Jaap Deinum Dept of Medicine Div of Vascular Medicine Research contracts ZONMW Consulting Medtronics Daiichi Sankyo Takeda Dutch Society of Hypertension Employment in industry ID: 915890
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Slide1
Cardiovasculaire Autonome Functiestoornissen
Jaap DeinumDept. of MedicineDiv. of Vascular Medicine
Slide2Research contracts:
-ZON-MWConsulting:-Medtronics, Daiichi Sankyo, Takeda (Dutch Society of Hypertension)
Employment in industry:
-
Stockholder of a healthcare company:-Owner of a healthcare company:-Other:-
Jaap Deinum, RadboudUMCAssociate Professor of Internal Medicine
‘
small
font
size
and
rapid
clicking
away
of
disclosure
slide
denote
serious
conflicts
of interest’
Slide3https://forms.lumc.nl/lumc2/symposium_wsaaliteratuurlijst: jaap.deinum
@radboudumc.nl
Slide4Cardiovasculaire Autonome Functiestoornissen
Jaap DeinumDept. of MedicineDiv. of Vascular Medicine
F
z
Slide5AF
POTSNMS
Normotension
Labile
HTHBP
Postural
orthostatic
tachycardia
syndrome
increase
in
heart
rate >30
bpm
, within 10 minutes of standing, without OH, relieved by recumbency
Neurally mediated syncope aka vasovagal syncope, reflex syncope
Orthostatic intolerance
Orthostatic
hypotension
PhaeochromocytomaBaroreflex failure
Orthostatic
hypotension
: SBP
decrease
of >20 mm Hg
or
DBP
decrease
of >10 mm Hg
within
3
minutes
of standing
Slide6Transient loss of conscience (‘collapse’) vs SyncopeSyncope= transient loss of conscience due to transient global cerebral hypoperfusion
characterized by rapid onset, short duration, and spontaneouscomplete recoveryESC guideline 2010Orthostatic intolerance: light-headedness, blurred vision, cognitive difficulties,and generalized weakness; palpitations, chest pain, and tremulousness
Slide7Afferent
Efferentheart
heart
ratevessels vascular tone
contractility
kidney
renin
/
AII
Na
+
reabsorption
Carotid
baroreceptors
sympathetic
nn
Vasomotor
center
Aortic
and
Cardiopulm
.
baroreceptors
N IX
N X
N X
Slide8Standing:
decrease of venous return
Slide9Afferent
Efferentheart
heart
rate
↑vessels vascular tone↑
contractility
↑
kidney
renin
/
AII
Na
+
reabsorption
Carotid
baroreceptors
sympathetics
Vasomotor
center
Aortic
and
Cardiopulm
.
baroreceptors
N IX
N X
N X
+
+
-
BP
↓
Slide10What’s needed?-good history-taking skills! It’s fun!
-beat-to-beat blood pressure registration (finger blood pressure)-Head-up-tilt bed-tube with resistance connected to sphygmomanometer to monitor expiratory pressure-neurologist and cardiologist with an interest in syncope
Slide11Slide12SOME
tests of autonomic functionafferent
integration
efferent
effect
PNS
SNS
tilt
IX X CZS
medulla
HR
deep breathing
X
medulla
HR (insp)
valsalva
IX X CZS
medulla
depends on phase
LBNP
IX X
medulla
HR
carotid
massage
IX
medulla
HR,
BP
cold pressor
pain fibers
CZS
BP,
HR
handgrip
muscle aff.
CZS
BP,
HR
arithmetic
CZS
CZS
BP
Slide13Valsalva
test
+
SNS
+Positive Airway PressurePNS
-
+
Slide14J
Clin Neurol 2013;9:1-8
Slide15Maintaining
postural normotension-adequate blood volume-intact baroreceptors-intact autonomic
nervous
system
-skeletal muscle pump-renin-angiotensin system activity
Slide16Symptoms of autonomic failure
dizziness, tiredness neck / shoulder pain (coathanger phenomenon) blurred vision, impaired thinking reduced exercise tolerance
reduced heat tolerance
syncope
1. Related to orthostatic hypotension2. Gastrointestinal: difficulty swallowing, obstipation 3. Urogenital : impotence, micturition
4.
Siccasyndrome
and hypo/
anhidrosis
adrenergic
failure
cholinergic
failure
Slide17Male, 68 yr
-gradual onset of dizzyness upon standing-decreased exercise tolerance
(-
impotence
)-orthostatic hypotension: 168/98 supine, 88/54 mm Hg standing -heart rate 76->78 bpm
Slide18Valsalva (reflex/symp. + parasymp)SBPDBP
HF
Slide19Nocturnal hypertension
Slide20Autonomic
failure-pure autonomic failure-multiple system atrophy-
parkinson's
disease-secondaryAlways refer to neurologist!
Slide21Secondary autonomic failure
Brain (tumors/ ischemia) Myelum (ALS, spinal cord dissection etc) Diabetes mellitus Amyloidosis, porphyria
Hereditary (DBH,
Fabry
, Riley-Day, FAN) Infections (Guillain-Barré, Lyme, HIV, Chagas) Vitamin deficiencies Toxic (drugs, alcohol) Paraneoplastic
Slide22Management of autonomic failure: -adequate salt and water intake, fludrocortisone
-compressive stockings-elevated head of the bed (sin 10o x length of bed)-midodrine (α-agonist) -physical counterpressure manoeuvres
Slide23Reflex syncope
Slide24Barcroft J Physiol 1945
Slide25Differential diagnosis-vasovagal-cough-swallowing
-micturition-carotid hypersensitivity(-seizures)-arrhythmiasProdromal symptoms:-pallor-diaphoresis-yawning-sighing-nausea-abdominal discomfortPrecipitated
by
: (standing), warm environment,
emotional distressCardio-inhibitory vs vasodepressor
Slide26DiagnosisHistory & no orthostatic hypotension, HUT
Slide27Management
-avoid risky circumstances-adequate salt and water intake-explanation of mechanism-physical
counterpressure
manoeuvres-tilt training-rapid water drinking
Slide28Postural orthostatic
tachycardia syndrome increase in heart rate >30 bpm, within 10 minutes of standing, without OH, relieved by recumbency
plus
light-headedness, blurred vision, cognitive difficulties,
and generalized weakness; palpitations, chest pain, and tremulousness
Slide29112/68 mm Hg, supine
120/98 mm Hg, after standing for 2 min18 yr old woman
Slide30Slide31female:male 4.5:115-25 yearsantecedent viral illness25% family history
association with -chronic fatigue-insomnia-fibromyalgia-Ehlers-Danlos (?)-visceral pain syndromes-constipation-acral coldness-exercise intolerance-hyperventilation-anxiety-concentration difficulties-chest pain-nausea
-standing
cyanosis
POTSNeuropathic vs hyperadrenergic POTS
Slide32POTS
Slide33Mayo Clin Proc.
Dec 2012; 87(12): 1214–1225
Slide34Management-adequate salt & water intake-PCMs; rapid water drinking-exercise
program-drugs?-behavioral & cognitive approaches?
Slide35Driving?-expert report often required-reflex syncope, <3 episodes/yr, no episodes in sitting
position/distinct prodromal stage: no restriction-situational syncope (micturition, defecation, swallowing, cough): ususally no restriction except for cough syncope.-autonomic failure: if no complaints when seated and distinct prodromal warning, and no syncope for 3 months, no restriction
Slide36J Clin Neurol 2013;9:1-8
Summary
Slide37Zojuist nascholing #IVG over
#POTS, voortaan kunnen patiënten overal terecht! #RadboudoverbelastJaap Deinum @JaapDeinum