Pharmacological Management of Paroxysmal Sympathetic Hyperactivity: A Scoping Review.

Paroxysmal sympathetic hyperactivity (PSH) occurs in ∼10% of patients following acute severe brain injury. While PSH is associated with worse outcomes, there are no clinical practice guidelines to inform treatment. We aimed to systematically review the literature on the pharmacological management of PSH. MEDLINE, Embase, and Cochrane library databases were searched from inception to August 2020. Eligible studies met the following criteria: 1) randomized controlled trials, non-randomized controlled trials (case control or controlled cohort), observational studies, case series, and case reports; 2) study population of adult and pediatric patients; 3) exposure to an acute neurological insult complicated by PSH (or historic synonym); 4) description of pharmacological treatment of PSH. Our search retrieved 2729 citations with 83 articles assessed for inclusion. After full text extraction, 56 manuscripts inclusive of 459 patients met eligibility criteria. We identified 31 case reports, 15 case series (152 patients), seven retrospective case control or cohort studies (212 patients), and three prospective observational studies (52 patients). Traumatic brain injury was the most common precipitating insult (407 patients), followed by hypoxic encephalopathy (72 patients) and intracranial hemorrhage (10 patients). There were 48 drugs from 22 classes prescribed for the management of PSH. The most frequently prescribed agents were benzodiazepines, ß-blockers, opioids, α-2 agonists, and baclofen. However, route and dose of drug and subsequent outcome were inconsistently reported, such that no summary was possible. While a wide variety of drugs have been reported to treat PSH, there is a lack of even moderate-quality evidence to inform clinical decision making.

Central hemodynamics could explain the inverse association between height and cardiovascular mortality.

BACKGROUND: Mechanisms underlying the inverse relationship between height and cardiovascular mortality are unknown but could relate to central hemodynamics. We sought to determine the relation of height to central and peripheral hemodynamics, as well as clinical characteristics. METHODS: The study population was comprised of 1,152 randomly selected community-dwelling adults (aged 67.7 ± 12.3 years; 48% men). Brachial blood pressure (BP) was recorded by sphygmomanometry; central BP and aortic pulse wave velocity were estimated by applanation tonometry. Stepwise multiple regression analysis was used to determine associations between height and central and peripheral hemodynamics. RESULTS: Height was not significantly associated with aortic pulse wave velocity in men or women. The relationship with height and brachial systolic BP was borderline in women (ß = -0.115; P = 0.051) but not significant in men (ß = -0.096; P = 0.09). Conversely, central systolic BP, estimated by transfer function (ß = -0.139 for men [ßM]; ß = -0.172 for women [ßW]) or radial second systolic peak (ß M = -0.239; ß W = -0.281), augmentation index at 75 bpm (ß M = -0.189; ß W = -0.224), and aortic pulse wave timing (ß M = 0.224; ß W = 0.262) were independently associated with height in both sexes (P < 0.003 for all). Both men and women of greater than median height were less likely to have coronary artery disease (P < 0.05), to have systemic hypertension (P < 0.01), or to be taking vasoactive medication (P < 0.001) compared with participants of less than median height. CONCLUSIONS: Even after correcting for conventional cardiovascular risk factors, taller individuals have more favorable central hemodynamics and reduced evidence of coronary artery disease compared with shorter individuals. These findings may help explain the decreased cardiovascular risk associated with being taller and also have important clinical consequences regarding therapy.