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The Journals of Gerontology. Series A,... Apr 2024This study aimed to assess the associations of orthostatic hypotension (OH), in the presence or absence of frailty, with dementia and mortality in older adults.
BACKGROUND
This study aimed to assess the associations of orthostatic hypotension (OH), in the presence or absence of frailty, with dementia and mortality in older adults.
METHODS
We conducted a 15-year population-based cohort study including 2 703 baseline dementia-free individuals from the Swedish National Study on Aging and Care in Kungsholmen. At baseline, OH was defined as a decline in systolic/diastolic blood pressure ≥20/10 mm Hg 1 minute after standing up from a supine position. Frailty status was defined following Fried's frailty phenotype. Dementia was diagnosed following the Diagnostic and Statistical Manual of Mental Disorders-fourth edition criteria. Multistate flexible parametric survival models were used to estimate associations of OH and frailty with dementia and mortality.
RESULTS
Robust people with OH (adjusted hazard ratio [HR] = 2.28; 95% confidence interval [CI] = 1.47-3.54) and frail people without OH (HR = 1.98; 95% CI = 1.40-2.82) or with OH (HR = 2.73; 95% CI = 1.82-4.10) had a higher dementia risk than OH-free and robust people. Moreover, frail people, independently of the presence of OH, had higher mortality rate than OH-free and robust people. In individuals who developed dementia during the follow-up period, neither OH nor frailty was significantly associated with mortality.
CONCLUSIONS
Older adults with OH, whether robust or frail, may have a higher dementia risk than those without OH. Older adults with OH, when having frailty, may have a higher mortality rate than those without OH. The concurrent assessments of OH and frailty may provide prognostic values in terms of dementia and mortality risk in older adults.
Topics: Humans; Aged; Frailty; Hypotension, Orthostatic; Cohort Studies; Frail Elderly; Dementia
PubMed: 38195215
DOI: 10.1093/gerona/glae010 -
Journal of Parkinson's Disease 2024An attenuated heart rate response to exercise, termed chronotropic incompetence, has been reported in Parkinson's disease (PD). Chronotropic incompetence may be a marker...
BACKGROUND
An attenuated heart rate response to exercise, termed chronotropic incompetence, has been reported in Parkinson's disease (PD). Chronotropic incompetence may be a marker of autonomic dysfunction and a cause of exercise intolerance in early stages of PD.
OBJECTIVE
To investigate the relationship between chronotropic incompetence, orthostatic blood pressure change (supine - standing), and exercise performance (maximal oxygen consumption, VO2peak) in individuals with early PD within 5 years of diagnosis not on dopaminergic medications.
METHODS
We performed secondary analyses of heart rate and blood pressure data from the Study in Parkinson's Disease of Exercise (SPARX).
RESULTS
128 individuals were enrolled into SPARX (63.7±9.3 years; 57.0% male, 0.4 years since diagnosis [median]). 103 individuals were not taking chronotropic medications, of which 90 had a normal maximal heart rate response to exercise testing (155.3±14.0 bpm; PDnon-chrono) and 13 showed evidence of chronotropic incompetence (121.3±11.3 bpm; PDchrono, p < 0.05). PDchrono had decreased VO2peak compared to PDnon-chrono (19.7±4.5 mL/kg/min and 24.3±5.8 mL/kg/min, respectively, p = 0.027). There was a positive correlation between peak heart rate during exercise and the change in systolic blood pressure from supine to standing (r = 0.365, p < 0.001).
CONCLUSIONS
A subgroup of individuals with early PD not on dopaminergic medication had chronotropic incompetence and decreased VO2peak, which may be related to autonomic dysfunction. Evaluation of both heart rate responses to incremental exercise and orthostatic vital signs may serve as biomarkers of early autonomic impairment and guide treatment. Further studies should investigate whether cardiovascular autonomic dysfunction affects the ability to exercise and whether exercise training improves autonomic dysfunction.
Topics: Humans; Male; Female; Exercise Test; Parkinson Disease; Heart Failure; Autonomic Nervous System Diseases; Heart Rate
PubMed: 38189712
DOI: 10.3233/JPD-230006 -
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 -
Clinical Medicine (London, England) Nov 2023
Topics: Humans; Hypotension, Orthostatic; Quality Improvement
PubMed: 38182199
DOI: 10.7861/clinmed.23-6-s105 -
Clinical Medicine (London, England) Nov 2023
Topics: Humans; COVID-19; Postural Orthostatic Tachycardia Syndrome
PubMed: 38182196
DOI: 10.7861/clinmed.23-6-s48 -
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 -
Arrhythmia & Electrophysiology Review 2023Postural orthostatic tachycardia syndrome (POTS) is a chronic debilitating condition of orthostatic intolerance, predominantly affecting young females. Other than... (Review)
Review
Postural orthostatic tachycardia syndrome (POTS) is a chronic debilitating condition of orthostatic intolerance, predominantly affecting young females. Other than postural tachycardia, symptoms of POTS include a spectrum of non-cardiac, systemic and neuropsychiatric features. Despite the availability of widespread pharmacological and non-pharmacological therapeutic options, the management of POTS remains challenging. Exaggerated parasympathetic withdrawal and sympathetic overdrive during postural stress are principal mechanisms of postural tachycardia in POTS. Non-invasive, transcutaneous, vagus nerve stimulation (tVNS) is known to restore sympathovagal balance and is emerging as a novel therapeutic strategy in cardiovascular conditions including arrhythmias and heart failure. Furthermore, tVNS also exerts immunomodulatory and anti-inflammatory effects. This review explores the effects of tVNS on the pathophysiology of POTS and its potential as an alternative non-pharmacological option in this condition.
PubMed: 38173801
DOI: 10.15420/aer.2023.20 -
EBioMedicine Feb 2024The therapeutic effectiveness of the empirical and unselected use of oral rehydration salts (ORS) on postural tachycardia syndrome (POTS) is not satisfactory in...
BACKGROUND
The therapeutic effectiveness of the empirical and unselected use of oral rehydration salts (ORS) on postural tachycardia syndrome (POTS) is not satisfactory in children. Therefore, looking for suitable predictors of the therapeutic effects of ORS before treatment is extremely necessary to implement individualised treatment for paediatric patients with POTS.
METHODS
A retrospective case-control analysis of 130 patients (aged 5-18 years) who suffered from POTS with a 3-month treatment of ORS was conducted. A nomogram model was developed in the training set (n = 87) to predict the therapeutic response to ORS. Univariate analysis and logistic regression were applied to select the most useful predictors. ROC curves were applied to evaluate the discriminative performance of the nomogram model. The nomogram was then evaluated by calibration curves and the Hosmer-Lemeshow (H-L) test. The results were further validated using 1000 bootstrap resamples. External validation was performed in an independent validation set (n = 43).
FINDINGS
Among the ten variables with significant differences between the responders and non-responders in univariate analysis, five variables were found to be independently associated factors for ORS therapeutic efficacy among POTS children in the further logistic regression, including mean corpuscular haemoglobin concentration (MCHC), mean corpuscular volume (MCV), mean arterial pressure (MAP) at the first minute of the upright position, urine specific gravity (SG), and P-wave voltage peaking ratio (PWP). The nomogram model was established in the training set (AUC 0.926 [95% CI: 0.865-0.988], yielding a sensitivity of 87.8% and a specificity of 86.8%). The calibration curves showed good agreement between the prediction of the nomogram and actual observation in both the training and validation sets. The nomogram also effectively predicted the external validation set (sensitivity 82.1%, specificity 73.3%, and accuracy 79.1%).
INTERPRETATION
We established a feasible and high-precision nomogram model to predict the efficacy of ORS, which would help implement individualised treatment for children with POTS.
FUNDING
This study was supported by National High-Level Hospital Clinical Research Funding (Multi-centre Clinical Research Project of Peking University First Hospital) (2022CR59).
Topics: Humans; Child; Retrospective Studies; Salts; Postural Orthostatic Tachycardia Syndrome; Nomograms; Fluid Therapy
PubMed: 38171114
DOI: 10.1016/j.ebiom.2023.104951 -
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