Clinical Autonomic Dysfunction: Measurement, Indications, Therapies, and Outcomes

456 Pages·2015·21.78 MB·English

by  Joseph Colombo

Joseph Colombo
Rohit Arora
Nicholas L. DePace
Aaron I. Vinik
Clinical Autonomic
Dysfunction
Measurement,
Indications, Therapies,
and Outcomes
123
Clinical Autonomic Dysfunction

Joseph Colombo (cid:129) Rohit Arora
Nicholas L. D ePace (cid:129) Aaron I. Vinik
Clinical Autonomic
Dysfunction
Measurement, Indications, Therapies,
and Outcomes
Joseph Colombo, PhD Nicholas L. DePace, MD, FACC
Autonomic Laboratory Department of Cardiology
Department of Cardiology Hahnemann Hospital
Drexel University College of Medicine Drexel University College of Medicine
Philadelphia , PA Philadelphia , PA
USA USA
ANSAR Medical Technologies, Inc. Aaron I. Vinik, MD, PhD, FCP, MACP
Philadelphia , PA Department of Medicine
USA Eastern Virginia Medical School
Strelitz Diabetes Research Center
Rohit Arora, MD, FACC, FAHA, FACP, FSCAI Norfolk , VA
Department of Medicine USA
Captain James A. Lovell Federal
Health Care Center
North Chicago , IL
USA
Department of Cardiology
The Chicago Medical School
North Chicago , IL
USA
ISBN 978-3-319-07370-5 ISBN 978-3-319-07371-2 (eBook)
DOI 10.1007/978-3-319-07371-2
Springer Cham Heidelberg New York Dordrecht London
Library of Congress Control Number: 2014946970
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Thank you!

Pref ace
F or many years I have been asked to write a simple “how to” book for P&S monitoring. The
problem is that the autonomic nervous system is not simple. It cannot be dealt with as isolated
parts. The primary reason being that it itself is ubiquitous throughout the body, and its primary
role is to integrate, not isolate. After a number of aborted attempts to keep it simple, I remem-
bered that many fi rst works in a fi eld of science, including medicine, are simply a compendium
of important fi rst articles in the fi eld. When I looked, there were several dozen important fi rst
works, specifi cally based on P&S monitoring, that have been published covering many differ-
ent fi elds of medicine. Modeling this book on the compendium approach, we have pulled
together as complete a compendium as currently possible given what is published in the medi-
cal literature.
In the process of compiling this compendium, the answer to a frequently asked question is
readily available. The question regards P&S monitoring outcome studies. We believe the
question is much like asking for outcome studies for a thermometer. A thermometer does not
cure. It simply measures temperature to help a physician determine if the therapy caused the
temperature to normalize based on published normals. P&S monitoring simply measures
parasympathetic and sympathetic responses. The outcomes are based on the therapy that is
causing the change as compared to published normals. However, we believe the question to
be answered.
With established and accurate P&S monitoring technology, the tool exists to document
individual patient P&S responses to disease and therapy. This book illustrates the application
and interpretation of P&S monitoring as it relates to clinical medicine.
I n general, this is a “how to” book for the practicing clinician. It focuses on clinical applica-
tion of P&S monitoring, treating P&S dysfunction in the fi eld, and reporting on expected
outcomes. The focus is more on physiology and treatment, rather than anatomy and biochem-
istry. The book will review the many manuscripts that have been written and published on P&S
monitoring. In Part I , Introduction and History of Autonomic Nervous System Monitoring, the
book begins with an overview of the anatomy, physiology, and biochemistry of the autonomic
nervous system (ANS) and develops the need and the basis for advances in ANS monitoring,
specifi cally P&S monitoring. The basis for the advancements is the history of noninvasive
ANS measurements with HRV alone or beat-to-beat BP alone. The book continues with Part
II , Validation and General Evaluation of the Autonomic Nervous System. Part II details gen-
eral clinical applications of P&S monitoring that seem to be independent of specialty or dis-
ease and that have been published and continue to be well supported by practicing clinicians.
Part II describes the clinical method for assessing the P&S nervous systems, the interpretation
of the clinical test results, possible therapy options for treating P&S dysfunction, and the clini-
cal necessity and basis for P&S monitoring. Part II concludes with statements from the medi-
cal leadership as to the need for ANS monitoring as part of the standard of care for the diseases
or disorders included in the book.
The middle section of the book covers chronic care and critical care applications of P&S
monitoring. Part I II, Assessment and Management of the Parasympathetic and Sympathetic
Nervous Systems; Part I V , Internal Medicine; Part V , Cardiology; Part VI , Endocrinology; Part
V II , Neurology; Part V III , Other Chronic Care Specialties; and Part I X , Critical Care all focus
vii
viii Preface
on the pathophysiology of P&S dysfunction for specifi c diseases or disorders, expected test
results, possible therapy options to clinically treat the specifi c P or S dysfunction, and expected
outcomes. Whereas Part I I discusses the interpretation of the P&S data (virtually) in isolation
of the patient, Parts I II through I X apply the interpretations from Part I I to specifi c patients. In
application, the information in Part II can easily be (and has been) automated. There are only
four autonomic imbalances (high and low parasympathetic and high and low sympathetic) and
two states (resting and dynamic). Therefore, there are only eight abnormal autonomic states.
Parts I II through I X are where the majority of the physician’s knowledge and experience, and
time, are required to connect the P&S results with patient history to develop a therapy plan.
Part X , Sample Studies, includes case studies and longitudinal studies to provide examples
demonstrating the major concepts for some of the more common diseases or disorders for
which P&S monitoring is recommended. Due to the fact that the knowledge and application of
autonomic assessment, and more specifi cally P&S assessment, is still a growing fi eld within
healthcare, we believe it important to provide examples of what may be expected before and
after treatment as a further guide to the practicing physician in the fi eld. Again, this book is
more of a “how to” guide than a research manual. To that end, the book closes (Part X I ) by
providing an answer to the questions “Why test?” “How to intervene?” and “What are the
expected outcomes?” Please note that there is a purposeful level of repetition within the book
to enable sections to be read or taught independent from the rest of the book.
W e know that the major academic autonomic centers will continue to treat the worst (1–2 %)
of the autonomic cases identifi ed. We wish to enable more physicians to identify those cases
that require referral to the major academic centers. We also wish to encourage physicians to
diagnose and treat those less severe cases of autonomic dysfunction (including preclinical
cases) in the outpatient or offi ce setting. The goal is to improve outcomes and reduce costs
for all.
T o these ends, Clinical Autonomic Dysfunction: Measurement, Indications, Therapies, and
Outcomes focuses more on the pathophysiology and therapeutic approaches developed from
advances in P&S monitoring technology. Other scholarly books are available that focus more
on the anatomy (both microscopic at the cellular level and macroscopic through newer imaging
techniques) and biochemistry of the ANS. This book is a clinical-application approach for the
practicing clinician and provides methods which offer more information that augments the
other books. The intent is to focus on the needs of the primary care, and practicing, physicians
treating patients in the fi eld, as well as to support secondary care physicians. The book high-
lights how to document clinical problems before symptoms manifest at the secondary care
level. Highlighted also is the more information provided to promote primary prevention
(screening), subclinical disease detection and identifi cation (early disease therapy), as well as
secondary prevention (established disease therapy). This enables the primary care physician to
improve patient outcomes by: (1) maintaining wellness, (2) preventing symptoms and disor-
ders, and (3) screening for subclinical manifestations, as well as (4) the clinical manifestations
requiring referral to subspecialists. We also believe our book does, and will enable, further
activities in developing more effi cient and expedited therapeutic approaches to autonomic dys-
function as it relates to many disease states throughout medicine.
We trust that a broad range of physicians and healthcare providers in both chronic care, and
critical care, medicine will fi nd this book useful. We have attempted to share as much knowl-
edge as we have collected from chronic care medicine in the fi elds of cardiology, electrophysi-
ology, endocrinology, family practice, general practice, geriatrics, internal medicine, neurology,
pain management, pediatrics, pulmonology, and sleep medicine and from critical care medi-
cine in the fi elds of anesthesiology, critical care, emergency care, and neonatology.
This compendium will provide published evidence of the veracity and utility of P&S moni-
toring technology as the means for noninvasive, quantitative, independent, and simultaneous
assessment of P&S activity. On behalf of Drs. Arora, DePace, and Vinik, we wish to thank Shi
Hua Huang and Rosanna Colombo for their many hours in helping to prepare the fi gures and
text for publication, and the many contributors who have help to grow this important fi eld of
Preface ix
medicine and open it to the general practitioner. Individually, we would like to acknowledge
the much appreciated c ontributions from Dr. Theophane Loughrey, and those physicians con-
tinuing to utilize P&S monitoring and who have contributed signifi cantly to the fi eld, includ-
ing: Ramesh K Adiraju, MD; Scott B. Baker, MD; Peter G. Bernad, MD; Heather L. Bloom,
MD; Robert J. Bulgarelli, DO; Jay L. Karpen, MD; Raelen Maser, PhD; Gary L. Murray, MD;
Ralph Ortiz, DO; Edward S. Pereira, MD; Michael L. Rosenberg, MD; Ira M. Turner, MD;
William C. Shoemaker, MD; and many more.
Take care.
Philadelphia, PA, USA Joseph Colombo , PhD