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OBJECTIVE: This review aims to provide hospitalists with a streamlined understanding of the evaluation of syncope, a commonly encountered complaint in hospital medicine. METHODS: Authors conducted a literature review using the keyword 'syncope' to compile current evidence and recommendations regarding the categorization, risk stratification, and diagnostic evaluation of syncope. RESULTS: The review outlines the categorization of syncope into cardiac, neurally-mediated, and orthostatic types, detailing the clinical features, etiologies, and differential diagnoses of each. It provides a structured framework for history-taking, physical examination, orthostatic vital sign assessment, and risk stratification to guide clinicians in efficiently identifying high-risk patients requiring urgent intervention. Diagnostic modalities including electrocardiography, echocardiography, and point-of-care ultrasound are discussed, along with their respective indications and limitations. CONCLUSION: By embracing standardized approaches and evidence-based practices outlined in this review, hospitalists can optimize resource utilization, streamline patient care, and improve outcomes in patients presenting with syncope.
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Orthostatic testing, involving the transition from different body positions (e.g., from lying or sitting position to an upright or standing position), offers valuable insights into the autonomic nervous system (ANS) functioning and cardiovascular regulation reflected through complex adjustments in, e.g., measures of heart rate (HR) and heart rate variability (HRV). This narrative review explores the intricate physiological mechanisms underlying orthostatic stress responses and evaluates its significance for exercise science and sports practice. Into this matter, active orthostatic testing (e.g., active standing up) challenges the cardiovascular autonomic function in a different way than a passive tilt test. It is well documented that there is a transient reduction in blood pressure while standing up, leading to a reflex increase in HR and peripheral vasoconstriction. After that acute response systolic and diastolic blood pressures are usually slightly increased compared to supine lying body position. The ANS response to standing is initiated by instantaneous cardiac vagal withdrawal, followed by sympathetic activation and vagal reactivation over the first 25-30 heartbeats. Thus, HR increases immediately upon standing, peaking after 15-20 beats, and is less marked during passive tilting due to the lack of muscular activity. Standing also decreases vagally related HRV indices compared to the supine position. In overtrained endurance athletes, both parasympathetic and sympathetic activity are attenuated in supine and standing positions. Their response to standing is lower than in non-overtrained athletes, with a tendency for further decreased HRV as a sign of pronounced vagal withdrawal and, in some cases, decreased sympathetic excitability, indicating a potential overtraining state. However, as a significant main characteristic, it could be noted that additional pathophysiological conditions consist in a reduced responsiveness or counter-regulation of neural drive in ANS according to an excitatory stimulus, such as an orthostatic challenge. Hence, especially active orthostatic testing could provide additional information about HR(V) reactivity and recovery giving valuable insights into athletes' training status, fatigue levels, and adaptability to workload. Measuring while standing might also counteract the issue of parasympathetic saturation as a common phenomenon especially in well-trained endurance athletes. Data interpretation should be made within intra-individual data history in trend analysis accounting for inter-individual variations in acute responses during testing due to life and physical training stressors. Therefore, additional measures (e.g., psychometrical scales) are required to provide context for HR and HRV analysis interpretation. However, incidence of orthostatic intolerance should be evaluated on an individual level and must be taken into account when considering to implement orthostatic testing in specific subpopulations. Recommendations for standardized testing procedures and interpretation guidelines are developed with the overall aim of enhancing training and recovery strategies. Despite promising study findings in the above-mentioned applied fields, further research, thorough method comparison studies, and systematic reviews are needed to assess the overall perspective of orthostatic testing for training monitoring and fine-tuning of different populations in exercise science and training.
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Background: Both measured orthostatic hypotension and symptomatic orthostasis are common in PD but their relationship is unclear. Objective: We aim to determine clinical predictors of both measured orthostatic hypotension and reported symptomatic orthostasis in PD, including the impact of "on"/"off" status and seasons, and to determine the correlation between measured OH and subjective orthostasis. Methods: We analyzed BP readings, demographic and disease state predictors for both 1. Measured blood pressure OH criteria and 2. The subjective report of orthostatic symptoms, using logistic regression analyses from an initial "on" motor state clinical visit in all PD patient visits. We then correlated subjective orthostasis symptoms with BP measurements. We also compared intra-subject BP measures in PD patients seen in both "on" and "off" states, and when seen "on" in both summer and winter. Results: 723 consecutive visits over 2 years identified 250 unique PD individuals. Subjective orthostasis was reported by 44 % and "on" measured OH (>20 drop in SBP or 10 DBP upon standing) was seen in 30 %. Measured OH did not significantly correlate with any assessed clinical feature or specific medicine. Subjective orthostasis correlated most with older age, dementia, and L-dopa use. Subjective orthostasis correlated equally with absolute lower measured standing SBP and the drop in SBP from sitting to standing. Compared to the "off" state, "on" state showed lower sitting and standing SBP, more than DBP, but no significant change in BP drop upon standing. Seasons did not impact measured BP. Conclusions: Both OH and symptomatic orthostasis are common. Dopaminergic medications did not cause traditionally defined OH but lowered all SBP (sitting and standing) and thus reduced pulse pressure, possibly by increasing arteriole compliance simply by reducing motor tone, as this BP-lowering effect may be specific to Parkinsonism.
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Dysautonomia impacts multiple systems leading to a spectrum of severe disorders independent of the motor symptoms in Parkinson's disease (PD). Although the motor symptoms of dyskinesia and immobility in patients with PD were traditionally considered the major reasons leading to emergency visits, the significance of non-motor symptoms, particularly dysautonomia-related disorders, have been increasingly appreciated during their emergent encounters. We present the case of an elderly patient with advanced PD who was hit by a full spectrum of dysautonomia-related disorders, had frequent emergency visits and hospital admissions over one year, and eventually died on his fifth emergency visit. His dysautonomia-related disorders included dysphagia, gastroesophageal reflux disease, neurogenic bladder, chronic constipation, and cardiac dysautonomia with orthostatic intolerance. We further review emergent presentations, assessments, and immediate management of these dysautonomia-associated disorders in patients with PD. In summary, these dysautonomia-linked comorbidities can be debilitating and sometimes fatal. As for our case, the patient was on a clinical decline majorly due to dysautonomia and nearing the end of life over the past year. A holistic approach of possible de-escalating care and palliative care might lead to a better quality of life for the patients and their families. Nevertheless, generally speaking, emergent presentations of dysautonomia symptoms in patients with PD should be recognized and treated timely and appropriately in the emergency room. Emergency clinicians need to increase awareness and make efforts to manage these acute worsening episodes of dysautonomia disorders in patients with PD to prevent debilitating and fatal complications.
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Background While the effects of exercise on the cardiovascular system are well documented, ultra-endurance sports involve distances beyond the scope of traditional marathons and have grown in popularity at a staggering pace in recent years. While short-term high-intensity exercise stimulates sympathetic rises in heart rate (HR) and blood pressure (BP), the depletion of fluid and electrolyte reserves characteristic of ultra-endurance sports may contribute to decreases in overall BP after the race. If decompensation of the autonomic safety net occurs, orthostatic hypotension as a result of fluid loss during an event may cause fatigue, dizziness, syncope, or collapse. Methodology Subjects were recruited by emails sent to race participants and at pre-race meetings, and no participants were excluded from the study. We observed BP and HR changes in subjects before and after ultramarathon activity in both supine and standing positions over multiple races of variant length and terrain from 50 to 240 km from 2013 to 2018. Participants entered races in Florida, with a mean age of 43.8 and an average body mass index (BMI) of 21.2. In addition to pre-race and post-race measurements, positional post-race BPs and HRs were analyzed for orthostatic trends. Results Of those who participated, 140 completed the events and post-race HR and BP measurements were recorded. The mean systolic blood pressure (SBP) increase from pre-race to post-race standing was 21 mmHg, while the mean diastolic blood pressure (DBP) rise was 13 mmHg. While in a supine position, there was a 15 mmHg increase in SBP from pre-race to post-race, along with a 7 mmHg rise in diastolic pressure. Post-race supine to standing average BP change was insignificant. In the supine position, the mean HR increased by 20 beats per minute (bpm) after the race and by 27 bpm while standing. After the race, the average increase in HR supine to standing was 15 bpm. Conclusions The SBP changed much more notably than diastolic pressures likely due to the increase in stroke volume associated with the sympathetic response during exercise. HR values also climbed as a result of exercise stress in the setting of catecholamine release, and the combined influence contributed to increased cardiac output despite water and electrolyte loss during the event. Post-race, no trends of orthostatic hypotension were noted either with HR or BP when rising from a supine position. The significance of the contribution of fluid intake during the race to compensatory mechanisms under neural control requires further study.
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BACKGROUND: Although type 2 diabetes mellitus (T2DM) is an established risk factor for cognitive impairment, the underlying mechanisms remain poorly explored. One potential mechanism may be through effects of T2DM on cerebral perfusion. The current study hypothesized that T2DM is associated with altered peripheral and central hemodynamic responses to orthostasis, which may in turn be associated with cognitive impairment in T2DM. METHODS: A novel use of function-on-scalar regression, which allows the entire hemodynamic response curve to be modeled, was employed to assess the association between T2DM and hemodynamic responses to orthostasis. Logistic regression was used to assess the relationship between tissue saturation index (TSI), T2DM, and cognitive impairment. All analyses used cross-sectional data from Wave 3 of The Irish Longitudinal Study on Ageing (TILDA). RESULTS: Of 2 984 older adults (aged 64.3â ±â 8.0; 55% female), 189 (6.3%) had T2DM. T2DM was associated with many features that are indicative of autonomic dysfunction including a blunted peak heart rate and lower diastolic blood pressure. T2DM was associated with reduced TSI and also with greater odds of impaired performance on the Montreal Cognitive Assessment (odds ratio [OR]: 1.62; confidence interval [CI: 1.07, 2.56]; pâ =â .019). Greater TSI was associated with lower odds of impaired performance (OR: 0.90, CI [0.81-0.99]; pâ =â .047). CONCLUSIONS: T2DM was associated with impaired peripheral and cerebral hemodynamic responses to active stand. Both T2DM and reduced cerebral perfusion were associated with impaired cognitive performance. Altered cerebral perfusion may represent an important mechanism linking T2DM and adverse brain health outcomes in older adults.
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Disfunción Cognitiva , Diabetes Mellitus Tipo 2 , Humanos , Femenino , Anciano , Masculino , Diabetes Mellitus Tipo 2/complicaciones , Estudios Longitudinales , Mareo , Estudios Transversales , Disfunción Cognitiva/etiología , HemodinámicaRESUMEN
The rise of ultraendurance sports in the past two decades warrants evaluation of the impact on the heart and vessels of a growing number of athletes participating. Blood pressure is a simple, inexpensive method to evaluate one dimension of an athlete's cardiovascular health. No systematic review or meta-analysis to date has chronicled and delineated the effects of ultraendurance races, such as ultramarathons, marathons, half-marathons, and Ironman triathlon events, specifically on heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), and mean arterial pressure (MAP) measurements in supine and standing positions before and after the event. This meta-analysis reviews the effects of ultraendurance events on positional and calculated hemodynamic values. Data were extracted from 38 studies and analyzed using a random effects model with a total of 1,645 total blood pressure measurements. Of these, 326 values were obtained from a standing position, and 1,319 blood pressures were taken supine. Pre-race and post-race measurements were evaluated for clinical significance using established standards of hypotension and orthostasis. HR and calculated BP features, such as PP and MAP, were evaluated. Across all included studies, the mean supine post-race HR increased by 21±8 beats per minute (bpm) compared to pre-race values. The mean standing post-race HR increased by 23±14 bpm when compared with pre-race HR. Overall, there was a mean SBP decrease of 19±9 mmHg and a DBP decrease of 9±5 mmHg post-race versus pre-race values. MAP variations reflected SBP and DBP changes. The mean supine and standing pre-race blood pressures across studies were systolic (126±7; 124±14) and diastolic (76±6; 75±12), suggesting that some athletes may enter races with existing hypertension. The post-race increase in the mean HR and decline in mean blood pressure across examined studies suggest that during long-term events, ultramarathon athletes perform with relatively asymptomatic hypotension.
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PURPOSE: Sarcopenia and delayed orthostatic blood pressure (BP) recovery are two disorders increasingly associated with adverse clinical outcomes in older adults. There may exist a pathophysiological link between the two via the skeletal muscle pump of the lower limbs. Previously in a large population-based study, we found an association between probable sarcopenia and orthostatic BP recovery. Here, we sought to determine the association between confirmed sarcopenia and orthostatic BP recovery in falls clinic attendees aged 50 years or over. METHODS: One hundred and nine recruited patients (mean age 70 years, 58% women) underwent an active stand with non-invasive beat-to-beat haemodynamic monitoring. Hand grip strength and five-chair stands time were measured, and bioelectrical impedance analysis was performed. They were then classified as robust, probable sarcopenic or sarcopenic as per the European Working Group on Sarcopenia in Older People guidelines. Mixed effects models with linear splines were used to model the effect of sarcopenia status on orthostatic BP recovery, whilst controlling for potential confounders. RESULTS: Probable sarcopenia was identified in 32% of the sample and sarcopenia in 15%. Both probable and confirmed sarcopenia were independently associated with an attenuated rate of recovery of both systolic and diastolic BP in the 10-20 s period after standing. Attenuation was larger for confirmed than probable sarcopenia (systolic BP ß - 0.85 and - 0.59, respectively, P < 0.01; diastolic BP ß - 0.65, - 0.45, P < 0.001). CONCLUSION: Sarcopenia was independently associated with slower BP recovery during the early post-stand period. The potentially modifiable effect of the skeletal muscle pump in orthostatic haemodynamics requires further study.
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Hipotensión Ortostática , Sarcopenia , Humanos , Femenino , Anciano , Masculino , Presión Sanguínea/fisiología , Fuerza de la Mano , Factores de RiesgoRESUMEN
NEW FINDINGS: What is the central question of this study? The aim was to characterize adverse responses to whole-body hot water immersion and to investigate practical strategies to mitigate these effects. What is the main finding and its importance? Whole-body hot water immersion induced transient orthostatic hypotension and impaired postural control, which recovered to baseline within 10 min. Hot water immersion was well tolerated by middle-aged adults, but younger adults suffered from a greater frequency and severity of dizziness. Cooling the face with a fan or not immersing the arms can mitigate some of these adverse responses in younger adults. ABSTRACT: Hot water immersion improves cardiovascular health and sporting performance, yet its adverse responses are understudied. Thirteen young and 17 middle-aged adults (n = 30) were exposed to 2 × 30 min bouts of whole-body 39°C water immersion. Young adults also completed cooling mitigation strategies in a randomized cross-over design. Orthostatic intolerance and selected physiological, perceptual, postural and cognitive responses were assessed. Orthostatic hypotension occurred in 94% of middle-aged adults and 77% of young adults. Young adults exhibited greater dizziness upon standing (young subjects, 3 out of 10 arbitrary units (AU) vs. middle-aged subjects, 2 out of 10 AU), with four terminating the protocol early owing to dizziness or discomfort. Despite middle-aged adults being largely asymptomatic, both age groups had transient impairments in postural sway after immersion (P < 0.05), but no change in cognitive function (P = 0.58). Middle-aged adults reported lower thermal sensation, higher thermal comfort, and higher basic affect than young adults (all P < 0.01). Cooling mitigation trials had 100% completion rates, with improvements in sit-to-stand dizziness (P < 0.01, arms in, 3 out of 10 AU vs. arms out, 2 out of 10 AU vs. fan, 4 out 10 AU), lower thermal sensation (P = 0.04), higher thermal comfort (P < 0.01) and higher basic affect (P = 0.02). Middle-aged adults were predominantly asymptomatic, and cooling strategies prevented severe dizziness and thermal intolerance in younger adults.
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Hipotensión Ortostática , Intolerancia Ortostática , Adulto Joven , Humanos , Persona de Mediana Edad , Temperatura Corporal/fisiología , Mareo , Inmersión , Agua , Calor , FríoRESUMEN
OBJECTIVE: Familial dysautonomia (FD) is a rare inherited autosomal recessive disorder with abnormal somatosensory, enteric, and afferent autonomic neurons. We aimed to define the incidence of gastrointestinal bleeding and its associated risk factors in patients with FD. METHODS: In this retrospective case-control study, we identified all episodes of gastrointestinal bleeding in patients with FD, occurring over four decades (January 1980-December 2017), using the New York University FD registry. RESULTS: We identified 104 episodes of gastrointestinal bleeding occurring in 60 patients with FD. The estimated incidence rate of gastrointestinal bleeds in the FD population rate was 4.20 episodes per 1000 person-years. We compared the 60 cases with 94 age-matched controls. Bleeding in the upper gastrointestinal tract from gastric and duodenal ulcers occurred most frequently (64 bleeds, 75.6%). Patients were more likely to have a gastrostomy (G)-tube and a Nissen fundoplication [odds ratio (OR) 3.73, 95% confidence interval (CI) 1.303-13.565] than controls. The mean time from G-tube placement to first gastrointestinal bleed was 7.01 years. The mean time from Nissen fundoplication to bleed was 7.01 years. Cases and controls had similar frequency of intake of nonsteroidal antiinflammatory drugs (NSAID) and selective serotonin reuptake inhibitors (SSRI). CONCLUSION: The incidence of gastrointestinal bleeding in the pediatric FD population was estimated to be 4.20 per 1000 person-years, 21 times higher than in the general pediatric population (0.2 per 1000 person-years). Patients with FD with a G-tube and a Nissen fundoplication had a higher risk of a subsequent gastrointestinal bleeding.
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Disautonomía Familiar , Humanos , Niño , Disautonomía Familiar/complicaciones , Disautonomía Familiar/epidemiología , Estudios de Casos y Controles , Estudios Retrospectivos , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/complicaciones , Inhibidores Selectivos de la Recaptación de SerotoninaRESUMEN
BACKGROUND: Sarcopenia, delayed blood pressure (BP) recovery following standing, and orthostatic hypotension (OH) pose significant clinical challenges associated with ageing. While prior studies have established a link between sarcopenia and impaired BP recovery and OH, the underlying haemodynamic mechanisms remain unclear. METHODS: We enrolled 107 participants aged 50 and above from a falls and syncope clinic, conducting an active stand test with continuous non-invasive haemodynamic measurements. Hand grip strength and five-chair stand time were evaluated, and muscle mass was estimated using bioelectrical impedance analysis. Participants were categorised as non-sarcopenic or sarcopenic. Employing mixed-effects linear regression, we modelled the effect of sarcopenia on mean arterial pressure and heart rate after standing, as well as Modelflow®-derived parameters such as cardiac output, total peripheral resistance, and stroke volume, while adjusting for potential confounders. RESULTS: Sarcopenia was associated with diminished recovery of mean arterial pressure during the 10-20 s period post-standing (ß -0.67, p < 0.001). It also resulted in a reduced ascent to peak (0-10 s) and recovery from peak (10-20 s) of cardiac output (ß -0.05, p < 0.001; ß 0.06, p < 0.001). Furthermore, sarcopenia was associated with attenuated recovery (10-20 s) of total peripheral resistance from nadir (ß -0.02, p < 0.001) and diminished recovery from peak (10-20 s) of stroke volume (ß 0.54, p < 0.001). Notably, heart rate did not exhibit a significant association with sarcopenia status at any time interval post-standing. CONCLUSION: The compromised BP recovery observed in sarcopenia appears to be driven by an initial reduction in the peak of cardiac output, followed by attenuated recovery of cardiac output from its peak and total peripheral resistance from its nadir. This cardiac output finding seems to be influenced by stroke volume rather than heart rate. Possible mechanisms for these findings include cardio-sarcopenia, the impact of sarcopenia on the autonomic nervous system, and/or the skeletal muscle pump.
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BACKGROUND: E-learning based laboratory classes can replace or enhance in-classroom laboratories. They typically offer temporal flexibility, self-determined learning speed, repeatability and do not require supervision or face-to-face contact. The aim of this feasibility study was to investigate whether the established in-classroom laboratory class on the baroreceptor reflex (BRR) can be transformed into a new e-learning based asynchronous laboratory class for untrained, non-supervised students without medical equipment. The BRR is a fundamental cardiovascular process which is regularly visualized in physiology during in-classroom laboratories by a student-performed Active Standing Test (AST). During this voluntary provocation of orthostatic stress, the BRR reliably causes a solid rise in heart rate (HR) and a stabilization or even increase in blood pressure (BP). METHODS: The conventional AST was modified by omission of BP measurements which would require medical devices and was embedded into a framework of interactive digital material allowing independent student performance. With specific adaptions, this instrument was implemented to 1st and 2nd year curricula of human medicine, dental medicine, midwifery and pharmacy. An audience response system was used to collect the students' data on HR, epidemiology, technical problems, satisfaction and orthostatic symptoms. As primary outcome, we investigated the students' correct performance of the modified AST regarding textbook conformity of the HR data. Secondary outcomes included technical feasibility, the students' satisfaction and consistency of HR data within predefined subgroups (e.g., gender, curricula). Descriptive statistics are reported. RESULTS: The class was completed by 217 students (mean age: 23 ± 8 [SD], 81% female, 19% male). Mean reported rise of HR during standing was ~ 20 bpm (~ 30%) which is highly concordant to textbooks. Reported feasibility (~ 80% negated any technical issues) and students' satisfaction (4.4 on 5-point Likert-scale) were high. The HR data were consistent within the subgroups. CONCLUSION: This study demonstrates that the highly relevant BRR can be successfully addressed in an e-learning based asynchronous laboratory class implementing a non-supervised AST restricted to HR measurements embedded in digital material. The robust HR response and the adjustable complexity allow an application to different healthcare-related curricula. This class, therefore, provides a broad audience access to a fundamental concept of cardiovascular physiology.
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Barorreflejo , Instrucción por Computador , Adolescente , Adulto , Curriculum , Femenino , Humanos , Aprendizaje , Masculino , Estudiantes , Adulto JovenRESUMEN
Orthostatic hypotension (OH) is a well-recognized phenomenon occurring in multiple myeloma (MM) patients undergoing autologous stem cell transplant (ASCT), and is associated with significant morbidity and mortality. A retrospective analysis of patients admitted for first ASCT between June 2012 and April 2014 found that 161/222 (73%) patients were diagnosed with OH during the course of ASCT, including 51 patients who were found to have OH on the day of first orthostatic vitals check. Excluding these 51 patients, 110/171 (64%) patients developed OH during the peri-transplant period, at a median of 7 days post ASCT (95% CI: 6.5-8.5). OH did not significantly impact length of hospitalization, progression free and overall survival. Multivariable analysis revealed four risk factors (i.e. ≥0.5% weight loss/day, white race, gabapentin, antihypertensives) and two protective factors (i.e. antihistamine, proton pump inhibitor) associated with the development of peri-transplant OH.
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Trasplante de Células Madre Hematopoyéticas , Hipotensión Ortostática , Mieloma Múltiple , Antihipertensivos , Gabapentina , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Humanos , Hipotensión Ortostática/complicaciones , Hipotensión Ortostática/etiología , Mieloma Múltiple/complicaciones , Inhibidores de la Bomba de Protones , Estudios Retrospectivos , Factores de Riesgo , Trasplante Autólogo/efectos adversosRESUMEN
INTRODUCTION: Levodopa is the most effective medication for the treatment of motor symptoms of Parkinson's disease (PD). Several factors may affect the efficacy and tolerability of levodopa. These include the timing, dosage and administration of levodopa, concomitant drugs, food, PD-associated non-motor symptoms, and various neurologic and non-neurologic comorbidities. If not appropriately addressed, these issues may limit levodopa efficacy, tolerability, and compliance. AREAS COVERED: This article reviews the basics of the metabolism of orally administered levodopa, its side effects, and the factors that may affect its tolerability and efficacy. We provide several practical pearls to improve the tolerability and efficacy of levodopa. EXPERT OPINION: Protein-rich food delays and reduces levodopa absorption. Hence, levodopa should preferably be administered in a relatively empty stomach. Carbidopa dosing is crucial as it not only enhances the entry of levodopa into the central nervous system but also reduces levodopa's peripheral adverse effects. Patients experiencing the early side effects such as nausea/vomiting should be prescribed with anti-nausea medications that do not block dopamine receptors. Non-oral routes of administration can be used to obviate persistent gastrointestinal side effects. Implementation of these and other tips may help improve the tolerability and efficacy of levodopa.
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Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos , Enfermedad de Parkinson , Antiparkinsonianos , Carbidopa/efectos adversos , Combinación de Medicamentos , Humanos , Levodopa , Enfermedad de Parkinson/tratamiento farmacológicoRESUMEN
Background: Leg discomfort is common in the general population. Volume increase and discomfort in the lower legs especially occur in occupations with long standing or sitting periods and less movement. Are both related to each other? Patients and methods: A time-controlled standing period of 15 min was performed in this nonrandomized controlled study to investigate the change and temporal relationship of volume increase and the occurrence of lower leg discomfort. Sensations of discomfort and the urge to move were queried using a numerical rating scale from 0 to 10 (NRS). Correlation analysis was conducted between the lower leg volume and the data regarding the discomfort and urge to move in each subject. Further, linear mixed effect models were performed to detect a causal relationship between the lower leg volume and the sensations of discomfort/urge to move in the standing period. Results: Lower leg volume increased by an average of 63 ml (p<0.001) during the standing period. The sensations of discomfort increased by a mean of 3.46 points on the NRS (p<0.001) during orthostasis. Participants' urge to move increased by 3.47 points on the NRS (p<0.001) during the standing period. A significant correlation was shown between the increase of lower leg volume and the occurrence of discomfort sensation in 9 out of 15 subjects (p<0.05) and between the increase of lower leg volume and the urge to move in 11 out of 15 subjects (p<0.05). Association was shown between volume increase and symptoms in linear mixed effects models. Conclusions: Prolonged standing with lack of movement leads to an increase in the lower leg volume and a sensation of discomfort in venous healthy subjects. Causal relationships are indicated between these variables by linear mixed effects models.
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Pierna , Caminata , Voluntarios Sanos , Humanos , Extremidad Inferior , VenasRESUMEN
BACKGROUND: Postoperative orthostatic intolerance can limit mobilization after hip and knee arthroplasty. The literature is lacking on the incidence and risk factors associated with orthostatic intolerance after elective arthroplasty. METHODS: A retrospective case-control study of primary total hip, total knee, and unicompartmental knee arthroplasty patients was conducted. Patients with orthostatic events were identified, and potential demographic and perioperative risk factors were recorded. Orthostatic intolerance was defined as postoperative syncope, lightheadedness, or dizziness, limiting ambulation and/or requiring medical treatment. Statistical analysis was completed using Pearson's chi-square test for categorical data and t-tests for continuous data. Binary logistic regression was performed. RESULTS: A total of 500 consecutive patients were included. The overall incidence of orthostatic intolerance was 18%; 25% in total hip arthroplasty (THA) and 11% in total knee arthroplasty. On univariate analysis, significant risk factors for developing postoperative orthostatic intolerance include older age, female gender, THA surgery, lower American Society of Anesthesiologists class, absence of recreational drug use, lower estimated blood volume, lower preoperative diastolic blood pressure, spinal with monitored anesthesia care (MAC), posterior approach for THA, bupivacaine use in spinal, percent of blood loss, postoperative oxycodone or tramadol use, higher postoperative intravenous fluid volume, and lower postoperative hemoglobin. Multivariate analysis demonstrated persistent significance of female gender, THA surgery, spinal with MAC, bupivacaine use in spinal, and more intravenous fluid administered postoperatively. CONCLUSION: Orthostatic intolerance affects a significant number of arthroplasty patients. Awareness of risk factors and modification of perioperative variables linked to orthostatic intolerance may assist the surgeon in choosing the appropriate surgical setting, educating patients, and improving early postoperative recovery.
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Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Intolerancia Ortostática , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Bupivacaína , Estudios de Casos y Controles , Mareo/complicaciones , Femenino , Humanos , Incidencia , Intolerancia Ortostática/complicaciones , Intolerancia Ortostática/epidemiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de RiesgoRESUMEN
Postprandial orthostasis activates mechanisms of cardiovascular homeostasis to maintain normal blood pressure (BP) and adequate blood flow to vital organs. The underlying mechanisms of cardiovascular homeostasis in postprandial orthostasis still require elucidation. Fourteen healthy volunteers were recruited to investigate the effect of an orthostatic challenge (60°-head-up-tilt for 20 min) on splanchnic and systemic hemodynamics before and after ingesting an 800-kcal composite meal. The splanchnic circulation was assessed by ultrasonography of the superior mesenteric and hepatic arteries and portal vein. Systemic hemodynamics were assessed noninvasively by continuous monitoring of BP, heart rate (HR), cardiac output (CO), and the pressor response to an intravenous infusion on increasing doses of phenylephrine, an α1-adrenoceptor agonist. Neurohumoral regulation was assessed by spectral analysis of HR and BP, plasma catecholamine and aldosterone levels and plasma renin activity. Postprandial mesenteric hyperemia was associated with an increase in CO, a decrease in SVR and cardiac vagal tone, and reduction in baroreflex sensitivity with no change in sympathetic tone. Arterial α1-adrenoceptor responsiveness was preserved and reduced in hepatic sinusoids. Postprandial orthostasis was associated with a shift of 500 mL of blood from mesenteric to systemic circulation with preserved sympathetic-mediated vasoconstriction. Meal ingestion provokes cardiovascular hyperdynamism, cardiac vagolysis, and resetting of the baroreflex without activation of the sympathetic nervous system. Meal ingestion also alters α1-adrenoceptor responsiveness in the hepatic sinusoids and participates in the redistribution of blood volume from the mesenteric to the systemic circulation to maintain a normal BP during orthostasis.NEW & NOTEWORTHY A unique integrated investigation on the effect of meal on neurohumoral mechanisms and blood flow redistribution of the mesenteric circulation during orthostasis was investigated. Food ingestion results in cardiovascular hyperdynamism, reduction in cardiac vagal tone, and baroreflex sensitivity and causes a decrease in α1-adrenoceptor responsiveness only in the venous intrahepatic sinusoids. About 500-mL blood shifts from the mesenteric to the systemic circulation during orthostasis. Accordingly, the orthostatic homeostatic mechanisms are better understood.
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Sistema Nervioso Autónomo/fisiopatología , Sistema Cardiovascular/fisiopatología , Mareo/fisiopatología , Hemodinámica , Periodo Posprandial , Receptores Adrenérgicos alfa 1/metabolismo , Circulación Esplácnica , Agonistas de Receptores Adrenérgicos alfa 1/administración & dosificación , Adulto , Sistema Nervioso Autónomo/efectos de los fármacos , Sistema Nervioso Autónomo/metabolismo , Velocidad del Flujo Sanguíneo , Sistema Cardiovascular/inervación , Mareo/diagnóstico por imagen , Mareo/metabolismo , Femenino , Voluntarios Sanos , Hemodinámica/efectos de los fármacos , Arteria Hepática/diagnóstico por imagen , Arteria Hepática/fisiopatología , Humanos , Infusiones Intravenosas , Masculino , Arteria Mesentérica Superior/diagnóstico por imagen , Arteria Mesentérica Superior/fisiopatología , Persona de Mediana Edad , Fenilefrina/administración & dosificación , Vena Porta/diagnóstico por imagen , Vena Porta/fisiopatología , Receptores Adrenérgicos alfa 1/efectos de los fármacos , Transducción de Señal , Factores de Tiempo , Adulto JovenRESUMEN
BACKGROUND: Edema caused by orthostasis is a common clinical picture in the medical and occupational context. Medical compression therapy with compression stockings (CS) is considered a conservative therapeutic standard in edema therapy. The effect of CS on leg discomfort and the increase of the lower leg volume during a standing load still remains questionable. In addition, it is not entirely known whether there is a correlation between volume increase and discomfort in these individuals. METHOD: A timed, controlled standing load of 15âmin was conducted by the participants in this non-randomized controlled study to analyze the change in and correlation between lower leg volume increase and the occurrence of lower leg discomfort under compression therapy. Below-knee CS with an interface pressure of 23-32âmmHg were used. The lower leg volume was measured following previous studies using an optical three-dimensional volume (ml) measurement system, and sensations of discomfort and the urge to move were asked about using a numerical rating scale (NRS) of 0-10. The subjects conducted a leg movement for 15âs immediately after the standing period; the data were collected again subsequently. A correlation was calculated between the lower leg volume and the data regarding the discomfort and urge to move for each participant. The experiments had already been performed as part of a previous study including the same subjects who did not wear CS. The results of the study conducted here were compared with those of the participants who did not wear CS to investigate the effect of the CS. RESULTS: Lower leg volume increased by an average of 27âml (pâ<â0.001) (without CS: by 63âml) during standing load in the right leg. During the leg movement after standing load, the lower leg volume increased by 5âml (n.s.). The sensations of discomfort during the orthostasis increased by 2.6 points on the NRS (pâ<â0.001) (without CS: by 3.46 points) and decreased by 1.67 points (pâ<â0.001) during the leg movement shortly after the standing period. Participants' urge to move increased by 3.73 points on the NRS (pâ<â0.001) (without CS: by 3.47 points) while the participants performed the standing period and decreased by 2.73 points (pâ<â0.001) during the final movement exercise. A weakly significant correlation could be demonstrated between the increase in the lower leg volume and the occurrence of discomfort in 6 out of 13 subjects (pâ<â0.1), and between the increase in the lower leg volume and the urge to move in 8 out of 15 subjects (pâ<â0.1). CONCLUSION: Standing loads and lack of movement lead to an increase in the lower leg volume and sensation of discomfort in venous healthy subjects wearing CS, which are reduced by wearing them (pâ<â0.001). A weakly significant mathematical correlation (Pearson's correlation coefficient) could be shown between the increase in the lower leg volume and the occurrence of the urge to move in 8 out of 15 subjects (pâ<â0.1) and between the increase in lower leg volume and the occurrence of leg discomfort in 6 out of 13 subjects (pâ<â0.1).
Asunto(s)
Pierna , Medias de Compresión , Voluntarios Sanos , Humanos , Extremidad Inferior , SensaciónRESUMEN
Orthostatic hypotension (OH) is very common in older people and is encountered daily in emergency departments and medical admissions units. It is associated with a higher risk of falls, fractures, dementia and death, so prompt recognition and treatment are essential. In this review article, we describe the physiology of standing (orthostasis) and the pathophysiology of orthostatic hypotension. We focus particularly on aspects pertinent to older people. We review the evidence and consensus management guidelines for all aspects of management. We also tackle the challenge of concomitant orthostatic hypotension and supine hypertension, providing a treatment overview as well as practical suggestions for management. In summary, orthostatic hypotension (and associated supine hypertension) are common, dangerous and disabling, but adherence to simple structures management strategies can result in major improvements.
Asunto(s)
Hipertensión , Hipotensión Ortostática , Accidentes por Caídas , Anciano , Presión Sanguínea , Humanos , Hipotensión Ortostática/diagnóstico , Hipotensión Ortostática/terapiaRESUMEN
Previous research suggests individuals with intellectual disabilities (ID) may experience autonomic dysfunction, however, this has not been thoroughly investigated. The aim of this study was to compare the autonomic response to standing up (active orthostasis) and head-up tilt (passive orthostasis) in individuals with ID to a control group without ID. Eighteen individuals with and 18 individuals without ID were instrumented with an ECG-lead and finger-photoplethysmography for continuous heart rate and blood pressure recordings. The active and passive orthostasis protocol consisted of 10-min supine rest, 10-min standing, 10-min supine recovery, 5-min head-up tilt at 70°, followed by 10-min supine recovery. The last 5 min of each position was used to calculate hemodynamic and autonomic function (time- and frequency-domain heart rate and blood pressure variability measures and baroreflex sensitivity). Individuals with ID had higher heart rate during baseline and recovery (P < 0.05), and an attenuated hemodynamic (stroke volume, heart rate) and heart rate variability response to active and passive orthostasis (interaction effect P < 0.05) compared with individuals without ID. Mean arterial pressure (MAP) was higher in individuals with ID at all timepoints. Individuals with ID demonstrated altered hemodynamic and autonomic regulation compared with a sex- and age-matched control group, evidenced by a higher mean arterial pressure and a reduced response in parasympathetic modulation to active and passive orthostasis.NEW & NOTEWORTHY Individuals with ID demonstrated altered hemodynamic and autonomic regulation to the clinical autonomic function tasks standing up and head-up tilt (active and passive orthostasis). Higher resting heart rate and higher MAP throughout the protocol suggest a higher arousal level, and individuals with ID showed a blunted response in parasympathetic modulation. Further research should investigate the relationship of these findings with clinical outcomes.