The role of central autonomic nervous system dysfunction in Takotsubo syndrome: a systematic review

Introduction Takotsubo syndrome (TTS), also known as stress cardiomyopathy or “broken heart” syndrome, is a mysterious condition that often mimics an acute myocardial infarction. Both are characterized by left ventricular systolic dysfunction. However, this dysfunction is reversible in the majority of TTS patients. Purpose Recent studies surprisingly demonstrated that TTS, initially perceived as a benign condition, has a long-term prognosis akin to myocardial infarction. Therefore, the health consequences and societal impact of TTS are not trivial. The pathophysiological mechanisms of TTS are not yet completely understood. In the last decade, attention has been increasingly focused on the putative role of the central nervous system in the pathogenesis of TTS. Conclusion In this review, we aim to summarize the state of the art in the field of the brain–heart axis, regional structural and functional brain abnormalities, and connectivity aberrancies in TTS.

Autonomic Nervous System Dysfunction Is Associated With Re-hospitalization in Pediatric Septic Shock Survivors

Objective: Re-hospitalization after sepsis can lead to impaired quality of life. Predictors of re-hospitalization could help identify sepsis survivors who may benefit from targeted interventions. Our goal was to determine whether low heart rate variability (HRV), a measure of autonomic nervous system dysfunction, is associated with re-hospitalization in pediatric septic shock survivors.Materials and Methods: This was a retrospective, observational cohort study of patients admitted between 6/2012 and 10/2020 at a single institution. Patients admitted to the pediatric intensive care unit with septic shock who had continuous heart rate data available from the bedside monitors and survived their hospitalization were included. HRV was measured using age-normalized z-scores of the integer HRV (HRVi), which is the standard deviation of the heart rate sampled every 1 s over 5 consecutive minutes. The 24-h median HRVi was assessed on two different days: the last 24 h of PICU admission (“last HRVi”) and the 24-h period with the lowest median HRVi (“lowest HRVi”). The change between the lowest and last HRVi was termed “delta HRVi.” The primary outcome was re-hospitalization within 1 year of discharge, including both emergency department encounters and hospital readmission, with sensitivity analyses at 30 and 90 days. Kruskal-Wallis, logistic regression, and Poisson regression evaluated the association between HRVi and re-hospitalizations and adjusted for potential confounders.Results: Of the 463 patients who met inclusion criteria, 306 (66%) were re-hospitalized, including 270 readmissions (58%). The last HRVi was significantly lower among re-hospitalized patients compared to those who were not (p = 0.02). There was no difference in the lowest HRVi, but patients who were re-hospitalized showed a smaller recovery in their delta HRVi compared to those who were not re-hospitalized (p = 0.02). This association remained significant after adjusting for potential confounders. In the sensitivity analysis, a smaller recovery in delta HRVi was consistently associated with a higher likelihood of re-hospitalization.Conclusion: In pediatric septic shock survivors, a smaller recovery in HRV during the index admission is significantly associated with re-hospitalization. This continuous physiologic measure could potentially be used as a predictor of patients at risk for re-hospitalization and lower health-related quality of life.

Impaired heart rate recovery may predict radial artery spasm in patients undergoing coronary angiography via radial access

Objectives: Radial artery spasm (RAS) is associated with several pathophysiological pathways, including endothelial and autonomic dysfunction, and causes failed coronary interventions. Heart rate recovery (HRR) is a simple measurement of autonomic nervous system dysfunction. We aimed to investigate the relationship between HRR and RAS during coronary angiography (CA) in the present study. Patients and Methods: This study included 167 patients (mean age 54.6 ± 8.2, 131 males) who underwent a treadmill stress test (TST) according to the Bruce protocol before trans-radial CA. HRR in the first minute (HRR1) was calculated as the difference between peak heart rate and heart rate one minute after the TST. Patients were divided into two groups according to the presence of RAS. Results: Among the study population, RAS developed in 26 patients (15.5%). HRR1 and HRR in the third minute (HRR3) were lower in the RAS group. Also, the abnormal HRR1 rate was higher in the RAS group (35.5% vs. 76.9%, p < 0.001). Total procedural time, more than one puncture attempt, more than one catheter use, fluoroscopy time, radiation exposure, contrast volume was higher in the RAS group. Female gender, total procedural time, more than one catheter use, and abnormal HRR1 were independent predictors of RAS. Conclusion: The current data suggest that a significant relationship was found between abnormal HRR1 and RAS. HRR, a simple autonomic dysfunction parameter, can provide additional information regarding the success of radial procedures.

Congenital central hypoventilation syndrome: a life-threatening cause of neonatal apnoea

Congenital central hypoventilation syndrome (CCHS) is an uncommon genetic disease characterised by an autonomic nervous system dysfunction that affects ventilatory homeostasis. Involvement of other systems is also described, mainly cardiovascular, gastrointestinal and central nervous systems. We describe a rare case of CCHS diagnosed in a term newborn who presented with persistent apnoea in the first hours of life. After an exhaustive aetiological study excluding primary pulmonary, cardiac, metabolic and neurological diseases, this diagnosis was confirmed by a paired-like homeobox 2B gene sequence analysis. During hospitalisation, ventilation was optimised and multidisciplinary follow-up was initiated, including genetic counselling. At 2 months old, the child was discharged under non-invasive ventilation during sleep. This case illustrates the importance of early diagnosis, including genetic study and advances in home ventilation. These factors allow early hospital discharge and timely multidisciplinary intervention, which is crucial for patients’ quality of life and outcome optimisation.

The management of tetanus in adults in an intensive care unit in Southern Vietnam

Background: Tetanus remains common in many low- and middle-income countries (LMICs) yet the evidence base guiding management of this disease is extremely limited, particularly with respect to contemporary management options. Sharing knowledge about practice may facilitate improvement in outcomes elsewhere. Methods: We describe clinical interventions and outcomes of 180 adult patients ≥16 years-old with tetanus enrolled in prospective observational studies at a specialist infectious diseases hospital in Southern Vietnam. Patients were treated according to a holistic management protocol encompassing wound-care, antitoxin, antibiotics, symptom control, airway management, nutrition and de-escalation criteria. Results: Mortality rate in our cohort was 2.8%, with 90 (50%) patients requiring mechanical ventilation for a median 16 [IQR 12-24] days. Median [IQR] duration of ICU stay was 15 [8-23] days. Autonomic nervous system dysfunction occurred in 45 (25%) patients. Hospital acquired infections occurred in 77 (43%) of patients. Conclusion: We report favourable outcomes for patients with tetanus in a single centre LMIC ICU, treated according to a holistic protocol. Nevertheless, many patients required prolonged intensive care support and hospital acquired infections were common.

Progress in Understanding Ferroptosis and Its Targeting for Therapeutic Benefits in Traumatic Brain and Spinal Cord Injuries

Acute central nervous system (CNS) trauma, including spinal cord injury (SCI) and traumatic brain injury (TBI), always leads to severe sensory, motor and autonomic nervous system dysfunction due to a series of processes, including cell death, oxidative stress, inflammation, and excitotoxicity. In recent years, ferroptosis was reported to be a type of programmed cell death characterized by the consumption of polyunsaturated fatty acids and the accumulation of membrane lipid peroxides. The processes that induce ferroptosis include iron overload, imbalanced glutathione metabolism and lipid peroxidation. Several studies have indicated a novel association of ferroptosis and acute CNS trauma. The present paper reviews recent studies of the occurrence of ferroptosis, stressing the definition and process of ferroptosis and metabolic pathways related to ferroptosis. Furthermore, a summary of the existing knowledge of the role of ferroptosis in CNS trauma is presented. The aim here is to effectively understand the mechanisms underlying the occurrence of ferroptosis, as well as the relevant effect on the pathophysiological process of CNS trauma, to present a novel perspective and frame of reference for subsequent investigations.

The Heart of an Endurance Athlete: Impact of and Recovery After an Ultra-Endurance Event.

Background: Acute bouts of ultra-endurance exercise may cause an acute reduction in cardiac function, causing a physiological cascade which releases cardiac biomarkers. This study set out to determine the cardiac stress and recovery of participation in a three-day ultra-endurance mountain biking event of athletes using heart rate variability (HRV) as an outcome measure. Sixteen healthy participants (male and female) participating in a three-day ultra-endurance mountain biking event underwent a five-minute resting electrocardiography (ECG) recording in a supine position. Heart rate variability measurements were recorded two days before the race (baseline testing), after each race day, and at 24-hour post-event (recovery). Results: Time-domain and frequency domain measures showed significant (p≤0.05) changes from baseline in HRV parameters after each race day. The significant changes in HRV parameters reflected an increase in sympathetic activity after each day of the event. Our data revealed that the mean HR and RR variability variables did not return to baseline value after 24-hours of recovery, reflecting autonomic nervous system dysfunction, and that changes persisted for at least 24-hours post-event.Conclusion: Our study shows that competing in an ultra-endurance mountain bike event led to diminished vagal activity and a decrease in HRV throughout the event and persisted for at least 24-hours post-event. The body was under continuous sympathetic dominance during rest as well as during each day of racing, implying each race day can be considered a physiological stress. This may, in turn, cause a disturbance in homeostasis and an increase in autonomic nervous system dysfunction. This has implications for further research, including dysrhythmia risk, and monitoring of athletes in advising a return to strenuous activity.