Prevalence Of Autonomic Dysfunction Research Articles

Coefficient of R-R interval variations under deep breathing load in patients with wild-type transthyretin amyloid cardiomyopathy: A case-control study.

An autonomic nervous disorder is an important characteristic of cardiac amyloidosis; however, the prevalence of autonomic dysfunction in wild-type transthyretin amyloidosis (ATTRwt) has not been established. Analysis of the R-R interval coefficient of variation (CVR-R) is a noninvasive method to measure parasympathetic activity. We aimed to assess autonomic dysfunction of ATTRwt and determine the utility of CVR-R for the detection of ATTRwt in other cardiac diseases. This is a single-center, retrospective, case-control study. Fifty patients with heart failure (HF) were studied. The etiologies of HF were as follows: ATTRwt, n = 10; previous myocardial infarction (MI), n = 20; and left ventricular hypertrophy (LVH) due to other disease processes (e.g., aortic stenosis), n = 20. We measured the CVR-R at rest (CVR-Rrest), CVR-R with deep breaths (CVR-Rbreath), and the change rate (CVR-Rdiff rate). The relative change formula is as follows: CVR-Rdiff rate = (CVR-Rbreath - CVR-Rrest)/CVR-Rrest 100 (%). There was no difference in the CVR-Rrest levels among the three groups. The CVR-Rdiff rate levels in the ATTRwt group were significantly lower (ATTRwt: -8.77 [-43.8 to 10.9]; LVH: 67.4 [38.7 to 89.4]; MI: 83.7 [60.4 to 142.9]). Based on the receiver operative characteristic curve analysis to identify ATTRwt in HF, the best cut-off value for the CVR-Rdiff rate was 19.7 (area under the curve: 0.848). Our data suggested autonomic dysfunction in patients with ATTRwt. Measurement of the CVR-R in HF patients may be a convenient support tool for the detection of ATTRwt.

Instrumental Evaluation of COVID-19 Related Dysautonomia in Non-Critically-Ill Patients: An Observational, Cross-Sectional Study.

Coronavirus disease-19 (COVID-19) is a predominantly respiratory syndrome. Growing reports about a SARS-CoV-2 neurological involvement, including autonomic dysfunction (AD), have been reported, mostly in critically-ill patients, or in the long-COVID syndrome. In this observational, cross-sectional study, we investigated the prevalence of AD in 20 non-critically-ill COVID-19 patients (COVID+ group) in the acute phase of the disease through a composite instrumental evaluation consisting of Sudoscan, automated pupillometry, heart rate variability (HRV), and pulse transit time (PTT). All the parameters were compared to a control group of 20 healthy volunteers (COVID− group). COVID+ group presented higher values of pupillary dilatation velocities, and baseline pupil diameter than COVID− subjects. Moreover, COVID+ patients presented a higher incidence of feet sudomotor dysfunction than COVID− group. No significant differences emerged in HRV and PTT parameters between groups. In this study we observed the occurrence of autonomic dysfunction in the early stage of the disease.

Autonomic dysfunction, cardio-pulmonary parameters and masked heart failure in non-severe chronic obstructive pulmonary disease

Въведение: Автономната дисфункция (АД) и параметрите при кардиопулмоналното тестване (КПТ) се асоциират със сърдечна недостатъчност със запазена систолна функция (heart failure with preserved ejection fraction – HFpEF) в общата популация. При пациенти с нетежка хронична обструктивна белодробна болест (ХОББ) тяхното клинично значение и връзка с маскираната HFpEF е неизяснено. Цел: Целта на проучването е да се определят връзката и клиничното значение на АД и кардиопулмоналните параметри с HFpEF при пациенти с нетежък ХОББ, които се оплакват от задух при усилие, без клинично изявено сърдечно-съдово заболяване (ССЗ) (исхемична болест, сърдечна недостатъчност, неконтролирана артериална хипертония). Методи и резултати: При 68 пациенти с нетежък ХОББ без изявено ССЗ е приложено КПТ. Проведена е ехокардиография в покой и 1-2 минути след натоварването. Пациентите са разделени на две групи въз основа на стрес-индуцираното съотношение E/e’: пациенти с левокамерна диастолна дисфункция (ЛКДД) – E/e’ > 15 (пациенти с маскирана HFpEF) и пациенти без стрес-ЛКДД (пациенти без маскирана HFpEF). Хронотропната недостатъчност включва намаления индекс на хронотропен отговор (ИХО Заключение: Неправилното възстановяване на сърдечната честота след натоварването е единственият независим предиктор за маскирана HFpEF при пациенти с нетежък ХОББ. По-ниските нива на ’VO2, кислороден пулс, физическо натоварване, както и по-високото ’VE/’VCO2 съотношение се асоциират с маскирана HFpEF, като вероятно са нейно последствие, а не тригер. Background: Autonomic dysfunction (AD) and cardio-pulmonary exercise testing (CPET) parameters have been associated with masked heart failure with preserved ejection fraction (HFpEF) in the general population. Their clinical significance for masked HFpEF in chronic obstructive pulmonary disease (COPD) is however elusive. Aim: The aim of the study was to determine the prevalence, correlation and clinical significance of AD and CPET with masked HFpEF, in non-severe COPD patients, complaining of exertional dyspnea, without clinically overt cardio-vascular (CV) comorbidities (ischaemic heart disease, heart failure, uncontrolled arterial hypertension). Methods and results: We applied CPET and echocardiography in 68 COPD subjects. Echocardiography was performed before CPET and 1-2 minutes after peak exercise. Patients were divided into two groups: patients with and without masked HFpEF. Peak E/e’ – 15 was applied as a cut-off. Chronotropic incompetence (CI) was assumed if both failure to reach the target heart rate (HR) on exercise and diminished heart rate reserve Conclusion: Abnormal HRR is the only independent predictor of masked HFpEF in non-severe COPD patients. Despite of being associated with masked HFpEF, the lower ’VO2, lower oxygen pulse, higher ’VE/’VCO2 slope and lower exercise load seem to be the consequences, rather than the triggers for it.

Assessment of Functions of the Autonomic Nervous System in the Elderly with Different Comorbid Factors.

Background Studies in healthy elderly patients have shown the prevalence of autonomic dysfunction (AD) in the range of 20 to 30%. However, there is paucity in data pertaining to AD in the elderly in the Indian context. Objective To assess the prevalence of AD in the elderly irrespective of their comorbidity status. Methods A total of 141 elderly patients with or without comorbidities/symptoms of AD were included. Demographic and clinical details of the patients were recorded. Autonomic function tests (AFTs) such as deep breathing test, Valsalva ratio, orthostatic heart rate (OHR), isometric handgrip test, and orthostatic blood pressure were performed based on Ewing’s battery of tests. The sensitivity, specificity, positive predictive value, negative predictive value, and the accuracy of AFTs were evaluated. Results Most patients ( n = 85) were aged between 60 and 69 years, with a male predominance (58.87%). Hypertension and diabetes mellitus were the most common comorbidities. Postural hypotension was the most common symptom of AD. With advancing age, symptoms of AD manifested significantly more. Overall, 73.8% of patients had AD, of whom 45.4% had early AD. Number of AD symptoms, glycated hemoglobin (HbA1c) level, and comorbid factors (diabetes and hypertension) were significantly associated with the results of AFTs ( p < 0.05). AFTs were highly significant with respect to the results obtained ( p < 0.001). Deep breathing test, abnormal in majority of study patients, has a sensitivity of 93.3% and OHR has a specificity of 81.1% to determine AD. Conclusion The study concludes that age itself is an independent predictor of AD, which increases in severity if associated with comorbidities.

Autonomic dysfunction, cardio-pulmonary exercise testing and masked heart failure with preserved ejection fraction in non-severe chronic obstructive pulmonary disease.

Autonomic dysfunction (AD) and cardiopulmonary exercise testing (CPET) parameters have been associated with masked heart failure with preserved ejection fraction (HFpEF) in the general population. Their clinical significance for masked HFpEF in chronic obstructive pulmonary disease (COPD) is however elusive. The aim of the study was to determine the prevalence, correlation and clinical significance of AD and CPET with masked HFpEF, in non-severe COPD patients, complaining of exertional dyspnoea, without clinically overt cardio-vascular (CV) comorbidities. We applied CPET and echocardiography in 68 COPD subjects. Echocardiography was performed before CPET and 1-2min after peak exercise. Patients were divided into two groups: patients with and without masked HFpEF. Peak E/e' - 15 was applied as a cut-off. Chronotropic incompetence (CI) was assumed if both failure to reach the target heart rate (HR) on exercise and diminished heart rate reserve <80% occurred. Abnormal HR recovery (HRR) was taken if the decline is <12 beats within the first minute after exercise cessation. Univariate regression showed association between masked HFpEF, HRR, VO2, VO2 at AT, oxygen pulse and VE/VCO2 slope. The multivariate regression demonstrated HRR as the only independent predictor of masked HFpEF - (OR 10.28; 95% CI (3.55-29.80)). Abnormal HRR is the only independent predictor of masked HFpEF in non-severe COPD patients. Despite of being associated with masked HFpEF, the lower VO2, lower oxygen pulse, higher VE/VCO2 slope and lower exercise load seem to be the consequences, rather than the triggers for it.

Impaired cardiac autonomic response in lung transplant patients: A retrospective cohort study.

Cardiac autonomic dysfunction (AD) is associated with adverse prognosis in lung disease; however, its implications in lung transplantation have not been previously described. This study evaluated the prevalence of AD in lung transplant (LTx) candidates, its determinants, prognostic implications, and prevalence post-transplant. Retrospective one-year study of 103 LTx candidates with AD assessed using heart rate (HR) from the six-minute walk test (6MWT). Impaired chronotropic response index (CRI) was defined as <80% age-adjusted HR during 6MWT. Abnormal HR recovery (HRR) was categorized as reduction in HR≤12 beats/minute after the first minute of 6MWT cessation. Abnormal CRI and HRR were observed in 94% and 76% of patients, respectively. A lower CRI was associated with obstructive lung disease and lower estimated aerobic capacity. CRI was independently associated with 6MW distance [12m per 10% CRI, P=0.03], but not with post-transplant cardiovascular events, hospital stay, or one-year mortality. At 3months post-transplant, no improvement was observed in CRI (99%, n=66/67, P=0.25) or HRR (88%, n=36/41, P=0.12). Cardiac AD was prevalent in LTx candidates and recipients, with chronotropic incompetence a modest contributor to exercise intolerance pretransplant. Further study may help determine whether direct autonomic measures such as HR variability may be more prognostic of LTx outcomes.

Chronic kidney disease is linked to carotid calcified atherosclerotic plaque in patients with metabolic syndrome

Background The prevalence of metabolic syndrome (MetS) is rising continuously. MetS is recently proposed as a predictor for the occurrence of vascular defects causing stroke. Objective Carotid atherosclerosis is a major cause of disabling stroke and death. The presence of carotid plaques is associated with future cardiovascular (CV) events, with local plaque composition being an independent outcome predictor. We examined the association between ultrasonographically determined carotid plaque calcification and CV risk factors in MetS. Methods This was a cross-sectional study with a total of 58 patients with MetS who underwent routine carotid ultrasonography of both carotid arteries to detect presence of calcified atherosclerotic plaque. Plaques with high echogenic nodules and posterior shadowing were considered calcified. Those who had no apparent cardiovascular vascular disease (CVD). After careful clinical examinations and biochemical evaluations. We used logistic regression models to assess the relationship between CV risk factors and carotid plaque calcification in studied subjects. Results Of this study subjects, the mean age was 63.8 ± 7.8 years. Carotid calcification was detected in 19.3% of the patients. We found that presence of carotid plaque calcification had statistically significantly positive correlations with the prevalence of autonomic dysfunction (p = 0.03), CKD (p = 0.001), framingham stroke risk score (FSRS) (p = 0.005), mean arterial pressure (MAP) (p = 0.05), and log creatinine (log cre) (p = 0.02), and negative correlations with log estimated Glomerular filtration rate (log eGFR) (p = -0.01). Results of logistic regression analysis showed that prevalence of CKD (p = 0.02) was significantly associated with carotid plaque calcification after adjustment of confounding risk factors. Conclusions Our results suggest that carotid plaque calcification presence significantly related to CKD.

Cardiac autonomic dysfunction in breast cancer survivors.

10057 Background: Cardiac autonomic dysfunction (AD) has been associated with increased cardiovascular (CV) and all-cause mortality in several diseases. We evaluated the prevalence, functional and prognostic significance of cardiac AD in a cohort of breast cancer (BC) survivors referred for exercise treadmill testing (ETT). Methods: Cardiac AD was defined as the presence of both an elevated resting heart rate (HR ≥ 80 beats per minute) and abnormal HR recovery (HRR ≤ 12 beats per minute if active cool down, or ≤ 18 beats per minute if passive recovery) at 1 minute after peak exercise. Presence of cardiac AD, exercise capacity, and all-cause mortality were assessed in 448 women (age 62.6±10.0 years), 8.7 [range 4.5, 14.3] years from BC diagnosis, compared to 448 cancer-free, age- and sex-matched controls, all of whom were clinically referred for ETT. Results: Elevated resting HR (23.7% vs. 17.0%, p = 0.013), abnormal HRR (25.9% vs. 20.3%, p = 0.048), and cardiac AD (8.0% vs. 4.2%, p = 0.025) were more prevalent in BC survivors than controls. BC survivors with cardiac AD had reduced exercise capacity compared to those without AD (Table). Among controls, cardiac AD was not associated with decreased exercise capacity. Among BC survivors (age-adjusted hazard ratio 1.90 (95% CI 0.78-4.62) and controls (age-adjusted hazard ratio 4.09 (95% CI 0.49-34.18), cardiac AD was not associated with increased all-cause mortality. Conclusions: Among patients referred for ETT, BC survivors have an increased prevalence of cardiac AD relative to controls. Cardiac AD is associated with decreased exercise capacity, but not increased all-cause mortality, in BC survivors. Available strategies to modulate cardiac AD may improve functional capacity in BC survivors. Table: Impact of markers of cardiac AD on exercise capacity. [Table: see text]

Prevalence of autonomic dysfunction in hospitalized patients with Guillain-Barré syndrome.

There is a paucity of data regarding autonomic dysfunction (AD) in Guillain-Barré Syndrome (GBS). Concern exists regarding inpatient mortality risk in GBS. We sought to identify the prevalence of AD in GBS inpatients. We used the Health Cost and Utilization Project Nationwide Inpatient Sample (NIS). GBS hospitalizations were identified by International Classification of Diseases, Ninth Revision, Clinical Modification code-357.0. Non-GBS hospitalizations were matched to these cases 4:1 by age and gender. We identified 2,587 GBS patients and a control population of 10,348 patients during 2010-2011. The most common manifestations of AD were: diarrhea/constipation (15.5%), hyponatremia (14.9%), syndrome of inappropriate antidiuretic hormone secretion (SIADH) (4.8%), bradycardia (4.7%), and urinary retention (3.9%). GBS patients had higher rates of reversible cardiomyopathy, syncope, tachycardia, and Horner syndrome (P < 0.0001). AD most commonly manifests as diarrhea/constipation, SIADH/hyponatremia, and cardiac dysfunction. This report can help increase awareness of AD in GBS and aid in early identification, treatment, and mortality reduction. Muscle Nerve 56: 331-333, 2017.

Evaluation of autonomic neuropathy in alcoholic liver disease in Manipur

Context: The prevalence of autonomic neuropathy in alcoholic liver disease and its correlation with severity of liver disease is not known in Manipur population. Aims: The aim of this study was to study the prevalence of autonomic dysfunction in patients with chronic alcoholic liver disease and to determine the degree of severity of alcoholic liver disease by Child–Turcotte-Pugh scoring and its correlation with autonomic profile. Settings and Design: A cross-sectional study involving eighty adult patients with chronic alcoholic liver attending Medicine out patient's Department in a tertiary care teaching hospital in Imphal, from October 2011 to September 2013. Subjects and Methods: Autonomic profile included a preformed questionnaire and five autonomic function tests (3 parasympathetic and 2 sympathetic). Parasympathetic tests (heart rate variation to [1] deep and slow breathing, [2] Valsalva maneuver, and [3] standing) and sympathetic tests (blood pressure response to [1] postural change and [2] sustained isometric hand grip) were performed. Autonomic neuropathy detected was graded as normal, early, definite, severe, and atypical. Results: Autonomic dysfunction was observed in 58 (72.5%) patients (early 30 [37.5%], definite 10 [12.5%], severe 18 [22.5%], normal 22 [27.5%]). Heart rate response to standing (30:15 ratio) was the most altered parasympathetic test in 39 (67.2%). The parameters that correlated with the severity of autonomic dysfunction were Child–Pugh scoring (P = 0.000), platelet count (P = 0.000, cirrhosis (P = 0.001), varices (P = 0.02), and portal hypertension (P = 0.000). Conclusions: Screening of alcoholic liver disease patients with autonomic function tests directly correlated with the severity of alcoholic liver disease. Autonomic tests should be a part of patient work in alcoholic liver disease so that early intervention can be performed.

Su1283 Does Autonomic Dysfunction Contribute to Poor Quality of Life in Patients With Inflammatory Bowel Disease? A Prospective Study

Introduction: Autonomic dysfunction (AD) in inflammatory bowel disease (IBD) patients (pts) may result from direct autonomic nerve injury and/or perturbation of central neural systems important for autonomic regulation. Because AD may be linked to fatigue, abdominal symptoms, and quality of life (QoL), the presence of AD could be an important contributor to a poor clinical course. Thus, we sought to determine the prevalence and impact of AD on the natural history of IBD pts followed over a one year time period. Methods: We conducted a prospective study of 530 consented IBD pts followed in a natural history registry at a tertiary referral clinic. All participants completed the composite autonomic symptom score (COMPASS31; score range 0-100), a validated survey used to identify subjects with high risk of AD (scores >32.5). Same day short inflammatory bowel disease questionnaire (SIBDQ) and Harvey Bradshaw and ulcerative colitis activity index (UCAI) scores were used to assess for health related QoL and disease activity. SIBDQ <50 designated poor QoL. The PHQ9 was used to screen for depression. Linked demographic, clinical data, medication use, health care utilization (emergency department (ED) visits, hospital admissions, telephone calls) and total annual cost of care for these pts over one year were included in the analysis. Results: 530 IBD pts completed the COMPASS31; 67% had Crohn's disease (CD) and 33% ulcerative colitis (UC), with a mean age 41.6± 14.3 yr. 57.5% of the subjects were female. 19.4% of IBD patients had high risk for AD. There was no difference in gender, IBD type, disease duration or rates of annual CRP elevation between pts with AD and those without AD. Pts with AD had higher rates of depression (39.8% vs. 19.4%; p<0.0001), fatigue (97% vs. 75.2%; p<0.0001), abdominal pain (80.2% vs. 57.3%; p<0.0001), abnormal ESR (48.4% vs. 37.3%; p< 0.01), and poor QoL (median SIDBQ 37 vs. 57; p< 0.0001) compared to pts without AD. CD pts with AD were noted to have higher disease activity as compared to CD pts without AD (median HB 6 vs. 2; p<0.0001). On the contrary, there was no difference between disease activity for UC pts with and without AD (median UCAI 3 vs. 2; p=0.06). Using multivariable logistic regression adjusting for IBD type, gender, disease activity, medications with direct impact on autonomic activity, and depression, patients with AD had a 6.7 times greater chance of having poor quality of life (p<0.01 CI 3.8-11.8). Pts with AD had a significantly higher annual cost of care (median annual cost $5,044 for AD IBD vs. $2,895 for no AD IBD; p=0.0002). Conclusions: AD is present in a subset of IBD pts and exerts a significant impact on QoL, patterns of healthcare utilization and cost. Fatigue and abdominal pain are seen in the vast majority of IBD patients with AD. Screening for AD in IBD patients is warranted.

Prevalence of autonomic dysfunction in patients with multiple sclerosis.

Autonomic nervous system dysfunction is commonly seen in multiple sclerosis patients and should be explored in the routine evaluation. Composite Autonomic Symptom Score questionnaire was validated as a self-assessment instrument of autonomic symptoms. Determine the frequency of autonomic symptoms in multiple sclerosis patients through a Portuguese version of Composite Autonomic Symptom Score; compare questionnaire results between patients and a control group; assess the feasibility of this questionnaire application in multiple sclerosis Portuguese patients. This case-control study used a Portuguese translated version of Composite Autonomic Symptom Score to determine the frequency of autonomic symptoms in multiple sclerosis patients. One-hundred and three relapsing-remitting multiple sclerosis patients - median age 41 years, median disease duration 6 years, median EDSS score 1 - and 80 healthy subjects were included. Alterations in autonomic function were reported in 97.1% of the cases, with statistical significance in orthostatic intolerance and gastrointestinal domain scores. Nevertheless, the difference between multiple sclerosis patients (41.7%) without confounding factors that could interfere with autonomic dysfunction (i.e. comorbidities or medications) and controls showed no statistical significance. Our results may be related to the short disease duration, young age and lowdisability status of our patients unaffected by confounding factors. The questionnaire was not designed specifically for multiple sclerosis and it may not be as sensible to early autonomic symptoms as to more severe manifestations. Further studies are needed to achieve more robust results, validate this questionnaire and assess its application in multiple sclerosis patients in Portugal.

Association between non-alcoholic fatty liver disease and autonomic dysfunction in a Chinese population.

Autonomic dysfunction (AD) accompanying with chronic liver disorders led to an increased risk of mortality. However, researches that investigated the association between non-alcoholic fatty liver disease (NAFLD) and AD were insufficient. To study the association of NAFLD with AD in middle-aged and elderly Chinese adults. Four thousand nine hundred seventy-four adults aged 40 years or older were enrolled in this cross-sectional study. NAFLD was diagnosed by hepatic B-mode ultrasonography. Autonomic function was assessed using a simple EZSCAN test by measuring sudomotor function, with an AD index > 50% defined as a manifestation of AD. Pearson correlation, multiple stepwise linear regression, univariate and multivariate logistic regression was employed to examine the relationship between NAFLD and AD, controlling for potential confounders. The prevalence of AD was significantly higher in participants with NAFLD than those without (40.75 vs. 26.86%, P < 0.0001). Age, body mass index, status of diabetes, sex, diastolic blood pressure and prevalent NAFLD, were positively correlated with AD index in multiple stepwise linear regression analysis (all P < 0.05), whereas total cholesterol was negatively related to it (P = 0.0043). Compared with the participants without NAFLD, those with NAFLD had an increased odds of the prevalent AD (odds ratio 1.38; 95% confidence interval 1.15-1.64; P = 0.0004) after controlling for multiple confounders. The presence of NAFLD was significantly associated with AD, as indicated by abnormal sudomotor function. The association was independent from various conventional risk factors.

Autonomic dysfunction in different subtypes of post-acute ischemic stroke

ObjectivesCentral autonomic impairment is frequent in ischemic stroke at acute or chronic stages. The mechanism by which these symptoms occur in patients with ischemic stroke has not been elucidated. This study sought to investigate cardiovascular autonomic function in patients with different subtypes of post-acute ischemic stroke. Methods77 ischemic stroke patients [50 patients with large-artery atherosclerosis (LAA) and 27 patients with small-vessel occlusion (SVO), average 6months after stroke onset] and 37 elderly controls were recruited. All performed Ewing's battery autonomic function tests and power spectral analysis of heart rate variability (HRV). ResultsStroke patients with both LAA and SVO had significantly lower low frequency power spectral density than controls. The prevalence of autonomic dysfunction in both groups (82.0% patients with LAA and 63.0% with SVO) was higher than that in controls (21.6%). Patients with LAA showed impairment of all parasympathetic tests (all P<0.05) and one of the sympathetic tests (mean fall in systolic blood pressure on standing: P=0.058) and those with SVO only showed impairment in two parasympathetic tests (heart rate response to deep breathing: P=0.010; heart rate response to standing: P=0.004) in comparison with controls. Patients with LAA had significantly more impairment than those with SVO in some autonomic parameters (Valsalva ratio: P=0.039; mean fall in systolic blood pressure on standing: P=0.015). ConclusionsIrrespective of the subtype of the ischemia, post-acute stroke patients showed a parasympathetic cardiac deficit. Additionally, parasympathetic and sympathetic cardiovascular modulations were more severely impaired in patients with LAA.

Assessment of autonomic dysfunction in childhood guillain-barré syndrome.

Autonomic dysfunction (AD) is a common and important complication in Guillain-Barré syndrome (GBS) and may be the cause of significant morbidity or death. Limited studies have evaluated this complication in childhood GBS. Our objectives were to show the prevalence of AD in children with GBS and investigate its association with the severity of the disease. Study included 28 children admitted with a diagnosis of GBS. Heart rate variability (HRV), motor function disability of the upper limbs and GBS disability scores were measured at admission and the results were compared with 20 healthy age/gender matched subjects (2-13 years; 43% male). GBS subtypes were defined by electromyography: acute inflammatory demyelinating polyneuropathy (AIDP) or acute motor axonal neuropathy (AMAN). The mean age was 5.5±3.4 years (range 1.5-14 years; 50% male). AIDP and AMAN subtypes comprised 57.1% and 42.9% of cases, respectively. In the upper limbs, 85.7% and in the GBS disability grading, 50% of patients had ≤ 3 scores, implying less severe motor dysfunction. There was no difference in the mean heart rate between patients vs. controls (103.9 vs. 98.2 bpm; P= 0.16), but half of patients showed AD and HRV was significantly reduced in patients compared to controls. Of the 16 patients with AIDP, 11 (68.8%) showed reduced HRV compared to 3 (25%) out of 12 AMAN cases (P= 0.02). There was no significant relation between HRV and motor disability scores. AD was present in half of children with mild GBS and it showed no significant association with disease severity.

Rates of autonomic dysfunction in HIV patients receiving antiretroviral therapy

We read the work by Robinson-Papp et al. with interest. The authors report that 61 % of participants had autonomic dysfunction (AD) as defined by a composite autonomic severity score (CASS) >3, with peripheral nerve dysfunction being the strongest predictor, affecting 90 % of participants who have HIV-associated distal symmetric polyneuropathy. Eighty-six percent of individuals with AD were symptomatic on survey of autonomic symptoms (SAS). The Composite Autonomic Scoring Scale (CASS) is a validated scale designed to quantify autonomic failure. CASS is derived from three areas of autonomic function: adrenergic, cardiovagal, and sudomotor (1996; Weimer 2010; Low et al. 2008). A CASS of 6 is indicative of severe autonomic failure (Low et al. 2008). CASS has been correlated with cardiovascular disease events and mortality (Gehrking et al. 2013). A CASS of 4–6 has been associated with orthostatic hypotension, abnormal sweating, and gastrointestinal abnormalities and is usually seen in autonomic failure (Low 1993). The authors report a median CASS of 3, suggesting that 50 % of subjects had a CASS of >3. The study reported on the CASS upper range of 6. A CASS this high would implicate major clinical outcomes and mortality which frankly have not been seen in large epidemiologic studies. The rates and severity of AD may have been overestimated in this study. In a convenience sample of 48 virologically suppressed HIV-infected individuals with and without polyneuropathy, we reported on a median CASS of 1 (IQR 1), and 40 % of subjects were symptomatic. We utilized the Composite Autonomic Symptom Scale to measure autonomic symptoms, a better instrument to detect and quantitate AD compared to the SAS used in the study. We wonder whether using the Q-sweat test for evaluating the sudomotor response used in the study may have overestimated AD. The qualitative sudomotor axon reflex test (QSART) has been a routine postganglionic sudomotor function test of the Mayo Clinic since 1983. The Q-sweat test is a commercial quantitative sweat measurement test modeled on QSART, but can overestimate sudomotor dysfunction (Sletten et al. 2010). In the era of combination antiretroviral therapy (cART), dramatic improvements in morbidity and mortality have been witnessed. However, autonomic symptoms such as light-headedness, dry mouth and eyes, cold feet, and constipation, as noted in the study and ours, have become common complaints among HIV-infected patients. AD has been correlated with HIV disease progression (Becker et al. 1997; Chow et al. 2011). Individuals with AIDS receiving cART have better measures of autonomic function compared to individuals that are not on cART (Correia et al. 2006). Forty-two percent of the study participants had a detectable viral load. Early and lifelong suppression of HIV infection and avoidance of medications that cause peripheral neuropathy and metabolic disorders needs to be considered for HIV-infected individuals (Askgaard et al. 2011). AD is a common condition. The rate and severity of autonomic dysfunction may not appear as elevated as suggested by the authors. Nonetheless, we commend Robinson-Papp et al. for bringing attention to AD which we agree is an underappreciated condition that is becoming increasingly common among our aging HIV-infected patients. Further investigation is needed to explain the prevalence and nature of AD, and its potential treatment.

Autonomic nervous system evaluation in Type 2 diabetic patients and effect of its duration

Introduction: Dysfunction of the autonomic nervous system is common in diabetic patients. Presence of autonomic dysfunction should alert the physicians of its serious consequences that require timely preventive measures. Objectives: This study was done to fi nd out the autonomic nervous system involvement in Type 2 diabetic patients and to see its relation with the duration of diabetes. Methods: This was a hospital based cross-sectional study. All consecutive diabetic patients of both genders attending Kathmandu Medical College and a private clinic, Temple of Healing were included. A battery of six well validated and accepted autonomic nervous system evaluation tests were done to evaluate the autonomic function in 245 Type 2 diabetic patients. Results: Prevalence of autonomic dysfunction was found to be 71.02% with 58.78% patients having mild autonomic dysfunction and 12.24% having moderate dysfunction. Severe autonomic dysfunction was detected in none of the patients. Parasympathetic dysfunction was much more common than sympathetic dysfunction (68.16% vs. 17.96%). No association was found between autonomic dysfunction and duration of diabetes. Conclusions: Autonomic dysfunction is very common in diabetics and can be detected by simple tests. Timely detection of autonomic dysfunction in diabetic patients is advised so that its preventive measures can be effective. DOI: http://dx.doi.org/10.3126/jkmc.v1i2.8142 Journal of Kathmandu Medical College, Vol. 1, No. 2, Oct.-Dec., 2012: 77-83

Complex assessment of cardiovascular risk factors at Health Centres

Aim.To assess the potential of Health Centres in identification of individuals at higher cardiovascular risk.Material and methods.In total, 1583 individuals (mean age 51,79±14,75 years) participated in a complex screening programme, including laboratory and instrumental examination.Results.The screening resulted in identification of individuals with high normal blood pressure (HNBP) and newly diagnosed arterial hypertension (AH) (prevalence 21%). In participants with HNBP, a combination of 2 risk factors (RFs) was the most prevalent (37,79%), while in people with newly diagnosed AH, a combination of 3 RFs was the most common (39,88%). The prevalence of autonomic dysfunction or “Myocardium” parameter increase, as an isolated RF, reached 8,84% and 9,45%, respectively. Abnormal ankle-brachial index (ABI) values were registered in 29,66% of the participants. In 18,97%, ABI values exceeded 1,3, while in 10,69%, they were under 0,9. ABI screening identified 11% of asymptomatic individuals with increased cardiovascular risk.Conclusion.A screening programme could identify individuals with preAH, primary autonomic dysfunction, functional myocardial instability, or subclinical atherosclerosis of peripheral arteries. Therefore, all subjects with increased cardiovascular risk require lifestyle modification and additional laboratory and instrumental examination, in order to assess the target organ damage and the need for pathogenetic therapy.

Autonomic dysfunction in ischemic stroke with carotid stenosis

Impaired autonomic function is common in acute ischemic stroke. Previous limited studies have suggested that atherosclerosis may affect the distensibility of the carotid sinus and then impair the cardiovascular autonomic function. This study sought to investigate cardiovascular autonomic function in patients with ischemic stroke with carotid stenosis. Eighty-five patients with ischemic stroke (58 ones without carotid stenosis and 27 ones with carotid stenosis, average 6 months after stroke onset) and 37 elderly controls were recruited. All performed Ewing's battery autonomic function tests. From Ewing's battery of autonomic function tests, atypical, definite, or severe autonomic dysfunction was identified in 69.0% patients without carotid stenosis and 88.9% with carotid stenosis, with significant difference between the two groups, and the prevalence of autonomic dysfunction in both groups was higher than that in controls (21.6%). Patients with carotid stenosis showed impairment of all parasympathetic tests (all P < 0.05) and one of the sympathetic tests [Mean fall in systolic blood pressure (BP) on standing: P = 0.051], and those without carotid stenosis only showed impairment in two parasympathetic tests (Valsalva ratio: P = 0.014; heart rate response to deep breathing: P < 0.001) in comparison with controls. Patients with carotid stenosis had significantly more impairment than those without carotid stenosis in some autonomic parameters (Valsalva ratio: P < 0.05; mean fall in systolic BP on standing: P < 0.05). Cardiovascular autonomic function is impaired in patients with ischemic stroke, but patients with carotid stenosis show more severely impaired parasympathetic and sympathetic functions.

Cardiovascular autonomic function in 422 patients with orthostatic symptoms

The objective of the study was to evaluate retrospectively the prevalence of orthostatic hypotension (OH) and supine hypertension of patients referred to our Autonomic Laboratory with suspected autonomic dysfunction (AD). Standard cardiovascular tests (deep breathing, lying to standing, Valsalva manoeuvre, postural blood pressure) were performed to quantify autonomic function. According to their clinical presentation, 422 patients (221 males, median age 60 years, range 21-79 years) were classified into 4 groups: without neurological features (n=122), with parkinsonian features (n=145), with peripheral neuropathy (n=100) and with other neurological features (n=55). AD was mild in 9% and moderate to severe in 20% of the population. OH was isolated in 14% and associated with AD in 16% of the patients. Supine hypertension was present in 45% of the patients. Cardiovascular function was normal in 57% of the population. Prevalence of OH (isolated and with AD) was higher in patients with supine hypertension (43%) than with normal blood pressure (19%) (p=0.001). Prevalence of isolated OH and AD increased with age (OH: 0% before 40 years, 14% over 40 years; p=0.01; AD: 7% before 40 years, 21% over 40 years; p=0.02). Patients with peripheral neuropathy and parkinsonian features showed the highest prevalence of AD, 36% e 27% respectively. In conclusion, supine hypertension was very frequent in our patients; its presence may impair baroreceptor function and worsen orthostatic tolerance. OH, both isolated and with AD, was also a common feature. Autonomic assessment and identification of OH and supine hypertension, especially in the elderly, is necessary for determining the prognosis and for appropriate therapeutic intervention.