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1.
Ann Emerg Med ; 76(6): 730-738, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33010956

RESUMO

STUDY OBJECTIVE: Falls are a major cause of mortality and morbidity in adults aged 65 years and older and a common chief complaint in the emergency department (ED). However, the rate of missed opportunities to diagnose and intervene in modifiable fall-risk factors in the ED is unknown. We hypothesize that although ED providers (defined as ED attendings, residents, and advanced care providers) excel at assessing and ruling out injury, they miss the opportunity to identify a large portion of the modifiable risk factors that contribute to a patient's fall. Our objective is to quantify the number of missed opportunities to identify and reduce fall-risk factors in older adult ED patients presenting after a fall. METHODS: This secondary analysis used data from a prospective cohort study of older patients at a single academic urban ED. The original study investigated the standard ED evaluation after a fall in older adults. All patients in the original study had a falls evaluation conducted at their ED visit by trained research assistants; this served as the standard fall evaluation. We reviewed the charts of study patients and identified modifiable fall-risk factors. We then determined the number of missed opportunities to intervene in these risk factors during the ED encounter; the primary outcome was the percentage of missed opportunities to identify risk factors in older ED patients who fell. RESULTS: We found that of the 400 patient charts reviewed, 349 patients had a modifiable risk factor for falling. Of those patients with known modifiable risk factors, the ED team missed identifying the factors in 335 patients (96%). The most commonly missed fall-risk factors were visual acuity (147/154; 96%) and the use of high-risk medications (245/259;95%). Gait abnormalities had the lowest rates of missed modifiable risk factors, at 56% of patients (109/196). When a modifiable risk factor was identified and intervened in, it was most commonly done in the ED observation unit by a physician or physical therapist, and often consisted of an outpatient referral or primary care physician follow-up. CONCLUSION: Providers frequently fail to identify and intervene in modifiable fall-risk factors in older adult patients presenting to the ED after a fall; this is a missed opportunity. Addressing the risk factors that contributed to the fall during a fall-related ED visit may minimize fall risk and promote safer mobility.


Assuntos
Acidentes por Quedas/prevenção & controle , Acidentes por Quedas/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Transtornos Neurológicos da Marcha/diagnóstico , Avaliação Geriátrica/métodos , Avaliação Geriátrica/estatística & dados numéricos , Humanos , Hipotensão Ortostática/complicações , Hipotensão Ortostática/diagnóstico , Masculino , Avaliação de Resultados em Cuidados de Saúde , Doenças do Sistema Nervoso Periférico/complicações , Doenças do Sistema Nervoso Periférico/diagnóstico , Polimedicação , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Baixa Visão/complicações , Acuidade Visual/fisiologia
2.
J Cardiovasc Transl Res ; 13(4): 549-569, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32748206

RESUMO

Heart failure (HF)is a condition at high risk for orthostatic hypotension (OH)given the large proportion of patients at an advanced age and high burden of comorbidities contributing to OH, as well as a high prevalence of medications with neurovascular and volume modulating properties. Early identification of OH in HF seems to be crucial as OH can have an impact on patient symptoms, activity level and independence, be a marker of specific pathophysiological changes or be an indicator of need for personalized treatment. OH might contribute significantly to bad enough prognosis in HF, as, besides a risk of falls and cognitive decline, it was found to be associated with cardiovascular morbidity and mortality. In this review, we aimed to incentivize the routine use of orthostatic testing in HF, as well as stimulate future research in this field, which could lead to significant advances in the treatment and outcomes.


Assuntos
Pressão Sanguínea , Insuficiência Cardíaca/fisiopatologia , Hipotensão Ortostática/fisiopatologia , Postura , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Humanos , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/epidemiologia , Hipotensão Ortostática/terapia , Masculino , Pessoa de Meia-Idade , Prevalência , Prognóstico , Adulto Jovem
3.
Blood Press Monit ; 25(5): 267-270, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32675475

RESUMO

OBJECTIVES: Orthostatic hypotension is a well-known disorder, but orthostatic hypertension (OHT) still remains unclear in older adults. The aim of this study was to determine the comparison orthostatic hypotension with OHT according to fall risk and geriatric assessment parameters. METHODS: A total of 741 patients who were admitted to the geriatric clinic and underwent comprehensive geriatric assessment were reviewed. Orthostatic blood pressure changes were measured by head-up-tilt Table test within the first three minutes. Orthostatic hypotension was defined as 20 or 10-mmHg drop in systolic and/or diastolic blood pressure from supine to standing position. OHT was defined as an increase in systolic blood pressure of 10 mmHg or more while the patient was standing up from the supine position. RESULTS: The mean age was 75 ± 8 and 65. About 65% of all participants were female. The rate of orthostatic hypotension and OHT was 17.3 and 7.2%, respectively. The falls and dementia were more frequent, and the Instrumental Activities of Daily Living (IADL) score was lower in orthostatic hypotension group than in OHT and control groups (P < 0.05). These variables were similar between OHT and control groups (P > 0.05). The rates of falls [odds ratio (OR) = 2.02; 95% confidence interval (CI), (0.94-4.33); P = 0.044] and dementia [OR = 2.65; 95% CI, (1.08-6.48); P = 0.032] in orthostatic hypotension group were still higher than in OHT group, even after adjusting for age, sex, estimated glomerular filtration rate and drugs. CONCLUSION: Orthostatic hypotension may be more significant in terms of falls, dementia and impaired IADLs scores in older adults than in OHT and control groups. It seems that OHT may be of no clinical importance in geriatric practice.


Assuntos
Hipertensão , Hipotensão Ortostática , Atividades Cotidianas , Idoso , Pressão Sanguínea , Determinação da Pressão Arterial , Feminino , Humanos , Hipotensão Ortostática/diagnóstico , Masculino
6.
Blood Press ; 29(4): 209-219, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32131615

RESUMO

Purpose: Orthostatic hypotension (OH) is a common disorder, especially among hospitalised patients. Classic OH is defined as occurring 3 or less minutes of orthostatic stress, and delayed OH as occurring after 3 min of stress. We aimed to compare clinical characteristics and prognosis between inpatients with classic vs. delayed OH.Methods: We performed a retrospective analysis of data from 358 inpatients, aged ≥60 years, who were evaluated for the occurrence of OH at the initial phase of ambulation in four previous prospective studies in our department. Demographic, clinical and prognostic data were compared between patients with (n = 191) vs. without (n = 167) OH, classic (n = 138) vs. delayed (n = 53) OH and seated (n = 115) vs. standing (n = 76) OH.Results: Demographic characteristics, duration of bed rest, the main reasons for admission and the use of offending medications were comparable between the delayed and classic OH groups. Mean maximal postural diastolic (p < .001) and systolic (p = .063) blood pressure falls were higher among patients with classic v. delayed OH. No statistically significant difference between the patients with classic and delayed OH were observed in the occurrence of OH-related symptoms (62.3 vs. 69.8%, p = .42). During a median follow-up of 5.5 years, no statistically significant differences in survival were observed between patients with vs. without OH (p = .14), classic vs. delayed OH (p = .68) and seated vs. standing OH (p = .067). On multivariate analysis, these variables remained not significantly associated with decreased survival.Conclusions: Among inpatients, delayed OH is associated with a lesser magnitude of orthostatic blood pressure fall than classic OH. However, rates of symptomatic OH and long-term mortality were comparable between the groups. Thus, among hospitalised patients, delayed OH should be considered as posing the same severity as classic OH.


Assuntos
Pressão Sanguínea , Hipotensão Ortostática/diagnóstico , Postura , Idoso , Idoso de 80 Anos ou mais , Feminino , Hospitalização , Humanos , Hipotensão Ortostática/mortalidade , Hipotensão Ortostática/fisiopatologia , Hipotensão Ortostática/terapia , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo
7.
PLoS One ; 15(3): e0229860, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32134983

RESUMO

PURPOSE: We have evaluated the clinical significance of the washout rate (WR) on I-123 MIBG scans through the analysis of the relationship between the I-123 MIBG scans and autonomic status in patients with Parkinson's disease (PD). MATERIALS AND METHODS: Sixty patients with clinical PD who had decreased HMR were enrolled. An autonomic symptom was evaluated using a head-up tilt test and the Composite Autonomic Severity Score (CASS). An I-123 MIBG scan and F-18 FP-CIT positron emission tomography (PET) were performed. All of the patients were classified into three groups according to the WR. The differences in patient characteristics and the imaging parameters among the three groups were evaluated, and a correlation analysis was also performed. RESULTS: The frequency of orthostatic hypotension was significantly different among the three groups. The difference in systolic pressure (dSysPr) and the difference in diastolic pressure (dDiaPr) of group 3 was significantly larger than those of groups 1 and 2. From the correlation analysis, it can be seen that age, Hoehn and Yahr (H&Y) stage, dSysPr, and dDiaPr had a weak positive correlation with the WR. The total CASS score was significantly higher in group 3 compared with groups 1 and 2. The WR had a moderate positive correlation with the cardiosympathetic score and the total CASS score. CONCLUSION: The WR is related to autonomic dysfunction. An I-123 MIBG cardiac scan is considered to be a good method to evaluate not only the differential diagnosis of Parkinson's disease but also the degree of autonomic dysfunction.


Assuntos
3-Iodobenzilguanidina/administração & dosagem , Sistema Nervoso Autônomo/diagnóstico por imagem , Radioisótopos do Iodo/administração & dosagem , Doença de Parkinson/diagnóstico por imagem , Tomografia Computadorizada com Tomografia por Emissão de Pósitrons/métodos , Compostos Radiofarmacêuticos/administração & dosagem , 3-Iodobenzilguanidina/metabolismo , Idoso , Idoso de 80 Anos ou mais , Pressão Sanguínea , Feminino , Radioisótopos de Flúor/administração & dosagem , Radioisótopos de Flúor/metabolismo , Coração/diagnóstico por imagem , Humanos , Hipotensão Ortostática/diagnóstico , Radioisótopos do Iodo/metabolismo , Masculino , Mediastino/diagnóstico por imagem , Pessoa de Meia-Idade , Compostos Radiofarmacêuticos/metabolismo , Estudos Retrospectivos , Tropanos/administração & dosagem , Tropanos/metabolismo
8.
High Blood Press Cardiovasc Prev ; 27(1): 93-101, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32048202

RESUMO

INTRODUCTION: Orthostatic hypotension (OH) and atrial fibrillation (AF) are both regarded as independent risk factors for transient ischemic attack (TIA). However, the clinical implication of OH in the presence of AF is unclear. This study investigates, for the first time, the association between blood pressure (BP), OH and mortality in a cohort of patients with AF and TIA symptoms. AIM: To investigate the incidence of the association between OH, AF and TIA. METHODS: This retrospective observational study utilised the Leicester one-stop transient TIA clinic patient database to consider the initial systolic and diastolic BP of 688 patients with a diagnosis of AF. The primary outcome was time until death. Covariant measures included status of AF diagnosis (known or new AF), cardiovascular risk factors, and primary clinic diagnosis [cerebrovascular (CV) versus non-cerebrovascular (non-CV)]. Statistical models adjusted for sex, age, previous AF diagnosis. RESULTS: Mortality rate was higher in the over 85 age group [191.5 deaths per 1000 person years (py) (95% CI 154.0-238.1)] and lower in the aged 75 and younger age group [40.0 deaths per 1000 py (95% CI 27.0-59.2)] compared to intermediate groups. A 10 mmHg increase in supine diastolic BP was associated with a significant reduction in the hazard of mortality for patients suspected of TIA with AF [adjusted HR 0.79 (95% CI 0.68-0.92), p < 0.001]. The mortality rate for patients with OH was 119.0 deaths per 1000 py compared with a rate of 98.0 for patients without OH (rate ratio 1.2, p = 0.275). CONCLUSION: Higher diastolic BP may be a marker for reduced mortality risk in patients with a previous AF diagnosis and non-CV diagnosis. Lower diastolic BP and the presence of AF pertain to a higher mortality risk. This study raises the importance of opportunistic screening for both OH and AF in patients presenting to TIA clinic.


Assuntos
Fibrilação Atrial/epidemiologia , Hipotensão Ortostática/epidemiologia , Ataque Isquêmico Transitório/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/mortalidade , Fibrilação Atrial/fisiopatologia , Pressão Sanguínea , Inglaterra/epidemiologia , Feminino , Frequência Cardíaca , Humanos , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/mortalidade , Hipotensão Ortostática/fisiopatologia , Incidência , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/mortalidade , Ataque Isquêmico Transitório/fisiopatologia , Masculino , Estudos Retrospectivos , Fatores de Risco
10.
BMC Cardiovasc Disord ; 20(1): 54, 2020 02 04.
Artigo em Inglês | MEDLINE | ID: mdl-32019498

RESUMO

BACKGROUND: Neurogenic orthostatic hypotension, a sustained decrease in blood pressure upon standing, is caused by autonomic nervous system failure and characterized by an insufficient increase in heart rate needed to maintain blood pressure upon standing. In this case, neurogenic orthostatic hypotension symptoms preceded a diagnosis of Parkinson disease. A diagnosis of underlying neurogenic orthostatic hypotension significantly changed the course of treatment for this patient. CASE PRESENTATION: An 84-year-old woman was referred to a cardiologist by her primary care practitioner for evaluation of exertional dyspnea and chest pain upon walking a few feet. Her medical history included hypertension, hypothyroidism, and osteoarthritis. Based on her continued symptoms, the patient underwent 2 cardiac catheterizations for coronary artery stenosis. After the catheterizations, exertional dyspnea and chest pain continued, and subsequently, dysphagia to solid foods and episodic dizziness developed. Orthostatic evaluation showed a supine blood pressure of 150/80 mmHg with a heart rate of 70 beats per min. Upon standing for 3 min, the patient's blood pressure decreased to 110/74 mmHg with a heart rate of 76 beats per min. The diagnostic criteria for orthostatic hypotension were met, and the lack of an adequate compensatory heart rate increase upon standing was consistent with a neurogenic cause (ie, neurogenic orthostatic hypotension), which was supported by tilt-table testing results. Although nonpharmacologic treatments were initially successful, episodes of lightheadedness, chest pain, and dyspnea upon standing became more frequent, and the patient was prescribed droxidopa (200 mg; 3 times daily). Droxidopa significantly improved her symptoms, with the patient reporting resolution of her chest pain and significant improvement of dyspnea and dizziness. She was diagnosed with Parkinson disease approximately 6 months later. CONCLUSIONS: This case highlights the importance of evaluating and identifying potential causes of symptoms of cardiovascular disease when persistent symptoms do not improve after cardiac interventions. This case complements findings demonstrating that signs of autonomic failure, such as neurogenic orthostatic hypotension, may precede the motor symptoms of Parkinson disease. Importantly, this case provides real-world evidence for the efficacy of droxidopa to treat the symptoms of neurogenic orthostatic hypotension, after an appropriate diagnosis.


Assuntos
Pressão Sanguínea , Dor no Peito/etiologia , Doença da Artéria Coronariana/complicações , Estenose Coronária/complicações , Dispneia/etiologia , Hipotensão Ortostática/etiologia , Doença de Parkinson/complicações , Idoso de 80 Anos ou mais , Antiparkinsonianos/uso terapêutico , Dor no Peito/diagnóstico , Dor no Peito/fisiopatologia , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/terapia , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/fisiopatologia , Estenose Coronária/terapia , Droxidopa/uso terapêutico , Dispneia/diagnóstico , Dispneia/fisiopatologia , Feminino , Humanos , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/fisiopatologia , Doença de Parkinson/diagnóstico , Doença de Parkinson/tratamento farmacológico , Doença de Parkinson/fisiopatologia , Intervenção Coronária Percutânea , Postura , Resultado do Tratamento
11.
J Neurol ; 267(4): 1097-1102, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31893293

RESUMO

BACKGROUND: Cerebellar ataxias are a heterogeneous group of disorders of both genetic and non-genetic origin. In sporadic cases, two entities are recognized: multiple system atrophy of cerebellar type (MSA-C) and SAOA (sporadic adult-onset ataxia). The presence of severe cardiovascular autonomic failure reliably distinguishes MSA-C from other ataxias, but it may appear only late in the disease course. OBJECTIVE: To evaluate the diagnostic yield of cardiovascular autonomic function tests in the work-up of cerebellar ataxia. METHODS: We applied a cardiovascular autonomic tests battery in consecutive patients with neurodegenerative cerebellar ataxia and matched healthy controls. We recorded the presence of both orthostatic hypotension (OH) and blood pressure falls non-fulfilling the criteria of OH (non-OH BP). Sporadic cases were followed-up for an eventual conversion to MSA-C. RESULTS: Forty-two patients were recruited, 19 of whom with sporadic disease (2 probable MSA-C, 6 possible MSA-C, 11 SAOA). Sporadic and hereditary cases showed no difference concerning ataxia severity at baseline. At head-up tilt, non-OH BP falls were detected in nine patients, but not in controls. This finding was significantly more frequent in sporadic cases (p = 0.006) and was detected in five out of seven patients that during follow-up converted to possible/probable MSA-C. Findings at standing test were normal in four out of nine cases with non-OH BP falls at head-up tilt. CONCLUSIONS: A complete cardiovascular autonomic battery with head-up tilt can detect early signs of BP dysregulation which may be missed at bed-side tests, thus warranting its application in the first line work-up of cerebellar ataxias.


Assuntos
Sistema Nervoso Autônomo/fisiopatologia , Ataxia Cerebelar , Progressão da Doença , Hipotensão , Atrofia de Múltiplos Sistemas , Adulto , Idoso , Ataxia Cerebelar/complicações , Ataxia Cerebelar/diagnóstico , Ataxia Cerebelar/fisiopatologia , Feminino , Seguimentos , Humanos , Hipotensão/diagnóstico , Hipotensão/etiologia , Hipotensão/fisiopatologia , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/etiologia , Hipotensão Ortostática/fisiopatologia , Masculino , Pessoa de Meia-Idade , Atrofia de Múltiplos Sistemas/complicações , Atrofia de Múltiplos Sistemas/diagnóstico , Atrofia de Múltiplos Sistemas/fisiopatologia , Índice de Gravidade de Doença
12.
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
13.
Continuum (Minneap Minn) ; 26(1): 154-177, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31996627

RESUMO

PURPOSE OF REVIEW: This article reviews the management of orthostatic hypotension with emphasis on neurogenic orthostatic hypotension. RECENT FINDINGS: Establishing whether the cause of orthostatic hypotension is a pathologic lesion in sympathetic neurons (ie, neurogenic orthostatic hypotension) or secondary to other medical causes (ie, non-neurogenic orthostatic hypotension) can be achieved by measuring blood pressure and heart rate at the bedside. Whereas fludrocortisone has been extensively used as first-line treatment in the past, it is associated with adverse events including renal and cardiac failure and increased risk of all-cause hospitalization. Distinguishing whether neurogenic orthostatic hypotension is caused by central or peripheral dysfunction has therapeutic implications. Patients with peripheral sympathetic denervation respond better to norepinephrine agonists/precursors such as droxidopa, whereas patients with central autonomic dysfunction respond better to norepinephrine reuptake inhibitors. SUMMARY: Management of orthostatic hypotension is aimed at improving quality of life and reducing symptoms rather than at normalizing blood pressure. Nonpharmacologic measures are the key to success. Pharmacologic options include volume expansion with fludrocortisone and sympathetic enhancement with midodrine, droxidopa, and norepinephrine reuptake inhibitors. Neurogenic supine hypertension complicates management of orthostatic hypotension and is primarily ameliorated by avoiding the supine position and sleeping with the head of the bed elevated.


Assuntos
Gerenciamento Clínico , Hipotensão Ortostática/diagnóstico , Idoso , Diagnóstico Diferencial , Feminino , Humanos , Hipotensão Ortostática/complicações , Masculino , Pessoa de Meia-Idade
14.
Clin Exp Hypertens ; 42(5): 409-419, 2020 Jul 03.
Artigo em Inglês | MEDLINE | ID: mdl-31589076

RESUMO

Background: Impaired orthostatic blood pressure (BP) response is a frequent finding in the elderly. The goal of the study was to investigate the association of variability of supine-to-orthostatic BP with cold pressor reflection and heart rate variability in the elderly.Methods: From June 2010 to September 2013, 287 elderly aged ≥ 60 years were enrolled in Jinan area, China. The elderly were classified into lower (n = 96), intermediate (n = 95), and higher (n = 96) tertile groups according to the tertile of the percentage change of supine-to-orthostatic systolic BP.Results: There were significant increasing trends in systolic BP response to the CPT at 0 and 60 sec; the plasma levels of epinephrine, norepinephrine, and angiotensin II; and decreasing trends in DNN, SDNN index, and SDANN from the lower to the higher tertile group, and differences between any two groups were significant (P < .05). The percentage change of supine-to-orthostatic systolic BP was positively correlated with systolic BP response to CPT at 0 and 60 sec, VLF, epinephrine, norepinephrine, and angiotensin II (P < .001) and negatively correlated with SDNN, SDNN index, SDANN, rMSSD, pNN50, LF, and ratio of LF/HF (P < .001). The BP response to CPT, parameters of HRV, and the plasma levels of norepinephrine and angiotensin II were independently associated with the percentage change of supine-to-orthostatic systolic BP after adjustment for confounders.Conclusion: Aggressive variability of supine-to-orthostatic systolic BP might be significantly associated with the imbalance of sympathetic and parasympathetic activity, especially high sensitivity sympathetic response in the elderly.Abbreviations: BP: blood pressure; BMI: body mass index; CPT: cold pressor test; HRV: heart rate variability; SDNN: standard deviation of all normal-to-normal R-R intervals; SDNN index: mean of the standard deviations of all 5-min normal-to-normal R-R intervals of the entire recording; SDANN: standard deviation of the averages of normal-to-normal R-R intervals during all 5-min periods of the entire recording; rMSSD: square root of the mean squared differences between successive normal R-R intervals; pNN50: number of adjacent normal R-R intervals differing by more than 50 ms; VLF: very low frequency; LF: low frequency; HF: high frequency; TCHO: total cholesterol; HDL-c: high-density lipoprotein cholesterol; LDL-c: low-density lipoprotein cholesterol; FPG: fasting plasma glucose; SD: standard deviation.


Assuntos
Envelhecimento/fisiologia , Resposta ao Choque Frio/fisiologia , Frequência Cardíaca/fisiologia , Hipotensão Ortostática , Sistema Nervoso Parassimpático/fisiopatologia , Sistema Nervoso Simpático/fisiopatologia , Idoso , Pressão Sanguínea/fisiologia , China , Feminino , Humanos , Hipertensão/fisiopatologia , Hipotensão Ortostática/sangue , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/etiologia , Hipotensão Ortostática/fisiopatologia , Masculino
15.
Intern Emerg Med ; 15(2): 281-287, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31428921

RESUMO

Orthostatic hypotension (OH) is a multifactorial disorder, often asymptomatic. The prevalence of OH increases with age, ranging from 5 to 11% among middle-aged patients to 55% in the frail elderly depending on age and associated comorbidities. OH is often unrecognized or misdiagnosed and little is known about its prevalence in hospitalized elderly patients. Our aims were: (1) to determine the prevalence of OH in a cohort of elderly patients hospitalized in two internal medicine wards in Italy; (2) and to describe their characteristics and symptoms. During the 5 months from March 1, 2017 to July 31, 2017, the first 85 consecutive patients (65 years or older) admitted in two internal medicine wards were enrolled. Patients were included in the study if they were able to get out of bed alone or with minor assistance, and able to stand up for at least 3 min. The study population comprised 85 patients with a mean age of 79.6 ( ± 7.2) years. OH was found in 64 (75.3%), occasional OH in 41 (48.2%), persistent OH in 23 (27.1%), and 21 (24.7%) patients had no OH. All patients had diastolic OH and 37 (57.8%) also systolic. Patients with persistent OH were oldest, with a higher percentage of renal failure. Twenty-six patients (40.6%) with OH reported symptoms. Dizziness was the most common symptom, especially after breakfast. No association was found between type of medications and risk of OH. Mortality risk was not statistically different between patients with or without OH 3 (p = 0.10) and 6 months after discharge (p = 0.18), but a trend was observed. We found that OH is very common in the patients admitted in the internal medicine wards, particularly diastolic OH. Close attention should be paid to OH and its symptoms, especially dizziness, in the oldest-old patients, and in patients with renal failure.


Assuntos
Hipotensão Ortostática/diagnóstico , Quartos de Pacientes/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Pressão Sanguínea/fisiologia , Feminino , Humanos , Hipotensão Ortostática/epidemiologia , Hipotensão Ortostática/mortalidade , Medicina Interna/métodos , Medicina Interna/estatística & dados numéricos , Itália/epidemiologia , Modelos Logísticos , Masculino , Quartos de Pacientes/organização & administração , Prevalência , Fatores de Risco
16.
Hypertension ; 75(2): 524-531, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31838912

RESUMO

Assessment of the cerebrovascular and cardiovascular response to standing has prognostic value for a range of outcomes in the older adult population. Studies generally attempt to control for standing speed differences by asking participants to stand in a specified time but little is known about the range of transition times observed. This study aimed to characterize how standing speed associates with cardiovascular and cerebrovascular measures following transition from supine to standing. Continuous cerebral oxygenation, heart rate, systolic and diastolic blood pressure were monitored for 3 minutes after transitioning from supine to standing. An algorithm was used to calculate the time taken to transition from existing Finometer data (from the height correction unit). Linear mixed-effects models were used to assess the influence of transition time on each of the signals while adjusting for covariates. Transition time ranged from 2 to 27 s with 17% of participants taking >10 s to stand. Faster transition was associated with a more extreme decrease 10 s after standing but improved recovery at 20 s for cerebral oxygenation and blood pressure. Standing faster was associated with an elevated heart rate on initiation of stand and a quicker recovery 10 to 20 s after standing. The speed of transitioning from supine to standing position is associated with cardiovascular and cerebrovascular response in the early period after standing (<40 s). Care should be taken in the interpretation of findings which may be confounded by standing speed and statistical adjustment for standing time should be applied where appropriate.


Assuntos
Envelhecimento/fisiologia , Pressão Sanguínea/fisiologia , Frequência Cardíaca/fisiologia , Hipotensão Ortostática/fisiopatologia , Posição Ortostática , Decúbito Dorsal/fisiologia , Idoso , Feminino , Seguimentos , Humanos , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/epidemiologia , Irlanda , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos
17.
J Am Coll Cardiol ; 74(23): 2939-2947, 2019 12 10.
Artigo em Inglês | MEDLINE | ID: mdl-31806138

RESUMO

Afferent baroreflex failure is most often due to damage of the carotid sinus nerve because of neck surgery or radiation. The clinical picture is characterized by extreme blood pressure lability with severe hypertensive crises, hypotensive episodes, and orthostatic hypotension, making it the most difficult form of hypertension to manage. There is little evidence-based data to guide treatment. Recommendations rely on understanding the underlying pathophysiology, relevant clinical pharmacology, and anecdotal experience. The goal of treatment should be improving quality of life rather than normalization of blood pressure, which is rarely achievable. Long-acting central sympatholytic drugs are the mainstay of treatment, used at the lowest doses that prevent the largest hypertensive surges. Short-acting clonidine should be avoided because of rebound hypertension, but can be added to control residual hypertensive episodes, often triggered by mental stress or exertion. Hypotensive episodes can be managed with countermeasures and short-acting pressor agents if necessary.


Assuntos
Barorreflexo/fisiologia , Determinação da Pressão Arterial/métodos , Pressão Sanguínea/fisiologia , Gerenciamento Clínico , Hipotensão Ortostática/diagnóstico , Humanos , Hipotensão Ortostática/fisiopatologia
18.
J Fam Pract ; 68(9): 512-514, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31725137

RESUMO

We typically take a blood pressure within 3 minutes of a patient rising from a supine to a standing position. But is that too long?


Assuntos
Determinação da Pressão Arterial/métodos , Hipotensão Ortostática/diagnóstico , Posição Ortostática , Tontura/etiologia , Humanos , Hipotensão Ortostática/fisiopatologia , Decúbito Dorsal , Fatores de Tempo
19.
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
20.
Neurology ; 93(16): e1526-e1534, 2019 10 15.
Artigo em Inglês | MEDLINE | ID: mdl-31527282

RESUMO

OBJECTIVE: To determine the frequency, evolution, and associated features of orthostatic hypotension (OH) over 7 years of prospective follow-up in a population-based, initially drug-naive Parkinson disease (PD) cohort. METHODS: We performed repeated lying and standing blood pressure measurements in 185 patients with newly diagnosed PD and 172 matched normal controls to determine the occurrence of (1) OH using consensus-based criteria and (2) clinically significant OH (mean arterial pressure in standing position ≤75 mm Hg). We applied generalized estimating equations models for correlated data to investigate associated features of these 2 outcomes in patients with PD. RESULTS: OH was more common in patients with PD than controls at all visits, with the relative risk increasing from 3.0 (95% confidence interval [CI] 1.6-5.8; p < 0.001) at baseline to 4.9 (95% CI 2.4-10.1; p < 0.001) after 7 years. Despite a high cumulative prevalence of OH (65.4%) and clinically significant OH (29.2%), use of antihypotensive drugs was very rare (0.5%). OH was independently associated with older age (odds ratio [OR] 1.06 per year; 95% CI 1.03-1.10), lower Mini-Mental State Examination score (OR 0.91 [0.85-0.97] per unit), and longer follow-up time (OR 1.12 [1.03-1.23] per year). Clinically significant OH was associated with the same characteristics, in addition to higher levodopa equivalent dosage (OR 1.16 [1.07-1.25] per 100 mg). CONCLUSIONS: In this population-based study, we found OH to be a very frequent but undertreated complication in early PD, with associations to both disease-specific symptoms and drug treatment. Our findings suggest that clinicians should more actively assess and manage OH abnormalities in PD.


Assuntos
Pressão Sanguínea/fisiologia , Hipotensão Ortostática/fisiopatologia , Doença de Parkinson/fisiopatologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Pressão Sanguínea/efeitos dos fármacos , Feminino , Seguimentos , Humanos , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/tratamento farmacológico , Levodopa/uso terapêutico , Masculino , Pessoa de Meia-Idade , Razão de Chances , Doença de Parkinson/complicações , Doença de Parkinson/tratamento farmacológico , Estudos Prospectivos , Índice de Gravidade de Doença
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