicine, University of Missouri Columbia School of Medicine, D109 Diabetes Center HSC, One Hospital Drive, Columbia, MO 65212, USA; Diabetes and Cardiovascular Research Center, University of Missouri, One Hospital Drive, Columbia, MO 65212, USA; Harry S Truman Memorial Veterans Hospital, 800 Hospital Drive, Columbia, MO 65201, USA
| | - Sofia Syed
- Division of Endocrinology, Diabetes & Metabolism, Department of Internal Medicine, University of Missouri Columbia School of Medicine, D109 Diabetes Center HSC, One Hospital Drive, Columbia, MO 65212, USA; Diabetes and Cardiovascular Research Center, University of Missouri, One Hospital Drive, Columbia, MO 65212, USA
| | - L Romayne Kurukulasuriya
- Division of Endocrinology, Diabetes & Metabolism, Department of Internal Medicine, University of Missouri Columbia School of Medicine, D109 Diabetes Center HSC, One Hospital Drive, Columbia, MO 65212, USA
| | - Camila Manrique
- Division of Endocrinology, Diabetes & Metabolism, Department of Internal Medicine, University of Missouri Columbia School of Medicine, D109 Diabetes Center HSC, One Hospital Drive, Columbia, MO 65212, USA; Diabetes and Cardiovascular Research Center, University of Missouri, One Hospital Drive, Columbia, MO 65212, USA; Harry S Truman Memorial Veterans Hospital, 800 Hospital Drive, Columbia, MO 65201, USA
| | - James R Sowers
- Division of Endocrinology, Diabetes & Metabolism, Department of Internal Medicine, University of Missouri Columbia School of Medicine, D109 Diabetes Center HSC, One Hospital Drive, Columbia, MO 65212, USA; Diabetes and Cardiovascular Research Center, University of Missouri, One Hospital Drive, Columbia, MO 65212, USA; Harry S Truman Memorial Veterans Hospital, 800 Hospital Drive, Columbia, MO 65201, USA; Department of Medical Physiology and Pharmacology, University of Missouri, One Hospital Drive, Columbia, MO 65212, USA.
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Immink RV, Pott FC, Secher NH, van Lieshout JJ. Hyperventilation, cerebral perfusion, and syncope. J Appl Physiol (1985) 2013; 116:844-51. [PMID: 24265279 DOI: 10.1152/japplphysiol.00637.2013] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This review summarizes evidence in humans for an association between hyperventilation (HV)-induced hypocapnia and a reduction in cerebral perfusion leading to syncope defined as transient loss of consciousness (TLOC). The cerebral vasculature is sensitive to changes in both the arterial carbon dioxide (PaCO2) and oxygen (PaO2) partial pressures so that hypercapnia/hypoxia increases and hypocapnia/hyperoxia reduces global cerebral blood flow. Cerebral hypoperfusion and TLOC have been associated with hypocapnia related to HV. Notwithstanding pronounced cerebrovascular effects of PaCO2 the contribution of a low PaCO2 to the early postural reduction in middle cerebral artery blood velocity is transient. HV together with postural stress does not reduce cerebral perfusion to such an extent that TLOC develops. However when HV is combined with cardiovascular stressors like cold immersion or reduced cardiac output brain perfusion becomes jeopardized. Whether, in patients with cardiovascular disease and/or defect, cerebral blood flow cerebral control HV-induced hypocapnia elicits cerebral hypoperfusion, leading to TLOC, remains to be established.
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Affiliation(s)
- R V Immink
- Laboratory for Clinical Cardiovascular Physiology, Department of Anatomy, Embryology, and Physiology, AMC Center for Heart Failure Research, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
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Wellenius GA, Boyle LD, Wilker EH, Sorond FA, Coull BA, Koutrakis P, Mittleman MA, Lipsitz LA. Ambient fine particulate matter alters cerebral hemodynamics in the elderly. Stroke 2013; 44:1532-6. [PMID: 23709640 DOI: 10.1161/strokeaha.111.000395] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND PURPOSE Short-term elevations in fine particulate matter air pollution (PM2.5) are associated with increased risk of acute cerebrovascular events. Evidence from the peripheral circulation suggests that vascular dysfunction may be a central mechanism. However, the effects of PM2.5 on cerebrovascular function and hemodynamics are unknown. METHODS We used transcranial Doppler ultrasound to measure beat-to-beat blood flow velocity in the middle cerebral artery at rest and in response to changes in end-tidal CO2 (cerebral vasoreactivity) and arterial blood pressure (cerebral autoregulation) in 482 participants from the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly (MOBILIZE) of Boston study. We used linear mixed effects models with random subject intercepts to evaluate the association between cerebrovascular hemodynamic parameters and mean PM2.5 levels 1 to 28 days earlier adjusting for age, race, medical history, meteorologic covariates, day of week, temporal trends, and season. RESULTS An interquartile range increase (3.0 µg/m(3)) in mean PM2.5 levels during the previous 28 days was associated with an 8.6% (95% confidence interval, 3.7%-13.8%; P<0.001) higher cerebral vascular resistance and a 7.5% (95% confidence interval, 4.2%-10.6%; P<0.001) lower blood flow velocity at rest. Measures of cerebral vasoreactivity and autoregulation were not associated with PM2.5 levels. CONCLUSIONS In this cohort of community-dwelling seniors, exposure to PM2.5 was associated with higher resting cerebrovascular resistance and lower cerebral blood flow velocity. If replicated, these findings suggest that alterations in cerebrovascular hemodynamics may underlie the increased risk of particle-related acute cerebrovascular events.
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Affiliation(s)
- James R Sowers
- Professor of Medicine, and Medical Pharmacology and Physiology, Director Division of Endocrinology and Metabolism, Director of the Diabetes and Cardiovascular Center of Excellence, University of Missouri-Columbia School of Medicine, One Hospital Dr, Columbia, MO 65212, USA.
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Chaudhary S, Scouten A, Schwindt G, Janik R, Lee W, Sled JG, Black SE, Stefanovic B. Hemodynamic effects of cholinesterase inhibition in mild Alzheimer's disease. J Magn Reson Imaging 2012; 38:26-35. [PMID: 23239554 DOI: 10.1002/jmri.23967] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 10/25/2012] [Indexed: 11/11/2022] Open
Abstract
PURPOSE To evaluate the spatiotemporal progression of perfusion changes in early stages of Alzheimer's disease (AD), we imaged the perfusion response to pharmacological treatment in a group of mild AD patients and contrasted it to the perfusion of age-, sex-, and education-matched healthy volunteers over the same time interval. MATERIALS AND METHODS We used pseudo continuous arterial spin labeling (PCASL) MRI for quantitative three-dimensional mapping of perfusion immediately before and 6 months after cholinesterase inhibitor treatment. RESULTS Before treatment, patients were found hypoperfused relative to their healthy counterparts in the gray matter of lateral temporal lobe, posterior cingulate, and anterior cingulate as well as in the white matter of the posterior cingulate. Most of the cortical regions investigated and the white matter of posterior cingulate and prefrontal regions showed treatment-elicited increases in perfusion, which were not secondary to changes in regional tissue volume nor were they associated with improvement in either MMSE or ADAS-Cog scores, although lack of deterioration suggested a cognitive benefit. CONCLUSION This study provides a hemodynamic profile of mild AD and sheds light on the perfusion changes related to prolonged cholinesterase inhibition in this early disease stage.
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Safar ME, Nilsson PM, Blacher J, Mimran A. Pulse pressure, arterial stiffness, and end-organ damage. Curr Hypertens Rep 2012; 14:339-44. [PMID: 22555981 DOI: 10.1007/s11906-012-0272-9] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Whereas larger arteries participate in the dampening of blood pressure (BP) oscillations resulting from intermittent ventricular ejection, smaller arteries steadily deliver an adequate supply of blood from the heart to the peripheral organs. Numerous active mechanisms are involved in this process. Cyclic stress acts differently from steady stress, inducing stronger and stiffer material of the vessel wall than under static conditions. Cyclic strain participates in the phenotypic plasticity of smooth muscle cells, initiates transduction mechanisms and induces the transcriptional profile of mechanically induced genes. Finally, the autoregulatory mechanism protecting the brain, heart and kidney from cardiovascular (CV) damage differ markedly according to their localization. Whereas the heart is dependent on pulsatile forces, owing to the diastolic perfusion of coronary arteries, the brain and the kidney are rather influenced by steady mechanical forces. For the kidney, the transmission of pulsatile pressure may greatly contribute to glomerular sclerosis in the elderly.
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Affiliation(s)
- Michel E Safar
- Paris Descartes University; AP-HP; Diagnosis and Therapeutic Center, Hôtel-Dieu, 1, place du Parvis Notre-Dame, 75181, Paris Cedex 04, France.
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Sabayan B, van Vliet P, de Ruijter W, Gussekloo J, de Craen AJM, Westendorp RGJ. High blood pressure, physical and cognitive function, and risk of stroke in the oldest old: the Leiden 85-plus Study. Stroke 2012; 44:15-20. [PMID: 23132780 DOI: 10.1161/strokeaha.112.663062] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND PURPOSE Epidemiological studies have shown mixed findings on the association between hypertension and stroke in the oldest old. Heterogeneity of the populations under study may underlie variation in outcomes. We examined whether the level of physical and cognitive function moderates the association between blood pressure and stroke. METHODS We included 513 subjects aged 85 years old from the population-based Leiden 85-plus Study. Systolic blood pressure, diastolic blood pressure, mean arterial pressure, and pulse pressure were measured at baseline. Activities of daily living and Mini-Mental State Examination were assessed to estimate level of physical and cognitive function, respectively. Five-year risk of stroke was estimated with Cox regression analysis. RESULTS In the entire cohort, there were no associations between various measures of blood pressure and risk of stroke except for the inverse relation between pulse pressure and stroke risk (hazard ratio [HR], 0.80 [95% confidence interval [CI], 0.66-0.98]). Among subjects with impaired physical functioning, higher systolic blood pressure (HR, 0.74 [95% CI, 0.59-0.92]), mean arterial pressure (HR: 0.68 [95% CI, 0.47-0.97]), and pulse pressure (HR, 0.71 [95% CI, 0.55-0.93]) were associated with reduced risk of stroke. Likewise, among subjects with impaired cognitive functioning, higher systolic blood pressure was associated with reduced risk of stroke (HR, 0.80 [95% CI, 0.65-0.98]). In subjects with unimpaired cognitive functioning, higher diastolic blood pressure (HR: 1.98 [95% CI, 1.21-3.22]) and mean arterial pressure (HR, 1.70 [95% CI, 1.08-2.68]) were associated with higher risk of stroke. CONCLUSIONS Our findings suggest that impaired physical and cognitive function moderates the association between blood pressure and stroke.
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Affiliation(s)
- Behnam Sabayan
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands.
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Affiliation(s)
- Jill N. Barnes
- From the Department of Anesthesiology, Mayo Clinic, Rochester, MN
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