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Background and purpose: Centers for training in autonomic nervous system (ANS) disorders are not widely available and the recent coronavirus 2019 pandemic temporarily reduced training opportunities in autonomic medicine across European countries. Here we evaluated the current state of education, clinical skills and postgraduate educational preferences on ANS disorders of European neurology residents and consultants. Methods: A 23‐item questionnaire was developed and distributed online amongst European neurology residents and consultants via mailing lists of the European Academy of Neurology. The questions assessed demographics, current training opportunities and learning preferences in ANS disorders. Six multiple‐choice questions were used to self‐evaluate knowledge of ANS disorders. Results: In all, 285 individuals answered the survey (60% female, mostly 25–34 years of age). All respondents considered clinical autonomic skills necessary for good clinical neurological practice, and 92% would like to increase their ANS knowledge. Female respondents and those who trained in Southern/Eastern/Greater Europe more frequently judged ANS skills important for clinical practice than male respondents (p = 0.012) and respondents from Northern/Western Europe (p = 0.011). Female and younger respondents felt less confident in managing ANS disorders (p = 0.001 and p < 0.001, respectively). Respondents below 45 years of age (p < 0.001) and those with lower confidence in managing ANS disorders (p = 0.004) were more likely to recommend that ANS education is embedded in the residency curriculum. Conclusions: Most European neurology residents and consultants reported a need for more autonomic education, with additional gender, age and regional differences. These findings underscore the importance of increasing the educational content on autonomic medicine in European medical and postgraduate curricula. [ABSTRACT FROM AUTHOR]

Background: 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. [ABSTRACT FROM AUTHOR]

Purpose: Multiple system atrophy (MSA) and Parkinson's disease (PD) are sporadic neurodegenerative diseases characterized by an accumulation of misfolded α-synuclein. Cardiovascular autonomic failure develops in both MSA and PD, although studies indicate different sites of autonomic nervous system lesion. However, it is unclear whether this could potentially aid the differential diagnosis of these diseases. Here we determined whether cardiovascular autonomic function testing (CAFT) can discriminate between the parkinsonian variant of MSA (MSA-P) and PD based on either an expert-based blinded evaluation or a systematic comparison of cardiovascular autonomic function indices. Methods: We included 22 patients aged 55–80 with neurogenic orthostatic hypotension (nOH) who had been diagnosed with either clinically probable MSA-P (n = 11) according to current consensus criteria or clinically definite PD (n = 11) according to the Queen Square criteria. Three physicians with expertise in CAFT were blinded to the neurological diagnosis and were asked to identify the correct neurological diagnosis by applying a self-created evaluation scheme to the CAFT recordings. Afterwards, a systematic comparison of clinical–demographic characteristics and CAFT parameters was carried out. Results: Neither the raters (overall diagnostic accuracy: 58.46%) nor the evaluation scheme created post hoc (72.73%) showed reliable discriminatory capacity. The inter-rater reliability was slight (κ = 0.01). We observed no statistically significant differences in cardiovascular autonomic indices between PD and MSA-P patients. Conclusion: CAFT is the gold standard for assessing the presence and severity of cardiovascular autonomic failure, but the results of our pilot study suggest that CAFT might be of limited value in the differential diagnosis between MSA-P and PD once nOH is present. [ABSTRACT FROM AUTHOR]

Recent data suggest autonomic dysfunction in patients suffering dementia. This study evaluated autonomic modulation in dementia patients with and without autonomic involvement, employing ECG spectral analysis in the time-frequency domain (wavelet transform) in supine resting and head-up tilt (HUT) position. Thirty-six patients were prospectively evaluated at the Department of Neurology and Psychiatry, General Hospital of the City of Linz, between 2009 and 2014. A standard cardiovascular autonomic test series (Ewing battery) was performed to screen for autonomic dysfunction. The Ewing battery diagnoses were used as reference standard and compared to the diagnostic results obtained by spectral analysis (time-frequency domain) of ECG recordings. Based on the Ewing battery results, 14 patients suffered autonomic dysfunction, while 22 did not. Time frequency domain was accessed by using the continuous wavelet transformation (CWT) with an analytical Morlet mother wavelet in supine resting and HUT position. Within each cohort the modification of spectral components from supine resting to HUT was analyzed reflecting the autonomic modulation. For patients without autonomic dysfunction, a significant increase of autonomic modulation was detected by wavelet transformed ECG recordings (8%, p < 0.05; low frequency content) during HUT compared to supine resting. There was no significant modulation between HUT and supine resting in patients suffering autonomic dysfunction. In dementia patients suffering autonomic dysfunction, CWT identified blunted autonomic regulation only by analysis of ECG recordings without the need to assess other biosignals or tests depending on the patient's cooperation. Further studies are needed to evaluate whether CWT is a suitable method to support the standard Ewing battery in demented patients. [ABSTRACT FROM AUTHOR]

The article presents a study which evaluates the postganglionic sympathetic sudomotor function in tauopathies Alzheimer's disease (AD) and behavioral variant of frontotemporal dementia (bvFTD). A structured history from 15 patients with AD and 14 patients with bvFTD was taken and quantitative sudomotor axon reflex test (QSART) was used in the study. Results showed involvement of postganglionic sudomotor in AD and bvFTD is most likely not part of the disease.

Background: Patients with autonomic failure may experience postural dizziness, syncope, and falls. Identifying symptomatic dysautonomia in dementia is of importance to ensure appropriate management and reduce risk of falls. Objective: The aim of this prospective study is to identify cardiovascular autonomic dysfunction in patients suffering from behavioral variant of frontotemporal dementia (bvFTD), compared to Alzheimer's disease (AD). Methods: Patients were prospectively recruited from 2009 until 2013. Clinical autonomic function tests were carried out in an Autonomic Unit according to Ewing's cardiovascular battery. Parasympathetic tests included resting heart rate variability, deep breathing, and Valsalva. Sympathetic function tests compromised blood pressure regulation on valsalva, cutaneous cold stimulation, and 70° head up tilt including of plasma noradrenaline. Results: 26 patients (17 female) with bvFTD and 18 patients (10 female) with AD were examined. Mean age of bvFTD was 69 ± 11 years, AD 74 ± 9 years. History taking was often not conclusive and did not correlate with autonomic signs. In 42% bvFTD patients and 44% AD patients, autonomic dysfunction was demonstrated. Manifest orthostatic hypotension (OH) was present in 19% of bvFTD and 33% AD patients. Frequency of autonomic dysfunction and orthostatic hypotension did not differ between bvFTD and AD, but were significantly higher than in healthy controls. Autonomic dysfunction was associated with an increased risk of falling (assessed with Tinetti Score). Conclusion: This is the first prospective study to elucidate autonomic dysfunction in bvFTD patients. There is a considerable higher frequency of cardiovascular dysfunction and OH in bvFTD. History taking may be not conclusive thus cannot exclude cardiovascular dysautonomia. [ABSTRACT FROM AUTHOR]

Reflex syncope is classified based on the efferent autonomic system as vasodepressant type, cardioinhibitory type and mixed type. We employed quantitative sweat testing to assess differences in sudomotor sympathetic activity in relation to the type of reflex syncope. In cardioinhibitory type sweating started in 7/9 patients after and in vasodepressor type in 11/12 patients before syncope. In mixed type sweating in 20 patients started before and in 10 after syncope. The onset of sweating correlated significantly with the onset of syncope symptoms. These results possibly reflect different onsets of emotional sweating. [ABSTRACT FROM AUTHOR]

Electrocardiogram (ECG) is essential for evaluating the autonomic nervous system. Ensuring the quality of real-world ECG datasets is critical, but manual control of large datasets is impractical. Thus, automated quality control is necessary. This paper introduces a new quality index, the peak-distance quality index (PDQI), based on the modulation spectrum approach. Real-life data from 1000 ECG recordings, each 600 s long, were collected at the stroke unit of the University Hospital Tulln. Each ECG was visually evaluated, including the duration of the signal, artefacts and noise, and the number of extrasystoles. The power-modulation spectrum, the percentage of ECG in each signal, and modulation spectrum-based quality index (MS-QI) and PDQI were calculated. The area under the curve (AUC) for the detection of high-quality ECGs was calculated for both quality indices, as well as the optimal threshold for each index. The percentage of ECG signals in the recordings based on the modulation spectrum correlates with expert rating (r = 0.99, p < 0.001). The AUC for PDQI for the detection of extrasystoles is 0.96, and the AUC for MSQI for the detection of artefacts is 0.83. The optimal thresholds for PDQI and MSQI are 0.44 and 0.17, respectively The power modulation spectrum can be applied to large amounts of data to detect ECG signals within biosignals and calculate quality indices. MSQI can be used for artefact detection and PDQI for extrasystole detection in ECG signals. A combined approach using both quality indices can provide a picture of the underlying data quality. • Big-data collected during long term monitoring could be used for research. • Artefacts corrupt the electrocardiogram for metrics of heart rate variability. • Large data challenge the golden standard "human expert" for detecting artefacts. • Automated Modulation spectrum-based quality indices provide reliable information. • MS-QI and PDQI can be used to discriminate between different data-quality. [ABSTRACT FROM AUTHOR]