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Kulkarni S, Jenkins D, Dhar A, Mir F. Treating Lows: Management of Orthostatic Hypotension. J Cardiovasc Pharmacol 2024; 84:303-315. [PMID: 39027973 PMCID: PMC11368167 DOI: 10.1097/fjc.0000000000001597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/24/2024] [Indexed: 07/20/2024]
Abstract
ABSTRACT Orthostatic hypotension is a prevalent clinical condition, caused by heterogenous etiologies and associated with significant morbidity and mortality. Management is particularly challenging in patients with uncontrolled hypertension. A thorough assessment is needed to draw an appropriate management plan. The treatment aims to improve postural symptoms while minimizing side effects and reducing iatrogenic exacerbation of supine hypertension. A personalized management plan including rationalizing medications, patient education, identification, and avoidance of triggers, as well as nonpharmacological therapies such as compression devices, dietary modifications, and postural aids, make the first steps. Among pharmacological therapies, midodrine and fludrocortisone are the most prescribed and best studied; pyridostigmine, atomoxetine, and droxidopa are considered next. Yohimbine remains an investigational agent. A multidisciplinary team may be required in some patients with multiple comorbidities and polypharmacy. However, there is a lack of robust efficacy and safety evidence for all therapies. Building robust real-world and stratified clinical trials based on underlying pathophysiology may pave the way for further drug development and better clinical strategies and in this challenging unmet medical need.
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Affiliation(s)
- Spoorthy Kulkarni
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Clinical Pharmacology and Therapeutics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Danny Jenkins
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Lewisham and Greenwich NHS Foundation Trust, London, United Kingdom; and
| | - Arko Dhar
- University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Fraz Mir
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Clinical Pharmacology and Therapeutics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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De Agustín Del Burgo JM, Blaya Haro F, D’Amato R, Blaya A, Juanes Méndez JA. Development of a Smart Leg Splint by Using New Sensor Technologies and New Therapy Possibilities. SENSORS 2021; 21:s21155252. [PMID: 34372488 PMCID: PMC8348511 DOI: 10.3390/s21155252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 07/29/2021] [Accepted: 07/31/2021] [Indexed: 11/22/2022]
Abstract
Nowadays, after suffering a fracture in an upper or lower limb, a plaster cast is placed on the affected limb. It is a very old and efficient technique for recovery from an injury that has not had significant changes since its origin. This project aims to develop a new low-cost smart 3D printed splint concept by using new sensing techniques. Two rapidly evolving Advanced Manufacturing (AM) technologies will be used: 3D scanning and 3D printing, thus combining engineering, medicine and materials evolution. The splint will include new small and lightweight sensors to detect any problem during the treatment process. Previous studies have already incorporated this kind of sensor for medical purposes. However, in this study it is implemented with a new concept: the possibility of applying treatments during the immobilization process and obtaining information from the sensors to modify the treatment. Due to this, rehabilitation treatments like infrared, ultrasounds or electroshock may be applied during the treatment, and the sensors (as it is showed in the study) will be able to detect changes during the rehabilitation process. Data of the pressure, temperature, humidity and colour of the skin will be collected in real time and sent to a mobile device so that they can be consulted remotely by a specialist. Moreover, it would be possible to include these data into the Internet of Things movement. This way, all the collected data might be compared and studied in order to find the best treatment for each kind of injury. It will be necessary to use a biocompatible material, submersible and suitable for contact with skin. These materials make it necessary to control the conditions in which the splint is produced, to assure that the properties are maintained. This development, makes it possible to design a new methodology that will help to provide faster and easier treatment.
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Affiliation(s)
| | - Fernando Blaya Haro
- ETSIDI-Departamento de Ingeniería Mecánica, Química y Diseño Industrial, Universidad Politécnica de Madrid (UPM), Ronda de Valencia 3, 28012 Madrid, Spain;
| | - Roberto D’Amato
- ETSIDI-Departamento de Ingeniería Mecánica, Química y Diseño Industrial, Universidad Politécnica de Madrid (UPM), Ronda de Valencia 3, 28012 Madrid, Spain;
- Correspondence: ; Tel.: +34-91-067-7654
| | - Alonso Blaya
- Departamento de Fisioterapía de la, Universidad Europea de Madrid, 28670 Madrid, Spain;
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Hockin BCD, Claydon VE. Intermittent Calf Compression Delays the Onset of Presyncope in Young Healthy Individuals. Front Physiol 2020; 10:1598. [PMID: 32038283 PMCID: PMC6993600 DOI: 10.3389/fphys.2019.01598] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 12/19/2019] [Indexed: 12/26/2022] Open
Abstract
Orthostatic fluid shifts reduce the effective circulating volume and thus contribute to syncope susceptibility. Recurrent syncope has a devastating impact on quality of life and is challenging to manage effectively. To blunt orthostatic fluid shifts, static calf compression garments are often prescribed to patients with syncope, but have questionable efficacy. Intermittent calf compression, which mimics the skeletal muscle pump to minimize pooling and filtration, holds promise for the management of syncope. We aimed to evaluate the effectiveness of intermittent calf compression for increasing orthostatic tolerance (OT; time to presyncope). We conducted a randomized single-blind crossover study, in which participants (n = 21) underwent three graded 60° head-up-tilt tests to presyncope with combined lower body negative pressure on separate days. Low frequency intermittent calf compression (ICLF; 4 s on and 11 s off) at 0-30 and 0-60 mmHg was applied during two tests and compared to a placebo condition where the garment was fitted, but no compression applied. We measured continuous leg circumference changes (strain gauge plethysmography), cardiovascular responses (finger plethysmography; Finometer Pro), end tidal gases (nasal cannula), and cerebral blood flow velocity (CBFv, transcranial Doppler). The 0-60 mmHg ICLF increased OT (33 ± 2.2 min) compared to both placebo (26 ± 2.4 min; p < 0.001) and 0-30 mmHg ICLF (25 ± 2.7 min; p < 0.001). Throughout testing 0-60 mmHg ICLF reduced orthostatic fluid shifts compared to both placebo and 0-30 mmHg ICLF (p < 0.001), with an associated improvement in stroke volume (p < 0.001), allowing blood pressure to be maintained at a reduced heart rate (p < 0.001). In addition, CBFv was higher with 0-60 mmHg ICLF than 0-30 mmHg ICLF and placebo (p < 0.001). Intermittent calf compression is a promising novel intervention for the management of orthostatic intolerance, which may provide affected individuals renewed independence and improved quality of life.
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Affiliation(s)
- Brooke C D Hockin
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada.,International Collaboration On Repair Discoveries, The University of British Columbia, Vancouver, BC, Canada
| | - Victoria E Claydon
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada.,International Collaboration On Repair Discoveries, The University of British Columbia, Vancouver, BC, Canada
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Sarafis ZK, Monga AK, Phillips AA, Krassioukov AV. Is Technology for Orthostatic Hypotension Ready for Primetime? PM R 2019; 10:S249-S263. [PMID: 30269810 DOI: 10.1016/j.pmrj.2018.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 04/04/2018] [Accepted: 04/12/2018] [Indexed: 01/29/2023]
Abstract
Spinal cord injury (SCI) often results in the devastating loss of motor, sensory, and autonomic function. After SCI, the interruption of descending sympathoexcitatory pathways disrupts supraspinal control of blood pressure (BP). A common clinical consequence of cardiovascular dysfunction after SCI is orthostatic hypotension (OH), a debilitating condition characterized by rapid profound decreases in BP when assuming an upright posture. OH can result in a diverse array of insidious and pernicious health consequences. Acute effects of OH include decreased cardiac filling, cerebral hypoperfusion, and associated presyncopal symptoms such as lightheadedness and dizziness. Over the long term, repetitive exposure to OH is associated with a drastically increased prevalence of heart attack and stroke, which are leading causes of death in those with SCI. Current recommendations for managing BP after SCI primarily include pharmacologic interventions with prolonged time to effect. Because most episodes of OH occur in less than 3 minutes, this delay in action often renders most pharmacologic interventions ineffective. New innovative technologies such as epidural and transcutaneous spinal cord stimulation are being explored to solve this problem. It might be possible to electrically stimulate sympathetic circuitry caudal to the injury and elicit rapid modulation of BP to manage OH. This review describes autonomic control of the cardiovascular system before injury, resulting cardiovascular consequences after SCI such as OH, and the clinical assessment tools for evaluating autonomic dysfunction after SCI. In addition, current approaches for clinically managing OH are outlined, and new promising interventions are described for managing this condition.
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Affiliation(s)
- Zoe K Sarafis
- ICORD-BSCC, University of British Columbia, Vancouver, BC, Canada(∗)
| | - Aaron K Monga
- ICORD-BSCC, University of British Columbia, Vancouver, BC, Canada(†)
| | - Aaron A Phillips
- Departments of Physiology and Pharmacology, Clinical Neurosciences, Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada(‡)
| | - Andrei V Krassioukov
- ICORD-BSCC; Experimental Medicine Program; Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia; GF Strong Rehabilitation Center, Vancouver Coastal Health; 818 West 10th Avenue, Vancouver, BC, Canada, V5Z1M9(§).
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Hockin BC, Ruiz IA, Brar GK, Claydon VE. Intermittent calf compression reverses lower limb pooling and improves cardiovascular control during passive orthostasis. Auton Neurosci 2019; 217:102-113. [DOI: 10.1016/j.autneu.2018.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 12/10/2018] [Accepted: 12/17/2018] [Indexed: 12/26/2022]
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