Cardiac amyloidosis at a glance.

Amyloidosis can affect any organ in the body by deposition of amyloid fibrils. When these aggregate in the heart, it leads to cardiac amyloidosis a life-threatening and progressive disease. Although considered a rare condition, advances in imaging techniques and raised awareness have shown that it might be more frequent than has been historically estimated. Cardiac amyloidosis can be hereditary or occur as a consequence of the ageing process but, regardless of type, patients experience a heavy symptomatic burden. This article provides an overview of its pathophysiology, signs and symptoms and how any nurse can look for the main red flags in clinical practice. Early referral for specialist care can have a significant impact on disease progression and patient quality of life.

New horizons in the ageing autonomic nervous system: orthostatic hypotension and supine hypertension.

Blood pressure regulation is an automatic, moment-by-moment buffering of the blood pressure in response to physiological changes such as orthostasis, exercise and haemorrhage. This finely orchestrated reflex is called the baroreflex. It is a regulated arc of afferent, central and efferent arms. Multiple physiological changes occur with ageing that can disrupt this reflex, making blood pressure regulation less effective. In addition, multiple changes can occur with ageing-related diseases such as neurodegeneration, atherosclerosis, deconditioning and polypharmacy. These changes commonly result in orthostatic hypotension, hypertension or both, and are consistently associated with multiple adverse outcomes. In this article, we discuss the healthy baroreflex, and physiological and pathophysiological reasons for impaired baroreflex function in older people. We discuss why the common clinical manifestations of orthostatic hypotension and concomitant supine hypertension occur, and strategies for balancing these conflicting priorities. Finally, we discuss strategies for treating them, outlining our practice alongside consensus and expert guidance.

"Be Careful What You Swallow": A Case Series of Swallow Syncope.

Swallow (deglutition) syncope is a rare form of neurally mediated cardioinhibitory reflex syncope occurring during swallowing. Patients may present to clinicians across multiple disciplines, so high awareness and careful evaluation are essential. We report 3 such individuals, describing our strategies in diagnosis, investigation and treatment, particularly focusing on conservative management. (Level of Difficulty: Intermediate.).

Orthostatic hypotension in older people: considerations, diagnosis and management.

Orthostatic hypotension (OH) is very common in older people and is encountered daily in emergency departments and medical admissions units. It is associated with a higher risk of falls, fractures, dementia and death, so prompt recognition and treatment are essential. In this review article, we describe the physiology of standing (orthostasis) and the pathophysiology of orthostatic hypotension. We focus particularly on aspects pertinent to older people. We review the evidence and consensus management guidelines for all aspects of management. We also tackle the challenge of concomitant orthostatic hypotension and supine hypertension, providing a treatment overview as well as practical suggestions for management. In summary, orthostatic hypotension (and associated supine hypertension) are common, dangerous and disabling, but adherence to simple structures management strategies can result in major improvements.

Autonomic dysfunction in 'long COVID': rationale, physiology and management strategies.

The SARS-CoV-2 (COVID-19) pandemic has caused unprecedented morbidity, mortality and global disruption. Following the initial surge of infections, focus shifted to managing the longer-term sequelae of illness in survivors. 'Post-acute COVID' (known colloquially as 'long COVID') is emerging as a prevalent syndrome. It encompasses a plethora of debilitating symptoms (including breathlessness, chest pain, palpitations and orthostatic intolerance) which can last for weeks or more following mild illness. We describe a series of individuals with symptoms of 'long COVID', and we posit that this condition may be related to a virus- or immune-mediated disruption of the autonomic nervous system resulting in orthostatic intolerance syndromes. We suggest that all physicians should be equipped to recognise such cases, appreciate the symptom burden and provide supportive management. We present our rationale for an underlying impaired autonomic physiology post-COVID-19 and suggest means of management.