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Are the orthostatic fluid shifts to the calves augmented in autonomic failure?

Thijs RD, Kamper AM, van Dijk AD, van Dijk JG - Clin. Auton. Res. (2009)

Bottom Line: Multiple regression analysis was used to examine the effect of AF on orthostatic fluid shifts after adjustment for potential confounders.Patients did not differ from controls with respect to the increase of calf volume after 5 min HUT.No correlation was found between the degree of orthostatic hypotension and the orthostatic calf volume change in AF.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology and Clinical Neurophysiology, Leiden University Medical Centre, Postal Zone J3-R, PO Box 9600, 2300 RC, Leiden, The Netherlands. r.d.thijs@lumc.nl

ABSTRACT

Background: In autonomic failure (AF), blood pressure (BP) falls upon standing which is commonly ascribed to defective vasoconstriction and excessive pooling. Observations on the amount of pooling in AF are contradictory.

Methods: We evaluated pooling using strain-gauge plethysmography (SGP) during head-up tilt (HUT) with a parachute harness fixed to the tilt table to avoid muscle tension in the lower limbs and thus to maximise pooling. 23 healthy subjects and 12 patients with AF were tilted for 5 min. BP and calf volume changes, as measured by SGP, were measured continuously. Multiple regression analysis was used to examine the effect of AF on orthostatic fluid shifts after adjustment for potential confounders.

Results: Patients did not differ from controls with respect to the increase of calf volume after 5 min HUT. The acute (0-1 min) and the prolonged (1-5 min) phases of calf volume responses to HUT were also similar between patients and controls. No correlation was found between the degree of orthostatic hypotension and the orthostatic calf volume change in AF. In one patient an additional measurement was made before rising from bed in the early morning demonstrating a greater albeit small increase of calf volume upon HUT.

Conclusion: Orthostatic fluid shifts at the level of the calf in AF are not augmented during the course of the day despite marked hypotension. However, a small increase of pooling may be expected when the patient first gets out of bed in the morning probably due to the absence of oedema.

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Orthostatic fluid shifts at the level of the calf during 5 min of head-up tilt with a parachute harness in a 28-year-old patient with young onset Parkinson’s disease. Upon tilting in the afternoon (a) only a small fall of blood pressure (BP) was found (systolic BP fall: 23 mmHg). This orthostatic fall was accompanied by a 1.3% increase of calf volume. By contrast, head-up tilt in the early morning (b) caused severe orthostatic hypotension (systolic BP fall: 69 mmHg), but only a small increase of calf volume (1.7%) was seen compared to the afternoon measurements. The observed diurnal variations in pooling are best explained by the development of oedema during the course of the day preventing fluid filtration
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Fig3: Orthostatic fluid shifts at the level of the calf during 5 min of head-up tilt with a parachute harness in a 28-year-old patient with young onset Parkinson’s disease. Upon tilting in the afternoon (a) only a small fall of blood pressure (BP) was found (systolic BP fall: 23 mmHg). This orthostatic fall was accompanied by a 1.3% increase of calf volume. By contrast, head-up tilt in the early morning (b) caused severe orthostatic hypotension (systolic BP fall: 69 mmHg), but only a small increase of calf volume (1.7%) was seen compared to the afternoon measurements. The observed diurnal variations in pooling are best explained by the development of oedema during the course of the day preventing fluid filtration

Mentions: A 28-year-old patient with young onset Parkinson’s disease was admitted to our hospital because of frequent syncope owing to severe orthostatic hypotension. 24-h BP recording demonstrated marked diurnal BP variations with lowest values in the early morning. Nocturnal weight loss averaged 2 kg. During the course of the day she habitually developed marked ankle oedema. After an afternoon measurement an additional measurement was performed in the early morning. The patient had not been standing upright that morning prior to the experiment except for micturition during the night. She had slept with elastic stockings to limit the effect of standing on the amount of pooling. As shown in Fig. 3, BP fall induced by HUT was greatest in the early morning (early morning systolic BP fall 69 mmHg vs. afternoon 23 mmHg). Calf volume increased more in the early morning (1.7%) than in the afternoon (1.3%). The increase seen in the acute phase of HUT was comparable in both measurements (early morning: 0.7%; afternoon: 1.0%), whereas the increase during the prolonged phase of HUT was markedly reduced in the afternoon (early morning 1.0 vs. 0.3% afternoon).Fig. 3


Are the orthostatic fluid shifts to the calves augmented in autonomic failure?

Thijs RD, Kamper AM, van Dijk AD, van Dijk JG - Clin. Auton. Res. (2009)

Orthostatic fluid shifts at the level of the calf during 5 min of head-up tilt with a parachute harness in a 28-year-old patient with young onset Parkinson’s disease. Upon tilting in the afternoon (a) only a small fall of blood pressure (BP) was found (systolic BP fall: 23 mmHg). This orthostatic fall was accompanied by a 1.3% increase of calf volume. By contrast, head-up tilt in the early morning (b) caused severe orthostatic hypotension (systolic BP fall: 69 mmHg), but only a small increase of calf volume (1.7%) was seen compared to the afternoon measurements. The observed diurnal variations in pooling are best explained by the development of oedema during the course of the day preventing fluid filtration
© Copyright Policy
Related In: Results  -  Collection

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getmorefigures.php?uid=PMC2821504&req=5

Fig3: Orthostatic fluid shifts at the level of the calf during 5 min of head-up tilt with a parachute harness in a 28-year-old patient with young onset Parkinson’s disease. Upon tilting in the afternoon (a) only a small fall of blood pressure (BP) was found (systolic BP fall: 23 mmHg). This orthostatic fall was accompanied by a 1.3% increase of calf volume. By contrast, head-up tilt in the early morning (b) caused severe orthostatic hypotension (systolic BP fall: 69 mmHg), but only a small increase of calf volume (1.7%) was seen compared to the afternoon measurements. The observed diurnal variations in pooling are best explained by the development of oedema during the course of the day preventing fluid filtration
Mentions: A 28-year-old patient with young onset Parkinson’s disease was admitted to our hospital because of frequent syncope owing to severe orthostatic hypotension. 24-h BP recording demonstrated marked diurnal BP variations with lowest values in the early morning. Nocturnal weight loss averaged 2 kg. During the course of the day she habitually developed marked ankle oedema. After an afternoon measurement an additional measurement was performed in the early morning. The patient had not been standing upright that morning prior to the experiment except for micturition during the night. She had slept with elastic stockings to limit the effect of standing on the amount of pooling. As shown in Fig. 3, BP fall induced by HUT was greatest in the early morning (early morning systolic BP fall 69 mmHg vs. afternoon 23 mmHg). Calf volume increased more in the early morning (1.7%) than in the afternoon (1.3%). The increase seen in the acute phase of HUT was comparable in both measurements (early morning: 0.7%; afternoon: 1.0%), whereas the increase during the prolonged phase of HUT was markedly reduced in the afternoon (early morning 1.0 vs. 0.3% afternoon).Fig. 3

Bottom Line: Multiple regression analysis was used to examine the effect of AF on orthostatic fluid shifts after adjustment for potential confounders.Patients did not differ from controls with respect to the increase of calf volume after 5 min HUT.No correlation was found between the degree of orthostatic hypotension and the orthostatic calf volume change in AF.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology and Clinical Neurophysiology, Leiden University Medical Centre, Postal Zone J3-R, PO Box 9600, 2300 RC, Leiden, The Netherlands. r.d.thijs@lumc.nl

ABSTRACT

Background: In autonomic failure (AF), blood pressure (BP) falls upon standing which is commonly ascribed to defective vasoconstriction and excessive pooling. Observations on the amount of pooling in AF are contradictory.

Methods: We evaluated pooling using strain-gauge plethysmography (SGP) during head-up tilt (HUT) with a parachute harness fixed to the tilt table to avoid muscle tension in the lower limbs and thus to maximise pooling. 23 healthy subjects and 12 patients with AF were tilted for 5 min. BP and calf volume changes, as measured by SGP, were measured continuously. Multiple regression analysis was used to examine the effect of AF on orthostatic fluid shifts after adjustment for potential confounders.

Results: Patients did not differ from controls with respect to the increase of calf volume after 5 min HUT. The acute (0-1 min) and the prolonged (1-5 min) phases of calf volume responses to HUT were also similar between patients and controls. No correlation was found between the degree of orthostatic hypotension and the orthostatic calf volume change in AF. In one patient an additional measurement was made before rising from bed in the early morning demonstrating a greater albeit small increase of calf volume upon HUT.

Conclusion: Orthostatic fluid shifts at the level of the calf in AF are not augmented during the course of the day despite marked hypotension. However, a small increase of pooling may be expected when the patient first gets out of bed in the morning probably due to the absence of oedema.

Show MeSH
Related in: MedlinePlus