Кардиоваскуларни автономни нарушения при множествена склероза
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Дата
2019-07-03
Автори
Дамянов/Damyanov, Петър Ангелов /Petar Angelov
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Summary ***
Introduction: Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system and may have in its clinical picture symptoms of autonomic dysfunction. MS patients often have disturbances in urinary, gastrointestinal, sexual, sudomotor, pupilomotor and cardiovascular functions. Urinary and sexual dysfunction are particularly stressful for most patients, limit their activity, and play a significant role in their overall disability and quality of life. The clinical role of other autonomic symptoms, including cardiovascular, is less well understood. Various studies have found that abnormalities in cardiovascular autonomic tests in MS patients are heterogeneous and variable. On the other hand, the association of cardiovascular dysfunction and fatigue syndrome in MS is possible but poorly studied.
The aim of the study is to determine the frequency and severity of cardiovascular autonomic dysfunction in multiple sclerosis patients, to investigate the association of cardiovascular dysfunction with fatigue syndrome and to sеarch for correlation between the number and the localization of demyelinating lesions in the CNS with the results from the cardiovascular autonomic tests.
Contingent and methods: Ninety-one MS patients (63 women, 28 males, mean age 41,7 ± 10 years), 64 (70%) with relapsing-remitting and 27 (30%) - with secondary-progressive form of the disease were investigated. The control group includes 67 healthy subjects (mean age 40,8±8,4). Arterial pressure and heart rate (HR) were monitored. Standardized cardiovascular tests were applied and the heart rate variability (HRV) was evaluated at rest, during deep breathing and orthostatic test by a power spectral analysis. Questionnaires for assessing the autonomic symptoms (COMPASS 31-BG), for Fatigue (FSS) and for depression (BDI II) were used.
Results: The subjective orthostatic complaints were common in MS (57%) (COMPASS 31-BG), while the incidence of orthostatic hypotension was 3,6% - 3 patients (2 males and 1 female), all with a secondary progression of MS and a severe disability. From the parasympathetic tests, the change in HR in deep breathing (difference E-I) is the most common abnormal test (in 20% of patients). From the sympathetic tests most abnormal was dynamometry (in 17% of patients). We found at least one abnormal cardiovascular tests (CVT) in 37,7% of MS patients (parasympathetic CVT – 26,7%, sympathetic CVT – 5,8%) and at least two abnormal CVT in 7,3% of MS patients. Statistical significance was found between MS and the control group for the parasympathetic, sympathetic and total autonomic score (Mann-Whithney U-test p <0,05).
Lack of correlation of the orthostatic intolerance with the results of cardiovascular tests (Spearman correlations rs≤0,20). The frequency parameters: SDRR, LF, HF, TP are significantly lower in MS at rest, during deep breathing, and orthostatism in relation to reduced HRV.
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The severity and duration of MS affect cardiovascular autonomic functions, more pronounced for parasympathetic cardiac control. The form of the disease significantly affects the variability of heart rate and sympathetic balance. At rest, LFnu and HFnu are significant in SPMS compared to controls (sympathetic domination for SPMS at rest). The change in LF/HF ratio in orthostatism is significant in RRMS and controls (sympathetic reactivity for SPMS in orthostatism).
Significant difference between FSS scores for MS patients (4,42 ±1,53) and controls (3,3±1,1) was observed. Sixty-three percent of the patients have fatigue and 20,7% of them have mild and moderate depression, which correlates with FSS scores. Patients with fatigue have autonomic impairment, with prevalence of abnormalities in sympathetic cardiovascular tests. Spectral analysis show low sympathetic reactivity with a small rise in low frequencies in orthostatic test for the patients with fatigue, that indicated a sympathetic dysfunction.
Cardiovascular tests showed a very poor correlation with the finding of MRI. We found a weak dependence of the parasympathetic score with the number of supratentorial lesions (rs = 0,24) and of the total autonomic score with the atrophy of brain stem and cervical myelone (rs = 0,26). The LF/HF ratio does not correlate with plaque count and localization as well as with atrophy
Conclusion: Multiple sclerosis leads to dysfunction of the autonomic nervous system with decreased heart rate variability and reduced blood pressure reactivity, which determines the presence of impaired cardiovascular autonomic control. Cardiovascular dysfunction is predominantly subclinical and there is no significant association between the presence of autonomic symptoms and the results of cardiovascular tests. Combined cardiovascular dysfunction was found, with predominance of parasympathetic dysfunction. The fatigue syndrome in MS may be associated with impaired sympathetic cardiovascular function. There is no correlation between cardiovascular dysfunction in MS and MRI findings.
Описание
дисертационен труд
за присъждане на образователна и научна степен ”Доктор”,
професионално направление 7.1. Медицина
Научен ръководител:
Акад. проф. д-р Иван Миланов, дмн
София, 2019.
Ключови думи
множествена склероза - усложнения, кардиоваскуларни нарушения, епидемиология, оценка на кардио-васкуларната функция, стандартизирани тестове , Multiple Sclerosis, Cardiovascular autonomic dysfunction, Epidemiology, Cardio-vascular function test