Autonomic Society Research Articles

Assessment of comorbid symptoms in pediatric autonomic dysfunction.

Pediatric patients with autonomic dysfunction and orthostatic intolerance (OI) often present with co-existing symptoms and signs that might or might not directly relate to the autonomic nervous system. Our objective was to identify validated screening instruments to characterize these comorbidities and their impact on youth functioning. The Pediatric Assembly of the American Autonomic Society reviewed the current state of practice for identifying symptom comorbidities in youth with OI. The assembly includes physicians, physician-scientists, scientists, advanced practice providers, psychologists, and a statistician with expertise in pediatric disorders of OI. A total of 26 representatives from the various specialties engaged in iterative meetings to: (1) identify and then develop consensus on the symptoms to be assessed, (2) establish committees to review the literature for screening measures by member expertise, and (3) delineate the specific criteria for systematically evaluating the measures and for making measure recommendations by symptom domains. We review the measures evaluated and recommend one measure per system/concern so that assessment results from unrelated clinical centers are comparable. We have created a repository to apprise investigators of validated, vetted assessment tools to enhance comparisons across cohorts of youth with autonomic dysfunction and OI. This effort can facilitate collaboration among clinical settings to advance the science and clinical treatment of these youth. This effort is essential to improving management of these vulnerable patients as well as to comparing research findings from different centers.

Orthostatic Hypertension: A Newcomer Among the Hypertension Phenotypes.

The prognostic role and the clinical significance of orthostatic hypertension (OHT) remained undefined for long because data were sparse and often inconsistent. In recent years, evidence has been accumulating that OHT is associated with an increased risk of masked and sustained hypertension, hypertension-mediated organ damage, cardiovascular disease, and mortality. Most evidence came from studies in which OHT was defined using systolic blood pressure (BP) whereas the clinical relevance of diastolic OHT is still unclear. Recently, the American Autonomic Society and the Japanese Society of Hypertension defined OHT as an orthostatic systolic BP increase ≥20 mm Hg associated with a systolic BP of at least 140 mm Hg while standing. However, also smaller orthostatic BP increases have shown clinical relevance especially in people ≤45 years of age. A possible limitation of the BP response to standing is poor reproducibility. OHT concordance is better when the between-assessment interval is shorter, when OHT is evaluated using a larger number of BP readings, and if home BP measurement is used. The pathogenetic mechanisms leading to OHT are still controversial and may vary according to age. Excessive neurohumoral activation seems to be the main determinant in younger adults whereas vascular stiffness plays a more important role in older individuals. Conditions associated with higher activity of the sympathetic nervous system and/or baroreflex dysregulation, such as diabetes, essential hypertension, and aging have been found to be often associated with OHT. Measurement of orthostatic BP should be included in routine clinical practice especially in people with high-normal BP.

Creating a data dictionary for pediatric autonomic disorders.

Whether evaluating patients clinically, documenting care in the electronic health record, performing research, or communicating with administrative agencies, the use of a common set of terms and definitions is vital to ensure appropriate use of language. At a 2017 meeting of the Pediatric Section of the American Autonomic Society, it was determined that an autonomic data dictionary comprising aspects of evaluation and management of pediatric patients with autonomic disorders would be an important resource for multiple stakeholders. Our group created the list of terms for the dictionary. Definitions were prioritized to be obtained from established sources with which to harmonize. Some definitions needed mild modification from original sources. The next tier of sources included published consensus statements, followed by Internet sources. In the absence of appropriate sources, we created a definition. A total of 589 terms were listed and defined in the dictionary. Terms were organized by Signs/Symptoms, Triggers, Co-morbid Disorders, Family History, Medications, Medical Devices, Physical Examination Findings, Testing, and Diagnoses. Creation of this data dictionary becomes the foundation of future clinical care and investigative research in pediatric autonomic disorders, and can be used as a building block for a subsequent adult autonomic data dictionary.

Autonomic failure: a neglected presentation of Parkinson's disease

Neurogenic orthostatic hypotension is a fall in blood pressure upon standing due to sympathetic autonomic failure, which can cause orthostatic intolerance and syncope. Pure autonomic failure is a sporadic disorder traditionally defined by the presence of idiopathic neurogenic orthostatic hypotension, usually with signs of neurogenic bladder and bowel dysfunction, but no other neurological features. 1 The Consensus Committee of the American Autonomic Society and the American Academy of NeurologyConsensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. Neurology. 1996; 461470 Crossref PubMed Scopus (974) Google Scholar Neuropathological findings of α-synuclein aggregates in the brainstem and skin autonomic fibres of affected people led researchers to interpret pure autonomic failure as a peculiar α-synucleinopathy limited to the autonomic nervous system, but studies in the past 5 years provided a substantial paradigm shift in our understanding of this disorder. 2 Kaufmann H Norcliffe-Kaufmann L Palma JA et al. Natural history of pure autonomic failure: a United States prospective cohort. Ann Neurol. 2017; 81: 287-297 Crossref PubMed Scopus (148) Google Scholar , 3 Giannini G Calandra-Buonaura G Asioli GM et al. The natural history of idiopathic autonomic failure: the IAF-BO cohort study. Neurology. 2018; 91: e1245-e1254 Crossref PubMed Scopus (14) Google Scholar , 4 Coon EA Mandrekar JN Berini SE et al. Predicting phenoconversion in pure autonomic failure. Neurology. 2020; 95: e889-e897 Crossref PubMed Scopus (10) Google Scholar Up to a third of people with pure autonomic failure develop another α-synucleinopathy, including Parkinson's disease, suggesting that pure autonomic failure might in fact be a premotor presentation thereof. 2 Kaufmann H Norcliffe-Kaufmann L Palma JA et al. Natural history of pure autonomic failure: a United States prospective cohort. Ann Neurol. 2017; 81: 287-297 Crossref PubMed Scopus (148) Google Scholar , 3 Giannini G Calandra-Buonaura G Asioli GM et al. The natural history of idiopathic autonomic failure: the IAF-BO cohort study. Neurology. 2018; 91: e1245-e1254 Crossref PubMed Scopus (14) Google Scholar , 4 Coon EA Mandrekar JN Berini SE et al. Predicting phenoconversion in pure autonomic failure. Neurology. 2020; 95: e889-e897 Crossref PubMed Scopus (10) Google Scholar Importantly, people with pure autonomic failure who progress to Parkinson's disease show a peripheral pattern of lesions in the autonomic nervous system. 2 Kaufmann H Norcliffe-Kaufmann L Palma JA et al. Natural history of pure autonomic failure: a United States prospective cohort. Ann Neurol. 2017; 81: 287-297 Crossref PubMed Scopus (148) Google Scholar , 4 Coon EA Mandrekar JN Berini SE et al. Predicting phenoconversion in pure autonomic failure. Neurology. 2020; 95: e889-e897 Crossref PubMed Scopus (10) Google Scholar Parkinson's disease outside the brain: targeting the autonomic nervous systemPatients with Parkinson's disease present with signs and symptoms of dysregulation of the peripheral autonomic nervous system that can even precede motor deficits. This dysregulation might reflect early pathology and therefore could be targeted for the development of prodromal or diagnostic biomarkers. Only a few objective clinical tests assess disease progression and are used to evaluate the entire spectrum of autonomic dysregulation in patients with Parkinson's disease. However, results from epidemiological studies and findings from new animal models suggest that the dysfunctional autonomic nervous system is a probable route by which Parkinson's disease pathology can spread both to and from the CNS. Full-Text PDF

Editors' Note: Systolic Blood Pressure Postural Changes Variability is Associated With Greater Dementia Risk

In “Systolic Blood Pressure Postural Changes Variability is Associated With Greater Dementia Risk,” Rouch et al. reported that systolic orthostatic hypotension (OHYPO, defined as a fall of ≥15 mm Hg in systolic blood pressure after standing from a sitting position on ≥1/3 visits) and visit-to-visit systolic blood pressure postural changes variability were associated with an increased risk of dementia. There was no association between diastolic OHYPO (a fall of ≥7 mm Hg in diastolic blood pressure) and risk of dementia. Soysal noted that the criteria used differed from those published by the 1996 Consensus Committee of the American Autonomic Society and American Academy of Neurology, which defined OHYPO as a fall of ≥20 mm Hg in systolic blood pressure and/or ≥10 mm Hg in diastolic blood pressure. Soysal further pointed out that systolic OHYPO is associated with frailty, fear of falling, malnutrition, and sarcopenia, all of which are associated with dementia. Rouch et al. responded that they did not use the criteria Soysal cited because they are applicable to the transition from supine-to-standing, which is more hazardous than standing from a sitting position. Instead, they selected their thresholds based on previous large studies and recent literature that these values were associated with 80% sensitivity and 89% specificity. In “Systolic Blood Pressure Postural Changes Variability is Associated With Greater Dementia Risk,” Rouch et al. reported that systolic orthostatic hypotension (OHYPO, defined as a fall of ≥15 mm Hg in systolic blood pressure after standing from a sitting position on ≥1/3 visits) and visit-to-visit systolic blood pressure postural changes variability were associated with an increased risk of dementia. There was no association between diastolic OHYPO (a fall of ≥7 mm Hg in diastolic blood pressure) and risk of dementia. Soysal noted that the criteria used differed from those published by the 1996 Consensus Committee of the American Autonomic Society and American Academy of Neurology, which defined OHYPO as a fall of ≥20 mm Hg in systolic blood pressure and/or ≥10 mm Hg in diastolic blood pressure. Soysal further pointed out that systolic OHYPO is associated with frailty, fear of falling, malnutrition, and sarcopenia, all of which are associated with dementia. Rouch et al. responded that they did not use the criteria Soysal cited because they are applicable to the transition from supine-to-standing, which is more hazardous than standing from a sitting position. Instead, they selected their thresholds based on previous large studies and recent literature that these values were associated with 80% sensitivity and 89% specificity.

Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness : Consensus statement of the European Federation of Autonomic Societies (EFAS) endorsed by the American Autonomic Society (AAS) and the European Academy of Neurology (EAN).

An expert committee was formed to reach consensus on the use of Tilt Table Testing (TTT) in the diagnosis of disorders that may cause transient loss of consciousness (TLOC) and to outline when other provocative cardiovascular autonomic tests are needed. While TTT adds to history taking, it cannot be a substitute for it. An abnormal TTT result is most meaningful if the provoked event is recognised by patients or eyewitnesses as similar to spontaneous ones. The minimum requirements to perform TTT are a tilt table, a continuous beat-to-beat blood pressure monitor, at least one ECG lead, protocols for the indications stated below and trained staff. This basic equipment lends itself to perform (1) additional provocation tests, such as the active standing test carotid sinus massage and autonomic function tests; (2) additional measurements, such as video, EEG, transcranial Doppler, NIRS, end-tidal CO2 or neuro-endocrine tests; (3) tailor-made provocation procedures in those with a specific and consistent trigger of TLOC. TTT and other provocative cardiovascular autonomic tests are indicated if the initial evaluation does not yield a definite or highly likely diagnosis, but raises a suspicion of (1) reflex syncope, (2) the three forms of orthostatic hypotension (OH), i.e. initial, classic and delayed OH, as well as delayed orthostatic blood pressure recovery, (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT is to teach patients with reflex syncope and OH to recognise hypotensive symptoms and to perform physical counter manoeuvres.

Long-COVID postural tachycardia syndrome: an American Autonomic Society statement

COVID-19 is a global pandemic that has had a devastating effect on the health and economy of much of human civilization. While the acute impacts of COVID-19 were the initial focus of concern, it is becoming clear that in the wake of COVID-19, many patients are developing chronic symptoms that have been called Long-COVID. Some of the symptoms and signs include those of postural tachycardia syndrome (POTS). Understanding and managing long-COVID POTS will require a significant infusion of health care resources and a significant additional research investment. In this document from the American Autonomic Society, we outline the scope of the problem, and the resources and research needed to properly address the impact of Long-COVID POTS.

Autonomic function testing in the COVID-19 pandemic: an American Autonomic Society position statement.

COVID-19 is a global pandemic that is wreaking havoc with the health and economy of much of human civilization. In this document from the American Autonomic Society, we identify the potential risks of exposure to patients, physicians, and allied healthcare staff. We provide guidance for conducting autonomic function testing safely in this environment.

Autonomic medical practice viewed through the lens of physician-rating websites.

To survey online patient ratings of physicians practicing autonomic medicine. Online patient review scores of US physician members of the American Autonomic Society were compared to scores of US physicians in general and to indices of professional expertise. The 68 autonomic physicians who had been rated scored 3.80 ± 0.82 on a composite five-star scale, in which 5 was the most favorable score, as compared to 3.84 ± 0.98 for all US physicians (no significant difference, p = 0.8). Scores correlated inversely with autonomic physicians' number of scientific publications (p = 0.01), h-index (p = 0.01), and m-index (p = 0.0004). Scores of diplomates of the United Council for Neurologic Subspecialties certified in autonomic disorders or who were ranked in the top 1% of US physicians by Castle Connolly had scores comparable to those of other autonomic physicians. Scores did not correlate with physician gender, number of reviews, or years in practice. A quality patient experience, accurate diagnosis, and appropriate treatment are goals shared by patients and autonomic specialists. In this study, patient reviews of autonomic physicians were comparable to those of physicians across specialties. Metrics of greater autonomic expertise were associated with equal or lower patient satisfaction scores. In conclusion, compiled subjective reviews are a useful but incomplete indicator of autonomic physician quality and expertise. An ideal profile would combine clinical and nonclinical indicators of professional competence. Reliable information is needed to empower autonomic patients to make truly informed healthcare choices.

Human papillomavirus (HPV) vaccine and autonomic disorders: a position statement from the American Autonomic Society.

Human papillomavirus (HPV) vaccination has been anecdotally connected to development of dysautonomia, chronic fatigue, complex regional pain syndrome and postural tachycardia syndrome. To critically evaluate a potential connection between HPV vaccination and above noted conditions. We reviewed the literature containing the biology of the virus, pathophysiology of infection, epidemiology of associated cancers, indications of HPV vaccination, safety surveillance data and published reports linking HPV vaccination to autonomic disorders. At this time the American Autonomic Society finds that there are no data to support a causal relationship between HPV vaccination and CRPS, chronic fatigue, POTS or other forms of dysautonomia. Certain conditions are prevalent in the same patient populations that are vaccinated with the HPV vaccine (peri-pubertal males and females). This association, however, is insufficient proof of causality.

Human papillomavirus (HPV) vaccine and autonomic disorders: a position statement from the American Autonomic Society.

Human papillomavirus (HPV) vaccination has been anecdotally connected to the development of dysautonomia, chronic fatigue, complex regional pain syndrome and postural tachycardia syndrome. To critically evaluate a potential connection between HPV vaccination and the above-noted conditions. We reviewed the literature containing the biology of the virus, pathophysiology of infection, epidemiology of associated cancers, indications of HPV vaccination, safety surveillance data and published reports linking HPV vaccination to autonomic disorders. At this time, the American Autonomic Society finds that there are no data to support a causal relationship between HPV vaccination and CRPS, chronic fatigue, and postural tachycardia syndrome to other forms of dysautonomia. Certain conditions are prevalent in the same populations that are vaccinated with the HPV vaccine (peri-pubertal males and females). This association, however, is an insufficient proof of causality.

Management of supine hypertension in patients with neurogenic orthostatic hypotension: scientific statement of the American Autonomic Society, European Federation of Autonomic Societies, and the European Society of Hypertension.

: Supine hypertension commonly occurs in patients with neurogenic orthostatic hypotension due to autonomic failure. Supine hypertension promotes nocturnal sodium excretion and orthostatic hypotension, thus, interfering with quality of life. Perusal of the literature on essential hypertension and smaller scale investigations in autonomic failure patients also suggest that supine hypertension may predispose to cardiovascular and renal disease. These reasons provide a rationale for treating supine hypertension. Yet, treatment of supine hypertension, be it through nonpharmacological or pharmacological approaches, may exacerbate orthostatic hypotension when patients get up during the night. Fall-related complications may occur. More research is needed to define the magnitude of the deleterious effects of supine hypertension on cardiovascular, cerebrovascular, and renal morbidity and mortality. Integration of more precise cardiovascular risk assessment, efficacy, and safety data, and the prognosis of the underlying condition causing autonomic failure is required for individualized management recommendations.

Abstracts of the 1st meeting of the Austrian Autonomic Society - Otto Loewi Gesellschaft.

Abstracts of the 1st meeting of the Austrian Autonomic Society - Otto Loewi Gesellschaft.

Familial Autonomic Ganglionopathy Caused by Rare CHRNA3 Genetic Variants: Novel Genetic Cause of Neurogenic Orthostatic Hypotension

Background: To identify and determine the molecular basis of a new Mendelian cause of familial neurogenic orthostatic hypotension (nOH). Method: The proband developed disabling nOH at 39 yrs of age. He was evaluated at the Vanderbilt Autonomic Dysfunction Center and was diagnosed with severe autonomic failure and small nonreactive pupils. Plasma norepinephrine levels were abnormally low, and dopamine levels were within normal limits. Of note, his sister had onset of nOH in her late teens. Their parents, brother and the proband's three children were healthy. Findings: Patient was referred to the UDN where whole exome sequencing of DNAs from the proband and his affected sister showed that both were compound heterozygotes for c.907_908delCT (p.L303Dfs*115) /c.688G>A (p.D230N) variants in the acetylcholine receptor, neuronal nicotinic, alpha 3 subunit (CHRNA3) gene. CHRNA3 is a subunit of nicotinic acetylcholine receptors (nAChRs) that regulates blood pressure through modulation of synaptic transmission in the autonomic ganglia. The frameshift (fs) and missense CHRNA3 variants were inherited from the sibs' mother and father, respectively, and their non-affected brother was a nl/p.D230N heterozygote. The fs variant is obviously pathogenic and the p.D230N variant is predicted to be damaging (SIFT)/probably damaging (PolyPhen2). Furthermore, we predict from structural modeling that the p.D230N variant lies on the interface between CHRNA3 and other nAChR subunits and that it would destabilize the nAChR pentameric complex. Interestingly, homozygous knock-out mice without detectable CHRNA3 had autonomic failure and dilated pupils. In humans, the presence of acquired nAChR autoantibodies against the alpha 3 subunit is associated with nOH and non-reactive pupils. Interpretation: We report sibs affected with autonomic failure and miosis of unknown etiology who are compound heterozygotes for CHRNA3 variants that co segregate with and have predicted effects on nAChR structure that suggest they likely cause this family's nOH. Funding Statement: The study was supported by Vanderbilt CTSA grant 1UL1 RR000445 from NACTS/NIH and NIH/NINDS U54 30 NS065736; JAP, JDC, JHN and RH was supported in part by NIH Common Fund and NIH/NHGRI UO1HG007674. Declaration of Interests: C.A.S. has received research grant from Doris Duke Foundation. I.B. and C.A.S. received grant support from Office of Orphan Products Development. Food and Drug Administration, Grant #FD-R-04778-01-A3. C.A.S. has received speaker honorarium from Lundbeck Pharmaceuticals. I.B., and C.A.S. received consulting honoraria from Lundbeck and Theravance Biopharma. C.A.S is member of the Board for the American Autonomic Society. Ethics Approval Statement: Both affected sibs were referred to the Undiagnosed Diseases Network (UDN). They were enrolled at the Vanderbilt clinical site, and they consented to the study (IRB protocol NHGRI 15-HG0130) before any genetic studies were done.

Study ii- beighton score and delta heart rate (Δ HR) correlation in patients with ehlers danlos syndrome (EDS) and postural orthostatic tachycardia syndrome (POTS)

Introduction: Postural Orthostatic Tachycardia Syndrome (POTS) affects primarily young women. A subset of POTS patients also had EDS.We have conducted Study I with POTS and EDS demonstrated that In Patients with EDS, B-score predicted delta heart rate with patients with higher Beighton score having higher delta heart rate, there were no significant association between POTS and EDS(p > 0.05) presented in American Autonomic society. We want to take the study further and conduct the research in large cohort of patients. AIM: The purpose of this research is to understand the relation of change in Heart rate during first 10 minutes of tilt table and Beighton score (B-Score) in patients with both EDS and POTS. Methods: 353 Patients referred to our clinic from January 2014 to April 2015 with POTS. Patients underwent a tilt table test in Autonomic Lab and B-Score was measured in all the patients. Patients were divided in to two groups Group 1 (B-Score 4 to 6), Group 2 (B-score 7 to 9). Results: 353 Patients with EDS and POTS were included. Out of 353 patients 94% are females (n = 331, age 27.28 ± 18.24), 6% are males (n = 22, age 32.16 ± 13.24), Group1 (B-Score 4-6, n = 64, delta HR 43.81 ± 15.42 bpm) and Group2 (B-Score 7 to 9, n = 289, delta HR 50.14 ± 18.88 bpm) P Value < 0.01. Conclusion: Our study II research results demonstrated that POTS and EDS have significant association. Patient with higher Beighton score has higher delta heart rate.

2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia, and Vasovagal Syncope

This international consensus statement was written by experts in the field who were chosen by the Heart Rhythm Society, in collaboration with representatives from the American Autonomic Society (AAS), the American College of Cardiology (ACC), the American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), the European Heart Rhythm Association (EHRA), the Pediatric and Congenital Electrophysiology Society (PACES), and the Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE)-Latin American Society of Cardiac Pacing and Electrophysiology. This document is intended to help front-line cardiologists, arrhythmia specialists, and other health care professionals interested in the care of patients who present with presumed postural tachycardia syndrome (POTS), inappropriate sinus tachycardia (IST), and vasovagal syncope (VVS). It is not intended to be a comprehensive narrative review, as excellent reviews, chapters, and entire volumes have appeared recently.1–3 This document has 3 objectives: (1) establish working criteria for the diagnosis of POTS, IST, and VVS; (2) provide guidance and recommendations on their assessment and management; and (3) identify key areas in which knowledge is lacking, to highlight opportunities for future collaborative research efforts. To maintain this pragmatic focus, we excluded several related topics, including a detailed approach to syncope and other syndromes of transient loss of consciousness, the impact of syncope on other disorders, most orthostatic hypotension syndromes, the effects of the autonomic system on arrhythmias, the use of syncope scores or syncope units, and recommendations on training programs and staffing criteria. A number of sections contain very brief reviews, given that the material has recently been covered elsewhere. We refer readers to the excellent European Society of Cardiology guidelines2 and related recent reviews.1,4 The writing group aimed to provide a succinct, evidence-based document at a uniform level, rather than a comprehensive narrative review. As much as possible, we made recommendations based on published evidence. There was a wide range in terms of the level of evidence available, and we included the highest-level evidence for each section. Inevitably, this led to heterogeneity in the level of evidence included. Each section, indeed the entire document, is a compromise among clinical need, succinctness, clarity, and level of evidence. The specific wording of definitions, recommendations, and the choice of references were the result of prolonged debate, consensus-seeking, and repeated votes. Each section was drafted by compact writing groups with 3–5 members who completed the first versions and developed preliminary recommendations. The group assignments were based on individual interests and expertise. The recommendations and text underwent iterative revisions to resolve differences, increase clarity, and align the document format with that recommended by the American College of Cardiology.5 All members of the writing group and peer reviewers provided disclosure statements of all relationships that might present real or perceived conflicts of interest, as shown in the Appendices. The recommendations and definitions in this document are based on the consensus of the full writing group following the Heart Rhythm Society’s process for establishing consensus-based guidance for clinical care. To identify consensus, we conducted surveys of the entire writing group, using a predefined threshold for agreement as a vote of >75% on each recommendation. An initial failure to reach consensus was resolved by subsequent discussion and re-voting. The final minimum consensus was 76% and the mean was 94%. The consensus recommendations in this document use the commonly used class I, IIa, IIb, and III classifications and the corresponding language according to the most recent statement of the American College of Cardiology.6 Class I is a strong recommendation, denoting benefit greatly exceeding risk. Class IIa is a somewhat weaker recommendation, denoting benefit probably exceeding risk, and class IIb denotes benefit equivalent or possibly exceeding risk. Class III is a recommendation against a specific treatment, because either there is no net benefit or there is net harm. Level A denotes the highest level of evidence, usually from multiple clinical trials with or without registries. Level B evidence is of a moderate level, either from randomized trials (B–R) or well-executed nonrandomized trials (B-NR). Level C evidence is from weaker studies with significant limitations, and level E is simply a consensus opinion in the absence of credible published evidence. When considering the guidance provided in this document, it is important to remember that there are no absolutes with regard to many clinical situations. The writing group was struck by the large number of issues lacking high-level evidence. To this end, the document provides evidence-informed recommendations, striking a balance between the need for recommendations and the availability of evidence. Health care providers and patients need to jointly make the final decision regarding care in light of their individual circumstances.

Five Things to Know About Orthostatic Hypotension and Aging

To the Editor: Orthostatic hypotension is an important condition to diagnose and manage in elderly adults. This letter provides a concise, evidence-based update on five things a clinician should know about orthostatic hypotension and aging. A large prospective study identified the presence of OH as an independent risk factor for recurrent falls in elderly adults (aged ≥60) who had experienced falls in the last 6 months (relative risk = 2.6; 95% confidence interval = 1.7–4.6).1 Because falls in elderly adults can result in hip fracture, head trauma, and functional decline, clinicians should screen for and manage OH in these high-risk individuals. There is also recent evidence that OH may contribute to cognitive decline that can occur with aging.2 The Consensus Committee of the American Autonomic Society and the American Academy of Neurology have defined OH as a sustained reduction of systolic blood pressure (SBP) of 20 mmHg or of diastolic blood pressure (DBP) of 10 mmHg or more within 3 minutes of standing.3 However, the most-recent 2011 consensus statement update includes definitions for other variants of OH, including initial and delayed OH. Initial OH was defined as a transient blood pressure decrease (≥40 mmHg SBP or ≥20 mmHg DBP) within 15 seconds of standing, and delayed OH was defined as OH that occurs more than 3 minutes after a postural challenge.4 These types of OH need to be considered when screening high-risk individuals, especially because delayed OH may be more difficult to detect in the setting of clinical time restrictions. An observational study of 342 individuals aged 75 and older found the prevalence of OH in those receiving zero, one, two, or three or more potentially causative medications was 35%, 58%, 60%, and 65%, respectively.5 High-risk medications were identified as antihypertensives, diuretics, antidepressants, and alpha-blocker prostate medications.5 Diseases affecting the central (e.g., Parkinson's disease) and peripheral (e.g., diabetes mellitus) nervous systems are more prevalent and increase the risk of OH in elderly adults. OH associated with type 1 and type 2 diabetes mellitus is primarily due to peripheral neuropathy with damage of the small diameter fibers, for which poor glycemic control is an established risk factor.6 OH was present in 18.2% of individuals aged 65 and older in a large observational study, of whom 87% were asymptomatic.7 Even with profound OH (drop in systolic blood pressure ≥60 mmHg), up to 43% had typical symptoms (e.g., dizziness, visual symptoms, shoulder “coat-hanger” pain), whereas 33% had no symptoms at all, and 24% had atypical symptoms including backache and lower extremity discomfort.8 Start by correcting reversible causes (e.g., anemia, hypovolemia), initiating nonpharmacological measures, and removing or reducing high-risk medications when possible; if these measures fail, pharmacological management of OH should be considered (Table 1). The goal of treatment is to improve the individual's functional capacity and quality of life and to prevent injury, rather than to achieve a target blood pressure.9 Target water intake to 2–2.5 L/d.10 When symptomatic, rapidly drinking 500 mL of water can quickly expand plasma volume.10 Midodrine 2.5–10 mg orally up to three times per day.10 Short-acting alpha adrenomimetic (up to 4 hours); acts through direct blood vessel constriction. Conflict of Interest: The authors have no conflict of interest with the contents of this manuscript. Dr. P. Mills received research salary funding from the Vancouver Coastal Health Research Institute, TD Grants in Medical Excellence, and VGH & UBC Hospital Foundation during the writing of this manuscript. Author Contributions: All authors contributed equally to the conception and writing of this manuscript. Sponsor's Role: None.

REFLEKSI PERUBAHAN SOSIAL MASYARAKAT PERKOTAAN DI INDONESIA DALAM IKLAN DI MEDIA CETAK PERIODE 1990 – 2000

A modern industrialist society is an ideal society from economic growth theory by W.W. Rostow. Indonesia during the New Order government applied this theory to a program called Pembangunan Lima Tahun (Five Years Development). As the same as economic growth theory, the New Order's program also had a modern, autonomic and prosperous society as an ideal society. Even this program did not complete properly, brought a wealthy society in a part of the urban society as a positive result. This change, had influenced the urban society's lifestyle. In major of urban society, wealth is a one motive to have a hedonist lifestyle. Advertising as the component of marketing had an important part in the industrial process. In order to do its persuasive function, sometimes advertising creative applied urban lifestyle approach to got consumers interest. In the other hand, urban lifestyle could be identified through print ads visualization.Keyword : Social Change, Indonesian Tone, and Printer Ad

Orthostatic hypotension in very old individuals living in nursing homes

Orthostatic hypotension has a prognostic role in determining cardiovascular and all-cause mortality. The aim of this study was to assess the prevalence of orthostatic hypotension and its association with blood pressure (BP) levels, arterial stiffness, cardiovascular and metabolic disorders and medication in individuals aged 80 years and over living in nursing home. In 994 individuals (77% women, mean age 88±5 years), the presence of orthostatic hypotension was tested according to American Autonomic Society and American Academy of Neurology guidelines. Arterial stiffness was evaluated with carotid-femoral pulse wave velocity (cf-PWV), peripheral to central pulse pressure amplification (PPA) and augmentation index. Cardiovascular and metabolic disorders as well as medications were recorded from patients' medical records. The prevalence of orthostatic hypotension was 18%. Treated hypertensive patients with SBP 140 mmHg or less had a lower prevalence of orthostatic hypotension than patients with SBP more than 140 mmHg (respectively, 13 vs. 23%; P < 0.001). Individuals with orthostatic hypotension exhibited higher brachial and central PP than individuals without orthostatic hypotension (respectively, 69±18 vs. 65±16 mmHg and 57±17 vs. 54±15 mmHg; P < 0.01). In these same individuals, a significant increase in augmentation index (31.1±14.0 vs. 27.2±13.6%; P < 0.01), but not in cf-PWV or in PPA, was observed. Individuals with orthostatic hypotension were treated more frequently with β-blockers and less frequently with angiotensin receptor blockers or nitrates than individuals without orthostatic hypotension (P < 0.05 for both). Contrary to the general belief, elderly individuals with well controlled BP (SBP < 140 mmHg) show lower orthostatic hypotension, thus constituting a complementary argument for efficaciously treating hypertension in these individuals.

前庭血管系反射と起立性循環調節

There is little definitive evidence of the clinical significance of the vestibular-cardiovascular reflex in humans, despite the fact that the vestibular system is known to contribute to cardiovascular control in animals. Our first finding in this paper was that about 10% of 1479 dizzy patients in our hospital met the criteria for orthostatic hypotension (OH) set by the American Autonomic Society (2011). Second, a positive rate of the criteria for the OH was significantly higher in patients with abnormal subjective visual vertical (SVV) than patients with normal SVV, however abnormality of canal function did not affect the positive rate of the OH. Third, we classified 248 dizzy patients aged<65 into three groups based on their vestibular evoked myogenic potential (VEMP) responses; absent VEMP, asymmetry VEMP and normal VEMP. In order to investigate the effect of the otolith disorder, which was estimated by the VEMP, on the orthostatic blood pressure responses, the subjects' systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate were monitored during the orthostatic test after standing up. The male patients in the absent VEMP group presented a significant drop in their DBP at 1 min. after standing up (p<0.05) without any change in SBP. In the entire group of participants, a total of 19.6% of the patients in the absent VEMP group fulfilled the criteria for orthostatic hypotension (OH), which was significantly larger than the 8.6% of patients in the normal VEMP group and the 7.2% in the asymmetry VEMP group (P<0.05). Our results suggest that vestibular disorders due to the dysfunction of otolith organs provoke OH.