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Journal of Cardiology Cases Jan 2024Neurogenic orthostatic hypotension (OH) causes severe orthostatic intolerance. We evaluated hemodynamic parameters in a patient with pure autonomic failure (PAF) using...
UNLABELLED
Neurogenic orthostatic hypotension (OH) causes severe orthostatic intolerance. We evaluated hemodynamic parameters in a patient with pure autonomic failure (PAF) using various unique approaches. A 60-year-old woman had worsening light-headedness, fatigue, and severe OH without compensatory tachycardia. PAF was diagnosed based on negative neurological findings, testing, and imaging results. The active standing test did not increase the heart rate (HR), and it decreased cardiac output, indicating impaired sympathetic control of cardiovascular activity. HR did not change during the supine bicycle exercise stress test, whereas blood pressure decreased. The patient had an accentuated reaction to isoproterenol but did not respond to atropine sulfate. Isoproterenol 0.01 μg/kg/min caused a 153 % increase in HR that required more than 30 min to return to its original value, suggesting hypersensitivity to catecholamines and decreased parasympathetic activity. As for why atropine sulfate (0.04 mg/kg) did not increase HR, we assumed that parasympathetic activity was already suppressed or the sympathetic effects were not predominant. Intravenous atropine sulfate may be useful in diagnosing PAF, which generally lacks specific neurological physical findings. A proper understanding of the hemodynamics involved in the management of PAF-associated OH is crucial.
LEARNING OBJECTIVE
The autonomic control of cardiovascular function is impaired in pure autonomic failure, and neurogenic orthostatic hypotension can be diagnosed by evaluating changes in heart rate. Treatment should be based on the hemodynamic characteristics using non-invasive cardiac output monitoring, pharmacological approaches, and supine bicycle exercise stress tests.
PubMed: 38188316
DOI: 10.1016/j.jccase.2023.09.002 -
Journal of Family Medicine and Primary... Nov 2023Orthostatic hypotension (OH), an important cause of falls in the elderly, is grossly underdiagnosed. Our study aimed to determine the prevalence and associated factors...
OBJECTIVE
Orthostatic hypotension (OH), an important cause of falls in the elderly, is grossly underdiagnosed. Our study aimed to determine the prevalence and associated factors of OH among the elderly attending a secondary care hospital. Furthermore, we assessed and compared the effectiveness of simple arm and leg tensing exercises, performed just prior to standing, to mitigate the orthostatic fall in blood pressure (BP) in elderly OH patients.
MATERIALS AND METHODS
A cross-sectional study screened elderly patients (≥65 years) for OH and recruited them into a randomized controlled trial (CTRI/2020/08/027182) of two parallel groups performing either arm tensing or leg tensing exercises just before standing up. We performed an interim analysis of the ongoing trial using paired -test for within-group comparisons. Patients identified to have OH based on systolic or diastolic fall in BP were analyzed separately. Chi-square analysis compared the improvement in OH status between the two groups.
RESULTS
Nineteen out of 186 screened elderly patients were diagnosed with OH (10.21%, 95% CI: 7.99-12.43). Arm exercise significantly reduced the orthostatic-induced fall in systolic and diastolic BP, while leg exercise effectively reduced only the systolic fall in BP among patients with OH. The proportion of patients with OH after arm exercise (20%) was significantly lower than after leg exercise (77.8%) ( = 0.023, Fischer's exact test).
CONCLUSION
We found a 10.21% prevalence of OH in our elderly population. Furthermore, we found that simple isometric arm tensing exercise ameliorates the fall in BP on standing up in OH patients.
PubMed: 38186782
DOI: 10.4103/jfmpc.jfmpc_1009_23 -
Clinical Medicine (London, England) Nov 2023
Topics: Humans; Hypotension, Orthostatic; Quality Improvement
PubMed: 38182199
DOI: 10.7861/clinmed.23-6-s105 -
F1000Research 2023Capillary leak is the hallmark of development of severe dengue. A rise in haematocrit has been a major warning sign in WHO guidelines. Postural hypotension, which could... (Observational Study)
Observational Study
BACKGROUND
Capillary leak is the hallmark of development of severe dengue. A rise in haematocrit has been a major warning sign in WHO guidelines. Postural hypotension, which could reflect the intravascular volume reduction in capillary leak has been noted as warning sign in CDC and Pan American Health Organisation guidelines. We evaluated the diagnostic accuracy of postural hypotension as a marker of development of severe dengue.
METHODS
150 patients admitted with dengue fever were recruited in this prospective observational study. Diagnostic accuracy of conventional warning signs (abdominal pain, persistent vomiting, fluid accumulation, mucosal bleeding, lethargy, liver enlargement, increasing hematocrit with decreasing platelets) and postural hypotension was evaluated.
RESULTS
23 (15.3%) subjects developed severe dengue. Multiple logistic regression analysis showed that ascites/pleural effusion and postural fall in systolic blood pressure of >10.33% had odds ratio of 5.024(95%CI:1.11 - 22.75) and 11.369 (95% CI:2.27 - 56.87), respectively. Other parameters did not reach statistical significance. Sensitivity and specificity of ascites/pleural effusion were 82.6% and 88.2% for development of severe dengue whereas postural fall in systolic blood pressure had sensitivity and specificity of 87% and 82.7%.
CONCLUSIONS
These findings present a strong case for including postural hypotension as a warning sign in patients with dengue fever, especially in resource limited settings.
Topics: Humans; Severe Dengue; Ascites; Blood Pressure; Hypotension, Orthostatic; Pleural Effusion
PubMed: 38178940
DOI: 10.12688/f1000research.132714.2 -
Internal Medicine (Tokyo, Japan) Jan 2024Anti-IgLON5 disease shows various neurological manifestations, of which dysautonomia is one of the major symptoms and is rarely improved by immunotherapy. We herein...
Anti-IgLON5 disease shows various neurological manifestations, of which dysautonomia is one of the major symptoms and is rarely improved by immunotherapy. We herein report a patient with anti-IgLON5 disease who showed several autonomic failures, including vocal cord palsy for four months. The patient presented with cognitive impairments, bulbar symptoms accompanied by myorhythmia in the pharynx and tongue, cerebellar ataxia with tremor, motor neuron symptoms in the limbs, gastrointestinal dysfunction, orthostatic hypotension, non-rapid eye movement sleep disorder on polysomnography, and severe vocal cord palsy. Combined immunotherapy improved his symptoms, including vocal cord palsy, suggesting that combined immunotherapy might improve dysautonomia in anti-IgLON5 disease.
PubMed: 38171876
DOI: 10.2169/internalmedicine.2865-23 -
Scientific Reports Jan 2024Postural orthostatic tachycardia syndrome (POTS) presents heterogeneously and is diagnosed when appropriate symptoms are present in conjunction with a heart rate...
Postural orthostatic tachycardia syndrome (POTS) presents heterogeneously and is diagnosed when appropriate symptoms are present in conjunction with a heart rate increase of at least 30 beats-per-minute upon standing without orthostatic hypotension. Much of the current understanding of POTS is based on clinical expertise, particularly regarding POTS phenotypes and their potential role in targeting pharmacologic treatment. This study describes the symptom presentation of POTS by phenotypes at a subspecialty POTS clinic. Data was collected prospectively during clinical visits between April 17, 2014 and February 8, 2021. This data was abstracted retrospectively by chart review. Most of the 378 study participants were female (89.9%) with a mean age 23.0 ± 4.9 years. Lightheadedness was the most common (97.6%) symptom and the most disruptive of quality of life (29.9%). Patients reported substantial functional impairment across multiple life domains, with 3.0 ± 2.8 days lost and 4.7 ± 2.3 unproductive days per week. There were no differences in symptom presentation among POTS phenotypes. POTS phenotypes are not distinguishable based on symptoms alone; if phenotyping is sought, testing is necessary. Further research is needed in better classifying POTS phenotypes with the potential goal of tailoring treatment.
Topics: Humans; Female; Adolescent; Young Adult; Adult; Male; Postural Orthostatic Tachycardia Syndrome; Quality of Life; Retrospective Studies; Heart Rate; Hypotension, Orthostatic
PubMed: 38168762
DOI: 10.1038/s41598-023-50886-8 -
BMC Neurology Jan 2024In persons with Parkinson's Disease (PD) or certain forms of atypical parkinsonism, orthostatic hypotension is common and disabling, yet often underrecognized and...
Study protocol for the Heads-Up trial: a phase II randomized controlled trial investigating head-up tilt sleeping to alleviate orthostatic intolerance in Parkinson's Disease and parkinsonism.
BACKGROUND
In persons with Parkinson's Disease (PD) or certain forms of atypical parkinsonism, orthostatic hypotension is common and disabling, yet often underrecognized and undertreated. About half of affected individuals also exhibit supine hypertension. This common co-occurrence of both orthostatic hypotension and supine hypertension complicates pharmacological treatments as the treatment of the one can aggravate the other. Whole-body head-up tilt sleeping (HUTS) is the only known intervention that may improve both. Evidence on its effectiveness and tolerability is, however, lacking, and little is known about the implementability.
METHODS
In this double-blind multicenter randomized controlled trial (phase II) we will test the efficacy and tolerability of HUTS at different angles in 50 people with PD or parkinsonism who have both symptomatic orthostatic hypotension and supine hypertension. All participants start with one week of horizontal sleeping and subsequently sleep at three different angles, each maintained for two weeks. The exact intervention will vary between the randomly allocated groups. Specifically, the intervention group will consecutively sleep at 6°, 12° and 18°, while the delayed treatment group starts with a placebo angle (1°), followed by 6° and 12°. We will evaluate tolerability using questionnaires and compliance to the study protocol. The primary endpoint is the change in average overnight blood pressure measured by a 24-hour ambulatory blood pressure recording. Secondary outcomes include orthostatic blood pressure, orthostatic tolerance, supine blood pressure, nocturia and various other motor and non-motor tests and questionnaires.
DISCUSSION
We hypothesize that HUTS can simultaneously alleviate orthostatic hypotension and supine hypertension, and that higher angles of HUTS are more effective but less tolerable. The Heads-Up trial will help to clarify the effectiveness, tolerability, and feasibility of this intervention at home and can guide at-home implementation.
TRIAL REGISTRATION
ClinicalTrials.gov NCT05551377; Date of registration: September 22, 2022.
Topics: Humans; Parkinson Disease; Hypotension, Orthostatic; Orthostatic Intolerance; Blood Pressure Monitoring, Ambulatory; Hypertension; Blood Pressure; Randomized Controlled Trials as Topic; Multicenter Studies as Topic; Clinical Trials, Phase II as Topic
PubMed: 38166676
DOI: 10.1186/s12883-023-03506-x -
The Journal of Clinical Endocrinology... May 2024In type 2 diabetes mellitus (T2DM), orthostatic hypotension (OH) is associated with cognition, but the mechanisms governing the link between OH and cognition are still...
CONTEXT
In type 2 diabetes mellitus (T2DM), orthostatic hypotension (OH) is associated with cognition, but the mechanisms governing the link between OH and cognition are still unclear.
OBJECTIVE
We sought to analyze Alzheimer's disease (AD) biomarkers and the part of complement proteins in modulating the association of OH with cognitive impairment and examine whether OH could accelerate the clinical progression of mild cognitive impairment (MCI) to dementia in T2DM.
METHODS
We recruited patients with T2DM with MCI and collected general healthy information and blood samples. Complement proteins of astrocyte-derived exosomes were isolated and AD biomarkers of neuronal cell-derived exosomes isolated were quantified by enzyme-linked immunosorbent assay. Cognitive assessments were performed at patient enrollment and follow-up.
RESULTS
Mediation analysis showed that the influence of OH on cognition in T2DM was partly mediated by baseline AD biomarkers and complement proteins. Cox proportional-hazards regression proved the OH group had a higher risk of developing dementia compared to the T2DM without OH group.
CONCLUSION
In T2DM with MCI patients, AD biomarkers and complement proteins mediate the effects of OH on cognitive impairment and OH may be a risk factor of progression from MCI to dementia in T2DM.
Topics: Humans; Diabetes Mellitus, Type 2; Cognitive Dysfunction; Male; Female; Disease Progression; Hypotension, Orthostatic; Aged; Biomarkers; Middle Aged; Dementia; Risk Factors; Alzheimer Disease; Complement System Proteins; Follow-Up Studies
PubMed: 38165720
DOI: 10.1210/clinem/dgad764 -
Frontiers in Neurology 2023Headache is a frequent symptom among patients with hypermobility spectrum disorders. This mini review focuses specifically on a challenging aspect of headache evaluation... (Review)
Review
Headache is a frequent symptom among patients with hypermobility spectrum disorders. This mini review focuses specifically on a challenging aspect of headache evaluation in all patients, but especially those with hypermobility - the orthostatic headache. While the differential for an orthostatic headache is overall limited, patients with hypermobility disorders have risk factors for all of the most commonly encountered orthostatic headache disorders. The most common conditions to produce orthostatic headaches are discussed - spontaneous intracranial hypotension, cervicogenic headache, and postural orthostatic tachycardia syndrome. Less common etiologies of orthostatic headache pertinent to any patient are presented in table format.
PubMed: 38162438
DOI: 10.3389/fneur.2023.1321350 -
Neurotrauma Reports 2023Transcutaneous spinal cord stimulation (tSCS) is an emerging therapeutic strategy to target spinal autonomic circuitry to normalize and stabilize blood pressure (BP) in...
Transcutaneous spinal cord stimulation (tSCS) is an emerging therapeutic strategy to target spinal autonomic circuitry to normalize and stabilize blood pressure (BP) in hypotensive persons living with chronic spinal cord injury (SCI). Our aim is to describe our current methodological approach to identify individual tSCS parameters that result in the maintenance of seated systolic blood pressure (SBP) within a pre-defined target range. The parent study is a prospective, randomized clinical trial in which eligible participants will undergo multiple mapping sessions to optimize tSCS parameter settings to promote stable SBP within a target range of 110-120 mm Hg for males and 100-120 mm Hg for females. Parameter mapping includes cathode electrode placement site (T7/8, T9/10, T11/12, and L1/2), stimulation frequency (30, 60 Hz), current amplitudes (0-120 mA), waveform (mono- and biphasic), pulse width (1000 μs), and use of carrier frequency (0, 10 kHz). Each participant will undergo up to 10 mapping sessions involving different electrode placement sites and parameter settings. BP will be continuously monitored throughout each mapping session. Stimulation amplitude (mA) will be increased at intervals of between 2 and 10 mA until one of the following occurs: 1) seated SBP reaches the target range; 2) tSCS intensity reaches 120 mA; or 3) the participant requests to stop. Secondary outcomes recorded include 1) symptoms related to autonomic dysreflexia and orthostatic hypotension, 2) Likert pain scale, and 3) skin appearance after removal of the tSCS electrode. Clinical Trials Registration: NCT05180227.
PubMed: 38156073
DOI: 10.1089/neur.2023.0063