Increased cardiac stiffness is associated with autonomic dysfunction in patients with temporal lobe epilepsy.

Autonomic dysfunction is linked to sudden death regardless of the presence of structural heart disease. The pathway from autonomic dysfunction to sudden death is not fully understood, but myocardial sympathetic stimulation leading to arrhythmia and/or cardiac fibrosis might play a role. Our goal was to evaluate cardiac stiffness by echocardiography and its association with clinical, structural, and autonomic variables in people with epilepsy (PWE) compared to healthy controls. A 12-lead electrocardiogram, treadmill testing, and transthoracic echocardiography from 30 patients with temporal lobe epilepsy (TLE) without any known cardiovascular disorders were compared to 30 individuals without epilepsy matched by sex, age, and body mass index. Distribution of cardiovascular risk factors was similar in both groups. PWE had a higher left ventricle stiffness, left ventricle filling pressure, and greater left atrial volume as well as markers of autonomic dysfunction such as impaired chronotropic index and percentage achieved of predicted peak heart rate at effort. In multiple regressions, autonomic dysfunction explained 52% of stiffness and carbamazepine treatment and polytherapy with antiepileptic drugs (AEDs) explained, additionally, 6% each. Stiffness is increased in young patients with TLE and is related to autonomic dysfunction and to a lesser extent, carbamazepine use and polytherapy with AEDs.

Long-term anabolic steroids in male bodybuilders induce cardiovascular structural and autonomic abnormalities.

OBJECTIVE: The aims of this study were to examine the hypothesis that users of anabolic androgenic steroids (AAS) would have cardiac autonomic disorders and that there is a correlation between sympathetic modulation, high blood pressure (BP) and alterations to cardiac dimensions. METHODS: Forty-five male subjects were enrolled in the study. They were categorized into three groups comprising bodybuilders actively using AAS (AAS users; n = 15), bodybuilders who had never used AAS (nonusers; n = 15) and age-paired healthy sedentary controls (n = 15). Hemodynamic parameters, linear and nonlinear analyses of heart rate variability and electrocardiography and echocardiography analyses were performed at rest. RESULTS: Bodybuilders in the AAS group had a higher mean BP than those in the ASS nonuser group (p < 0.05) and the sedentary controls (p < 0.001). Cardiac sympathetic modulation was higher in AAS users than in AAS nonusers (p < 0.05) and the sedentary controls (p < 0.001), and parasympathetic modulation was lower in AAS users than in nonusers and the sedentary controls (p < 0.05). Shannon entropy was lower in AAS users than in the sedentary (p < 0.05) controls, and the corrected QT interval and QT dispersion were higher in AAS users than in the sedentary controls (p < 0.05). The interventricular septal thickness, left ventricle posterior wall thickness and relative diastolic wall thickness were higher in AAS users than in AAS nonusers and the sedentary controls (p < 0.001). AAS users showed a positive correlation between increased sympathetic modulation and high BP (r = 0.48, p < 0.005), as well as sympathetic modulation and cardiac hypertrophy (r = 0.66, p < 0.001). CONCLUSION: There was a marked cardiac autonomic alteration in AAS users, with a shift toward sympathetic modulation predominance and vagal attenuation. The high BP observed in our group of bodybuilders using AAS was associated with increased sympathetic modulation, and this increased sympathetic modulation was associated with structural alterations in the heart. This association may constitute an important mechanism linking AAS abuse to increased cardiovascular risk.

Assessment of late anthracycline-induced cardiotoxicity by 123I-mIBG cardiac scintigraphy in patients treated during childhood and adolescence.

PURPOSE: The goal of this study was to evaluate late cardiotoxic effects of anthracyclines (ATC) by evaluating cardiac sympathetic activity in a cohort of asymptomatic patients previously treated with ATC for childhood cancers. METHODS: We studied 89 asymptomatic patients previously treated with ATC with a normal echocardiogram (49 men and 40 women) and a control group of 40 healthy individuals (26 men and 14 women). Both groups underwent planar myocardial 123I-meta-iodobenzylguanidine scintigraphy (123I-mIBG). From these images, the early and late heart-to-mediastinum (H/M) ratio and washout rate (WR) were assessed. RESULTS: The mean survival at the time of the 123I-mIBG scintigraphy was 5.3 ± 3.4 years. Patients treated with ATC had a lower but clinical normal left ventricular ejection fraction (LVEF) compared to controls (60.44 ± 6.5 vs 64.1 ± 6.0%, P < 0.01). Both the late H/M ratio and WR were not able to discriminate ATC treated patients from controls. The cumulative ATC dose was the only independent predictor of the LVEF, explaining approximately 12% of the variation in LVEF (P = 0.01). CONCLUSIONS: Although the pathophysiology behind ATC cardiotoxicity is most likely multifactorial, myocardial sympathetic activity is not associated with a reduction in LVEF 5-years after completion of chemotherapy.

Psychiatric manifestations in patients with dysautonomy associated with systemic lupus erythematosus.

The psychiatric manifestations of three patients with systemic lupus erythematosus (SLE) and neuropathic dysautonomic processes are described. All patients had a severe form of SLE with neurological, renal, articular, pulmonary or haematological manifestations. All three have two types of psychiatric manifestations: (1) a chronic and progressive depression and (2) a complex dissociative disorder during the acute episodes of postural hypotension. A provocative test with SPECT with 99mTc-HmPAO to be done during the episode of orthostatic hypotension may contribute to clinical assessment of complex changes in cerebral regional perfusion.

Autonomic bladder dysfunction in an adolescent with type 1 diabetes.

Diabetic autonomic bladder dysfunction is rare in the pediatric age group. An adolescent girl aged 16 years and 7 months, with type 1 diabetes mellitus since the age of 6 years, was diagnosed as having diabetic cystopathy. Ultrasonography of the urinary tract showed a distended bladder with normal kidneys. Laboratory evaluation revealed: normal serum urea, creatinine and electrolytes and elevated microalbuminuria. Urodynamic study demonstrated an impaired bladder sensation, increased cystometric capacity and detrusor arreflexia. Although more prevalent in adults and the elderly, autonomic bladder dysfunction must be considered in adolescents with type 1 diabetes mellitus.

Determinants of accelerated small intestinal transit in alcohol-related chronic pancreatitis.

Patients with chronic pancreatitis may have abnormal gastrointestinal transit, but the factors underlying these abnormalities are poorly understood. Gastrointestinal transit was assessed, in 40 male outpatients with alcohol-related chronic pancreatitis and 18 controls, by scintigraphy after a liquid meal labeled with (99m)technetium-phytate. Blood and urinary glucose, fecal fat excretion, nutritional status, and cardiovascular autonomic function were determined in all patients. The influence of diabetes mellitus, malabsorption, malnutrition, and autonomic neuropathy on abnormal gastrointestinal transit was assessed by univariate analysis and Bayesian multiple regression analysis. Accelerated gastrointestinal transit was found in 11 patients who showed abnormally rapid arrival of the meal marker to the cecum. Univariate and Bayesian analysis showed that diabetes mellitus and autonomic neuropathy had significant influences on rapid transit, which was not associated with either malabsorption or malnutrition. In conclusion, rapid gastrointestinal transit in patients with alcohol-related chronic pancreatitis is related to diabetes mellitus and autonomic neuropathy.

Cardiac sympathetic dysautonomia in children with chronic kidney disease.

BACKGROUND: The pathophysiology of cardiovascular disease (CVD) in chronic kidney disease (CKD) remains uncertain, but autonomic dysfunction seems to be involved. The aim of the study is to investigate the cardiac dysautonomia in uremic pediatric individuals through iodine 123 metaiodobenzylguanidine (MIBG) scintigraphy and heart rate variability (HRV) analysis. METHODS AND RESULTS: We divided 40 CKD patients (aged 5-21 years) into 4 groups according to the treatment for CKD: conservative (n = 7), continuous ambulatory peritoneal dialysis (n = 5), hemodialysis (n = 13), and kidney transplantation (n = 15). Planar and tomographic I-123 MIBG images were acquired, and early and late cardiac uptake, cardiac and lung washout, and regional I-123 MIBG uptake were evaluated. Hemodialysis patients showed increased cardiac washout (P = .002), a heterogeneous pattern of I-123 MIBG distribution (P = .036), and lower values of the low-frequency (LF) component of HRV (P = .040). Subjects undergoing continuous ambulatory peritoneal dialysis had reduced lung washout (P = .030). The cardiac washout correlated positively with parathyroid hormone levels and negatively with creatinine clearance. There was a significant negative association between the LF component and cardiac washout. CONCLUSIONS: Uremic cardiac dysautonomia may be characterized by a decreased LF component of HRV, increased I-123 MIBG washout, and a heterogeneous distribution pattern in the left ventricular walls; these abnormalities were not present after kidney transplantation.

Cardiac sympathetic activity pre and post resynchronization therapy evaluated by 123I-MIBG myocardial scintigraphy.

BACKGROUND: Imaging with (123)I-metaiodobenzylguanidine (MIBG) is used for the assessment of cardiac sympathetic activity (CSA). We analyzed CSA before and after cardiac resynchronization therapy (CRT), and correlated these data with CRT response. METHODS AND RESULTS: Thirty patients with chronic heart failure and classic indications for CRT were prospectively studied before and at least 3 months after CRT. The variables analyzed were: QRS width, left-ventricular ejection fraction (LVEF), left-ventricular end-diastolic diameter (LVEDD), heart/mediastinum MIBG uptake ratio (H/M), and washout rate (WR). After CRT, patients were divided into two groups: group 1 (21 patients), responders improving to functional class (FC) I or II; and group 2 (9 patients), nonresponders remaining in FC III or IV. After CRT, only group 1 showed favorable changes in QRS width (P =.003), LVEF (P =.01), LVEDD (P =.04), and H/M ratio (P =.003). The H/M ratio and WR were associated with CRT response (P =.005 and P =.04, respectively). The H/M ratio was the only independent predictor of CRT response (P =.01). Receiver operating characteristic curves showed that the optimal H/M ratio cutoff point was 1.36 (sensitivity, 75%; specificity, 71%). CONCLUSIONS: Improvement in CSA correlated with a positive CRT response. Lower MIBG uptake before therapy was associated with CRT nonresponse. The H/M ratio could be helpful in selecting patients for CRT.

Abnormal intragastric distribution of a liquid nutrient meal in patients with diabetes mellitus.

Disordered gastric motility and emptying are well known complications of diabetes mellitus (DM), but the pattern of intragastric distribution of food has not been extensively studied in diabetics. We examined the partition of a liquid nutrient meal between the proximal and distal stomach and the relationships between intragastric distribution of food and gastric emptying (GE) and the symptoms in DM patients with and without autonomic neuropathy (AN). Fourteen healthy volunteers and 20 DM patients (13 with AN; 9 with dyspepsia symptoms) ingested a liquid nutrient meal (250 ml; 437 kcal) labeled with [99mTc]phytate. Anterior and posterior serial images of the stomach were taken for 90 min with a gamma camera. Regions of interest for the proximal and the distal halves of the stomach and for the total gastric area were defined. Counts from each region along time allowed estimation of GE and the proportion of activity retained in the proximal stomach after meal ingestion (initial) and throughout GE (mean). GE half-times in controls (median; range: 66 min; 29-90 min) were not significantly different from diabetics (76 min; 5->150 min, P > 0.10), but abnormal GE was found in 11 DM patients (seven delayed and four rapid). In DM patients, initial retention in the proximal stomach (42%; 16-79%) was significantly lower (P < 0.02) than in controls (55%; 44-71%). Mean retention in the proximal stomach throughout emptying also was significantly lower (P < 0.05) in DM patients (43%; 18-58%) than in controls (51%; 32-69%). There were no differences between subgroups of patients with normal, delayed, or rapid gastric emptying regarding mean meal retention in the proximal stomach. Patients with evidence of AN or with dyspepsia symptoms had significantly decreased retention of food in the proximal stomach throughout gastric emptying. We concluded that patients with diabetes mellitus have abnormally decreased retention of gastric contents in the proximal stomach after a liquid meal, which seems to be related to the occurrence of autonomic neuropathy and dyspepsia symptoms, but not to disordered gastric emptying.