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Pronk AC, Wang L, van Poelgeest EP, Leeflang MMG, Daams JG, Hoekstra AG, van der Velde N. The impact of cardiovascular diagnostics and treatments on fall risk in older adults: a scoping review and evidence map. GeroScience 2024; 46:153-169. [PMID: 37864713 PMCID: PMC10828261 DOI: 10.1007/s11357-023-00974-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/07/2023] [Indexed: 10/23/2023] Open
Abstract
BACKGROUND We aimed to summarize the published evidence on the fall risk reducing potential of cardiovascular diagnostics and treatments in older adults. METHODS Design: scoping review and evidence map. DATA SOURCES Medline and Embase. ELIGIBILITY CRITERIA all available published evidence; Key search concepts: "older adults," "cardiovascular evaluation," "cardiovascular intervention," and "falls." Studies reporting on fall risk reducing effect of the diagnostic/treatment were included in the evidence map. Studies that investigated cardiovascular diagnostics or treatments within the context of falls, but without reporting a fall-related outcome, were included in the scoping review for qualitative synthesis. RESULTS Two articles on cardiovascular diagnostics and eight articles on cardiovascular treatments were included in the evidence map. Six out of ten studies concerned pacemaker intervention of which one meta-analyses that included randomized controlled trials with contradictory results. A combined cardiovascular assessment/evaluation (one study) and pharmacotherapy in orthostatic hypotension (one study) showed fall reducing potential. The scoping review contained 40 articles on cardiovascular diagnostics and one on cardiovascular treatments. It provides an extensive overview of several diagnostics (e.g., orthostatic blood pressure measurements, heart rhythm assessment) useful in fall prevention. Also, diagnostics were identified, that could potentially provide added value in fall prevention (e.g., blood pressure variability and head turning). CONCLUSION Although the majority of studies showed a reduction in falls after the intervention, the total amount of evidence regarding the effect of cardiovascular diagnostics/treatments on falls is small. Our findings can be used to optimize fall prevention strategies and develop an evidence-based fall prevention care pathway. Adhering to the World guidelines on fall prevention recommendations, it is crucial to undertake a standardized assessment of cardiovascular risk factors, followed by supplementary testing and corresponding interventions, as effective components of fall prevention strategies. In addition, accompanying diagnostics such as blood pressure variability and head turning can be of added value.
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Affiliation(s)
- Anouschka C Pronk
- Department of Internal Medicine, Section of Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands
| | - Liping Wang
- Department of Internal Medicine, Section of Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands
| | - Eveline P van Poelgeest
- Department of Internal Medicine, Section of Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands.
| | - Mariska M G Leeflang
- Department of Epidemiology and Data Science Section of Methodology, Amsterdam University Medical Centres, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Joost G Daams
- Medical Library, University of Amsterdam, Amsterdam, The Netherlands
| | - Alfons G Hoekstra
- Computational Science Lab, Informatics Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Nathalie van der Velde
- Department of Internal Medicine, Section of Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands
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The Enduring Controversy of Cervicogenic Vertigo, and Its Place among Positional Vertigo Syndromes. Audiol Res 2021; 11:491-507. [PMID: 34698085 PMCID: PMC8544230 DOI: 10.3390/audiolres11040045] [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: 09/05/2021] [Revised: 09/22/2021] [Accepted: 09/22/2021] [Indexed: 11/22/2022] Open
Abstract
The idea of cervicogenic vertigo (CV) was proposed nearly a century ago, yet despite considerable scrutiny and research, little progress has been made in clarifying the underlying mechanism of the disease, developing a confirmatory diagnostic test, or devising an appropriately targeted treatment. Given the history of this idea, we offer a review geared towards understanding why so many attempts at clarifying it have failed, with specific comments regarding how CV fits into the broader landscape of positional vertigo syndromes, what a successful diagnostic test might require, and some practical advice on how to approach this in the absence of a diagnostic test.
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Wu TC, Hachul DT, Darrieux FCDC, Scanavacca MI. Carotid Sinus Massage in Syncope Evaluation: A Nonspecific and Dubious Diagnostic Method. Arq Bras Cardiol 2018; 111:84-91. [PMID: 30110049 PMCID: PMC6078367 DOI: 10.5935/abc.20180114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 12/08/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Carotid sinus hypersensitivity (CSH) is a frequent finding in the evaluation of syncope. However, its significance in the clinical setting is still dubious. A new criterion was proposed by Solari et al. with a symptomatic systolic blood pressure (SBP) cut-off value of ≤ 85 mmHg to refine the vasodepressor (VD) response diagnosis. OBJECTIVE To determine and compare the response to carotid sinus massage (CSM) in patients with and without syncope according to standard and proposed criteria. METHODS CSM was performed in 99 patients with and 66 patients without syncope. CSH was defined as cardioinhibitory (CI) for asystole ≥ 3 seconds, or as VD for SBP decrease ≥ 50 mmHg. RESULTS No differences in the hemodynamic responses were observed during CSM between the groups, with 24.2% and 25.8% CI, and 8.1% and 13.6% VD in the symptomatic and asymptomatic groups, respectively (p = 0.466). A p value < 0.050 was considered statistically significant. During the maneuvers, 45 (45.45%) and 34 (51.5%) patients in the symptomatic and asymptomatic groups achieved SBP below ≤ 85 mmHg. Symptoms were reported especially in those patients in whom CSM caused a SBP decrease to below 90 mmHg and/or asystole > 2.5 seconds, regardless of the pattern of response or the presence of previous syncope. CONCLUSION The response to CSM in patients with and without syncope was similar; therefore, CSH may be an unspecific condition. Clinical correlation and other methods of evaluation, such as long-lasting ECG monitoring, may be necessary to confirm CSH as the cause of syncope.
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Affiliation(s)
- Tan Chen Wu
- Instituto do Coração (InCor) - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Denise T Hachul
- Instituto do Coração (InCor) - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
| | | | - Maurício I Scanavacca
- Instituto do Coração (InCor) - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
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Nguyen TAN, Abdelhamid YA, Phillips LK, Chapple LS, Horowitz M, Jones KL, Deane AM. Nutrient stimulation of mesenteric blood flow - implications for older critically ill patients. World J Crit Care Med 2017; 6:28-36. [PMID: 28224105 PMCID: PMC5295167 DOI: 10.5492/wjccm.v6.i1.28] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 12/16/2016] [Accepted: 01/02/2017] [Indexed: 02/06/2023] Open
Abstract
Nutrient ingestion induces a substantial increase in mesenteric blood flow. In older persons (aged ≥ 65 years), particularly those with chronic medical conditions, the cardiovascular compensatory response may be inadequate to maintain systemic blood pressure during mesenteric blood pooling, leading to postprandial hypotension. In older ambulatory persons, postprandial hypotension is an important pathophysiological condition associated with an increased propensity for syncope, falls, coronary vascular events, stroke and death. In older critically ill patients, the administration of enteral nutrition acutely increases mesenteric blood flow, but whether this pathophysiological response is protective, or precipitates mesenteric ischaemia, is unknown. There are an increasing number of older patients surviving admission to intensive care units, who are likely to be at increased risk of postprandial hypotension, both during, and after, their stay in hospital. In this review, we describe the prevalence, impact and mechanisms of postprandial hypotension in older people and provide an overview of the impact of postprandial hypotension on feeding prescriptions in older critically ill patients. Finally, we provide evidence that postprandial hypotension is likely to be an unrecognised problem in older survivors of critical illness and discuss potential options for management.
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Neurocardiovascular Instability and Cognition. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2016; 89:59-71. [PMID: 27505017 PMCID: PMC4797838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Neurocardiovascular instability (NCVI) refers to abnormal neural control of the cardiovascular system affecting blood pressure and heart rate behavior. Autonomic dysfunction and impaired cerebral autoregulation in aging contribute to this phenomenon characterized by hypotension and bradyarrhythmia. Ultimately, this increases the risk of falls and syncope in older people. NCVI is common in patients with neurodegenerative disorders including dementia. This review discusses the various syndromes that characterize NCVI icluding hypotension, carotid sinus hypersensitivity, postprandial hypotension and vasovagal syncope and how they may contribute to the aetiology of cognitive decline. Conversely, they may also be a consequence of a common neurodegenerative process. Regardless, recognition of their association is paramount in optimizing management of these patients.
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Jansen S, Bhangu J, de Rooij S, Daams J, Kenny RA, van der Velde N. The Association of Cardiovascular Disorders and Falls: A Systematic Review. J Am Med Dir Assoc 2015; 17:193-9. [PMID: 26455926 DOI: 10.1016/j.jamda.2015.08.022] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 08/21/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Cardiovascular disorders are recognized as risk factors for falls in older adults. The aim of this systematic review was to identify cardiovascular disorders that are associated with falls, thus providing angles for optimization of fall-preventive care. DESIGN Systematic review. DATA SOURCES Medline and Embase. ELIGIBILITY CRITERIA FOR SELECTING STUDIES studies addressing persons aged 50 years and older that described cardiovascular risk factors for falls. Key search terms for cardiovascular abnormalities included all synonyms for the following groups: structural cardiac abnormalities, cardiac arrhythmia, blood pressure abnormalities, carotid sinus hypersensitivity (CSH), orthostatic hypotension (OH), vasovagal syncope (VVS), postprandial hypotension (PPH), arterial stiffness, heart failure, and cardiovascular disease. Quality of studies was assed using the Newcastle-Ottawa Scale. RESULTS Eighty-six studies were included. Of studies that used a control group, most consistent associations with falls were observed for low blood pressure (BP) (4/5 studies showing a positive association), heart failure (4/5), and cardiac arrhythmia (4/6). Higher prevalences of CSH (4/6), VVS (2/2), and PPH (3/4) were reported in fallers compared with controls in most studies, but most of these studies failed to show clear association measures. Coronary artery disease (6/10), orthostatic hypotension (9/25), general cardiovascular disease (4/9), and hypertension (7/25) all showed inconsistent associations with falls. Arterial stiffness was identified as an independent predictor for falls in one study, as were several echocardiographic abnormalities. CONCLUSION Several cardiovascular associations with falls were identified, including low BP, heart failure, and arrhythmia. These results provide several angles for optimizing fall-preventive care, but further work on standard definitions, as well as the exact contribution of individual risk factors on fall incidence is now important to find potential areas for preventive interventions.
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Affiliation(s)
- Sofie Jansen
- Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jaspreet Bhangu
- Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland; Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland.
| | - Sophia de Rooij
- Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; University Centre for Geriatric Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Joost Daams
- Department of Clinical Library, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Rose Anne Kenny
- Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland; Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Nathalie van der Velde
- Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Alagiakrishnan K. Current Pharmacological Management of Hypotensive Syndromes in the Elderly. Drugs Aging 2015; 32:337-48. [DOI: 10.1007/s40266-015-0263-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Ray JC, Kusumoto F, Goldschlager N. Syncope. J Intensive Care Med 2014; 31:79-93. [PMID: 25286917 DOI: 10.1177/0885066614552988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 06/26/2014] [Indexed: 11/17/2022]
Abstract
Syncope is common representing approximately 3% of ED visits and up to 6% of hospital admissions, with a cost close to 2 billion dollars per year. Diagnostic testing is often poorly sensitive and evaluations commonly lack a standardized approach. A mindful and systematic approach can increase sensitivity and improve diagnostic accuracy. A thorough history and physical exam is paramount, as conclusions drawn from the history and exam will guide further assessment. Developing a strategy for the first and, if necessary, subsequent tests will improve the accuracy of identifying the etiology of syncope and reduce cost. Although syncope has a favorable prognosis, identification of patients with structural heart disease is critical, as these patients are at greatest risk for mortality. Several risk scoring systems have been developed to help separate high risk from low risk patients.
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Affiliation(s)
- Jordan C Ray
- Division of Cardiovascular disease, Department of Medicine, Electrophysiology and Pacing Service, Mayo Clinic, Jacksonville, FL, USA
| | - Fred Kusumoto
- Division of Cardiovascular disease, Department of Medicine, Electrophysiology and Pacing Service, Mayo Clinic, Jacksonville, FL, USA
| | - Nora Goldschlager
- Cardiology Division, Department of Medicine, San Francisco General Hospital, San Francisco, CA, USA Department of Medicine, University of California, San Francisco, CA, USA
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Tan MP, Chadwick TJ, Kerr SRJ, Parry SW. Symptomatic presentation of carotid sinus hypersensitivity is associated with impaired cerebral autoregulation. J Am Heart Assoc 2014; 3:e000514. [PMID: 24947997 PMCID: PMC4309040 DOI: 10.1161/jaha.113.000514] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Carotid sinus hypersensitivity (CSH) is associated with syncope, unexplained falls, and drop attacks in older people but occurs asymptomatically in 35% of community‐dwelling elders. We hypothesized that impaired cerebral autoregulation is associated with the conversion of asymptomatic CSH to symptomatic CSH. We therefore conducted a case–control study evaluating individuals with CSH with and without the symptoms of syncope or unexplained falls, as well as non‐CSH controls, to determine whether the blood pressure and heart rate changes associated with CSH are associated with symptoms only when cerebral autoregulation is altered. Methods and Results Bilateral middle cerebral artery blood flow velocities (BFV) were measured in consecutive patients with symptomatic CSH (n=22) and asymptomatic controls with (n=18) and without CSH (n=14) using transcranial Doppler ultrasonography during lower body negative pressure‐induced systemic hypotension. Within‐group comparisons revealed significantly lower cerebrovascular resistance index (CVRi) at nadir for the asymptomatic CSH group (right, mean [95% CI]: 2.2 [1.8, 2.8] versus 2.6 [2.2, 3.0]; P=0.005; left: 2.8 [2.4, 3.3] versus 3.1 [2.7, 3.8]; P=0.016). Between‐group comparisons showed higher mean BFV (right: estimated mean difference, B=5.49 [1.98, 8.80], P=0.003; left: 4.82 [1.52, 8.11], P=0.005) and lower CVRi (right: B=0.08 [0.03, 0.12], P=0.003, left: B=0.07 [0.02, 0.12], P=0.006) in asymptomatic CSH versus symptomatic CSH groups. There were no significant differences in bilateral mean BFV or right CVRi between the non‐CSH and symptomatic CSH groups but differences were present for left CVRi (B=0.07 [0.02, 0.013], P=0.015). Conclusion Cerebral autoregulation is altered in symptomatic CSH and therefore appears to be associated with the development of hypotension‐related symptoms in individuals with CSH.
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Affiliation(s)
- Maw Pin Tan
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia (M.P.T.)
| | - Tom J Chadwick
- Institute of Health and Society, Newcastle University, United Kingdom (T.J.C.)
| | - Simon R J Kerr
- Institute for Ageing and Health, Newcastle University and Falls and Syncope Service, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom (S.J.K., S.W.P.)
| | - Steve W Parry
- Institute for Ageing and Health, Newcastle University and Falls and Syncope Service, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom (S.J.K., S.W.P.)
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