scholarly journals Utility of autonomic testing for the efficient diagnosis and effective pharmacological management of neurogenic orthostatic hypotension

2019 ◽  
Vol 12 (8) ◽  
pp. e228423
Author(s):  
Sami bin Alam ◽  
Waiel Almardini ◽  
Amer Suleman
Keyword(s):  
Heart Rate ◽  
Orthostatic Hypotension ◽  
Symptomatic Relief ◽  
Neurogenic Orthostatic Hypotension ◽  
Pharmacological Management ◽  
Autonomic Testing ◽  
History Of ◽  
Head Up Tilt ◽  
Deep Breathing Test

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.

Abstract P179: Comparison of Earlier versus Later Orthostatic Hypotension Assessment Times in Middle-Age Adults of the Atherosclerosis Risk in Communities Study (ARIC)

Circulation ◽  
2017 ◽  
Vol 135 (suppl_1) ◽  
Author(s):  
Stephen P Juraschek ◽  
Natalie Daya ◽  
Andreea M Rawlings ◽  
Lawrence J Appel ◽  
Edgar R Miller ◽  
...  
Keyword(s):  
Orthostatic Hypotension ◽  
Standing Position ◽  
Adverse Outcomes ◽  
Cox Models ◽  
Atherosclerosis Risk In Communities ◽  
Adverse Health Outcomes ◽  
History Of ◽  
Risk Of Fall

Background: Guidelines recommend assessing orthostatic hypotension (OH) 3 minutes after rising from supine to standing positions. Hypothesis: Measurements performed immediately after standing will be as informative as measurements performed closer to 3 minutes after standing with regards to symptoms of dizziness or risk of adverse outcomes. Methods: OH, defined as a drop in blood pressure (systolic ≥20 mm Hg or diastolic ≥10 mm Hg) from the supine to standing position, was measured up to five times at 25 seconds intervals in middle-aged (range 44 to 66 years) ARIC participants (1987-1989). Associations between each measurement and history of dizziness upon standing were examined via logistic regression. We used Cox models to examine the association between each of five measurements with risk of fall, fracture, syncope, and all-cause mortality over a median follow-up of 23 years. Results: In 11,449 participants (mean age 54 years, 54% women, 26% black) 10% reported a history of dizziness upon standing. OH assessed at measurement 1 (performed at a mean of 28 seconds after standing) was associated with risk of fall ( P = 0.03), fracture ( P = 0.05), syncope ( P <0.001), and mortality ( P < 0.001) ( Table ). Furthermore, measurement 1 was the only measurement associated with higher odds of dizziness upon standing (OR: 1.5; P = 0.001). Measurement 2 (performed on average 53 seconds after standing) was associated with all long-term outcomes. Measurements 4 and 5 (mean 100 and 116 seconds after standing) were generally less informative with regards to prospective outcomes than earlier measurements and were not statistically associated with history of dizziness. Conclusions: OH measurements obtained, on average, within the first 30 seconds of standing were predictive of long-term adverse health outcomes and were the most strongly related to symptoms of dizziness compared to later measurements. These findings suggest that BP measurements for determining orthostatic hypotension should be performed immediately after standing.

scholarly journals The Challenge of the Non-Compliant Patient: A Case of Caesarean Section Scar Ectopic Pregnancy

2021 ◽  
pp. 1-3
Author(s):  
Jessica Audet ◽  
Brittany Noel Robles ◽  
Nicolle M Arroyo Lluberas ◽  
Jessica Audet ◽  
Daniel Faustin ◽  
...  
Keyword(s):  
Ectopic Pregnancy ◽  
Emergency Laparotomy ◽  
Pharmacological Management ◽  
Compliant Patient ◽  
Life Saving ◽  
Close Observation ◽  
Life Threatening ◽  
History Of ◽  
Ruptured Uterus

Ectopic pregnancy is a quite common and life-threatening pregnancy. The most common site of ectopic implantation of a fertilized embryo is the fallopian tube. In extremely rare situations, the embryo can implant in other locations, which makes the diagnosis and management even more complex. Although close observation of a new pregnancy is key in the diagnosis and treatment of an ectopic pregnancy, there is still a major risk of life-threatening outcomes. This is a case report of a 31-year-old patient with a history of multiple pregnancies who presented to a community hospital in the spring of 2021 with an ectopic caesarean scar pregnancy. A diagnosis of ectopic pregnancy was on a timely basis, and surgical management was advised. Upon refusal of treatment and admission, pharmacological management was initiated, but patient compliance challenged the success of the therapy. Patient non-compliance to close follow-up resulted in a ruptured uterus. Emergency laparotomy with supracervical hysterectomy was performed as a life-saving procedure.

P1096Cardioneuroablation changes the type of vaso-vagal response in patients with asystolic reflex syncope

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
R Piotrowski ◽  
A Zuk ◽  
J Baran ◽  
A Sikorska ◽  
T Krynski ◽  
...  
Keyword(s):  
Heart Rate ◽  
Heart Rate Variability ◽  
Postgraduate Medical Education ◽  
Sinus Node ◽  
Pacemaker Implantation ◽  
Heart Rate Variability Parameter ◽  
History Of ◽  
The Right ◽  
The Impact

Abstract Funding Acknowledgements Centre of Postgraduate Medical Education No. 501-1-10-14-19 Background. Cardioneuroablation (CNA) - ablation of ganglionated plexi (GP) to eliminate or reduce parasympathetic overactivity, has been recently proposed as a new therapeutic method in patients with vaso-vagal syncope (VVS) due to cardioinhibitory or mixed mechanism. Purpose. To assess the impact of CNA on the type of VV response during tilt testing (TT). Methods. The study group consisted of the first 20 patients (7 males, mean age 38 ± 9 – year – old) enrolled in the ongoing prospective Roman study (NCT 03903744). All patients had a history of ECG documented syncope due to asystole and confirmed asystolic form of VVS at baseline TT. CNA was performed using electroanatomical system Carto 3 and radiofrequency applications delivered in the right and left atrium at the right anterior GP and right inferior GP sites. The second TT was performed three months later. Resting heart rate (HR) and heart rate variability parameter (SDDN) were also assessed. Results. At baseline TT, nineteen patients had cardioinhibitory syncope (asystole ranging from 3 to 60 s)  (sinus node arrest – 17 patients, A-V block – 2 patients) and 1 had mixed form of VVS (asystole lasting 3 s preceded by hypotension). During three-month follow-up no syncopal episodes were noted. At the 3-month TT, 6 (30 %) patients had no syncope whereas the remaining 13 (65 %)  had syncope – twelve (60 %) due to vasodepressor mechanism and only one (5 %) due to asystole - as before CNA. One patient did not have TT because of pregnancy. Mean resting HR after CNA was significantly faster and SDNN significantly lower than before the procedure (82 ± 9 vs 69 ± 11 beats/min, p = 0.0004 and 74 ± 22 vs 143 ± 40 ms, p = 0.00003, respectively) and these changes were was similar in those who fainted during second TT and those who did not (82 ± 11 vs 81 ± 4 beats/min, p = NS and (75 ± 2 vs 77 ± 18 ms, p = NS, respectively). Conclusions. CNA profoundly affects the type of VV reaction causing normalization of the response to tilting or changing cardiodepression to vasodepression. These effects are also depicted by changes in HR and heart rate variability. Elimination of TT-induced reflex asystole may prevent clinical recurrences of syncope during short-term follow-up. These findings encourage to conduct further studies involving CNA since this method appears to be effective and obviates the need for pacemaker implantation in young people with reflex asystolic syncope.

Afferent baroreflex dysfunction and age-related orthostatic hypotension

1991 ◽  
Vol 81 (s25) ◽  
pp. 531-538 ◽  
Author(s):  
A. L. Tonkin ◽  
L. M. H. Wing ◽  
M. J. Morris ◽  
V. Kapoor
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Cold Stress ◽  
Orthostatic Hypotension ◽  
Autonomic Neuropathy ◽  
Isometric Exercise ◽  
Control Subjects ◽  
Age Related ◽  
Head Up Tilt ◽  
Elderly Control

1. To test the hypothesis that in apparently healthy elderly subjects with orthostatic hypotension there is afferent baroreflex dysfunction, cardiovascular and neurohumoral responses were measured after separate stimuli which activated baroreceptor (head-up tilt) and non-baroreceptor (cold stress, isometric exercise) afferent pathways. 2. In 15 healthy elderly control subjects blood pressure did not change with 60° head-up tilting and there was a moderate increase in heart rate, whereas in 13 subjects with age-related orthostatic hypotension head-up tilting was associated with a marked fall in blood pressure but a similar heart rate response to that in the elderly control group. In contrast, both groups of subjects had similar blood pressure and heart rate responses to cold stress and sustained isometric exercise. 3. Nine subjects with autonomic neuropathy also showed a marked hypotensive response to head-up tilt, but produced no pressor response to cold stress or isometric exercise. 4. The plasma concentrations of noradrenaline, adrenaline and neuropeptide-Y-like immunoreactivity rose and that of atrial natriuretic peptide fell after head-up tilt in the study population as a whole. There were no significant differences between groups despite the much greater blood pressure drops in the subjects with autonomic neuropathy and in those with age-associated orthostatic hypotension. 5. The aorto-iliac pulse wave velocity index was significantly higher in subjects with age-associated orthostatic hypotension compared with that in control subjects. 6. The pattern of responses to the separate stresses observed in the group with age-associated orthostatic hypotension is characteristic and different from that in the elderly control subjects and the subjects with autonomic neuropathy. It suggests that age-associated orthostatic hypotension is related predominantly to dysfunction in the afferent limb of the baroreflex arc, possibly partially caused by a splinting of arterial baroreceptors by non-compliant arterial walls.

24 PYRIDOSTIGMINE FOR TREAMENT OF NEUROGENIC ORTHOSTATIC HYPOTENSION: A FOLLOW-UP SURVEY STUDY.

2004 ◽  
Vol 52 (Suppl 2) ◽  
pp. S381.1-S381
Author(s):  
P. Sandroni ◽  
T. L. Opfer-Gehrking ◽  
W. Singer ◽  
P. A. Low
Keyword(s):  
Orthostatic Hypotension ◽  
Survey Study ◽  
Neurogenic Orthostatic Hypotension

The Carpal Boss

1995 ◽  
Vol 20 (3) ◽  
pp. 405-408 ◽  
Author(s):  
S. FUSI ◽  
H. K. WATSON ◽  
C. B. CUONO
Keyword(s):  
Surgical Treatment ◽  
Cancellous Bone ◽  
Symptomatic Relief ◽  
Surgical Patients ◽  
Male And Female ◽  
Articular Surfaces ◽  
History Of ◽  
The Mean ◽  
Bony Abnormality

Between 1969 and 1989,116 patients were evaluated and treated surgically for symptomatic carpal boss. Their mean age was 32 years and male and female patients were equally affected. 28 patients gave a history of previous injury. Surgical treatment consisted of excision of the localized bony abnormality and the associated degenerative arthritic process to the level of normal articular surfaces and normal adjacent cancellous bone. The mean follow-up period for the patients in this study was 42 months. Complete symptomatic relief was observed in 94% of the patients undergoing surgical treatment. Recurrence or persistence of symptoms developed in seven surgical patients. Six had a second operation with more extensive removal of sclerotic bone and degenerate cartilage, and all patients had relief of symptoms.

scholarly journals Abnormal respiratory patterns in a series of post-concussive patients

Neurology ◽  
2018 ◽  
Vol 91 (23 Supplement 1) ◽  
pp. S28.1-S28
Author(s):  
Karissa Arca ◽  
Brent P Goodman ◽  
Amaal J Starling
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Nervous System ◽  
Autonomic Nervous System ◽  
Clinical Feature ◽  
Sympathetic Hyperactivity ◽  
Paroxysmal Sympathetic Hyperactivity ◽  
Autonomic Testing ◽  
Severe Tbi ◽  
Head Up Tilt

BackgroundAutonomic nervous system dysfunction has been identified in patients following traumatic brain injury (TBI), including concussion. Abnormal postural heart rate and blood pressure instability have been identified in post-concussive patients. Recently, we have identified abnormal respiratory patterns during autonomic testing for post-concussive symptoms. Tachypnea is a clinical feature of autonomic instability in paroxysmal sympathetic hyperactivity following severe TBI and the purpose of this study is to identify abnormal respiratory patterns in patients with autonomic nervous system impairment following mild TBI.MethodsA retrospective review of patients in the Mayo Clinic Arizona Concussion Program from October 2017 to March of 2018 was performed. Clinical features and autonomic testing were reviewed. Autonomic testing included blood pressure and heart rate responses to Valsalva, heart rate variability during deep breathing, blood pressure and heart rate responses to head-up tilt, sudomotor testing, and respiratory responses using respiratory inductive plethysmography. Patients with co-morbidities or medications with potential to influence autonomic testing were excluded.ResultsFifteen patients with a history of concussion were studied. Nine of 15 patients had abnormal cardiovascular responses on autonomic testing, typically excessive postural tachycardia with head-up tilt. Abnormal respiratory patterns were identified in 8 of 9 patients with abnormal autonomic testing and in 3 of 6 patients without other abnormalities on autonomic testing. A number of different respiratory patterns were identified including tachypnea, prolonged apneic episodes, Cheyne-Stokes, and other unusual respiratory patterns.ConclusionWe have identified abnormal respiratory patterns in a series of concussion patients with or without other signs of dysautonomia. Tachypnea has been previously reported as a clinical feature of paroxysmal sympathetic hyperactivity following severe TBI and was present in some patients in this series. The clinical significance and mechanisms involved in the generation of respiratory dysrhythmia require further study, but may be another manifestation of post-concussive dysautonomia.

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