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Bradyarrhythmias and cardiac pacemakers in the elderly
Published in Wilbert S. Aronow, Jerome L. Fleg, Michael W. Rich, Tresch and Aronow’s Cardiovascular Disease in the Elderly, 2019
Naktal Hamoud, Fernando Tondato, Win-Kuang Shen
Carotid sinus massage (CSM) can induce a physiologic response, with induction of bradycardia, associated or not with hypotension, especially in individuals older than 40 years of age. The diagnostic criteria for CSH has been standardized as a pause 3 seconds (cardioinhibitory component) and/or >50 mmHg drop in systolic blood pressure (vasodepressor component), in response to 3–5 seconds of CSM (45). It is classified as a mixed response when both criteria are met. The CSM should be performed on both sides and with beat-to-beat monitoring of blood pressure and HR. If no abnormal response is detected while the patient is supine, the maneuver should be repeated in the upright position (commonly done during tilt table test, with table inclined at 70 degrees). Up to 30% of patients will have a positive CSM test only in the upright position (33). The CSM is considered positive only if the test reproduces the clinical symptoms (44) because up to 10% of the normal population can have a pronounced physiologic response to CSM, meeting the described criteria for bradycardia and/or hypotension, without relevant clinical significance (44).
Falls Risk and Prevention in the Diabetic Patient
Published in Medha N. Munshi, Lewis A. Lipsitz, Geriatric Diabetes, 2007
Lewis A. Lipsitz, Attila Priplata
Tilt-table testing should be reserved for patients whose fall history suggests reflex-mediated syncope or orthostatic hypotension when the physical examination is not diagnostic. A head-up tilt at 60° to 80° for up to 45 minutes can precipitate neurally mediated (vasovagal) syncope with associated bradycardia and hypotension. Using isoproterenol can increase the test’s sensitivity. However, isoproterenol is often contraindicated in elderly patients with known or suspected coronary artery disease. The development of vasovagal syncope during the tilt table test only suggests that vasovagal syncope may have caused the unexplained episode. Usually, vasovagal syncope can be readily diagnosed without the tilt test from a history of typical vagal prodromes (e.g., nausea; light-headedness; pale, cold, clammy skin). The tilt test may also help identify delayed orthostatic hypotension as the cause of a fall or syncope.
Neuroimaging to enhance understanding of cardiovascular autonomic changes associated with mild traumatic brain injury: a scoping review
Published in Brain Injury, 2023
Jacinta Thorne, Sarah Hellewell, Gill Cowen, Melinda Fitzgerald
Studies that identified cardiovascular changes at rest were primarily conducted during the very early acute phase following injury. One study found that mean heart rate was higher in those with minor head injury compared to controls in the first 48 h following injury (55), one identified reduced arterial pressure at rest when assessed at Day 3 (63), and one observed lower pNN50, a measure of HRV, at day 3 which normalized by day 21 (46). A further two studies identified blood pressure recorded at hospital admission as a significant contributor to models predicting outcome at 90 and 180 days (59,60). Studies that reported cardiovascular variables at rest when measured later post-injury found no difference compared to healthy controls. Three of these studies were conducted in the later acute phase (68,74,75), but most were conducted in the sub-acute (71), persistent (77,78) or chronic phases (56,58,67,69). Differences in heart rate in response to exertion were noted in three studies, with elevated heart rate during the first minute of exercise onset in concussed individuals compared to controls (65) and lower heart rate at the point of maximum exercise tolerance, which normalized following a sub-threshold aerobic exercise intervention (61,62,65). Shannon et al. also noted higher mean systolic blood pressure during the tilt table test in previously concussed individuals (77).
The future of cardioneuroablation in cardiovascular medicine
Published in Expert Review of Cardiovascular Therapy, 2022
Tolga Aksu, Asad Khan, Henry Huang
In the ISSUE 1 study, 111 patients with syncope were implanted with an ILR. 82 patients had a negative tilt table test, and 29 patients had a positive test [42]. In the group with negative tilt table tests, 11 patients experienced prolonged sinus pauses defined as >3 seconds, mainly from sinus arrest. In almost all cases, pauses were preceded by progressive sinus bradycardia suggesting NMRS as the etiology of their syncope. In another study done by Entem et al. [43], 140 patients with unexplained syncope after conventional work-up (including tilt table testing) underwent ILR implantation from 1998 to 2006. Bradycardic arrhythmias including heart block, sinus bradycardia, and asystolic pauses were seen in 27 patients. Recently, we demonstrated the use of ILR as an effective indicator of vagal denervation by using complete and durable elimination of heart rate variability on ILR [44]. It is the authors opinion that ILRs may improve comparison between intervention and control arms after CNA by providing increased accuracy during long term follow‐up due to clustered and/or nature of VVS over time.
Understanding and managing autonomic dysfunction in persons with multiple sclerosis
Published in Expert Review of Neurotherapeutics, 2021
Ivan Adamec, Magdalena Krbot Skorić, Mario Habek
Case 1. A 55-year-old male was diagnosed with relapsing remitting MS nine years prior with his first symptoms being leg weakness. After eight years of disease duration his neurologic disability started progressing and his neurologic examination revealed spastic triparesis with restricted ambulation. At that time, he was diagnosed with secondary progressive MS. Due to complaints of lightheadedness in the upright position cardiovascular autonomic testing was performed. Tilt table test revealed a fall of blood pressure from 129/97 mmHg in the supine position to 104/79 mmHg in the upright position (Figure 2b). The blood pressure response to Valsalva maneuver was pathologic with mean levels of blood pressure not reaching baseline in late phase II (Figure 2a). The patient was diagnosed with neurogenic orthostatic hypotension and was given advice on regular hydration and was taught counter pressure maneuvers to be used when experiencing orthostatic symptoms.