Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 878
Filtrar
1.
Adv Exp Med Biol ; 1232: 85-90, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31893398

RESUMO

Delayed orthostatic hypotension (OH) is a minor subset of orthostatic dysregulation (OD). Cerebral blood oxygenation in juvenile patients with delayed OH has not been studied. We investigated the bilateral changes in cerebral oxygenation in the prefrontal cortex during an active standing test in 23 juvenile patients with delayed OH using near-infrared spectroscopy (NIRS). We measured the oxy-Hb, deoxy-Hb, and total-Hb during the active standing test. Four observations were made during the test: t1 in a resting supine position, t2 when maintaining blood pressure, and the remaining two (t3, t4) during hypotension. The concentration of oxy-Hb significantly decreased prior to satisfying the diagnostic criteria of delayed OH after standing and did not change thereafter. The concentration of deoxy-Hb increased gradually during the measurement periods. In addition, total-Hb increased from t2 to t3. There was no significant difference in the change in each Hb parameter between the left and right cerebral hemispheres. Our results indicate that NIRS parameters are more sensitive than blood pressure for the interpretation of cerebral autoregulation in juvenile patients with delayed OH.


Assuntos
Sistema Cardiovascular , Circulação Cerebrovascular , Hipotensão Ortostática , Oxigênio , Posição Ortostática , Adolescente , Pressão Sanguínea , Circulação Cerebrovascular/fisiologia , Humanos , Hipotensão Ortostática/sangue , Hipotensão Ortostática/diagnóstico , Oxigênio/sangue , Espectroscopia de Luz Próxima ao Infravermelho
2.
Neurology ; 93(14): e1339-e1347, 2019 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-31484717

RESUMO

OBJECTIVE: To evaluate the pattern and severity of autonomic dysfunction in autopsy-confirmed progressive supranuclear palsy (PSP) compared to α-synuclein pathology. METHODS: Autopsy-confirmed cases of 14 patients with PSP, 18 with multiple system atrophy (MSA), and 24 with Lewy body disease (LBD) with antemortem autonomic testing were reviewed retrospectively. All patients underwent comprehensive clinical evaluations by a movement disorder specialist, formal autonomic testing, and postmortem examinations at Mayo Clinic. RESULTS: The absence of orthostatic hypotension (OH) was the strongest autonomic parameter that distinguished PSP from α-synucleinopathies (0% vs 69%, p < 0.0001). Tests of adrenergic failure, which distinguish neurogenic OH, also differentiated PSP from other groups. These included the pressure recovery time (p = 0.0008), adrenergic impairment score (p = 0.001), and magnitude of change of systolic (p = 0.0002) and diastolic (p = 0.0001) blood pressures (BPs) during upright tilt. In addition, REM sleep behavior disorder was seen less frequently (p = 0.006) in PSP (33%) compared to MSA (87%) and LBD (90%). Antemortem clinical diagnostic accuracy for these phenotypically variable disorders was 57% for PSP and 83% for α-synucleinopathies. CONCLUSION: Our results suggest that the cardiovascular adrenergic system, which sustains BP during standing, is relatively unaffected, if not spared, in PSP. These findings increase our understanding of the clinical signature of PSP and have the potential to improve diagnostic accuracy in atypical parkinsonisms by distinguishing PSP from the α-synucleinopathies.


Assuntos
Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/fisiopatologia , Paralisia Supranuclear Progressiva/diagnóstico , Paralisia Supranuclear Progressiva/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
3.
BMJ Case Rep ; 12(8)2019 Aug 20.
Artigo em Inglês | MEDLINE | ID: mdl-31434666

RESUMO

A 62-year-old man presented with a 2-year history of syncope, collapse and fluctuating blood pressure (BP). His medications included midodrine (10 mg, three times per day) and fludrocortisone (0.1 mg, two times per day), but neither treatment afforded symptomatic relief. Autonomic testing was performed. Head-up tilt table testing revealed a supine BP of 112/68 mm Hg (heart rate, 74 beats per minute (bpm)) after 6 min, which dropped to 76/60 mm Hg (83 bpm) within 2 min of 80° head-up tilt. Findings from a heart rate with deep breathing test and a Valsalva test were consistent with autonomic dysfunction. The patient was diagnosed with neurogenic orthostatic hypotension and treated with droxidopa (100 mg, two times per day; titrated to 100 mg, one time per day). After initiating treatment with droxidopa, the patient no longer reported losing consciousness on standing and experienced improvement in activities of daily living. These improvements were maintained through 1 year of follow-up.


Assuntos
Antiparkinsonianos/uso terapêutico , Sistema Nervoso Autônomo/fisiopatologia , Droxidopa/uso terapêutico , Hipotensão Ortostática/diagnóstico , Síncope/etiologia , Teste da Mesa Inclinada , Acidentes por Quedas , Atividades Cotidianas , Humanos , Hipotensão Ortostática/tratamento farmacológico , Hipotensão Ortostática/fisiopatologia , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
4.
Hypertension ; 74(3): 639-644, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31327261

RESUMO

There has been much interest in investigating vitamin D status with orthostatic hypotension. However, studies have been small, inconsistent, and with a lack of standardization. The aim of this study was to investigate the association with vitamin D status in a large, nationally representative older adult population using a traceable standard of measurement and an accurate assessment of beat-to-beat blood pressure (BP). This study used participants aged >50 years from The Irish Longitudinal Study on Ageing. Impaired stabilization of BP on standing was defined as a sustained drop of ≥20 mm Hg systolic BP or ≥10 mm Hg diastolic BP up to 40 seconds post stand (impaired stabilization of BP on standing). We also analyzed participants who sustained a drop of ≥20 mm Hg systolic BP or ≥10 mm Hg diastolic BP throughout the 110 seconds stand (OH110). Vitamin D was categorized into sufficient (≥50 nmol/L), insufficient (30-50 nmol/L), and deficient (<30 nmol/L) status. After exclusion criteria 4209 participants were included. Those with deficiency were more likely to be smokers, take antihypertensive medications and had higher levels of cardiovascular disorders compared with those with sufficient status. In a univariate logistic regression those with deficient (odds ratio, 1.18; 95% CI, 0.86-1.61; P=0.303) or insufficient (odds ratio, 1.13; 95% CI, 0.91; P=0.272) status were no more likely to have evidence of impaired stabilization of BP on standing on active stand compared with sufficiency. Similar findings were found for OH110: deficient (odds ratio, 0.85; 95% CI, 0.52-1.40; P=0.528) or insufficient (odds ratio, 0.86; 95% CI, 0.61-1.21; P=0.384) versus sufficiency. In conclusion, vitamin D is not significantly associated with orthostatic hypotension in older adults.


Assuntos
Avaliação Geriátrica/métodos , Hipotensão Ortostática/diagnóstico , Deficiência de Vitamina D/diagnóstico , Vitamina D/sangue , Idoso , Idoso de 80 Anos ou mais , Envelhecimento/fisiologia , Estudos de Coortes , Feminino , Hospitais Universitários , Humanos , Hipotensão Ortostática/epidemiologia , Vida Independente , Irlanda , Modelos Logísticos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Sensibilidade e Especificidade , Deficiência de Vitamina D/epidemiologia
5.
Intern Med ; 58(19): 2861-2864, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31178512

RESUMO

After experiencing upper respiratory-tract symptoms, a 41-year-old woman developed encephalitis with consciousness disturbance and respiratory failure. She had external ophthalmoplegia and facial diplegia. Magnetic resonance imaging revealed a brainstem lesion with spared longitudinal pontine bundles. Abnormal findings of the brainstem auditory-evoked potentials and blink reflex supported brainstem damage. The patient was positive for anti-N-methyl-D-aspartate receptor (NMDAR) antibodies. Repeated immunological treatments improved her symptoms, but severe orthostatic hypotension emerged. A head-up tilt test revealed no arginine vasopressin response to hypotension. The atypical symptoms of this case highlighted that the brainstem is one of the pivotal regions in anti-NMDAR encephalitis.


Assuntos
Encefalite Antirreceptor de N-Metil-D-Aspartato/diagnóstico , Tronco Encefálico/diagnóstico por imagem , Hipotensão Ortostática/etiologia , Adulto , Encefalite Antirreceptor de N-Metil-D-Aspartato/complicações , Eletroencefalografia , Feminino , Humanos , Hipotensão Ortostática/diagnóstico , Imagem por Ressonância Magnética
6.
Lakartidningen ; 1162019 Feb 19.
Artigo em Sueco | MEDLINE | ID: mdl-31192373

RESUMO

Syncope is the chief complaint in 1-2 percent of emergency department visits. Syncope belongs to the broader category transient loss of consciousness (TLOC), defined as a short loss of consciousness with loss of awareness and responsiveness, and with subsequent amnesia for the event. Syncope is defined as TLOC due to cerebral hypoperfusion, with rapid onset and spontaneous complete recovery. The main categories of syncope are reflex syncope, orthostatic hypotension, and cardiac syncope. The 2018 guidelines by the European Society of Cardiology emphasizes the process of risk stratification in the initial management of suspected syncope. Risk stratification serves to separate the patients with likely orthostatic and reflex syncope with good prognosis from the patients with likely cardiac syncope and high short-term risk of an adverse outcome. It determines the appropriate next level of care. Further evaluation should be based on clinical suspicion and frequency of symptoms.


Assuntos
Síncope/diagnóstico , Cardiologia , Procedimentos Clínicos , Diagnóstico Diferencial , Gerenciamento Clínico , Europa (Continente) , Humanos , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/etiologia , Hipotensão Ortostática/terapia , Guias de Prática Clínica como Assunto , Medição de Risco , Sociedades Médicas , Síncope/etiologia , Síncope/terapia , Síncope Vasovagal/diagnóstico , Síncope Vasovagal/etiologia , Síncope Vasovagal/terapia
8.
Zhonghua Xin Xue Guan Bing Za Zhi ; 47(5): 381-387, 2019 May 24.
Artigo em Chinês | MEDLINE | ID: mdl-31142082

RESUMO

Objective: To explore the characteristics of postural blood pressure changes in elderly inpatients and the related factors of orthostatic hypotension (OH). Methods: This study was a clinical case control study. Two hundred and sixty-six elderly patients (≥60 years old), who were hospitalized between April 2016 and November 2017 in Geriatric Department of Peking University First Hospital, were included. They were divided into direct standing group and indirect standing group. Direct standing group involved 102 patients, they changed posture from supine directly to standing position, and the blood pressures at the moments of supine, immediately after standing and the first, second, and third minute after standing were recorded by continuous noninvasive arterial pressure (CNAP) system. Indirect standing group involved 164 patients, and they changed posture from supine to sitting for 3 minutes, and then changed to standing position. Blood pressures at the moments of supine, immediately after sitting, the third minute after sitting, immediately after standing and the third minute after standing was recorded by CNAP. Blood pressure changes after different postural changes mode and the rates of OH were compared. The related factors of OH was analyzed by binary logistic regression analysis. Results: The lowest systolic blood pressures (SBP) mostly occurred immediately after postural change: immediately after standing for direct standing group (86.3%(88/102)), and immediately after sitting for indirect standing group (59.1%(97/164)). The lowest diastolic blood pressures (DBP) mostly occurred immediately after standing in the two groups: 87.3%(89/102) for direct standing group and 43.3% (71/164) for indirect standing group. The maximum SBP drop (SBP of supine minus the lowest SBP during postural changes) of direct standing group was significantly higher than indirect standing group (median 20.5(14.0, 29.3) vs. 18.0(11.0, 26.0) mmHg (1 mmHg=0.133 kPa, P<0.05). The rates of OH occurred immediately and within 3 minutes from supine to standing position were significantly higher in direct standing group than in indirect standing group (65.7% (67/102) vs. 43.9% (72/164), and 70.6% (72/102) vs. 49.4% (81/164), both P<0.05). Binary logistic regression analysis showed that brachial-ankle pulse wave velocity was positively associated with OH after a transition from supine to standing position (immediately and within 3 minutes, OR=1.002 (95%CI 1.000-1.004), 1.003 (95%CI 1.001-1.006), P=0.014, 0.006) in direct standing group. Conclusions: OH is common in elderly hospitalized patients. The most obvious blood pressure changes are likely to occur immediately after position changes. Adding a sitting position during the transition of supine to standing position may decrease the amplitude of SBP drop. Brachial-ankle pulse wave velocity is associated with OH after the transition from the supine to standing position in the elderly inpatients.


Assuntos
Pressão Arterial , Hipotensão Ortostática , Idoso , Índice Tornozelo-Braço , Pressão Sanguínea , Determinação da Pressão Arterial , Estudos de Casos e Controles , Humanos , Hipotensão Ortostática/diagnóstico , Pessoa de Meia-Idade , Postura , Análise de Onda de Pulso
9.
Blood Press ; 28(3): 146-156, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30982364

RESUMO

PURPOSE: Orthostatic hypotension (OH) is a common and clinically important disorder. Published papers vary regarding the definitions of OH and methodologies of evaluation. Moreover, substantial gaps in the skills and knowledge required for assessment of OH have been reported by clinicians. We aimed to provide current information regarding the definition, classification and evaluation of OH. METHODS: We performed a comprehensive search of medical databases, using the following keywords: "postural hypotension" or "orthostatic hypotension", combined with: "definition", "classification", "diagnosis", "evaluation" or "meaning". We selected for this review the most relevant recent publications and key papers in the field, published in the English language. RESULTS: Current data regarding definitions, classification and the evaluation of OH are reviewed. The various aspects of OH assessment are extensively discussed. Considerable discrepancies exist between the published guidelines regarding the methodology of OH diagnosing. We propose an algorithm for OH evaluation and a standardized protocol for bedside determination of OH by healthcare providers. CONCLUSIONS: Correct assessment of OH is essential for its accurate diagnosis. The methodology of OH evaluation has not been sufficiently standardized. We emphasize the clinical importance of the uniform investigation of OH, according to the current guidelines for OH definition and meaning.


Assuntos
Hipotensão Ortostática , Algoritmos , Técnicas e Procedimentos Diagnósticos/normas , Humanos , Hipotensão Ortostática/classificação , Hipotensão Ortostática/diagnóstico , Testes Imediatos/normas
10.
Neurol Res ; 41(8): 734-741, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31030628

RESUMO

Objectives: This study was designed to investigate clinical symptoms and blood pressure (BP) characteristics in Parkinson's disease (PD) with orthostatic hypotension (OH), and to figure out the influencing factors of PD with OH (PD-OH). Methods: Total 150 PD patients were divided into PD-OH and PD with no OH (PD-NOH) groups based on BP value. Series of scales were used to evaluate clinical symptoms. Twenty-four-hour ambulatory BP monitoring was adopted. Results: Total 49 PD patients (32.67%) were with OH. PD-OH group had significantly older age, longer disease duration, more diabetes cases, higher levels of fasting blood glucose, higher levels of hemoglobin A1c (HbA1c) and higher levodopa-equivalent daily doses (P < 0.05). Motor symptoms and non-motor symptoms, including autonomic dysfunction, fatigue and cognitive impairment indicated by significantly changed scores of related scales were found in PD-OH group (P < 0.05). PD-OH group had increased BP variability (BPV) and a higher proportion of non-dipper BP pattern (P < 0.05). Binary logistic regression analysis showed that age (B, 0.064; 95% CI, 1.007 ~ 1.128; P < 0.05), HbA1c (B, 1.091; 95% CI, 1.158 ~ 7.648; P < 0.05), and systolic BPV (B, 0.138; 95% CI, 1.004 ~ 1.312; P < 0.05) were independent related factors for PD-OH group. The PD-OH group had significantly compromised daily activities and quality of life (P < 0.05). Conclusion: Older age, higher levels of HbA1c and increased systolic BPV were the influencing factors of PD-OH patients. Daily activities and quality of life of PD-OH patients were fairly compromised.


Assuntos
Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/fisiopatologia , Doença de Parkinson/diagnóstico , Doença de Parkinson/fisiopatologia , Idoso , Pressão Sanguínea , Feminino , Hemoglobina A Glicada/análise , Humanos , Hipotensão Ortostática/complicações , Masculino , Pessoa de Meia-Idade , Doença de Parkinson/complicações , Fatores de Risco
11.
Ann Cardiol Angeiol (Paris) ; 68(3): 181-186, 2019 Jun.
Artigo em Francês | MEDLINE | ID: mdl-30914139

RESUMO

INTRODUCTION: Cardiac mortality among patients diagnosed with mental disorders is higher compared to the general population. Some authors suggest that cardiovascular risk is related to intrinsic factors specific to psychiatric disease. Nevertheless, the interpretation of these results is limited by the concomitant prescription of antipsychotics which have a cardiovascular effect. Studies evaluating the hemodynamic and electrocardiographic profile of drug naïve or drug-free patients suffering from mental disorders remain few. AIMS: The aims of this work were to study the electrocardiographic and hemodynamic profile of drug naïve or drug-free patients with mental disorders and to determine clinical and biological factors associated with any electrocardiographic abnormalities. SUBJECTS AND METHODS: It was a descriptive and evaluative cross-sectional study. We enrolled drug naïve or drug-free patients for at least two months. All subjects were inpatients and had at admission clinical, biological and electrocardiographic evaluation. RESULTS: Forty-four percent of the sample had asymptomatic electrocardiographic abnormalities. These subjects had lower serum thyroid hormone levels compared to healthy group (P=0.066). Hemodynamic profile showed that 12% of the population had orthostatic hypotension. CONCLUSION: Electrocardiographic and hemodynamic abnormalities are common among drug-free or drug naïve patients diagnosed with psychotic disorders. The association of electrocardiographic abnormalities with low levels of thyroxin requires more investigation.


Assuntos
Eletrocardiografia , Hemodinâmica , Transtornos Psicóticos/fisiopatologia , Adulto , Idoso , Doenças Assintomáticas , Determinação da Pressão Arterial , Distribuição de Qui-Quadrado , Estudos Transversais , Feminino , Frequência Cardíaca , Humanos , Hipotensão Ortostática/diagnóstico , Masculino , Pessoa de Meia-Idade , Transtornos Psicóticos/sangue , Estatísticas não Paramétricas , Tiroxina/sangue , Tunísia , Adulto Jovem
12.
BMC Geriatr ; 19(1): 80, 2019 03 13.
Artigo em Inglês | MEDLINE | ID: mdl-30866845

RESUMO

BACKGROUND: Orthostatic hypotension (OH; profound falls in blood pressure when upright) is a common deficit that increases in incidence with age, and may be associated with falling risk. Deficit accumulation results in frailty, regarded as enhanced vulnerability to adverse outcomes. We aimed to evaluate the relationships between OH, frailty, falling and mortality in elderly care home residents. METHODS: From the Minimum Data Set (MDS) document, a frailty index (FI-MDS) was generated from a list of 58 deficits, ranging from 0 (no deficits) to 1.0 (58 deficits). OH was evaluated from beat-to-beat blood pressure and heart rate (finger plethysmography) collected during a 15-min supine-seated orthostatic stress test. Retrospective and prospective falling rates (falls/year) were extracted from facility falls incident reports. All-cause 3-year mortality was determined. Data are reported as mean ± standard error. RESULTS: Data were obtained from 116 older adults (aged 84.2 ± 0.9 years; 44% males) living in two long term care facilities. The mean FI-MDS was 0.36 ± 0.01; FI-MDS was correlated with age (r = 0.277; p = 0.003). Those who were frail (FI ≥ 0.27) had larger Initial (- 17.8 ± 4.2 vs - 6.1 ± 3.3 mmHg, p = 0.03) and Consensus (- 22.7 ± 4.3 vs - 11.5 ± 3.3 mmHg, p = 0.04) orthostatic reductions in systolic arterial pressure. Frail individuals had higher prospective and retrospective falling rates and higher 3-year mortality. Receiver operating characteristic curves evaluated the ability of FI-MDS alone to predict prospective falls (sensitivity 72%, specificity 36%), Consensus OH (sensitivity 68%, specificity 60%) and 3-year mortality (sensitivity 77%, specificity 49%). Kaplan Meier survival analyses showed significantly higher 3-year mortality in those who were frail compared to the non-frail (p = 0.005). CONCLUSIONS: Frailty can be captured using a frailty index based on MDS data in elderly individuals living in long term care, and is related to susceptibility to orthostatic hypotension, falling risk and 3-year mortality. Use of the MDS to generate a frailty index may represent a simple and convenient risk assessment tool for older adults living in long term care. Older adults who are both frail and have impaired orthostatic blood pressure control have a particularly high risk of falling and should receive tailored management to mitigate this risk.


Assuntos
Acidentes por Quedas/mortalidade , Idoso Fragilizado , Instituição de Longa Permanência para Idosos , Hipotensão Ortostática/mortalidade , Hipotensão Ortostática/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Pressão Sanguínea/fisiologia , Feminino , Fragilidade , Avaliação Geriátrica/métodos , Frequência Cardíaca/fisiologia , Humanos , Hipotensão Ortostática/diagnóstico , Assistência de Longa Duração/métodos , Masculino , Estudos Prospectivos , Estudos Retrospectivos , Medição de Risco
13.
Presse Med ; 48(2): 134-142, 2019 Feb.
Artigo em Francês | MEDLINE | ID: mdl-30728099

RESUMO

Hypotension and especially very low diastolic blood pressure could be an at-risk situation in very old and frail patients and in those with coronary heart disease. Chronic hypotension in people with heart failure is an indicator of poor prognosis and hinders the management of therapy. Orthostatic hypotension is a decrease in blood pressure>20mmHg for systolic and/or>10mmHg for diastolic within 3minutes after transition from supine to upright. Orthostatic hypotension may be symptomatic or not. The search for orthostatic hypotension is part of the clinical examination of elderly patients with hypertension, falling, diabetes and or polymedication. First intention treatment aims to correct modifiable modifying factors and to limit the circulatory consequences of orthostatism by elastic venous compression.


Assuntos
Hipotensão Ortostática/etiologia , Hipotensão Ortostática/prevenção & controle , Hipotensão/etiologia , Hipotensão/prevenção & controle , Acidentes por Quedas/prevenção & controle , Idoso , Insuficiência Cardíaca/complicações , Humanos , Hipotensão Ortostática/diagnóstico , Hipovolemia/complicações , Hipovolemia/terapia , Postura , Prognóstico , Síncope/etiologia , Síncope/prevenção & controle
14.
Hypertension ; 73(4): 910-918, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30798661

RESUMO

Lewy body diseases involve neurogenic orthostatic hypotension (nOH), cardiac noradrenergic deficiency, and deposition of the protein AS (alpha-synuclein) in sympathetic ganglion tissue. Mechanisms linking these abnormalities are poorly understood. One link may be AS deposition within sympathetic neurons. We validated methodology to quantify AS colocalization with TH (tyrosine hydroxylase), a marker of sympathetic noradrenergic innervation, and assessed associations of AS/TH colocalization with myocardial norepinephrine content and cardiac sympathetic neuroimaging data in nOH. Postmortem sympathetic ganglionic AS/TH colocalization indices and myocardial norepinephrine contents were measured in 4 Lewy body and 3 rare non-Lewy body nOH patients. Sixteen Lewy body and 11 non-Lewy body nOH patients underwent in vivo skin biopsies and thoracic 18F-dopamine positron emission tomographic scanning, with cutaneous colocalization indices expressed versus cardiac 18F-dopamine-derived radioactivity. Ganglionic AS/TH colocalization indices were higher and myocardial norepinephrine lower in Lewy body than non-Lewy body nOH ( P=0.0020, P=0.014). The Lewy body nOH group had higher AS/TH colocalization indices in skin biopsies and lower myocardial 18F-dopamine-derived radioactivity than did the non-Lewy body nOH group ( P<0.0001 each). All Lewy body nOH patients had colocalization indices >1.5 in skin biopsies and 18F-dopamine-derived radioactivity <6000 nCi-kg/cc-mCi, a combination not seen in non-Lewy body nOH patients ( P<0.0001). In Lewy body nOH, AS deposition in sympathetic noradrenergic nerves is related to postmortem neurochemical and in vivo neuroimaging evidence of myocardial noradrenergic deficiency. These associations raise the possibility that intraneuronal AS deposition plays a pathophysiological role in the myocardial sympathetic neurodegeneration attending Lewy body nOH.


Assuntos
Neurônios Adrenérgicos/metabolismo , Hipotensão Ortostática/metabolismo , Corpos de Lewy/metabolismo , Miocárdio/metabolismo , alfa-Sinucleína/metabolismo , Neurônios Adrenérgicos/patologia , Idoso , Idoso de 80 Anos ou mais , Biópsia , Feminino , Humanos , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/fisiopatologia , Corpos de Lewy/patologia , Masculino , Pessoa de Meia-Idade , Miocárdio/patologia , Tomografia por Emissão de Pósitrons , Pele/metabolismo , Pele/patologia
15.
Presse Med ; 48(2): 127-133, 2019 Feb.
Artigo em Francês | MEDLINE | ID: mdl-30665788

RESUMO

After 80 years old, antihypertensive treatment significantly reduces cardiovascular events. In the elderly, blood pressure target depends on patients' frailty. After 80 years, French guidelines propose to aim a SBP<150 mmHg without orthostatic hypotension and without exceeding the prescription of more than three antihypertensive drugs. The target may be more ambitious for robust elderly patients. The new 2018 European guidelines set: a stricter target for robust elderly patient aged 80 years or older (SBP between 130 and 139 mmHg and DBP between 70 and 79 mmHg); this objective is less strict for frail elderly (with several comorbidities, with loss of autonomy, elderly living in nursing home or with orthostatic hypotension). A recent randomized controlled trial shows a significant reduction in mortality and cardiovascular events by achieving a low blood pressure goal in patients over the age of 75 years old. Five major drug classes can be used: thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers and beta-blockers. Beta-blockers are less efficient to prevent stroke and are indicated in second line. However, beta-blockers represent first choice of treatment in cases of heart failure, coronary artery disease or atrial fibrillation. Appropriate follow-up and monitoring enable assessment of safety (recording BP while standing, ionogram, creatinine).


Assuntos
Anti-Hipertensivos/uso terapêutico , Hipertensão/complicações , Hipertensão/tratamento farmacológico , Idoso de 80 Anos ou mais , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/etiologia , Comorbidade , Fragilidade/diagnóstico , Avaliação Geriátrica , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/prevenção & controle , Humanos , Hipertensão/diagnóstico , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/etiologia , Guias de Prática Clínica como Assunto , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle
16.
Acta Diabetol ; 56(1): 39-43, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30159748

RESUMO

AIMS: Cardiovascular autonomic testing is time consuming when adopting the entire Ewing battery of tests, hence, clinicians usually adopt an empirically reduced number of tests which may give controversial results. Our purpose was to examine the reliability of the cardiovascular tests most commonly used in autonomic diagnoses. METHODS: We tested 334 subjects, from an original group of 3745, who had shown an altered deep breathing test to both Lying to standing and Valsalva manoeuvre, assuming a value of postural hypotension of more than 15 mmHg as a sign of almost true dysautonomia. RESULTS: VM showed the highest sensitivity (85%) and, when coupled to LS, highest specificity (83%). CONCLUSIONS: VM could be useful when screening for possible or early autonomic neuropathy, VM + LS is useful as a diagnostic tool for probable or advanced autonomic neuropathy, and VM + LS + PH is useful for certain diagnosis of definite or late stage autonomic neuropathy.


Assuntos
Doenças do Sistema Nervoso Autônomo/diagnóstico , Doenças Cardiovasculares/diagnóstico , Sistema Cardiovascular/fisiopatologia , Angiopatias Diabéticas/diagnóstico , Neuropatias Diabéticas/diagnóstico , Técnicas de Diagnóstico Cardiovascular , Idoso , Sistema Nervoso Autônomo/fisiopatologia , Doenças Cardiovasculares/fisiopatologia , Angiopatias Diabéticas/fisiopatologia , Técnicas de Diagnóstico Endócrino , Feminino , Humanos , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/fisiopatologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Manobra de Valsalva/fisiologia
17.
Hypertension ; 73(1): 235-241, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30571543

RESUMO

Patients with autonomic failure are characterized by disabling orthostatic hypotension because of impaired sympathetic activity, but even severely affected patients have residual sympathetic tone which can be harnessed for their treatment. For example, norepinephrine transporter blockade with atomoxetine raises blood pressure (BP) in autonomic failure patients by increasing synaptic norepinephrine concentrations; acetylcholinesterase inhibition with pyridostigmine increases BP by facilitating ganglionic cholinergic neurotransmission to increase sympathetic outflow. We tested the hypothesis that pyridostigmine will potentiate the pressor effect of atomoxetine and improve orthostatic tolerance and symptoms in patients with severe autonomic failure. Twelve patients received a single oral dose of either placebo, pyridostigmine 60 mg, atomoxetine 18 mg or the combination on separate days in a single blind, crossover study. BP was assessed seated and standing before and 1-hour postdrug. In these severely affected patients, neither pyridostigmine nor atomoxetine improved BP or orthostatic tolerance compared with placebo. The combination, however, significantly increased seated BP in a synergistic manner (133±9/80±4 versus 107±6/66±4 mm Hg for placebo, 105±5/67±3 mm Hg for atomoxetine, and 99±6/64±4 mm Hg for pyridostigmine; P<0.001); the maximal increase in seated BP with the combination was 33±8/18±3 mm Hg at 60 minutes postdrug. Only the combination showed a significant improvement of orthostatic tolerance and symptoms. In conclusion, the combination pyridostigmine and atomoxetine had a synergistic effect on seated BP which was associated with improvement in orthostatic tolerance and symptoms. This pharmacological approach could be useful in patients with severe autonomic failure but further safety and long-term efficacy studies are needed.


Assuntos
Cloridrato de Atomoxetina , Doenças do Sistema Nervoso Autônomo , Pressão Sanguínea/efeitos dos fármacos , Hipotensão Ortostática , Brometo de Piridostigmina , Adulto , Cloridrato de Atomoxetina/administração & dosagem , Cloridrato de Atomoxetina/farmacocinética , Doenças do Sistema Nervoso Autônomo/diagnóstico , Doenças do Sistema Nervoso Autônomo/tratamento farmacológico , Doenças do Sistema Nervoso Autônomo/fisiopatologia , Determinação da Pressão Arterial/métodos , Estudos Cross-Over , Monitoramento de Medicamentos/métodos , Sinergismo Farmacológico , Quimioterapia Combinada/métodos , Feminino , Humanos , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/tratamento farmacológico , Hipotensão Ortostática/fisiopatologia , Masculino , Brometo de Piridostigmina/administração & dosagem , Brometo de Piridostigmina/farmacocinética , Método Simples-Cego , Resultado do Tratamento , Vasoconstritores/administração & dosagem , Vasoconstritores/farmacocinética
18.
Ageing Res Rev ; 48: 122-144, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30394339

RESUMO

BACKGROUND: Orthostatic hypotension (OH) may negatively affect physical functioning and aggravate morbidities, but existing evidence is contradictory. METHODS: MEDLINE (from 1946), PubMed (from 1966) and EMBASE databases (from 1947) were systematically searched for studies on the association of OH and physical functioning in older adults, categorized as: balance, gait characteristics, walking speed, Timed Up and Go time, handgrip strength (HGS), physical frailty, exercise tolerance, physical activity, activities of daily living (ADL), and performance on the Hoehn and Yahr scale (HY) and Unified Parkinson's Disease Rating Scale (UPDRS). Study quality was assessed using the Newcastle Ottawa Scale. RESULTS: Forty-two studies were included in the systematic review (29,421 individuals) and 29 studies in the meta-analyses (23,879 individuals). Sixteen out of 42 studies reported a significant association of OH with worse physical functioning. Meta-analysis showed a significant association of OH with impaired balance, ADL performance and HY/UPDRS III performance, but not with gait characteristics, mobility, walking speed, TUG, HGS, physical frailty, exercise tolerance, physical activity and UPDRS II performance. CONCLUSIONS: OH was associated with impaired balance, ADL performance and HY/UPDRS III performance, but not with other physical functioning categories. The results suggest that OH interventions could potentially improve some aspects of physical functioning.


Assuntos
Envelhecimento/fisiologia , Exercício/fisiologia , Marcha/fisiologia , Força da Mão/fisiologia , Hipotensão Ortostática/fisiopatologia , Idoso , Envelhecimento/psicologia , Estudos Transversais , Exercício/psicologia , Feminino , Humanos , Hipotensão Ortostática/diagnóstico , Masculino , Estudos Prospectivos , Caminhada/fisiologia , Caminhada/psicologia
19.
J Emerg Med ; 55(6): 780-787, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30316621

RESUMO

BACKGROUND: Syncope is a common presentation in the emergency department (ED). The differential diagnosis is long and includes benign conditions as well as acute life threats, such as dysrhythmias or pulmonary embolism. OBJECTIVE: The specific goals of this review are twofold: 1) to define the diagnostic utility of orthostatic vital signs (OVS) as a test for orthostatic syncope, and 2) to determine whether OVS help diagnose or exclude life-threatening causes of syncope in ED patients. METHODS: Three prospective cohort studies plus 2017 national guidelines for syncope management were identified, reviewed, and critically appraised. RESULTS: This literature review found that orthostatic hypotension is common among ED patients with syncope and is often diagnosed as the cause of syncope. CONCLUSIONS: OVS measurements do not, in isolation, reliably diagnose or exclude orthostatic syncope, nor do they appear to have value in ruling out life-threatening causes of syncope.


Assuntos
Serviço Hospitalar de Emergência , Hipotensão Ortostática/diagnóstico , Síncope/diagnóstico , Sinais Vitais , Diagnóstico Diferencial , Humanos
20.
Hypertension ; 72(4): 986-993, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30354704

RESUMO

Although orthostatic hypotension (OH) is often considered a contraindication to blood pressure (BP) treatment, evidence is lacking. We examined the effect of BP goal or initial medication choice on OH in AASK (African American Study of Kidney Disease and Hypertension), a 2×3 factorial trial. Blacks with chronic kidney disease attributed to hypertension were randomly assigned 1 of 2 BP goals: intensive (mean arterial pressure, ≤92 mm Hg) or standard (mean arterial pressure, 102-107 mm Hg) and 1 of 3 initial medications (ramipril, metoprolol, and amlodipine). Postural changes in systolic BP, diastolic BP, or heart rate (HR) were determined after 2 minutes and 45 seconds of standing. OH was assessed each visit and defined using the consensus definition (drop in systolic BP ≥20 mm Hg or diastolic BP ≥10 mm Hg). Median follow-up was 4 years. Outcomes were congestive heart failure, stroke, nonfatal cardiovascular disease (CVD), fatal CVD, any CVD (composite of preceding events), and all-cause mortality. There were 1094 participants (mean age, 54.5±10.7 years; 38.8% female; OH was assessed at 52 864 visits). Mean seated systolic BP, diastolic BP, and HR were 150.3±23.9 mm Hg, 95.5±14.2 mm Hg, and 72.0±12.6 bpm, respectively. A more intensive BP goal did not alter the distributions of standing BP and was not associated with OH, but metoprolol was associated with systolic OH compared with ramipril (odds ratio, 1.68; 95% CI, 1.15-2.46) and amlodipine (odds ratio, 1.94; 95% CI, 1.09-3.44). Although consensus OH was associated with stroke (HR, 5.01; 95% CI, 1.80-13.92), nonfatal CVD (HR, 2.28; 95% CI, 1.21-4.30), and any CVD event (HR, 2.12; 95% CI, 1.12-3.98), neither BP goal or medication altered this risk. Concerns about causing OH or its CVD consequences should not deter a lower BP goal among adults with chronic kidney disease attributed to hypertension.


Assuntos
Anlodipino , Pressão Sanguínea/efeitos dos fármacos , Doenças Cardiovasculares , Hipertensão , Hipotensão Ortostática , Metoprolol , Ramipril , Anlodipino/administração & dosagem , Anlodipino/efeitos adversos , Anti-Hipertensivos/administração & dosagem , Anti-Hipertensivos/efeitos adversos , Determinação da Pressão Arterial/métodos , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/mortalidade , Monitoramento de Medicamentos/métodos , Feminino , Humanos , Hipertensão/diagnóstico , Hipertensão/tratamento farmacológico , Hipertensão/fisiopatologia , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/tratamento farmacológico , Hipotensão Ortostática/fisiopatologia , Masculino , Metoprolol/administração & dosagem , Metoprolol/efeitos adversos , Pessoa de Meia-Idade , Ramipril/administração & dosagem , Ramipril/efeitos adversos , Estados Unidos
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA