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The Spectrum of Baroreflex Failure

      Baroreflex failure, in its most acute and complete form, is perhaps the most dramatic of all autonomic disorders. In major referral centers, the highest blood pressures encountered nowadays by Hypertension specialists and Autonomic specialists are often in patients with acute baroreflex failure. Pressure surges above 300 mmHg may occur in some individuals. But the spectrum of baroreflex failure is very broad, and includes individuals with both orthostatic hypertension and orthostatic hypotension, surges in heart rate, and in some cases emotional volatility. It is noteworthy that baroreflexes may become dysfunctional if (1) the baroreceptors themselves fail, (2) if their afferent pathways in the vagal and glossopharyngeal nerves fail, (3) if central cardiovascular control nuclei fail, or(4) if relevant efferent nerves effecting blood pressure control fail. Etiologies are as varied as neck injury, familial paraganglioma syndromes, neck irradiation, familial dysautonomia, and mitochondrial disease. Clinical management is complex, but patients are often improved by carefully tailored regimens of such agents as methyldopa, propranolol, and benzodiazepines. In Jordan´s syndrome of selective baroreflex failure (efferent vagus intact), bradycardia and sinus arrest may occur during sleep, and these patient may require a pacemaker as well.
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