Presence Of Orthostatic Hypotension Research Articles

Incidence and risk factors for non-cardiac syncope in a cohort of patients addressing an accredited Arterial Hypertension Center: the Innocent Study.

Hypotensive susceptibility in hypertensive patients could facilitate orthostatic hypotension, syncope and fall. The aim of this study was to identify incidence, clinical form, complications and risk factors for non-cardiac syncope in a cohort of hypertensive patients. This is an observational, case-controlled, retrospective study carried out on 168 patients, evaluated at the Hypertension Center of the University Hospital of Parma (Italy). Based on the presence of episodes of syncope during the six months prior to enrolment, we identified cases and controls and then we compared them to personal data, comorbidities, current drug regimens, presence of orthostatic hypotension, office and ambulatory blood pressure monitoring (ABPM) blood pressure (BP) values. In patients with previous syncopal episodes (29.8% of total), we more frequently found female gender, comorbidities associated with autonomic dysfunction, diuretics and non-CV drugs potentially associated with hypotension in their current drug regimen, orthostatic hypotension and lower office and ABPM BP values. To identify hypertensive patients at higher risk for syncope and falls, physicians should focus on comorbidities and current drug regimens, systematically perform an active standing test to identify orthostatic hypotension, employ ABPM to compare BP values with the pre-established target and highlight systolic BP drops and abnormalities suggesting concomitant autonomic dysfunction. The modulation of antihypertensive therapy is an effective tool to counteract the risk of non-cardiac syncope, with possible trauma or other negative influences.

Heart rate variability and its association with symptoms of orthostatic hypotension in spinal cord injury

Context/objective To assess differences in autonomic function using heart rate variability (HRV) parameters between people with and without orthostatic hypotension (OH), and to determine symptoms of OH in people with spinal cord injury (SCI). Methods R-R interval and blood pressure (BP) data were recorded using Finometer PRO® in both the supine position and at a 60-degree tilt using a tilt table, each lasting for 6 minutes. R-R interval data were processed using the Kubios HRV analysis software to convert R-R interval into time and frequency domains for further analysis. Results Compared to the non-OH group, the SCI group with OH exhibited lower values for root mean square of the successive differences (RMSSD) and standard deviation of normal-to-normal interval (SDNN), along with an elevated heart rate during tilt-up. Participants with OH symptoms had a lower average heart rate in the supine and 60-degree positions compared to asymptomatic participants. Logistic regression analysis indicated that SDNN in the supine position correlated with the presence of OH, and that the mean heart rate in the 60-degree position was related to the presence of symptoms. Conclusions Differences in HRV parameters were observed in people with SCI and OH, suggesting a reduced parasympathetic activity in the supine position, likely as a response to maintain homeostasis in BP regulation. Despite the presence or absence of OH symptoms, there was no difference in HRV parameters. This finding suggests that autonomic function may not be the primary determinant of these symptoms, with other factors likely being more influential.

Associations of Orthostatic Hypotension and Frailty With Dementia and Mortality in Older Adults: A Population-Based Cohort Study.

This study aimed to assess the associations of orthostatic hypotension (OH), in the presence or absence of frailty, with dementia and mortality in older adults. We conducted a 15-year population-based cohort study including 2703 baseline dementia-free individuals from the Swedish National Study on Aging and Care in Kungsholmen. At baseline, OH was defined as a decline in systolic/diastolic blood pressure ≥20/10mm Hg 1 minute after standing up from a supine position. Frailty status was defined following Fried's frailty phenotype. Dementia was diagnosed following the Diagnostic and Statistical Manual of Mental Disorders-fourth edition criteria. Multistate flexible parametric survival models were used to estimate associations of OH and frailty with dementia and mortality. Robust people with OH (adjusted hazard ratio [HR] = 2.28; 95% confidence interval [CI] = 1.47-3.54) and frail people without OH (HR = 1.98; 95% CI = 1.40-2.82) or with OH (HR = 2.73; 95% CI = 1.82-4.10) had a higher dementia risk than OH-free and robust people. Moreover, frail people, independently of the presence of OH, had higher mortality rate than OH-free and robust people. In individuals who developed dementia during the follow-up period, neither OH nor frailty was significantly associated with mortality. Older adults with OH, whether robust or frail, may have a higher dementia risk than those without OH. Older adults with OH, when having frailty, may have a higher mortality rate than those without OH. The concurrent assessments of OH and frailty may provide prognostic values in terms of dementia and mortality risk in older adults.

Neurogenic orthostatic hypotension in Parkinson’s disease: is there a role for locus coeruleus magnetic resonance imaging?

Locus coeruleus (LC) is the main noradrenergic nucleus of the brain, and degenerates early in Parkinson’s disease (PD). The objective of this study is to test whether degeneration of the LC is associated with orthostatic hypotension (OH) in PD. A total of 22 cognitively intact PD patients and 52 age-matched healthy volunteers underwent 3 T magnetic resonance (MRI) with neuromelanin-sensitive T1-weighted sequences (LC-MRI). For each subject, a template space-based LC-MRI was used to calculate LC signal intensity (LC contrast ratio—LCCR) and the estimated number of voxels (LCVOX) belonging to LC. Then, we compared the LC-MRI parameters in PD patients with OH (PDOH+) versus without OH (PDOH−) (matched for sex, age, and disease duration) using one-way analysis of variance followed by multiple comparison tests. We also tested for correlations between subject’s LC-MRI features and orthostatic drop in systolic blood pressure (SBP). PDOH− and PDOH+ did not differ significantly (p > 0.05) based on demographics and clinical characteristics, except for blood pressure measurements and SCOPA-AUT cardiovascular domain (p < 0.05). LCCR and LCVOX measures were significantly lower in PD compared to HC, while no differences were observed between PDOH− and PDOH+. Additionally, no correlation was found between the LC-MRI parameters and the orthostatic drop in SBP or the clinical severity of autonomic symptoms (p > 0.05). Conversely, RBD symptom severity negatively correlated with several LC-MRI parameters. Our results failed to indicate a link between the LC-MRI features and the presence of OH in PD but confirmed a marked alteration of LC signal in PD patients.

Pupil light reflex dynamics in Parkinson's disease.

Visual disturbance is common symptom in Parkinson's disease (PD), and defective pupil light reflex (PLR) is an anticipated contributing factor that may be associated to the presence of autonomic dysfunction, which is a common non-motor feature of PD. Studies investigating the intercorrelation between PLR and dysautonomia in PD are limited. The aim of this study was to investigate differences of PLR parameters, measured by eye-tracker, between patients with PD, with and without signs of dysautonomia, and healthy controls (HC). In total, 43 HC and 50 patients with PD were recruited and PLR parameters were measured with Tobii Pro Spectrum, during a long (1,000 ms) and a short (100 ms) light stimulus. Presence of orthostatic hypotension (OH) was used as proxy marker of dysautonomia. Linear mixed-effects model and non-parametric comparative statistics were applied to investigate differences among groups. Peak constriction velocity was slower in PD compared with HC, after adjustment for age and sex in the mixed model, and the difference was greater in the subgroup of PD with OH (unadjusted). Dilation amplitude and velocity were also gradually slower in HC vs. PD without OH vs. PD with OH (unadjusted for confounders). In the mixed model, age was significant predictor of dilation response. Our results support previous observations on defective PLR in PD, evaluated with eye-tracker, and show a possible association with autonomic dysfunction. Further studies with more patients and rigorous evaluation of autonomic dysfunction are needed to validate these findings.

Dynamic Alterations in Cerebral Hemodynamics Measured by Portable Near-Infrared Spectroscopy in Orthostatic Hypotension and Intolerance.

We aimed to evaluate dynamic alterations in cerebral total hemoglobin concentration (HbT) in individuals with orthostatic hypotension (OH) and orthostatic intolerance (OI) symptoms using a portable near-infrared spectroscopy (NIRS) system. Participants comprised 238 individuals (mean age, 47.9 years) without a history of cardiovascular, neurodegenerative, or cerebrovascular diseases, including those with unexplained OI symptoms and healthy volunteers. Participants were categorized by the presence of OH based on the supine-to-stand blood pressure (BP) drop and OI symptoms using on OH questionnaires: classic OH (OH-BP), OH symptoms alone (OH-Sx), and control groups. Random case-control matching sets were constructed, resulting in 16 OH-BP and 69 OH-Sx-control sets. The time-derivative of HbT change in the prefrontal cortex during the squat-to-stand maneuver was measured using a portable NIRS system. There were no differences in demographics, baseline BP, and heart rate among matched sets. The peak time of maximum slope variation in HbT change, indicating the recovery rate and speed of cerebral blood volume (CBV) change, was significantly longer in OH-Sx and OH-BP groups than in the control group under transition to a standing position after squatting. In the OH-BP subgrouping, the peak time of maximum slope variation in HbT change was significantly longer only in OH-BP with OI symptoms, but did not differ between OH-BP without OI symptoms and controls. Our results suggest that OH and OI symptoms are associated with dynamic alterations in cerebral HbT. Regardless of the severity of the postural BP drop, OI symptoms are associated with prolonged CBV recovery.

Central retinal microvasculature damage is associated with orthostatic hypotension in Parkinson’s disease

Orthostatic hypotension (OH) is a common non-motor symptom in Parkinson’s disease (PD). OH can cause cerebral and retinal hypoperfusion and is associated with microvascular damage in PD. Optical coherence tomography angiography (OCTA) is a non-invasive technology that can be used to visualize the retinal microvasculature and detect microvascular damage in PD. In the present study, 51 PD patients (OH+, n = 20, 37 eyes; OH−, n = 32, 61 eyes) and 51 healthy controls (100 eyes) were evaluated. The Unified Parkinson’s Disease Rating Scale III, Hoehn and Yahr scale, Montreal Cognitive Assessment, levodopa equivalent daily dose, and vascular risk factors, including hypertension, diabetes, and dyslipidemia, were investigated. PD patients underwent a head-up tilt (HUT) test. The PD patients had a lower superficial retinal capillary plexus (SRCP) density in the central region than control patients. The PDOH+ group had lower vessel density in the SRCP of the central region compared with the control group and lower vessel density in the DRCP of the central region than the PDOH− and control groups. The changes in systolic and diastolic blood pressure during the HUT test in PD patients showed a negative correlation with the vessel density in the DRCP central region. The presence of OH was a critical factor associated with central microvasculature damage in PD. These findings indicate that OCTA can be a useful and non-invasive tool for detecting microvasculature damage in PD patients.

Orthostatic Hypotension Is a Predictor of Fatigue in Drug-Naïve Parkinson's Disease.

Fatigue and orthostatic hypotension (OH) are common and disabling nonmotor symptoms (NMSs) of Parkinson's disease (PD), but none of the studies have reported on the longitudinal association between fatigue and OH. Drug-naïve PD patients were recruited from a hospital-based cohort and evaluated with the Parkinson Fatigue Scale (PFS), head-up tilt test, Unified PD Rating Scale, Hoehn and Yahr stage, Montreal Cognitive Assessment, Scale for Outcomes in PD-Autonomic (SCOPA-AUT), Beck Depression Inventory (BDI), Beck Anxiety Inventory, PD Sleep Scale, and medications at the baseline and follow-up visits. A total of 80 patients were included, and the mean ages were 66.6 and 63.8 years in the fatigue and nonfatigue groups, respectively. The prevalence of fatigue was 17.5% (14/80) at the baseline and follow-up (mean follow-up: 23.3 ± 9.9 months). The prevalence of OH in the fatigue group was 57.1%, and it was significantly higher than that of the nonfatigue group. Six of the 14 patients (42.9%) in the fatigue group had persistent fatigue at the follow-up, and eight of them (57.1%) converted to the nonfatigue group. Logistic regression analysis demonstrated that the changes of BDI and the presence of OH at the baseline were the predictors for fatigue in drug-naïve PD. Fatigue is a common NMS in PD but can vary depending on the disease course. OH and depression are the most relevant predictors for the development of fatigue in drug-naïve PD. The present study suggests that the management of autonomic symptoms and depression might be helpful for managing fatigue in PD.

Orthostatic hypotension, falls and in-hospital mortality among elderly patients with and without type 2 diabetes.

To evaluate the association of falls and in-hospital mortality with the presence of orthostatic hypotension and type 2 diabetes mellitus (T2D). The study also aims to identify whether the orthostatic hypotension assessed at 1 min or at 3 min can predict falls and mortality, as a secondary objective to identify the predictors of fall during hospitalization. We performed a prospective study with patients admitted to a university hospital. The risk of falls was assessed using the Morse questionnaire and the presence of falls was verified by the patient's medical records during hospitalization. The orthostatic hypotension was determined by measuring blood pressure at three times, considering as orthostatic hypotension the reduction of at least 20 mmHg in SBP or 10 mmHg in DBP. In-hospital mortality was consulted in the medical records. Patients with orthostatic hypotension were slower on Timed Up and Go test (TUG) (12.26 ± 3.16 vs. 16.08 ± 5.96 s, P = 20 s) and presence of orthostatic hypotension. After adjustments, patients with T2D and orthostatic hypotension had a 2.7 times greater risk of in-hospital falls and 1.54 times greater odds of in-hospital mortality when compared with patients without T2D and orthostatic hypotension. In this sample, sedentary patients and those with lower TUG had a higher risk of falls. The prevalence of falls was higher in patients with T2D. The association of T2D with orthostatic hypotension significantly increased both the risk of falls and the risk of in-hospital mortality.

Blood pressure regulation change with ageing: in-depth analysis of 1439 subjects with arterial hypertension and autonomic neuropathy.

Introduction: Blood pressure (BP) regulation is affected by ageing through different mechanisms, including alteration of neural control. Blood pressure variability (BPV) and heart rate variability (HRV) reflect the interaction of BP control mechanisms, and both increased BPV and reduced HRV have been associated to increased cardiovascular morbidity and mortality. The objective of this study was to assess BPV and HRV in hypertensive subjects in different age ranges and to compare them with subjects with established primary cardiovascular dysautonomia, i.e., Parkinson and related diseases. Methods: The study will include 1,439 subjects, divided in three groups: 777 hypertensive subjects aged 40-55 years, 601 hypertensive subjects aged 75-95 years, and 61 patients with primary cardiovascular autonomic neuropathy. Short-term BPV will be assessed through standard deviation (SD), weighted standard deviation (wSD), average real variability (ARV), coefficient of variation (CV), and variability independent of mean (VIM) of 24h ambulatory BP monitoring (ABPM). HRV will be evaluated by SD and CV of heart rate measured during ABPM. Expected outcomes: The expected outcomes of this study include the comparison of overall BPV and mid-term HRV among the three study subgroups, in order to identify similarities and differences in these indexes and to highlight possible common pathophysiological pathways. Furthermore, the characteristics associated with higher BPV and HRV will be analyzed in the three subgroups and compared among them. Similarly, differences in dipping and orthostatic hypotension prevalence will be assessed and characteristics associated with non-dipping status and presence of orthostatic hypotension will be reported. Finally, the association of increased BPV and reduced HRV with organ damage and cardiovascular morbidity will be evaluated.

PECULIARITIES OF TREATMENT OF ARTERIAL HYPERTENSION IN PATIENTS WITH METABOLIC SYNDROME

Objective: The Metabolic syndrome (MS) is characterized by a collection of risk factors, that increase the chance of developing cardiovascular complications. Classifications and definitions of the MS indicate that on its pathogenesis, as well as on resulting complications, five fundamental componets do participate – obesity, insulin resistance, endothelial dysfunction, aggregation of other components and diurnal pattern loss. The aim of our study was to detect changes in diurnal trait depending on the presence of metabolic syndrome. Design and method: Under the conditions of hospitalization we examined 56 persons with the presence of metabolic syndrome (average age 66 years) and 51 persons without metabolic syndrome (average age 61 years). To control the effectiveness of antihypertensive treatment, we used ambulatory blood pressure monitoring (ABPM) (Meditech and Marquette-Hellige devices) with oscillometric blood pressure measurement. Results: In the group of patients with MS dipping was present in 37.5 %, while in the group without MS in 57.1 %. Non dippers and risers where in the group with MS present in 58.9 %, while in the group without MS in 33.3 %. Monotherapy in patients with MS was present in 19.6 %, while in the group of patients without MS in 36.4 %. Four-combination of antihypertensives was in the group with MS in 23.2 %, while in patients without MS in 9.1 %. The mean blood pressure values in the group with MS were 134/79 mmHg and in the group without MS 132/83 mmHg. These blood pressure values were justifiably achieved due to differences in antihypertensive medication – monotherapy versus combination therapy. Conclusions: ABPM plays an important role in monitoring the effectiveness of antihypertensive treatment. In patients with MS achieving blood pressure targets is often a therapeutic problem, which usually requires a combination of three or more antihypertensives. Also presence of orthostatic hypotension, as a manifestation of cardiovascular autonomic neuropathy, may affect the treatment of arterial hypertension. Frequent loss of diurnal pattern in patients with MS is also of prognostic significance.

The Relationship Between Orthostatic Hypotension and Vitamin D Deficiency in Patients with Uncontrolled Type 2 Diabetes Mellitus

Objective: Vitamin D deficiency is common in diabetic patients, and studies showed that it could lead to neuropathy. Therefore, we aimed to determine relationship between 25-hydroxyvitamin D (25(OH)D) levels and orthostatic hypotension (OH) which is a component of autonomic neuropathy in diabetic patients.Materials and Methods: A total of 118 patients with Type 2 diabetes mellitus and aged 50-65 years were included. Patients were divided into two groups as OH present and OH not present. 25(OH)D and other variable parameters were evaluated between these two groups.Results: A total of 118 patients, 66 female and 52 male, were included in this cross-sectional study. The mean age of the patients was 56.2±3.2 years. 25(OH)D levels were found to be significantly lower in the group with OH (p&amp;lt;0.026). Age and sex-adjusted regression analysis were performed to examine the relationship between 25(OH)D level and OH. It was found that 25(OH)D didn’t predict the presence of OH in the univariate and multivariate analyses (p &amp;gt;0.05).Conclusion: 25(OH)D levels are significantly lower in diabetic patients with OH. Although an independent relationship between them has not been demonstrated, it can be thought that correcting Vitamin D deficiency will be beneficial in the treatment of OH.

Case report of Parkinson's disease and orthostatic hypotension

Introduction: Parkinson's disease is an idiopathic, slow progressive neurodegenerative condition with the loss of dopaminergic neurons in the substantia nigra compacta of the midbrain. Due to cardiovascular dysautonomia and impaired baroreflex function in Parkinson's disease, the development of orthostatic hypotension is most common, along with increased blood pressure variability, supine hypertension, nocturnal hypertension, etc. Orthostatic hypotension in Parkinson's disease increases the risk of developing coronary heart disease, myocardial infarction, and the risk of overall, and cardiovascular mortality. Case report: Orthostatic hypotension in Parkinson's disease is associated with an increased risk of gait disturbances, loss of balance, falls resulting in injuries and limb fractures, and mortality. In this paper, we presented a patient who had previously been treated for arterial hypertension, with the current clinical presentation of symptomatic orthostatic hypotension in Parkinson's disease. After neurological evaluation and the implementation of pharmacological and non-pharmacological therapy for orthostatic hypotension, gradual improvement and stabilization of blood pressure values are achieved, along with a reduction in orthostatic hypotension symptoms and a decrease in subjective discomfort. Conclusion: In the presence of orthostatic hypotension in Parkinson's disease, in addition to pharmacological therapy, nonpharmacological treatment measures are very important for stabilizing blood pressure values and reducing the symptoms of orthostatic hypotension.

Association of blood pressure and postural control in older adults with hypertension: an observational study

The study investigated the association of orthostatic hypotension (OH) with functional position change and balance in older adults with hypertension. The presence of OH was assessed with intermittent (OH intermittent) and continuous blood pressure (OH continuous) monitoring. The change in functional position was tested with sitting to standing assessment, balance performance using activity specific balance confidence scale (ABC), and timed up and go test (TUG). Testing unilateral and bilateral standing with and without altered sensory inputs was tested using the Humac balance system. ABC, TUG, and standing up time showed no significant association with OH intermittent and OH continuous. A significant association was found between bilateral standing with eyes closed on foam surface for overall stability index and OH intermittent. Older people with hypertension may be routinely examined for OH and appropriate intervention strategies should be included for comprehensive care.

Orthostatic hypotension in hereditary ATTR Val30Met amyloidosis: predictors and associated clinical features

Abstract Introduction The prevalence of orthostatic hypotension (OH) in patients with mutated transthyretin (TTR) amyloidosis (mATTR) is 40–60%. According to previous studies, OH is frequent and an early feature in patients with Val30Met mutation (the most prevalent form of mATTR). Aim To characterize TTR Val30Met patients with OH and to identify clinical characteristics associated with OH development. Methods Retrospective study of consecutive Val30Met TTR patients with suspected cardiac involvement observed at our cardiology clinic during 2019. Two groups were defined: group 1: patients without OH; group 2: patients with OH. Data was obtained by chart review. Statistically significant predictors of OH were found using logistic regression. Results We included a total of 248 patients (group 1 – 173; group 2 – 75). Group 1 patients were 52% male, median age 45 [interquartile range (IQR) 39–55] and median age at onset 34 (IQR 29,75–46,25) years. Left ventricle hypertrophy [LVH, defined as maximal LV wall thickness (LVT) ≥12 mm] occurred in 26,5%, with median maximal LVT 10 mm (IQR 9–12); 49,7% had conduction disturbances, 30,6% gastrointestinal (GI), 17,3% genitourinary (GU) manifestations and 5% were in Coutinho staging ≥2/3. Group 2 had 56% male, median age of 49 years at evaluation (IQR 42–65) and 35 years at onset (IQR 30–59). LVH was present in 42,9%, with median maximal LVT 11 mm (IQR 10–14); 74,7% had conduction disturbances, 56% GI and 42,7% GU manifestations and 21% were in Coutinho staging ≥2/3. In univariate analysis, higher age (p=0,005), presence of LVH (p=0,009), conduction disturbances (p&amp;lt;0,001), GU manifestations (p&amp;lt;0,001) and higher Coutinho staging (p&amp;lt;0,001) were all associated with the presence of OH, while age at onset was not (p=0,648). In multivariate analysis, only Coutinho staging [odds ratio (OR) 2.609; 95% confidence interval (95% CI) 1.344–5.065] and GU manifestations (OR 3,151; 95% CI 1,595–6,225) were found to be significant predictors of OH. Conclusion Our study suggests that OH is more associated with GU manifestations and Neurologic staging, than with amyloid cardiomyopathy or age, suggesting a predominant neurogenic component. The prevalence of OH in our sample of Val30Met patients was lower than previously described. Funding Acknowledgement Type of funding sources: None.

S3304 A Retrospective Analysis of Orthostatic Hypotension and Risk Stratification in Patients Presenting With Acute Gastrointestinal Bleeds

Introduction: Gastrointestinal bleeding (GIB) is a common presentation occurring in 150 per 100,000 patients with a mortality rate of 2-15%. The timely assessment of patients and accurate risk stratification is of the utmost importance. Physicians have adopted several risk stratification tools to help assess risk and guide medical management. One parameter that is ill-defined in risk stratification of acute GIBs is orthostatic hypotension (OH). The presence of OH in GIB is widely utilized as a surrogate for intravascular volume depletion and hemodynamic instability as a marker of increased mortality. Through retrospective analysis we assessed the proposed link between OH and disposition, intervention, and mortality and its ability to risk stratify patients with GIB. Methods: We conducted an IRB-approved, retrospective study in all patients from a single tertiary referral center with an ICD-10 diagnosis for GIB and OH between the years of 2018-2020. Our cohort consisted of 77 patients in whom we assessed timing of endoscopic intervention, intensive care unit (ICU) admission, and mortality using chi-square analyses. Results: Upon review of the 77 patients selected with GIB and OH, 46 (59.7%) were ultimately admitted to the ICU. Of the 46 patients in the ICU, 34 (74%) required endoscopic intervention with 7 (15%) requiring emergent intervention, defined as occurring within 6 hours of evaluation by gastroenterology. Of the 77 patients, 8 (10.4%) required emergent intervention, 24 (31.2%) required intervention within 24 hours of evaluation, and 19 (24.7%) intervention beyond 24 hours. There were 26 (33.8%) that required no intervention prior to discharge. Overall, 75 (97.4%) were discharged, while 2 (2.6%) passed away. Based on our initial data with chi-square analyses, there were no statistically significant associations between OH, intervention, disposition, and mortality. Conclusion: Acute GI bleeding require swift evaluation and risk stratification. It is taught that 1000cc (20% of body volume) of blood loss can induce orthostasis. This argues that OH upon presentation may represent significant hemodynamic instability and increase overall mortality. There are other etiologies of OH that may need to be considered independent of intravascular volume loss. Our initial data suggest that OH alone in the setting of GIB is insufficient in assessment for disposition, intervention, and mortality. Future studies are warranted to better risk stratify patients presenting with acute GIBs and the association with OH.Table 1.: Crosstab analysis comparing the intervention group with ICU admission and discharge status. Following the crosstab analysis, a chi-square test was used to compare the intervention groups on the categorical variables. The P-value for the intervention groups compared to admission was P = .21 while the P-value for discharge status was P = .08. There were no statistically significant associations to report.

Abstract P200: Orthostatic Hypotension Is An Independent Predictor Of Delayed Rehabilitation Recovery

Inpatient acute rehabilitation is crucial in the management of patients after injuries, surgery, or those with debilitating or neurological conditions. Orthostatic hypotension (OH) is commonly associated with these conditions and can negatively impact their recovery. We found an incidence of OH of 4% in a cohort of 8350 patients at Vanderbilt Stallworth Rehabilitation Hospital (60±17yr, 72% men vs. non-OH 60±18 yr, 57% men). On admission, OH patients had a longer predicted length of rehabilitation hospitalization stay (LOS; 18±6 vs. non-OH 16±5 days; P&lt;0.01) and lower Functional Independence Measure (FIM, 49±19 vs. non-OH 55±19; P&lt;0.01), reflecting greater medical complexity. Actual LOS was even longer than predicted in OH (actual-predicted LOS [ΔLOS], 1±11 vs. non-OH -2±8 days; P&lt;0.01) and FIM efficiency was lower ([discharge-admission FIM]/LOS, 2.5±1.6 vs. non-OH 3.1±1.9; P&lt;0.01), suggesting that OH may be an independent factor for worse rehabilitation outcomes. To test this hypothesis, we conducted univariate and multivariate regression analyses in the adult patients (n=8146) of this cohort to include other potential factors affecting ΔLOS and FIM efficiency (age, sex, diagnosis of admission and comorbidities grouped into 22 categories by organ systems). We found that OH was independently associated with a longer than predicted LOS (i.e. greater ΔLOS) and lower FIM efficiency (regression coefficient 2.2±0.5 and -0.4±0.1, respectively; P&lt;0.01). These associations remained significant after adjusting for predicted LOS and FIM on admission, suggesting that the effects of OH were not accounted for in these metrics. Other factors significantly associated with greater ΔLOS and lower FIM efficiency were comorbidities associated with the urinary tract, gastrointestinal and peripheral nervous systems, infections, electrolyte imbalance and pressure ulcers. In conclusion, OH has a major independent negative effect on rehabilitation outcomes, and is associated with longer than predicted inpatient rehabilitation LOS and lower functional gain. We suggest that the presence of OH should be considered when setting up the rehabilitation plan, to include management of OH.

FV 7. Cross-sectional area of the vagus nerve correlates with parasympathetic dysfunction in Parkinson's Disease

Introduction . In this study we evaluated the autonomic neural function in Parkinson's disease (PD) by combining the use of clinical scoring, functional evaluation with head-up tilt test (HUTT) and morphological studies of the vagus nerve (VN) with nerve ultrasound (NU). This allowed us to correlate morphological changes of the VN with markers of parasympathetic dysfunction from HUTT. Patients/Methods. In our study we used NU to compare the mean values of the cross-sectional area (CSA) of the VNs of 80 PD patients with those of controls (n=40) and patients with chronic inflammatory demyelinating polyneuropathy (CIDP) (n=76). In 69 cases HUTT data was analyzed concerning the presence of orthostatic hypotension (OH), postural orthostatic tachycardia syndrome (POTS) and chronotropic incompetence (CI). Functional haemodynamic parameters in HUTT were used to evaluate parasympathetic functions and correlate them with VN CSA (n=65). Results . In PD, the CSA of right / left VN was significantly smaller compared to the right/left VN of the control and CIDP patients (Table 1). Based on HUTT, 60.5 % of the patients were diagnosed with autonomic dysfunction (OH n=11, CI n=31, POTS n=1). Patients with OH showed significantly higher UPDRS-III values than those with CI (p=0.025). The CSA of the VN correlated inversely with heart rate and positively with parameters representing parasympathetic modulation through vagal activity (Fig. 1). Conclusion . By using NU significant morphological differences of the CSA of the VN were detected in CIDP, PD and a healthy control group. Furthermore, we demonstrated for the first time that anatomical characteristics of the VN correlate with parameters of parasympathetic function from the spectral analysis of cardiovascular parameters in HUTT for PD. This finding enables a new interpretation of the anatomical characteristics of the VN for PD patients and diagnosis of autonomic dysfunction. Fig. 1. Schematic presentation of the inverse correlation of the cross-sectional area of the right vagus nerve with the heart rate. Positive correlation with markers of parasympathetic activity HFnu-RRI. (Spearman Correlation). Abbreviations: HR=heart rate, HFnuRRI = high frequency power of the RR-Interval, bpm= beats per minute, CSA= cross-sectional area Table 1. Demographical and epidemiological characteristics as well as the cross-sectional area (CSA) of the vagus nerve. All values are provided as mean ± standard deviation. Abbreviations: INCAT/ODSS = inflammatory neuropathy cause and treatment/overall disability sum score, MDS-UPDRS III= MDS-Unified Parkinson's Disease Rating Scale, SCOPA-AUT= Scales for Outcomes in Parkinson's Disease- Autonomic Dysfunction, PDQ39 = Parkinson's Disease Questionnaire, CSA = cross sectional area.

The importance of heart rate variability in predicting cardiac autonomic dysfunction in patients with amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a progressive disease characterized by degeneration in the upper and lower motor neurons of the corticospinal tract, brain stem, and spinal cord. Recent studies have revealed that the disease does not present solely with motor neuron involvement. Accordingly, the aim of this study is to investigate the presence of cardiac autonomic impairment in patients diagnosed with ALS. A total of 61 patients, who were diagnosed with ALS according to the Revised El Escorial Criteria (R-EEC), were included in this prospective study, in addition to the 29 healthy individuals, who were included in the study as controls. In order to assess the cardiac autonomic involvement, the presence of orthostatic hypotension was investigated, and transthoracic echocardiography and 24-hour electrocardiogram (ECG) using a Holter monitor were performed. Orthostatic hypotension was detected in 14 (22.2%) patients. Holter electrocardiogram results of the patient group revealed statistically significantly lower heart rate variability (HRV) indicators in the time domain (SDNN, SDANN, SDNN index, rMSSD, and pNN50) and in the frequency domain (high frequency [HF], low frequency [LF], and very low frequency [VLF]) than those of the control group (P<.05). Contrary to the popular opinion, cardiac autonomic dysfunction in patients with ALS can occur at any stage of the disease. Therefore, it is recommended that the patients are evaluated via periodic examinations during the follow-up period for cardiac autonomic involvement.

Intensive risk factor management and cardiovascular autonomic neuropathy in type2 diabetes in the Action to Control Cardiovascular Risk in Diabetes trial: A post-hoc analysis.

In people with type 1 or 2 diabetes, cardiovascular autonomic neuropathy (CAN) is associated with the development of atherosclerotic cardiovascular disease (CVD) and with a high risk of lethal arrhythmias and sudden death. In the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, which included people with type 2 diabetes, participants with CAN at baseline were 1.55 to 2.14 times more likely to die than participants without CAN, and the presence of orthostatic hypotension (OH) at baseline was also associated with an increased risk of total death (hazard ratio, 1.61) and death or hospitalization due to heart failure (hazard ratio, 1.85).