Orthostatic hypotension: managing a difficult problem

Adrenoceptors: A Focus on Psychiatric Disorders and Their Treatments

Research into the involvement of adrenoceptor subtypes in the cause(s) of psychiatric disorders is particularly challenging. This is partly because of difficulties in developing animal models that recapitulate the human condition but also because no evidence for any causal links has emerged from studies of patients. These, and other obstacles, are outlined in this chapter. Nevertheless, many drugs that are used to treat psychiatric disorders bind to adrenoceptors to some extent. Direct or indirect modulation of the function of specific adrenoceptor subtypes mediates all or part of the therapeutic actions of drugs in various psychiatric disorders. On the other hand, interactions with central or peripheral adrenoceptors can also explain their side effects. This chapter discusses both aspects of the field, focusing on disorders that are prevalent: depression, schizophrenia, anxiety, attention-deficit hyperactivity disorder, binge-eating disorder, and substance use disorder. In so doing, we highlight some unanswered questions that need to be resolved before it will be feasible to explain how changes in the function of any adrenoceptor subtype affect mood and behavior in humans and other animals.

Non-pharmacological and drug treatment of autonomic dysfunction in multiple system atrophy: current status and future directions

Multiple system atrophy (MSA) is a sporadic, fatal, and rapidly progressive neurodegenerative disease of unknown etiology that is clinically characterized by autonomic failure, parkinsonism, cerebellar ataxia, and pyramidal signs in any combination. Early onset and extensive autonomic dysfunction, including cardiovascular dysfunction characterized by orthostatic hypotension (OH) and supine hypertension, urinary dysfunction characterized by overactive bladder and incomplete bladder emptying, sexual dysfunction characterized by sexual desire deficiency and erectile dysfunction, and gastrointestinal dysfunction characterized by delayed gastric emptying and constipation, are the main features of MSA. Autonomic dysfunction greatly reduces quality of life and increases mortality. Therefore, early diagnosis and intervention are urgently needed to benefit MSA patients. In this review, we aim to discuss the systematic treatment of autonomic dysfunction in MSA, and focus on the current methods, starting from non-pharmacological methods, such as patient education, psychotherapy, diet change, surgery, and neuromodulation, to various drug treatments targeting autonomic nerve and its projection fibers. In addition, we also draw attention to the interactions among various treatments, and introduce novel methods proposed in recent years, such as gene therapy, stem cell therapy, and neural prosthesis implantation. Furthermore, we elaborate on the specific targets and mechanisms of action of various drugs. We would like to call for large-scale research to determine the efficacy of these methods in the future. Finally, we point out that studies on the pathogenesis of MSA and pathophysiological mechanisms of various autonomic dysfunction would also contribute to the development of new promising treatments and concepts.

The Effect of a Biofeedback-Based Integrated Program on Improving Orthostatic Hypotension in Community-Dwelling Older Adults: A Pilot Study

BACKGROUND

Orthostatic hypotension (OH) is prevalent among community-dwelling older adults and is associated with multiple negative health outcomes. Older adults are susceptible to developing OH because aging alters autonomic nervous system function. Biofeedback is a noninvasive, nonpharmacological intervention that can modulate autonomic nervous system dysfunction in older adults.

OBJECTIVES

Our aim in this study was to examine the effect of a biofeedback-based integrated program on community-dwelling older adults with OH.

METHODS

We conducted a controlled pilot study. Community-dwelling older adults 65 years or older who had nonneurogenic OH were eligible. Data from 51 participants, comprising 27 in the intervention group and 24 in the control group, were analyzed. Weekly biofeedback-based integrated program consisting of biofeedback training along with group education about behavioral modification, physical activities, and telephone counseling was provided for 12 weeks. Orthostatic hypotension was evaluated by measuring the drop in systolic and diastolic blood pressure after postural changes. Autonomic nervous system function was measured using heart rate variability.

RESULTS

Among the indicators of heart rate variability, total power (P = .037) and low frequency (P = .017) increased significantly, suggesting that autonomic function improved. Severity of orthostatic symptoms (P < .001) and drops in systolic (P = .003) and diastolic (P = .012) blood pressure after postural changes decreased significantly in the intervention group.

CONCLUSION

Biofeedback-based integrated program was effective in improving autonomic nervous system function and alleviated OH. Therefore, biofeedback-based integrated program should be tested in a larger randomized controlled study with long-term follow-up.

Selected biomarkers of orthostatic intolerance

Orthostatic intolerance (OI) is defined as a group of diseases which symptoms are typically manifested in a standing position. These symptoms result from cerebral hypoperfusion and disappear in the supine position. We include postural orthostatic intolerance syndrome (POTS), orthostatic hypotension (OH) and vasovagal orthostatic syncope in this group of diseases. Each of them have similar clinical presentation (blurred vision, weakness, dizziness, nausea, headaches, fatigue). However, they vary from each other in biochemical, autonomic and hemodynamic characteristics. The aim of the work is to provide an overview of humoral and non-human markers that are involved in the etiopathogenesis of orthostatic intolerance.

Asymptomatic orthostatic hypotension and risk of falls in community-dwelling older people

INTRODUCTION

Many older people with orthostatic hypotension (OH) may not report typical symptoms of dizziness, light-headedness or unsteadiness. However, the relationships between OH and falls in the absence of typical symptoms are not yet established.

METHODS

Continuous orthostatic blood pressure (BP) was measured during active stand using a Finometer at Wave 1 of The Irish Longitudinal Study on Ageing in participants aged ≥ 70 years.OH, with and without dizziness, was defined as a sustained drop in systolic BP ≥ 20 and/or diastolic BP ≥ 10 mm Hg at 30, 60 and 90 seconds post-standing.The association between symptoms of dizziness and orthostatic BP was assessed with multi-level mixed-effects linear regression; logistic regression models assessed the longitudinal relationship between OH and falls at 6-year follow-up (Waves 2-5).

RESULTS

Almost 11% (n = 934, mean age 75 years, 51% female) had OH, two-thirds of whom were asymptomatic.Dizziness was not associated with systolic BP drop at 30 (β = 1.54 (-1.27, 4.36); p = 0.256), 60 (β = 2.64 (-0.19, 5.47); p = 0.476) or 90 seconds (β = 2.02 (-0.91, 4.95); p = 0.176) after standing in adjusted models.Asymptomatic OH was independently associated with unexplained falls (odds ratio 2.01 [1.11, 3.65]; p = 0.022) but not explained falls (OR 0.93 [0.53, 1.62]; p = 0.797) during follow-up.

CONCLUSIONS

Two-thirds of older people with OH did not report typical symptoms of light-headedness. Dizziness or unsteadiness after standing did not correlate with the degree of orthostatic BP drop or recovery. Participants with asymptomatic OH had a significantly higher risk of unexplained falls during follow-up, and this has important clinical implications for the assessment of older people with falls.

[Orthostatic Intolerance: A Clinical Approach]

Having suffered a syncope or dizziness are frequent reasons for admissions to an emergency ward. Carefully taken anamnesis and clinical examination are mostly leading to a correct diagnosis. Red flags like new ECG changes, syncope during physical activity or others should lead to further diagnostic steps. Orthostatic intolerance is one of the most common reasons for dizziness and/or syncope. Autonomic testing including tilt table testing has to be done carefully and judged in an overall view together with anamnesis and clinical presentation. We present a clinical approach to the wide field of orthostatic intolerance with hints for the need of further autonomic testing.

Orthostatische Intoleranz: eine klinische Betrachtung

Schwindel und Unwohlsein – zum Teil auch einhergehend mit einem passageren Bewusstseinsverlust – gehören zu den häufigsten Vorstellungsgründen sowohl in der Notaufnahme als auch in neurologischen und internistischen/allgemeinmedizinischen Praxen. Dieser CME-Artikel soll eine praxisnahe und klinische Herangehensweise zeigen, um dem Phänomen der orthostatischen Intoleranz in seinen zahlreichen Facetten auf die Spur zu kommen.

SumGNN: multi-typed drug interaction prediction via efficient knowledge graph summarization

MOTIVATION

Thanks to the increasing availability of drug-drug interactions (DDI) datasets and large biomedical knowledge graphs (KGs), accurate detection of adverse DDI using machine learning models becomes possible. However, it remains largely an open problem how to effectively utilize large and noisy biomedical KG for DDI detection. Due to its sheer size and amount of noise in KGs, it is often less beneficial to directly integrate KGs with other smaller but higher quality data (e.g. experimental data). Most of existing approaches ignore KGs altogether. Some tries to directly integrate KGs with other data via graph neural networks with limited success. Furthermore most previous works focus on binary DDI prediction whereas the multi-typed DDI pharmacological effect prediction is more meaningful but harder task.

RESULTS

To fill the gaps, we propose a new method SumGNN: knowledge summarization graph neural network, which is enabled by a subgraph extraction module that can efficiently anchor on relevant subgraphs from a KG, a self-attention based subgraph summarization scheme to generate reasoning path within the subgraph, and a multi-channel knowledge and data integration module that utilizes massive external biomedical knowledge for significantly improved multi-typed DDI predictions. SumGNN outperforms the best baseline by up to 5.54%, and performance gain is particularly significant in low data relation types. In addition, SumGNN provides interpretable prediction via the generated reasoning paths for each prediction.

AVAILABILITY AND IMPLEMENTATION

The code is available in Supplementary Material.

SUPPLEMENTARY INFORMATION

Supplementary data are available at Bioinformatics online.

Dyspnea in Chronic Low Ventricular Preload States

Dyspnea in low-preload states is an underrecognized but growing diagnosis in patients with unexplained dyspnea. Patients can often experience debilitating symptoms at rest and with exertion, as low measured preload often leads to decreased cardiac output and ultimately dyspnea. In the present article, we performed a review of the literature and a multidisciplinary evaluation to understand the pathophysiology, diagnosis, and treatment of dyspnea in low-preload states. We explored selected etiologies and suggested an algorithm to approach unexplained dyspnea. The mainstay of diagnosis remains as invasive cardiopulmonary exercise testing. We concluded with a variety of nonpharmacological and pharmacological therapies, highlighting that a multifactorial approach may lead to the best results.

Uncommon side effects of common drugs in patients with familial dysautonomia

PURPOSE

Patients with the autosomal recessive disorder of familial dysautonomia typically exhibit exacerbated adverse side effects to many common drugs. We aimed to catalog these adverse effects - with a focus on common drugs that are frequently administered to FD patients and compare their incidences to those within the general population.

METHODS

We used data of 595 FD patients from an international database with information on drugs received and adverse effects. To investigate the molecular causes of reported differences in drug responses in FD patients, we used expression microarrays to compare the mRNA expression profiles in peripheral blood leukocytes of FD patients (n = 12) and healthy individuals (n = 10).

RESULTS

Several drug classes, including cholinergics, anti-cholinergics, anti-convulsants, methylxanthines, SSRIs, and antibiotics caused either unreported symptoms or elevated rates of adverse events in FD patients. FD patients experienced different or more frequent adverse side effects than the general population in 31/123 drugs. These side effects included blood cell dyscrasias, amenorrhea, gastrointestinal bleeding, and bronchospasm. New findings include enhanced reaction of FD patients to H2 antagonist agents and to serotonin receptor agonists. We also detected eight genes differentially expressed between FD patients and healthy individuals that may underlie the differential drug responses of FD patients.

CONCLUSION

We provide evidence that suggests the use of several common drugs should be discontinued or reduced in FD patients.

Cardiovascular and cerebrovascular risk markers in Parkinson's disease: Results from a case-control study

BACKGROUND

The relationship between Parkinson's disease (PD) and cardiovascular and cerebrovascular disease is not yet well established. Recent data suggest an increased risk of myocardial infarction and stroke in PD patients. Therefore, we designed a study to assess surrogate markers of cardiovascular and cerebrovascular risk in PD.

METHODS

We conducted a case-control study comparing PD patients recruited from a Movement Disorders Unit with controls randomly invited from a primary healthcare center. All participants underwent a detailed clinical evaluation, including medical history, physical assessment, carotid ultrasound, blood and urine analysis, and 24-h ambulatory blood pressure monitoring. The primary outcome was the carotid intima-media thickness (CIMT).

RESULTS

We included 102 participants in each study arm. No significant difference was found in the CIMT among groups (MD: 0.01, 95% CI: -0.02, 0.04). Carotid plaques were more frequent in PD patients (OR: 1.90, 95% CI: 1.02, 3.55), although the lipid profile was more favorable in this group (LDL MD: -18.75; 95% CI: -10.69, -26.81). Nocturnal systolic blood pressure was significantly higher in PD patients (MD: 4.37, 95% CI: 0.27, 8.47) and more than half of the PD patients were non-dippers or reverse dippers (OR: 1.83, 95% CI: 1.04, 3.20).

CONCLUSION

We did not find a difference in CIMT between PD and controls. A higher frequency of carotid plaques and abnormal dipper profile supports the hypothesis that PD patients are not protected from cardiovascular and cerebrovascular disease.

Initial orthostatic hypotension and orthostatic intolerance symptom prevalence in older adults: A systematic review

Background

Initial orthostatic hypotension is a clinically relevant syndrome in older adults which has been associated with symptoms of orthostatic intolerance. The aim of this systematic review was to determine the prevalence of orthostatic intolerance symptoms in older adults with initial orthostatic hypotension.

Methods

MEDLINE (from 1946), EMBASE (from 1974) and Cochrane were searched to December 6th^, 2019 using the terms "initial orthostatic hypotension", "postural hypotension" and "older adults". Study selection involved the following criteria: published in English; mean or median age ≥ 65 years and diagnosis of initial orthostatic hypotension encompassed a decrease in systolic blood pressure by ≥ 40  mmHg and/or diastolic blood pressure by ≥ 20  mmHg within a maximum of 1 min following a postural change.

Results

Of 8311 articles, 12 articles reporting initial orthostatic hypotension prevalence in 3446 participants with a mean age of 75 (6 SD) years (56.5% female) were included. Five initial orthostatic hypotension definition variations were utilised and symptoms were reported in six articles (968 participants, mean age 73.4 (6.1 SD) years, 56% female). The prevalence of symptoms in older adults with initial orthostatic hypotension ranged from 24 to 100% and was dependent on variations in timing or the inclusion of symptoms in the initial orthostatic hypotension definition.

Conclusions

Where orthostatic intolerance symptoms were reported, a large proportion of older adults with a diagnosis of initial orthostatic hypotension were symptomatic. However, the literature on initial orthostatic hypotension and orthostatic intolerance symptoms is scarce and a variety of definitions of initial orthostatic hypotension are utilised.

Effect of artificial dawn light on cardiovascular function, alertness, and balance in middle-aged and older adults

STUDY OBJECTIVES

When arising in the morning, many older people experience dizziness and difficulty maintaining proper balance, as the cardiovascular system is not able to compensate to the postural shift (standing) and maintain sufficient blood flow to the brain. Such changes in cardiovascular function are observed in young individuals exposed to a dawn simulation light. In this study, we examined whether exposure to a dawn simulation light could impact cardiovascular function and consequent changes in balance in middle-aged and older adults.

METHODS

Twenty-three participants (67.3 ± 8.8 y), 12 of whom reported a history of dizziness in the morning, underwent two overnight stays in our laboratory. During both nights, they slept in complete darkness, except for the last 30 minutes of one of the nights during which a dawn simulation light was used. Continuous blood pressure (BP) and heart rate (HR) were monitored. Subjective and objective alertness, salivary cortisol, and mobile and standing balance were examined upon arising.

RESULTS

Dawn simulation light decreased (33%) the amount of sleep before morning awakening, lowered BP (6.24 mmHg), and increased HR (0.93 bpm). Despite these changes in physiology, there was no significant impact of dawn simulation on subjective or objective alertness, measures of standing or ambulatory balance, morning cortisol awakening response, or cardiovascular function after awakening.

CONCLUSION

While the dawn simulation did cause an increase in wake and a change in cardiovascular function prior to morning arousal in older adults, we could find no evidence of a functional change in either cardiovascular function or balance upon standing.

CLINICAL TRIAL

Registered on Clinicaltrials.gov, #NCT02632318, https://clinicaltrials.gov/ct2/show/NCT02632318.

Active women demonstrate acute autonomic and hemodynamic shifts following exercise in heat and humidity: A pilot study

The purpose of this study was to assess autonomic and hemodynamic recovery in women who performed moderate-intensity exercise in heat. Seven women (31.7 ± 7.6 years, 67.5 ± 4.4 kg, 25.7 ± 5.6% Fat, 43.9 ± 5.1 mL/kg/min) completed two identical bouts of graded treadmill walking (~60% VO₂peak). One bout was hot (37.5 ± 1.4°C, 46.5 ± 4.6% relative humidity (RH)), and the other was moderate (20.7 ± 1.1°C, 29.9 ± 4.1% RH). For 24 h before and one h after each bout, participants had heart rate variability monitored. After each exercise bout HR and BP were measured during 30 min of supine recovery and 10 min of orthostatic challenge. HF power and RMSSD were lower and LF power and LF:HF ratio greater following exercise in the heat and remained different from the moderate condition for 30 min (p < 0.05). During supine recovery, heat exposure led to higher HR (p = 0.002) and lower DBP (p = 0.016). SBP (p = 0.037) and DBP (p = 0.008) were both lower after 10 min of supine recovery following hot exercise than after moderate temperature. Average response did not reveal orthostatic hypotension despite heat causing a higher HR (p = 0.011) and lower SBP (p = 0.026) after 10 min of orthostatic exposure. Trained women exhibit an autonomic shift toward sympathetic dominance for at least 30 min after exercise in heat. Women who exercise in heat should be wary of an exacerbated HR response after exercise and low recovery blood pressures.

Cardiovascular Disorders Mediated by Autonomic Nervous System Dysfunction

Cardiovascular disorders, such as orthostatic hypotension and supine hypertension, are common in patients with neurodegenerative synucleinopathies such as Parkinson disease (PD), and may also occur in other conditions, such as peripheral neuropathies, that result in autonomic nervous system (ANS) dysfunction. Dysfunction and degeneration of the ANS are implicated in the development of orthostatic and postprandial hypotension and impaired thermoregulation. Neurogenic orthostatic hypotension (nOH) results from sympathetic failure and is a common autonomic disorder in PD. Supine hypertension may also occur as a result of both sympathetic and parasympathetic dysfunction in conjunction with nOH in the majority of patients with PD. Management of supine hypertension in the setting of nOH can be counterintuitive and challenging. Additionally, the presence of other noncardiovascular comorbidities, such as diabetes mellitus and peripheral edema, may further contribute to the burden of disease. ANS dysfunction thus presents major healthcare implications and challenges for neurology and cardiovascular practices, necessitating an integrated neurology and cardiology management approach.

Neurogenic Orthostatic Hypotension: State of the Art and Therapeutic Strategies

Neurogenic orthostatic hypotension (nOH) is a subtype of orthostatic hypotension in which patients have impaired regulation of standing blood pressure due to autonomic dysfunction. Several primary and secondary causes of this disease exist. Patients may present with an array of symptoms making diagnosis difficult. This review article addresses the epidemiology, pathophysiology, causes, clinical features, and management of nOH. We highlight various pharmacological and non-pharmacological approaches to treatment, and review the recent guidelines and our approach to nOH.

Time point of blood pressure drop in patients with orthostatic hypotension in the emergency department

OBJECTIVE

The purpose of this study was to identify the time of blood pressure (BP) drop in the orthostatic hypotension test, and to propose a realistic and appropriate duration in the orthostatic hypotension test.

METHODS

A total of 879 consecutive patients (61-year-old and 44% women) with positive on the orthostatic hypotension test in the emergency department were retrospectively reviewed. Orthostatic hypotension was defined as drop in standing SBP of at least 20 mmHg or standing DBP of at least 10 mmHg from their supine values after standing for 5 min. BP measurements was made at 1, 3, and 5 min after standing.

RESULTS

Six hundred and eighty-four (77.8%), 152 (17.3%) and 43 (4.9%) patients had BP drop meeting orthostatic hypotension criteria at 1, 3, and 5 min, respectively. In multivariable analysis, older age (≥60 years) and higher blood urea nitrogen (BUN) (≥15.5 mg/dl) were independently associated with early BP drop at 1 min, and younger age (<40 years) was independently associated with later BP drop at 5 min even after controlling for potential confounders.

CONCLUSION

To measure orthostatic BP for orthostatic hypotension diagnosis at emergency department, older patients (≥60 years) with high BUN (≥15.5 mg/dl) should be monitored carefully as BP can drop quickly within 1 min. On the contrary, in younger people (<40 years), BP drop occurred slowly after 3 min, suggesting that clinicians measure BP for a longer time.

Parkinson Disease and Orthostatic Hypotension in the Elderly: Recognition and Management of Risk Factors for Falls

Parkinson disease (PD) is often associated with postural instability and gait dysfunction that can increase the risk for falls and associated consequences, including injuries, increased burden on healthcare resources, and reduced quality of life. Patients with PD have nearly twice the risk for falls and associated bone fractures compared with their general population counterparts of similar age. Although the cause of falls in patients with PD may be multifactorial, an often under-recognized factor is neurogenic orthostatic hypotension (nOH). nOH is a sustained decrease in blood pressure upon standing whose symptomology can include dizziness/lightheadedness, weakness, fatigue, and syncope. nOH is due to dysfunction of the autonomic nervous system compensatory response to standing and is a consequence of the neurodegenerative processes of PD. The symptoms associated with orthostatic hypotension (OH)/nOH can increase the risk of falls, and healthcare professionals may not be aware of the real-world clinical effect of nOH, the need for routine screening, or the value of early diagnosis of nOH when treating elderly patients with PD. nOH is easily missed and, importantly, healthcare providers may not realize that there are effective treatments for nOH symptoms that could help lessen the fall risk resulting from the condition. This review discusses the burden of, and key risk factors for, falls among patients with PD, with a focus on practical approaches for the recognition, assessment, and successful management of OH/nOH. In addition, insights are provided as to how fall patterns can suggest fall etiology, thereby influencing the choice of intervention.

Hypertension and Arrhythmias

Hypertension is the most common cardiovascular risk factor and underlies heart failure, coronary artery disease, stroke, and chronic kidney disease. Hypertensive heart disease can manifest as cardiac arrhythmias. Supraventricular and ventricular arrhythmias may occur in the hypertensive patients. Atrial fibrillation and hypertension contribute to an increased risk of stroke. Some antihypertensive drugs predispose to electrolyte abnormalities, which may result in atrial and ventricular arrhythmias. A multipronged strategy involving appropriate screening, aggressive lifestyle modifications, and optimal pharmacotherapy can result in improved blood pressure control and prevent the onset or delay progression of heart failure, coronary artery disease, and cardiac arrhythmias.

Neurogenic Orthostatic Hypotension in Parkinson Disease: A Primer

Parkinson disease (PD) is associated with a variety of motor and non-motor clinical manifestations, including cardiovascular autonomic dysfunction. Neurogenic orthostatic hypotension (nOH) is a potentially serious manifestation of cardiovascular sympathetic failure that occurs in approximately 30% of patients with PD. Here we review the pathophysiology and effects of the condition as well as treatment considerations for patients with PD and nOH. Screening for nOH using orthostatic symptom questionnaires, orthostatic blood pressure measurements, and specialized autonomic testing is beneficial for the identification of symptomatic and asymptomatic cases because cardiac sympathetic denervation and nOH can occur even at early (premotor) stages of PD. Symptoms of nOH, such as orthostatic lightheadedness, in patients with PD, have been shown to adversely affect patient safety (with increased risk of falls) and quality of life and should prompt treatment with non-pharmacologic and, occasionally, pharmacologic measures. Patients with nOH are also at increased risk of supine hypertension, which requires balancing various management strategies. FUNDING: Lundbeck (Deerfield, IL).

(r)Alpha Lipoic Acid Is a Safe, Effective Pharmacologic Therapy of Chronic Orthostatic Hypotension Associated with Low Sympathetic Tone

Chronic orthostatic hypotension (OH), affecting 10 to 30% of the elderly, is associated with falls, and increased morbidity and mortality. Current pharmacologic therapy can cause or worsen hypertension and fluid retention. (r)α lipoic acid (ALA), a powerful natural antioxidant, avoids those complications and may assist management of chronic neurogenic orthostatic hypotension (NOH). The purpose of this study is to demonstrate improvement in the symptoms of orthostatic dysfunction with r-ALA, including improved sympathetic (S) and blood pressure (BP) responses to head-up postural change (standing). A cohort of 109 patients with low S tone upon standing was detected using the ANX -3.0, Autonomic Monitor, ANSAR Medical Technologies, Inc., Philadelphia, PA. From the cohort, 29 patients demonstrated NOH (change in (∆) standing BP ≥ -20/-10 mm Hg); 60 patients demonstrated orthostatic intolerance (OI, ∆ standing systolic BP between -6 and -19 mm Hg). These 89 were given ALA orally: either 590 to 788 mg (r)ALA or 867 to 1,500 mg of the less expensive 50 to 50% mixture (r)ALA and inactive (s)ALA. Changes in their S and parasympathetic (P) tone, and BPs, were compared with 20 control patients during mean follow-up of 2.28 years. Nineteen of 29 (66%) NOH patients responded with a ∆ standing BP from -28/-6 mm Hg to 0/+2 mm Hg. Forty of 60 (67%) of patients with OI responded with a ∆ standing BP of -9/+1 mm Hg to +6/+2 mm Hg. Although all patients treated with ALA increased S tone, the ∆ BP depended upon the pretreatment of S tone. Those with the lowest S tone responded the least well. The only treatment side effects were nausea, intolerable in only 5%. Nausea improved with routine gastrointestinal medications. Glucose levels improved in the 28% of patients who were diabetic. Also, resting hypertension improved. Control patients had no ∆ BP and no increase in S tone. (r)ALA improves S-, and BP, responses to head-up postural change, and thereby NOH/OI, in a majority of patients without causing harmful side effects.

Nonpharmacologic Management of Orthostatic Hypotension in Older People: A Systematic Review. The SENATOR ONTOP Series

OBJECTIVES

Nonpharmacologic therapies are often recommended as a first-line treatment for orthostatic hypotension (OH). However, the true effect of nonpharmacologic therapy remains unclear, particularly in the older population. We undertook a systematic review evaluating the efficacy of nonpharmacologic interventions in older people with OH to provide evidence-based recommendations.

DESIGN

Systematic review of systematic reviews.

SETTING AND PARTICIPANTS

MEDLINE, PubMed, EMBASE, and Cochrane Database of Systematic Reviews, CINHAL, and PsycINFO were searched up to June 2018. Two reviewers identified eligible systematic reviews from which primary studies were selected. We included both randomized and nonrandomized studies that evaluated any type of nonpharmacologic intervention and reported outcomes of change in postural drop in systolic blood pressure (SBP) and/or orthostatic symptoms measured using any validated instrument. The Cochrane risk of bias tool was used, with recommendations based on the GRADE approach.

RESULTS

Eleven trials were included. Meta-analysis of lower limb compression showed a reduction in the postural drop in SBP of 9.83 mmHg [95% confidence interval (CI) -12.56, -7.11], whereas abdominal compression showed a larger reduction in postural drop in SBP of 12.30 mmHg (95% CI -18.20, -6.39). Compression therapy was also beneficial in reducing OH symptoms. However, the quality of the evidence for compression therapy was very poor. One study each was identified for sleeping with head-up (SHU), home-based resistance training (HBRT), and multicomponent intervention but did not significantly reduce postural SBP drop. Bolus water drinking was effective in 1 study but the study was of low quality.

CONCLUSIONS/IMPLICATIONS

There is no high-quality evidence to recommend any of the nonpharmacologic therapies for the management of OH in older people. Yet, we make a weak recommendation for lower limb and abdominal compression therapy based on very low quality evidence. Large-scale trials are warranted in older people to substantiate the efficacy of nonpharmacologic therapies in OH.

Hypertension and cardiac arrhythmias: a consensus document from the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE)

Hypertension is a common cardiovascular risk factor leading to heart failure (HF), coronary artery disease, stroke, peripheral artery disease and chronic renal insufficiency. Hypertensive heart disease can manifest as many cardiac arrhythmias, most commonly being atrial fibrillation (AF). Both supraventricular and ventricular arrhythmias may occur in hypertensive patients, especially in those with left ventricular hypertrophy (LVH) or HF. Also, some of the antihypertensive drugs commonly used to reduce blood pressure, such as thiazide diuretics, may result in electrolyte abnormalities (e.g. hypokalaemia, hypomagnesemia), further contributing to arrhythmias, whereas effective control of blood pressure may prevent the development of the arrhythmias such as AF. In recognizing this close relationship between hypertension and arrhythmias, the European Heart Rhythm Association (EHRA) and the European Society of Cardiology (ESC) Council on Hypertension convened a Task Force, with representation from the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE), with the remit to comprehensively review the available evidence to publish a joint consensus document on hypertension and cardiac arrhythmias, and to provide up-to-date consensus recommendations for use in clinical practice. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and the patient in light of all of the circumstances presented by that patient.

Blood pressure circadian rhythms and adverse outcomes in type 2 diabetes patients diagnosed with orthostatic hypotension

AIMS/INTRODUCTION

Patients with diabetes frequently develop orthostatic hypotension (OH). The present study was designed to examine the relationship of blood pressure (BP) circadian rhythms and outcomes in diabetes with OH.

MATERIALS AND METHODS

In the present study, 173 inpatients with type 2 diabetes were enrolled. Patients were divided into an OH group and a non-OH group according to the BP changes detected in the supine and standing position. Then, 24-h ambulatory BP was monitored. Patients were followed up for an average of 45 ± 10 months post-discharge. Outcomes - death and major adverse cardiac and cerebrovascular events, including heart failure, myocardial infarction and stroke - were recorded.

RESULTS

There were 61 patients (35.26%) in the OH group and 112 patients (64.74%) in the non-OH group. In the OH group, the night-time systolic BP and night-time diastolic BP were higher, the blood BP rhythms were predominantly of the riser type (67.21%). OH was as an independent marker of riser type circadian rhythm (adjusted odds ratio 4.532, 95% confidence interval 2.579-7.966). In the OH group, the incidence rates of mortality, and major adverse cardiac and cerebrovascular events were increased significantly compared with those in the non-OH group (11.48 vs 2.68%, P = 0.014; 37.70 vs 8.93%, P < 0.01).

CONCLUSIONS

In patients who had type 2 diabetes diagnosed with OH, the BP circadian rhythm usually showed riser patterns, and they had increased rates of mortality, and major adverse cardiac and cerebrovascular events.

Orthostatic hypotension for the cardiologist

PURPOSE OF REVIEW

Orthostatic hypotension is a phenomenon commonly encountered in a cardiologist's clinical practice that has significant diagnostic and prognostic value for a cardiologist. Given the mounting evidence associating cardiovascular morbidity and mortality with orthostatic hypotension, cardiologists will play an increasing role in treating and managing patients with orthostatic hypotension.

RECENT FINDINGS

The American College of Cardiology, American Heart Association, and Heart Rhythm Society recently published consensus guidelines on the diagnosis, treatment, and management of syncope and their instigators, including orthostatic hypotension. Additionally, consensus guidelines have also been recently updated, reinforcing the universal definition orthostatic hypotension and its closely associated pathologies. Finally, the United States Food and Drug Administration (FDA) recently approved droxidopa, a synthetic oral norepinephrine prodrug, in 2014 for the treatment of neurogenic orthostatic hypotension (nOH), and it represents a well tolerated, effective, and easy to use intervention for nOH. This represents only the second drug approved by the FDA for orthostatic hypotension, the first being midodrine in 1986. A handful of smaller head-to-head studies have pitted not only pharmacologic agents to one another but also nonpharmacologic interventions to pharmacologic agents. Additionally, recent studies have also reported on more convenient screening tools for orthostatic hypotension.

SUMMARY

Though there have been many advances in the management of orthostatic hypotension, nOH remains a chronic, debilitating, and often progressively fatal condition. Cardiologists can play a very important role in optimizing hemodynamics in this patient population to improve quality of life and minimize cardiovascular risk.

Practical management of adverse events related to apomorphine therapy

The potential for adverse events is often cited as a barrier to the use of subcutaneous apomorphine therapy (intermittent injections and continuous infusion) in the management of Parkinson's disease. However, with proactive management most adverse effects are manageable if reported and tackled early enough. As such, proper clinician and patient awareness of the potential adverse effects is important to minimize their impact on the overall clinical utility of this efficacious antiparkinsonian agent. In this paper, we review the key local and systemic adverse effects reported during apomorphine titration, initiation and long-term treatment, and discuss practical management strategies.

Effects of the novel norepinephrine prodrug, droxidopa, on ambulatory blood pressure in patients with neurogenic orthostatic hypotension

The prodrug droxidopa increases blood pressure (BP) in patients with neurogenic orthostatic hypotension. The BP profile of droxidopa in neurogenic orthostatic hypotension patients (n = 18) was investigated using ambulatory BP monitoring. Following dose optimization and a washout period, 24-hour "off-drug" data were collected. "On-drug" assessment was conducted after 4-5 weeks of droxidopa treatment (mean dose, 444 mg, three times daily). Ambulatory monitoring off drug revealed that 90% of patients already had abnormalities in the circadian BP profile and did not meet criteria for normal nocturnal BP dipping. On treatment, both overall mean 24-hour systolic and diastolic BPs were higher compared to off drug (137/81 mm Hg vs. 129/76 mm Hg; P = .017/.002). Mean daytime systolic BP was significantly higher with droxidopa (8.4 ± 3.1 mm Hg; P = .014). Although nocturnal BP was not significantly higher on droxidopa versus off treatment (P = .122), increases in nocturnal (supine) BP ≥10 mm Hg were observed in four cases (22%). Severe supine systolic hypertensive readings at night (>200 mm Hg) were captured in one case and only while on treatment. These data demonstrate that ambulatory BP monitoring is useful to evaluate the circadian BP profile after initiating treatment with a pressor agent.