INTRODUCTION

Cardiac autonomic neuropathy (CAN) is a frequently underdiagnosed consequence of diabetes mellitus (DM), increasing the risk of cardiac arrhythmia, silent myocardial ischemia, and sudden cardiac death. Diabetic peripheral neuropathy (DPN) is a common consequence of diabetes. We aimed to study the proportion of CAN among patients with DPN and identify the predictors of CAN in these patients.

The study included a total of 60 patients with diabetic peripheral neuropathy, out of whom 19 (32%) had CAN. Of the 19 patients with CAN, 11 had severe CAN. There was no statistically significant association between the severity of DPN and CAN (p = 0.162). Logistic regression analysis (Model 3) showed that when adjusted for symptoms, risk factors, hypertension, and a specific ECG finding (left atrial enlargement), the determinants of CAN were the presence of motor symptoms, being overweight or obese, and the presence of left atrial enlargement.

The study included a total of 60 patients with diabetic peripheral neuropathy, out of whom 19 (32%) had CAN. Of the 19 patients with CAN, 11 had severe CAN. There was no statistically significant association between the severity of DPN and CAN (p = 0.162). Logistic regression analysis (Model 3) showed that when adjusted for symptoms, risk factors, hypertension, and a specific ECG finding (left atrial enlargement), the determinants of CAN were the presence of motor symptoms, being overweight or obese, and the presence of left atrial enlargement.

Among this cohort of persons with DM who all had DPN, CAN was found in one-third (32%) of the sample. Patients with DPN who are overweight or obese, have motor neuropathy, or have left atrial enlargement have the most significant risk for developing CAN and may be recommended for its screening. Given that CAN is a frequently overlooked condition, each early diagnosis of CAN may potentially prevent its debilitating complications and even fatal outcomes.

OBJECTIVE: To observe the effect of heat-sensitive moxibustion combined with medication on orthostatic hypotension (OH) of yang -qi deficiency in the elderly. METHODS: Sixty elderly patients with OH of yang -qi deficiency were randomly divided into an observation group (30 cases, 1 case dropped out) and a control group (30 cases). The patients in the control group were treated with oral midodrine hydrochloride tablets, 2.5 mg each time and twice daily, while the patients in the observation group were treated with heat-sensitive moxibustion in addition to the treatment in the control group. Acupoints selected included Dazhui (GV 14), Fengfu (GV 16), and Baihui (GV 20), with each session lasting 30-40 min, once daily. Both groups were treated for 4 weeks. Blood pressure in the supine and standing positions, as well as the decrease of blood pressure when the position changing from supine to standing, were measured before treatment and after 2 and 4 weeks of treatment. Clinical efficacy was also evaluated. RESULTS: After 4 weeks of treatment, both groups showed an increase in systolic blood pressure (SBP) and diastolic blood pressure (DBP) in both the supine and standing positions (P<0.05), and the decrease in SBP and DBP when the position changing from supine to standing was reduced (P<0.05). Compared with the control group, the observation group had higher SBP and DBP in both positions and a smaller decrease in SBP and DBP when the position changing from supine to standing (P<0.05). The total effective rate was 96.6% (28/29) in the observation group, which was higher than 70.0% (21/30) in the control group (P<0.05). CONCLUSION Heat-sensitive moxibustion combined with medication could increase the blood pressure in both supine and standing position, and decrease the reducing of blood pressure when the position changing from supine to standing in elderly patients with OH of yang-qi deficiency.
Humans ; Moxibustion ; Hypotension, Orthostatic/etiology* ; Male ; Aged ; Female ; Combined Modality Therapy ; Acupuncture Points ; Yang Deficiency/therapy* ; Blood Pressure/drug effects* ; Aged, 80 and over ; Middle Aged ; Midodrine

In the Systolic Blood Pressure Intervention Trial (SPRINT), intensive blood pressure (BP) lowering was associated with significant reduction in composite cardiovascular (CV) outcomes in hypertension. Subsequently, several meta-analyses have corroborated the findings from SPRINT and these benefits were more prominent in subjects with higher cardiovascular risk at baseline. As such, the recent American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guideline and the European Society of Hypertension (ESH)/European Society of Cardiology (ESC) guideline recommended the lowering of target BP to less than 130/80 mmHg in most hypertensive subjects. However, one should keep in mind the potential harm of too much BP lowering. Post hoc analysis of clinical trials have demonstrated increased cardiovascular mortality and events with too much BP lowering. Therefore, although intensive BP lowering may be beneficial in further reducing CV outcomes, too much reduction below 120/70 mmHg may actually harmful. In conclusion, although intensive BP lowering to achieve target BP below 130/80 mmHg is beneficial in reducing CV outcomes, one should do so cautiously as to avoid adverse events. As such, the first target of anti-hypertensive treatment should be to achieve BP lowering below 140/90 mmHg. Once that target is achieved, one could target BP below 130/80 mmHg keeping in mind to avoid signs of organ hypoperfusion such as orthostatic hypotension, orthostatic dizziness, weakness and serum creatinine elevation.
Blood Pressure ; Cardiology ; Cardiovascular Diseases ; Creatinine ; Dizziness ; Heart ; Hypertension ; Hypotension, Orthostatic ; Mortality

PURPOSE: To investigate the efficacy and safety of 0.4 mg of tamsulosin in patients with nocturia not responding to 0.2 mg.METHODS: Patients with intractable nocturia after treatment with 0.2 mg of tamsulosin for>1 month were included in a multicenter, prospective, observational, single-arm study. Patients were prescribed 0.4 mg of tamsulosin and followed up for 2 months to assess nocturnal voiding and nocturia-related bother. Changes in the mean number of nocturnal voids, the proportion of 50% responders, 3-day frequency-volume chart parameters, and questionnaire scores were assessed.RESULTS: Sixty-two patients were prescribed 0.2 mg of tamsulosin, of whom 56 were prescribed 0.4 mg of tamsulosin. Ten patients dropped out. A single case of orthostatic hypotension was reported. The mean age was 68 years. After 1 and 2 months of taking 0.4 mg of tamsulosin, 23.9% and 22.7% of patients demonstrated a>50% reduction of nocturia, and 16.1% and 19.4% of patients rated the treatment as “very effective,” respectively. Dose escalation to 0.4 mg of tamsulosin, compared to 0.2 mg, did not show an additional effect on reducing nocturnal urine volume. Multivariate logistic regression analysis showed that lower serum sodium levels (odds ratio [OR], 0.41, P=0.037) and the presence of urge incontinence (OR, 7.08, P=0.036) were predictors of a significant improvement of nocturia in response to 0.4 mg of tamsulosin.CONCLUSIONS: Dose escalation may yield a significant improvement of nocturia in>20% of patients, and may be especially helpful in patients with lower sodium levels and urge incontinence.
Adrenergic alpha-Antagonists ; Humans ; Hypotension, Orthostatic ; Logistic Models ; Male ; Nocturia ; Prospective Studies ; Sodium ; Urinary Incontinence, Urge

Orthostatic hypotension occurs when cardiovascular adaptive mechanisms fail to compensate the reduction in venous return that normally occurs on the upright position. A patient with orthostatic hypotension can be a challenging case for a dentist. A 78-year-old male came with idiopatic orthostatic hypotension and felt uncomfortable with his old crown restoration and discoloration on his upper teeth. Management of orthostatic hypotension can be handled by manipulating the dental chair interval movement position.
Hypotension, Orthostatic

The general concept and initial approach to syncope patients has been mentioned in the general sections. This special sections have been described the characteristics, diagnosis, and treatment with patient education for the each syncope. It has been described in order of reflex syncope, orthostatic hypotension, postural orthostatic tachycardia syndrome (POTS), cardiac syncope, and unexplained syncope. Several clinical issues will have been dealt with in special issues. Neurological assessment is added when the patients were diagnosed with psychogenic pseudosyncope (PPS). Although many childhood syncope caused by reflex syncope, they are also presented as syncope caused by arrhythmic events in patients with congenital heart disease. In the elderly patients, syncope is because of not only a single cause of syncope but a combination of various conditions. In case of a syncope patient visiting the emergency department, a standardized systematic approach will be required to determine whether hospitalize the patient according to the risk of recurrence and the needs for the syncope management unit. We also mention recommendations on the limits of driving, exercising and social life style that are relevant to syncope in all patients. In this guideline, we reviewed the Korean published literatures and European/American guidelines on syncope. We, writing and publishing committee for evaluation and management guidelines of syncope in the Korean Society for Holter and Noninvasive Electrocardiography (KSHNE) under the Korean Heart Rhythm Society (KHRS) are very pleased to be able to publish this guideline. We also hope this guideline will be a good support to manage the syncope patients and a useful trigger for further research in Korea.
Aged ; Diagnosis ; Electrocardiography ; Emergency Service, Hospital ; Heart ; Heart Defects, Congenital ; Hope ; Humans ; Hypotension, Orthostatic ; Korea ; Life Style ; Patient Education as Topic ; Postural Orthostatic Tachycardia Syndrome ; Recurrence ; Reflex ; Syncope ; Writing

Diabetic autonomic neuropathy (DAN) is a serious and common complication of diabetes, although it is often overlooked. Abnormal autonomic function tests are often found in peoples with diabetic peripheral neuropathy. Autonomic neuropathies affect the autonomic neurons (parasympathetic, sympathetic, or both) and are associated with a variety of site-specific symptoms. The symptoms and signs of DAN should be elicited carefully during the medical history and physical examination. Major clinical manifestations of DAN include hypoglycemia unawareness, resting tachycardia, orthostatic hypotension, gastroparesis, constipation, diarrhea, fecal incontinence, erectile dysfunction, neurogenic bladder, and sudomotor dysfunction with either increased or decreased sweating. When a patient has signs and symptoms of DAN, various autonomic function tests should be performed. Recognition and management of DAN may improve symptoms, reduce sequelae, and improve quality of life. Clinically relevant diabetic autonomic neuropathies such as cardiovascular, gastrointestinal, genitourinary, and sudomotor dysfunction should be considered in the optimal care of patients with diabetes. The present review summarizes the latest knowledge regarding clinical presentation, diagnosis, and management of DAN.
Constipation ; Diabetic Neuropathies* ; Diagnosis* ; Diarrhea ; Erectile Dysfunction ; Fecal Incontinence ; Gastroparesis ; Humans ; Hypoglycemia ; Hypotension, Orthostatic ; Male ; Neurons ; Peripheral Nervous System Diseases ; Physical Examination ; Quality of Life ; Sweat ; Sweating ; Tachycardia ; Urinary Bladder, Neurogenic

The recently published 2017 American College of Cardiology (ACC)/American Heart Association (AHA)/American Academy of Physician Assistants/Association of Black Cardiologists/American College of Preventive Medicine/American Geriatrics Society/American Pharmacists Association/American Society of Hypertension (ASH)/American Society for Preventive Cardiology/National Medical Association/Preventive Cardiovascular Nurses Association (2017 ACC/AHA/ASH guideline for short) lowered the threshold for diagnosis of hypertension from 140/90 mm Hg to 130/80 mm Hg. Also, the revised guideline recommends pharmacological treatment for all hypertensive patients with either previous cardiovascular disease or 10-year atherosclerotic cardiovascular disease (ASCVD) risk greater than 10%. Since most diabetic hypertensive patients have ASCVD risk greater than 10%, the guideline recommends that all diabetics with blood pressure (BP) above 130/80 mm Hg be treated both pharmacologically and with active lifestyle modification. Although the evidence suggests that intensive lowering of BP may be beneficial in diabetic patients, there is lack of evidence that pharmacologic treatment in subjects with baseline BP below 140 mm Hg is beneficial, with some studies suggesting actual potential for harm. Also, there are data to suggest a potential risk of increased risk of cardiovascular events and mortality in subjects whose diastolic BP (DBP) was lowered to below 60 mm Hg. As such, strict BP lowering may be beneficial if the target BP could be achieved without side effects such as orthostatic hypotension and decreased renal function. Also, lowering of DBP below 60 mm Hg should be avoided. Lastly, treatment should be started in subjects with baseline BP above 140/90 mm Hg until further evidence suggests otherwise.
Blood Pressure* ; Cardiology ; Cardiovascular Diseases ; Diagnosis ; Geriatrics ; Heart ; Humans ; Hypertension ; Hypotension, Orthostatic ; Life Style ; Mortality ; Pharmacists

OBJECTIVES: Fall is a major cause of morbidity and mortality among older adults. Falls result from many various causes, and dizziness is important risk for falls, especially in the elderly. Research on the relationship between chronic dizziness and falls in elderly people has been rarely performed and these were no studies that analyzed the risk of falls according to subtypes of chronic dizziness. METHODS: We conducted a prospective study of the association between subtypes of chronic dizziness and falls in the elderly between 65 to 75 years. We divided dizzy patients into 5 groups according to the results of symptom, vestibular and autonomic function test. Falls and new events (acute dizziness or other medical conditions) were checked monthly by telephone or out patient department follow-up for 6 months. RESULTS: Thirty-four patients were enrolled and all completed follow-up for 6 months. Nine patients classified as the falling groups and 34 patients as nonfalling group. Whereas the frequencies of orthostatic hypotension (n=6, 67%) and vestibular dysfunction (n=1, 11%) were higher in fall group, psychogenic dizziness (n=12, 35%), and vestibular migraine (n=3, 9%) were more frequent in nonfall group. CONCLUSIONS: The presence of dizziness in the elderly is a strong predictor of fall, especially orthostatic hypotension is an important predictor of fall. In order to lower the risk of falls in the elderly, an approach based on the cause of dizziness is needed.
Accidental Falls ; Adult ; Aged ; Classification ; Dizziness ; Follow-Up Studies ; Humans ; Hypotension, Orthostatic ; Migraine Disorders ; Mortality ; Prospective Studies ; Telephone

Orthostatic dizziness is a common dizziness syndrome characterized by nonvertiginous lightheadedness when patients rise to stand from a sitting or supine position. Orthostatic dizziness is commonly believed to derive from orthostatic hypotension (OH) or postural tachycardia syndrome (POTS). Tilt-table test and Valsalva maneuver are standardized methods for evaluating of adrenergic autonomic function and essential for diagnosis of OH and POTS. We described the guidelines and interpretations of the tilt-table test and Valsalva maneuver.
Diagnosis ; Dizziness ; Humans ; Hypotension, Orthostatic ; Postural Orthostatic Tachycardia Syndrome ; Supine Position ; Tilt-Table Test ; Valsalva Maneuver