The Heart and Parkinson’s

Parkinson’s disease patients are twice as likely to succumb to cardiovascular ailments than their age and risk factor-matched peers without Parkinson’s. The common cardiovascular ailments to affect this group include stroke, heart attacks, congestive heart failure, atrial arrhythmias, valvular heart disease and syncope. Let’s dive into what you should know.

Parkinson’s patients with significant limitations to movement and memory seem to be at a higher risk for heart attack and stroke. It is important to keep up with a daily routine of exercise to keep the body in motion and the mind active to prevent progression of Parkinson disease, as well as heart disease. The usual measures to prevent heart disease like a good diet, daily exercise, and keeping the lipid profile under control goes a long way to keep one safe. Symptoms of chest pain and shortness of breath may need the immediate attention of a cardiologist. Medications like aspirin and statins are frequently used to prevent progression of heart disease.

Some ergot-derived Parkinson’s disease drugs like cabergoline and pergolide, used as synergistic drugs to dopamine agonists, can in certain susceptible individuals cause deterioration of mitral and aortic valves leading to significant leaking (regurgitation). Patients on such medications should be checked at frequent intervals with echocardiogram to keep an eye on the valvular structures.

Syncope (transient loss of consciousness) and frequent falls can be common in the life of Parkinson’s patient. While motor symptoms like tremors, and loss of balance can certainly cause these falls, there are other dysautonomic effects on the heart which can cause drops in blood pressure (orthostatic hypotension / vasodepressor syncope) leading to these falls. These falls carry the potential for significant physical injury.

• A daily routine of exercise helps maintain the balance and stability and also improves lower extremity muscle tone that prevents blood pooling in lower extremity, thus preventing blood pressure drops.

• Drinking plenty of fluids 1.5-3L/day can help prevent these falls.

• Compression stockings can go a long way. Although medical grade compression stockings are the best, they are often very difficult to wear or tolerate for prolonged periods of time. Even lesser strength (10-20 lbs/sq inch) commercially available compression stockings which are easier to wear and put on, can go a long way. Abdominal binders to prevent gut circulation pooling can be helpful too.

• Breathing exercises, like breathing in through pursed lips with slow deep breathing, can prevent blood pooling in the abdomen by increasing the suction effect. To that effect, breath control exercises and yoga have been shown to increase longevity in this patient population.

• Highest propensity for these falls are in the early morning hours when one gets up from bed to go to the bathroom. Measures like putting wooden blocks under the head stand to elevate the bed at a slight angle, drinking some fluids kept by the bed, and moving the extremities (like pumping the heels) to achieve stability before getting up from bed can be useful to prevent these falls.

• If the BP is running low, adjustment of medications for blood pressure may be necessary.

• Medications like midodrine and droxidopa are frequently used by physicians as an adjunct to these measures. These medications quite often have to be titrated to achieve the desirable effect. These medications are geared towards reducing the symptoms during wakeful hours and hence the first dose to be taken immediately after waking up and the last dose should be taken at least 4 hours before bedtime.

Rhythm disorders of the heart like bradycardia (slow heart rates) or tachycardia (fast heart rates) can frequently affect Parkinson’s patients. These require the immediate attention of a cardiologist and may, under some circumstances, require the implantation of a device like a pacemaker or defibrillator. Parkinson’s patients implanted with DBS have neurostimulators in their brain, which are connected to a device on the chest. The newer generation of pacemaker and defibrillators don’t have any interaction with the neurostimulator and can be safely used concomitantly. In some cases where the patients have bilateral preexisting neurostimulators and do not have the space on the anterior chest wall to place another device, novel technologies like leadless pacemakers or subcutaneous defibrillators can be used to achieve the same results.