Abstract
Background: Neurohumoral compensatory mechanisms play an important role in stabilizing the functional activity of patients with heart failure using the arms of autonomic nervous system. Orthostatic Hypotension (OH) is one of the most incapacitating symptoms of Cardiac Autonomic Dysfunction (CAD). OH can include sympathetic withdrawal which in turn leads to marked disability and deterioration of heart failure symptoms. Progressive Autonomic Dysfunction (AD) associated with progressive deterioration and impact on mortality of many diseases as hypertension, diabetes and other chronic diseases. The idea of using (OH) as a bed-side simple test expecting the risk of deterioration of cardiac function and furthermore on mortality open a gateway for preventive medicine and care to these group of patients. For more confidential prove, studying subjective and objective factors in heart failure patients became necessary to support these idea. Methods and Results: Sixty-Four patients with known history of heart failure were collected. All patients taking the fixed regiment of 4 drugs (diuretic, ACE inhibitor, Digitalis and B-blocker) in appropriate tolerated doses for two weeks prior to the study. History taking and all routine investigations were done for all patients. Grouping is based upon wither they have (OH) or not. Group-A found to have normal Bp response to standing; they were 24 patients (18 male and 6 female) of mean Age (45 ± 8 years). Group-B discovered to have significant (OH) and was 22 patients (16 males and 6 females) of mean Age (43 ± 4 years). The first Clinical and Echocardiographic examination was done and considered as a base-line characteristic. Then, a Call-back after 6 months for follow-up and second visit examination is recorded. Furthermore, every patient was advised to report changes in his clinical symptoms in a note-book describing five main items to answer a questionnaire at the end of the study involves [times of admission to hospital, need for treatment modification, numbers of paroxysmal nocturnal dysnea, numbers of arrhythmic episodes and manifest lower limb edema]. At the end of the study, statistical methods are used to clarify the changes in their data and detect deterioration of cardiac functions by Echocardiographic results and their answers to the questionnaire. In the first visit, comparison of demographic, clinical and Echocardiographic data revealed no significant variations—odd values are excluded and the remaining 46 patients are then tested for their Bp response to standing and classified into two groups. Group-A (normal Bp response) and Group-B (having orthostatic hypotension). Group-A were 24 patients (18 male and 6 female) of mean Age (45 ± 8 years). Group-B were 22 patients (16 males and 6 females) of mean Age (43 ± 4 years). In the second visit (6-month later), divergence of data is observed and was statistically significant. Group-B was found to have a lower EF% and FS% (p = 0.01), a lower Dp/Dt (p = 0.01) and a higher Tie-Index and MR-jet area (p = 0.01). This means that, patients having orthostatic hypotension underwent significant deterioration of cardiac functions after a period of six-months. Indeed, the questionnaire proved frequent times of hospital admissions, paroxysmal nocturnal dysnea, need for treatment modification, arrhythmias and lower limb edema in group-B. Discussion: The present study conclude that, heart failure-patients having orthostatic
Highlights
The Central blood volume is abruptly reduced when one stands up
As Autonomic Dysfunction (AD) increases in severity, it leads to peripheral autonomic neuropathy, Diabetic Autonomic Neuropathy (DAN), and, symptoms associated with end-organ failure
Orthostasis may be difficult to detect and diagnose because both Autonomic Nervous System (ANS) branches are actively changing in a coordinated fashion during a normal response to postural change: the parasympathetics decrease or withdrawal and the sympathetics increase or surge [22,24,25]
Summary
A complex set of compensatory physiological mechanisms occur to maintain the upright posture These include reflex responses in the cardiovascular and autonomic nervous systems as well as activation of the skeletal muscle and respiratory pumps. As AD increases in severity, it leads to peripheral autonomic neuropathy, Diabetic Autonomic Neuropathy (DAN), and, symptoms associated with end-organ failure. This final stage is known as CAN [19]. Orthostasis may be difficult to detect and diagnose because both Autonomic Nervous System (ANS) branches are actively changing in a coordinated fashion during a normal response to postural change: the parasympathetics decrease or withdrawal and the sympathetics increase or surge [22,24,25]. Because CAN is treatable in all stages and because orthostasis is often treatable in parallel with the other effects of AD [26], the American Diabetes Association and the American Heart Association have recommended testing diabetic patients more than once per year to detect symptoms as early as possible to slow progression of AD [27,28]
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