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- Sympathovagal imbalance in early ischemic stroke is linked to impaired cerebral autoregulation and increased infarct volumesPublication . Castro, Pedro; Serrador, Jorge; Sorond, Farzaneh; Azevedo, Elsa; Rocha, IsabelBackground and purpose: Autonomic dysfunction is associated with worse outcome of ischemic stroke patients by mechanisms that are not fully understood. There is evidence of autonomic influence in cerebrovascular control but this has not been studied in acute stroke. Therefore, we examined the relationship between heart rate variability (HRV) and baroreflex sensitivity (BRS) in dynamic cerebral autoregulation in the early hours post ischemia, and its impact in clinical and radiological outcome. Methods: We prospectively enrolled 26 patients with acute ischemic stroke in middle cerebral artery. Arterial blood pressure (Finometer), cerebral blood flow velocity (transcranial Doppler), and electrocardiogram were recorded within 6 h. HRV was assessed by the standard side deviations of normal inter-beat intervals, spectral analysis and non-linear entropy indexes. Spontaneous BRS was assessed by spectral and sequence methods. Dynamic cerebral autoregulation was assessed by transfer function analysis (coherence, phase and gain). Infarct volume was calculated from computed tomography at 24 h. Clinical outcome was assessed by the modified Rankin scale. Results: Increased BRS and HRV high frequencies power, both reflecting increased vagal modulation, were correlated with higher gain values of cerebral autoregulation (p < 0.05). The higher vagal modulation was also associated with later large infarct volumes (p < 0.05) but not with clinical outcome. Conclusions: Increased vagal modulation in early hours of acute ischemic stroke, may interfere with cerebrovascular control and is associated with larger infarcts. Understanding the mechanisms that govern this complex interplay can be useful as novel therapeutic targets to improvement of outcome.
- EFAS/EAN survey on the influence of the COVID-19 pandemic on European clinical autonomic education and researchPublication . Fanciulli, Alessandra; Skorić, Magdalena Krbot; Leys, Fabian; Carneiro, Diogo Reis; Campese, Nicole; Calandra-Buonaura, Giovanna; Camaradou, Jennifer; Chiaro, Giacomo; Cortelli, Pietro; Falup-Pecurariu, Cristian; Granata, Roberta; Guaraldi, Pietro; Helbok, Raimund; Hilz, Max J.; Iodice, Valeria; Jordan, Jens; Kaal, Evert C. A.; Kamondi, Anita; Le Traon, Anne Pavy; Rocha, Isabel; Sellner, Johann; Senard, Jean Michel; Terkelsen, Astrid; Wenning, Gregor K.; Moro, Elena; Berger, Thomas; Thijs, Roland D.; Struhal, Walter; Habek, Mario; Adamec, Ivan; Aerts, Arnaud; Canta, Leo L. R.; Delamont, Robert Shane; de Lange, Frederik; Del Sorbo, Francesca; Devigili, Grazia; Di Leo, Rita; Dinh, Trang; Fortrat, Jacques-Olivier; Gierthmühlen, Janne; Hemels, Martin; Köhn, Julia; Krøigård, Thomas; Lipp, Axel; Maier, Andrea; Marinelli, Lucio; Mazzeo, Anna; Milenkovic, Ivan; Motyl, Maciej; Sora, Maria Grazia Natali; Navarro-Otano, Judith; Nilsen, Kristian Bernhard; Oliveira, Mario; Omland, Petter Moe; Pelliccioni, Giuseppe; Pereon, Yann; Resch, Roland Josef; Rocchi, Camilla; Roche, Frederic; Rutten, Joost; Tijero-Merino, Beatriz; Tutaj, Marcin; van der Heijden-Montfroy, A. M. H. G.; van Hoeve, Bas J. A.; van Orshoven, Narender; Wang, Ruihao; Z’Graggen, Werner J.Purpose: To understand the influence of the coronavirus disease 2019 (COVID-19) pandemic on clinical autonomic education and research in Europe. Methods: We invited 84 European autonomic centers to complete an online survey, recorded the pre-pandemic-to-pandemic percentage of junior participants in the annual congresses of the European Federation of Autonomic Societies (EFAS) and European Academy of Neurology (EAN) and the pre-pandemic-to-pandemic number of PubMed publications on neurological disorders. Results: Forty-six centers answered the survey (55%). Twenty-nine centers were involved in clinical autonomic education and experienced pandemic-related didactic interruptions for 9 (5; 9) months. Ninety percent (n = 26/29) of autonomic educational centers reported a negative impact of the COVID-19 pandemic on education quality, and 93% (n = 27/29) established e-learning models. Both the 2020 joint EAN-EFAS virtual congress and the 2021 (virtual) and 2022 (hybrid) EFAS and EAN congresses marked higher percentages of junior participants than in 2019. Forty-one respondents (89%) were autonomic researchers, and 29 of them reported pandemic-related trial interruptions for 5 (2; 9) months. Since the pandemic begin, almost half of the respondents had less time for scientific writing. Likewise, the number of PubMed publications on autonomic topics showed the smallest increase compared with other neurological fields in 2020-2021 and the highest drop in 2022. Autonomic research centers that amended their trial protocols for telemedicine (38%, n = 16/41) maintained higher clinical caseloads during the first pandemic year. Conclusions: The COVID-19 pandemic had a substantial negative impact on European clinical autonomic education and research. At the same time, it promoted digitalization, favoring more equitable access to autonomic education and improved trial design.
- Clinical presentation and management strategies of cardiovascular autonomic dysfunction following a COVID‐19 infection: a systematic reviewPublication . Reis Carneiro, Diogo; Rocha, Isabel; Habek, Mario; Helbok, Raimund; Sellner, Johann; Struhal, Walter; Wenning, Gregor; Fanciulli, AlessandraBackground: Cardiovascular autonomic dysfunction may reportedly occur after a coronavirus-disease-2019 (COVID-19) infection, but the available evidence is scattered. Here we sought to understand the acute and mid-term effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on cardiovascular autonomic function. Methods: We performed a systematic PubMed, Embase, Web of Science, medRxiv, and bioRxiv search for cases of cardiovascular autonomic dysfunction during an acute SARS-CoV-2 infection or post-COVID-19 condition. The clinical-demographic characteristics of individuals in the acute versus post-COVID-19 phase were compared. Results: We screened 6470 titles and abstracts. Fifty-four full-length articles were included in the data synthesis. One-hundred and thirty-four cases were identified: 81 during the acute SARS-CoV-2 infection (24 thereof diagnosed by history) and 53 in the post-COVID-19 phase. Post-COVID-19 cases were younger than those with cardiovascular autonomic disturbances in the acute SARS-CoV-2 phase (42 vs. 51 years old, p = 0.002) and were more frequently women (68% vs. 49%, p = 0.034). Reflex syncope was the most common cardiovascular autonomic disorder in the acute phase (p = 0.008) and postural orthostatic tachycardia syndrome (POTS) the most frequent diagnosis in individuals with post-COVID-19 orthostatic complaints (p < 0.001). Full recovery was more frequent in individuals with acute versus post-COVID-19 onset of cardiovascular autonomic disturbances (43% vs. 15%, p = 0.002). Conclusions: There is evidence from the scientific literature about different types of cardiovascular autonomic dysfunction developing during and after COVID-19. More data about the prevalence of autonomic disorders associated with a SARS-CoV-2 infection are needed to quantify its impact on human health.
- Inflammation and autonomic functionPublication . Leal, Ângela; Carvalho, Mafalda; Rocha, Isabel; Mota-Filipe, HelderInflammation is generally a temporary and limited condition but may lead to a chronic one if immune and physiological homeostasis are disrupted. The autonomic nervous system has an important role in the short- and, also, long-term regulation of homeostasis and, thus, on inflammation. Autonomic modulation in acute and chronic inflammation has been implicated with a sympathetic interference in the earlier stages of the inflammatory process and the activation of the vagal inflammatory reflex to regulate innate immune responses and cytokine functional effects in longer processes. The present review focuses on the autonomic mechanisms controlling proinflammatory responses, and we will discuss novel therapeutic options linked to autonomic modulation for diseases associated with a chronic inflammatory condition such as sepsis.
- O treino de ortostatismo (tilt training) aumenta a reserva vasoconstritora em doentes com síncope reflexa neurocardiogénicaPublication . Laranjo, Sergio; Oliveira, Mario; Tavares, Cristiano; Geraldes, Vera; Santos, Sofia; Oliveira, Eunice; Ferreira, Rui; Rocha, IsabelNeurocardiogenic syncope (NCS) is a common clinical entity resulting from an excessive reflex autonomic response, particularly during orthostatism. Treatment options are controversial and of limited effectiveness. Tilt training (TT) is a promising option to treat these patients. However, its mechanism of action and clinical impact remain unclear. Objective: To characterize hemodynamic and autonomic responses during a TT program in patients with NCS refractory to conventional measures. Methods: We studied 28 patients (50% male, mean age 41±14 years) without structural heart disease, with NCS documented by tilt testing. The TT program included 9 tilt sessions (3 times a week, 30 min) (60° - 6 sessions, 70° - 3 sessions), under ECG and blood pressure monitoring combined with home orthostatic self-training and 10° head-up during sleep. Systolic volume, cardiac output, total peripheral resistance, baroreflex sensitivity and heart-rate variability were computed. Patients were reassessed at 1 month and every 6 months for a maximum of 36 months (24±12 months). Results: Over the course of the TT program there was a significant increase in total peripheral resistance (1485±225 vs. 1591±187 dyn·s·cm(-5), p<0.05), with a decrease in standard deviation (206±60 vs. 150±42, p<0.05). During follow-up, syncope recurred in five patients (19%), with a significant reduction in the number of episodes (4.0±3.2/patient in the 12 months before TT vs. 1.4±0.8/patient post-TT, p<0.05). Conclusion: In refractory NCS, TT may be an effective therapeutic option, with long-term benefits. These results appear to be due to an increase in vasoconstrictor reserve combined with a reduction in its variance.