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Clinical Cardiology Jul 2023Vasovagal syncope (VVS) is the most prevalent type of syncope and its management includes pharmacologic and non-pharmacologic interventions. Recently, studies have... (Meta-Analysis)
Meta-Analysis Review
Vasovagal syncope (VVS) is the most prevalent type of syncope and its management includes pharmacologic and non-pharmacologic interventions. Recently, studies have investigated vitamin D levels in VVS patients. In this systematic review and meta-analysis, we aim to review these studies to find possible associations between vitamin D deficiency and vitamin D levels with VVS. International databases including Scopus, Web of Science, PubMed, and Embase were searched with keywords related to "vasovagal syncope" and "vitamin D." Studies were screened and the data were extracted from them. Random-effect meta-analysis was conducted to calculate the standardized mean difference (SMD) and 95% confidence interval (CI) for vitamin D levels in comparison to VVS patients and controls. Also, VVS occurrence was measured and the odds ratio (OR) and 95% CI were calculated for comparison of vitamin D deficient cases and nondeficient individuals. Six studies were included with 954 cases investigated. Meta-analysis showed that patients with VVS had significantly lower vitamin D serum levels in comparison to non-VVS cases (SMD -1.05, 95% CI -1.54 to -0.57, p-value < .01). Moreover, VVS occurrence was higher in vitamin D-deficient individuals (OR 5.43, 95% CI 2.40 to 12.27, p-value < .01). Our findings which show lower vitamin D levels in VVS patients can have clinical implications in order for clinicians to pay attention to this when approaching VVS. Further randomized controlled trials are certainly warranted to assess the role of vitamin D supplementation in individuals with VVS.
Topics: Humans; Tilt-Table Test; Syncope, Vasovagal; Syncope; Vitamin D Deficiency; Vitamin D
PubMed: 37226313
DOI: 10.1002/clc.24035 -
Frontiers in Cardiovascular Medicine 2022Physical counter pressure maneuvers (CPM) are movements that are recommended to delay or prevent syncope (fainting) by recruiting the skeletal muscle pump to augment... (Review)
Review
Physical counter pressure maneuvers (CPM) are movements that are recommended to delay or prevent syncope (fainting) by recruiting the skeletal muscle pump to augment cardiovascular control. However, these recommendations are largely based on theoretical benefit, with limited data evaluating the efficacy of CPM to prevent syncope in the real-world setting. We conducted a semi-systematic literature review and meta-analysis to assess CPM efficacy, identify literature gaps, and highlight future research needs. Articles were identified through a literature search (PubMed, April 2022) of peer-reviewed publications evaluating the use of counter pressure or other lower body maneuvers to prevent syncope. Two team members independently screened records for inclusion and extracted data. From 476 unique records identified by the search, 45 met inclusion criteria. Articles considered various syncopal conditions (vasovagal = 12, orthostatic hypotension = 8, postural orthostatic tachycardia syndrome = 1, familial dysautonomia = 2, spinal cord injury = 1, blood donation = 10, healthy controls = 11). Maneuvers assessed included hand gripping, leg fidgeting, stepping, tiptoeing, marching, calf raises, postural sway, tensing (upper, lower, whole body), leg crossing, squatting, "crash" position, and bending foreword. CPM were assessed in laboratory-based studies ( = 28), the community setting ( = 4), both laboratory and community settings ( = 3), and during blood donation ( = 10). CPM improved standing systolic blood pressure (+ 14.8 ± 0.6 mmHg, < 0.001) and heart rate (+ 1.4 ± 0.5 bpm, = 0.006), however, responses of total peripheral resistance, stroke volume, or cerebral blood flow were not widely documented. Most patients experienced symptom improvement following CPM use (laboratory: 60 ± 4%, community: 72 ± 9%). The most prominent barrier to employing CPM in daily living was the inability to recognize an impending faint. Patterns of postural sway may also recruit the skeletal muscle pump to enhance cardiovascular control, and its potential as a discrete, proactive CPM needs further evaluation. Physical CPM were successful in improving syncopal symptoms and producing cardiovascular responses that may bolster against syncope; however, practical limitations may restrict applicability for use in daily living.
PubMed: 36312294
DOI: 10.3389/fcvm.2022.1016420 -
The Journals of Gerontology. Series A,... Jan 2020Orthostatic hypotension (OH) is associated with increased risk of falls, cognitive impairment and death, as well as a reduced quality of life. Although it is presumed to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Orthostatic hypotension (OH) is associated with increased risk of falls, cognitive impairment and death, as well as a reduced quality of life. Although it is presumed to be common in older people, estimates of its prevalence vary widely. This study aims to address this by pooling the results of epidemiological studies.
METHODS
MEDLINE, EMBASE, PubMed, Web of Science, and ProQuest were searched. Studies were included if participants were more than 60 years, were set within the community or within long-term care and diagnosis was based on a postural drop in systolic blood pressure (BP) ≥20 mmHg or diastolic BP ≥10 mmHg. Data were extracted independently by two reviewers. Random and quality effects models were used for pooled analysis.
RESULTS
Of 23,090 identified records, 20 studies were included for community-dwelling older people (n = 24,967) and six were included for older people in long-term settings (n = 2,694). There was substantial variation in methods used to identify OH with differing supine rest duration, frequency and timing of standing BP, measurement device, use of standing and tilt-tables and interpretation of the diagnostic drop in BP. The pooled prevalence of OH in community-dwelling older people was 22.2% (95% CI = 17, 28) and 23.9% (95% CI = 18.2, 30.1) in long-term settings. There was significant heterogeneity in both pooled results (I2 > 90%).
CONCLUSIONS
OH is very common, affecting one in five community-dwelling older people and almost one in four older people in long-term care. There is great variability in methods used to identify OH.
Topics: Aged; Blood Pressure; Global Health; Humans; Hypotension, Orthostatic; Independent Living; Prevalence; Quality of Life; Risk Factors
PubMed: 30169579
DOI: 10.1093/gerona/gly188 -
Age and Ageing Sep 2021Initial orthostatic hypotension (OH) is a clinical syndrome of exaggerated transient orthostasis associated with higher risks of falls, frailty and syncope in older... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Initial orthostatic hypotension (OH) is a clinical syndrome of exaggerated transient orthostasis associated with higher risks of falls, frailty and syncope in older adults.
OBJECTIVE
To provide a prevalence estimate of initial OH in adults aged 65 years or older.
METHODS
Literature search of MEDLINE (from 1946), Embase (from 1947) and Cochrane Central Register of Controlled Trials was performed until 6 December 2019, using the terms 'initial orthostatic hypotension', 'postural hypotension' and 'older adults'. Articles were included if published in English and participants were 65 years or older. Random effects models were used for pooled analysis.
RESULTS
Of 5,136 articles screened, 13 articles (10 cross-sectional; 3 longitudinal) reporting data of 5,465 individuals (54.5% female) from the general (n = 4,157), geriatric outpatient (n = 1,136), institutionalised (n = 55) and mixed (n = 117) population were included. Blood pressure was measured continuously and intermittently in 11 and 2 studies, respectively. Pooled prevalence of continuously measured initial OH was 29.0% (95% CI: 22.1-36.9%, I2 = 94.6%); 27.8% in the general population (95% CI: 17.9-40.5%, I2 = 96.1%), 35.2% in geriatric outpatients (95% CI: 24.2-48.1%, I2 = 95.3%), 10.0% in institutionalised individuals (95% CI: 2.4-33.1%, I2 = 0%) and 21.4% in the mixed population (95% CI: 7.0-49.6, I2 = 0%). Pooled prevalence of intermittently measured initial OH was 5.6% (95% CI: 1.5-18.9%, I2 = 81.1%); 1.0% in the general population (95% CI: 0.0-23.9%, I2 = 0%) and 7.7% in geriatric outpatients (95% CI: 1.8-27.0%, I2 = 86.7%).
CONCLUSION
The prevalence of initial OH is high in older adults, especially in geriatric outpatients. Proper assessment of initial OH requires continuous blood pressure measurements.
Topics: Accidental Falls; Aged; Blood Pressure; Cross-Sectional Studies; Female; Frailty; Humans; Hypotension, Orthostatic; Male; Prevalence
PubMed: 34260686
DOI: 10.1093/ageing/afab090 -
NeuroRehabilitation 2018Recent evidence suggests that autonomic nervous dysfunction may be one of many potential factors contributing to persisting post-concussion symptoms. (Review)
Review
BACKGROUND
Recent evidence suggests that autonomic nervous dysfunction may be one of many potential factors contributing to persisting post-concussion symptoms.
OBJECTIVE
This is the first systematic review to explore the impact of concussion on multiple aspects of autonomic nervous system functioning.
METHODS
The methods employed are in compliance with the American Academy of Neurology (AAN) and PRISMA standards. Embase, MEDLINE, PsychINFO, and Science Citation Index literature searches were performed using relevant indexing terms for articles published prior to the end of December 2016. Data extraction was performed by two independent groups, including study quality indicators to determine potential risk for bias according to the 4-tiered classification scheme of the AAN.
RESULTS
Thirty-six articles qualified for inclusion in the analysis. Only three studies (one Class II and two Class IV) did not identify anomalies in measures of ANS functioning in concussed populations.
CONCLUSIONS
The evidence supports the conclusion that it is likely that concussion causes autonomic nervous system anomalies. An awareness of this relationship increases our understanding of the physical impact of concussion, partially explains the overlap of concussion symptoms with other medical conditions, presents opportunities for further research, and has the potential to powerfully inform treatment decisions.
Topics: Autonomic Nervous System; Humans; Post-Concussion Syndrome
PubMed: 29660949
DOI: 10.3233/NRE-172298 -
Autonomic Neuroscience : Basic &... Jan 2023Postural Orthostatic Tachycardia Syndrome (POTS) is a chronic health condition affecting mostly women of childbearing age, and significantly impacting their health and... (Review)
Review
BACKGROUND AND OBJECTIVE
Postural Orthostatic Tachycardia Syndrome (POTS) is a chronic health condition affecting mostly women of childbearing age, and significantly impacting their health and quality of life. It is currently poorly understood with no approved licensed treatments. The aim of this systematic review was to contextualize the symptom burden of POTS, and review factors associated with this burden that may guide future treatments. The specific questions were (1) How does symptom burden in POTS compare to the burden in other long term conditions (LTCs), (2) Which factors are associated with POTS symptom burden, and (3) Which interventions show promise in reducing symptom burden in POTS.
DATABASES AND DATA TREATMENT
Electronic databases (CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, APA PsycArticles, OpenGrey) were searched from inception to January 2022 for observational studies reporting on the association between any biological, psychological or social factors and symptom burden, and randomized controlled trials reporting on interventions for symptom burden in adults with POTS. Two reviewers independently conducted eligibility screening, data extraction and quality assessment. A narrative synthesis was undertaken.
RESULTS/CONCLUSION
5159 entries were screened for eligibility. Twenty-nine studies were included (1372 participants with POTS of a total sample size of 2314, 17 High-, 12 Medium-quality), seventeen were observational and twelve were randomized controlled experimental and intervention trials. Overall methodological quality of the evidence was medium-high but heterogeneity was high and sample sizes modest, allowing moderately robust conclusions. Orthostatic symptom burden was higher in POTS than other LTCs. Serum activity against adrenergic α1 receptors, physical functioning, depression, catastrophizing, prolonged cognitive stress testing and anxiety were significantly associated with symptom burden in medium-high quality studies. Preliminary medium-high quality evidence from predominantly proof-of-concept (n = 11) studies and one 3-month 2 × 2 factorial design trial suggest that compression garments, propranolol, pyridostigmine, desmopressin, and bisoprolol may hold promise in reducing symptom burden. Directions for future research include investigating associated factors over time, the development of complex interventions which address both biological and psychosocial factors associated with symptom burden, and effectiveness trials of these interventions.
SIGNIFICANCE
POTS symptom burden is high, particularly in relation to orthostatic intolerance when compared to other long-term conditions (LTCs). Despite this burden, there are no effectiveness randomized controlled trials of treatment to reduce symptoms in POTS. This review provides a starting point to understanding researched biological and psychosocial factors associated with this burden. There was however inconsistency in the measurement of symptom burden, lowering the confidence of cross-study inferences. A coherent definition of POTS symptom range, severity and impact along with a validated and reliable POTS-specific instrument is currently lacking. A standardized questionnaire to assess POTS symptom burden as a core outcome measure will help clarify future research and clinical practice.
Topics: Adult; Humans; Female; Male; Postural Orthostatic Tachycardia Syndrome; Quality of Life; Self Report; Anxiety; Orthostatic Intolerance; Chronic Disease; Randomized Controlled Trials as Topic
PubMed: 36525900
DOI: 10.1016/j.autneu.2022.103052 -
BMC Family Practice Jan 2021Postural hypotension (PH), the reduction in blood pressure when rising from sitting or lying 0to standing, is a risk factor for falls, cognitive decline and mortality.... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Postural hypotension (PH), the reduction in blood pressure when rising from sitting or lying 0to standing, is a risk factor for falls, cognitive decline and mortality. However, it is not often tested for in primary care. PH prevalence varies according to definition, population, care setting and measurement method. The aim of this study was to determine the prevalence of PH across different care settings and disease subgroups.
METHODS
Systematic review, meta-analyses and meta-regression. We searched Medline and Embase to October 2019 for studies based in primary, community or institutional care settings reporting PH prevalence. Data and study level demographics were extracted independently by two reviewers. Pooled estimates for mean PH prevalence were compared between care settings and disease subgroups using random effects meta-analyses. Predictors of PH were explored using meta-regression. Quality assessment was undertaken using an adapted Newcastle-Ottawa Scale.
RESULTS
One thousand eight hundred sixteen studies were identified; 61 contributed to analyses. Pooled prevalences for PH using the consensus definition were 17% (95% CI, 14-20%; I = 99%) for 34 community cohorts, 19% (15-25%; I = 98%) for 23 primary care cohorts and 31% (15-50%; I = 0%) for 3 residential care or nursing homes cohorts (P = 0.16 between groups). By condition, prevalences were 20% (16-23%; I = 98%) with hypertension (20 cohorts), 21% (16-26%; I = 92%) with diabetes (4 cohorts), 25% (18-33%; I = 88%) with Parkinson's disease (7 cohorts) and 29% (25-33%, I = 0%) with dementia (3 cohorts), compared to 14% (12-17%, I = 99%) without these conditions (P < 0.01 between groups). Multivariable meta-regression modelling identified increasing age and diabetes as predictors of PH (P < 0.01, P = 0.13, respectively; R = 36%). PH prevalence was not affected by blood pressure measurement device (P = 0.65) or sitting or supine resting position (P = 0.24), however, when the definition of PH did not fulfil the consensus description, but fell within its parameters, prevalence was underestimated (P = 0.01) irrespective of study quality (P = 0.04).
CONCLUSIONS
PH prevalence in populations relevant to primary care is substantial and the definition of PH used is important. Our findings emphasise the importance of considering checking for PH, particularly in vulnerable populations, to enable interventions to manage it. These data should contribute to future guidelines relevant to the detection and treatment of PH.
PROSPERO
CRD42017075423.
Topics: Blood Pressure; Blood Pressure Determination; Humans; Hypertension; Hypotension, Orthostatic; Prevalence
PubMed: 33388038
DOI: 10.1186/s12875-020-01313-8 -
Age and Ageing Apr 2023Management of antihypertensive therapy is challenging in patients with symptomatic orthostatic hypotension, a population often excluded from randomised controlled trials... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND PURPOSE
Management of antihypertensive therapy is challenging in patients with symptomatic orthostatic hypotension, a population often excluded from randomised controlled trials of antihypertensive therapy. In this systematic review and meta-analysis, we sought to determine whether the association of antihypertensive therapy and adverse events (e.g. falls, syncope), differed among trials that included or excluded patients with orthostatic hypotension.
METHODS
We performed a systematic review and meta-analysis of randomised controlled trials comparing blood pressure lowering medications to placebo, or different blood pressure targets on falls or syncope outcomes and cardiovascular events. A random-effects meta-analysis was used to estimate a pooled treatment-effect overall in subgroups of trials that excluded patients with orthostatic hypotension and trials that did not exclude patients with orthostatic hypotension, and tested P for interaction. The primary outcome was fall events.
RESULTS
46 trials were included, of which 18 trials excluded orthostatic hypotension and 28 trials did not. The incidence of hypotension was significantly lower in trials that excluded participants with orthostatic hypotension (1.3% versus 6.2%, P < 0.001) but not incidences of falls (4.8% versus 8.8%; P = 0.40) or syncope (1.5% versus 1.8%; P = 0.67). Antihypertensive therapy was not associated with an increased risk of falls in trials that excluded (OR 1.00, 95% CI; 0.89-1.13) or included (OR 1.02, 95% CI; 0.88-1.18) participants with orthostatic hypotension (P for interaction = 0.90).
CONCLUSIONS
The exclusion of patients with orthostatic hypotension does not appear to affect the relative risk estimates for falls and syncope in antihypertensive trials.
Topics: Humans; Antihypertensive Agents; Hypotension, Orthostatic; Hypotension; Blood Pressure; Syncope; Hypertension; Randomized Controlled Trials as Topic
PubMed: 37014001
DOI: 10.1093/ageing/afad044 -
Medicine Sep 2017Orthostatic hypotension (OH) is a major clinical sign of cardiovascular autonomic dysfunction in diabetic patients. Our aim was to quantitatively evaluate the prevalence... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Orthostatic hypotension (OH) is a major clinical sign of cardiovascular autonomic dysfunction in diabetic patients. Our aim was to quantitatively evaluate the prevalence and risk factors of OH in patients with diabetes mellitus (DM) and assess its prognosis.
METHODS
A comprehensive search of the PubMed, Embase, China National Knowledge Infrastructure, VIP Chinese Journal, Wanfang, and SINOMED databases was conducted for related published work up to September 25, 2016, and manually searched eligible studies from the references in accordance with the inclusion criteria.
RESULTS
We included 21 studies in the analysis, with a total sample size of 13,772. The pooled prevalence of OH in DM was 24% (95% confidence interval [CI]: 19-28%). Potential risk factors, that is, glycosylated hemoglobin A (HbA1c) (odds ratio [OR], 1.13, 95% CI, 1.07-1.20), hypertension (OR, 1.02, 95% CI, 1.01-1.02), and diabetic nephropathy (OR, 2.37, 95% CI, 1.76-3.19), were significantly associated with OH in DM. In addition, the prognosis of OH in DM was associated with higher risk of total mortality and cardiovascular events.
CONCLUSION
The pooled prevalence of OH in DM appears high. HbA1c, hypertension, and diabetic nephropathy are risk factors for OH in DM. OH indicates poor prognosis in diabetic patients. Attention should be focused on diabetic patients with the stated risk factors to prevent OH.
Topics: Diabetes Mellitus; Humans; Hypotension, Orthostatic; Prevalence; Prognosis; Risk Factors
PubMed: 28885363
DOI: 10.1097/MD.0000000000008004 -
European Heart Journal Sep 2018Systematically reviewing the literature found orthostatic hypotension (OH) to be associated with an increased risk of incident dementia but limited data were available... (Meta-Analysis)
Meta-Analysis
Orthostatic hypotension and symptomatic subclinical orthostatic hypotension increase risk of cognitive impairment: an integrated evidence review and analysis of a large older adult hypertensive cohort.
AIMS
Systematically reviewing the literature found orthostatic hypotension (OH) to be associated with an increased risk of incident dementia but limited data were available in those at highest risk, the hypertensive oldest-old. Our aim was to analyse the relationship between OH and incident cognitive decline or dementia in this group and to synthesize the evidence base overall.
METHOD AND RESULTS
Participants aged ≥80 years, with hypertension, were from the Hypertension in the Very Elderly Trial (HYVET) cohort. Orthostatic hypotension was defined as a fall of ≥15 mmHg in systolic and or ≥7 mmHg in diastolic pressure after 2 min standing from a sitting position. Subclinical orthostatic hypotension with symptoms (SOH) was defined as a fall
Orthostatic hypotension was associated with increased risk of cognitive decline (906 events), hazard ratio (HR) 1.36 (95% confidence interval 1.14-1.59). For incident dementia (241 events), HR 1.34 (0.98-1.84). When competing risk of cardiovascular events were taken into account results were HR 1.39 (1.19-1.62) and HR 1.34 (1.05-1.73), respectively. Subclinical orthostatic hypotension was associated with an increased risk of cognitive decline HR 1.56 (1.12-2.17) and dementia HR 1.79 (1.00-3.20). Combining the results from the HYVET cohort in a meta-analysis with the existing published literature in this area found a 21% (9-35%) increased risk of dementia with OH. CONCLUSION
Orthostatic hypotension indicates an increased risk of dementia and cognitive decline. SOH may also be considered a risk factor, at least in older hypertensive adults. Questions remain regarding the mechanisms and whether interventions to reduce impact of OH could protect cognition.
Topics: Aged, 80 and over; Blood Pressure; Cognitive Dysfunction; Cohort Studies; Dementia; Humans; Hypertension; Hypotension, Orthostatic; Risk Factors; Sensitivity and Specificity
PubMed: 30052878
DOI: 10.1093/eurheartj/ehy418