Burden of Cardiovascular Diseases in Elderly With Parkinson's Disease Who Start a Dopamine Agonist Agent

Congenital atrial abnormalities have been studied in relation to the risk of stroke.Of these, ASD, atrial septal aneurysm, and eustachian valve anatomy received particular attention, 4 although even ASD causing an important shunt can remain unrecognized until old age because hemodynamic decompensation secondary mainly to pulmonary hypertension may require several decades to develop.Unrecognized ASD with late development of symptoms has been previously described in elderly patients.5 Accordingly, the age at which nonneurological symptoms, mainly exertional dyspnea and fatigue, first appear is highly variable and not exclusively related to the size of the shunt. 1 As a consequence, ASD may be detected on the occasion of a diagnostic examination for unexplained neurological deficits, although new-onset heart failure, abnormal vascular chest x-ray, or unexplained hypoxemia (due to venous blood admixture) are more likely clues to the diagnosis.In our patient, ASD was the site of bidirectional embolization, likely due to the severe pulmonary hypertension; embolization was leftward (i.e., paradoxic) during exhalation, when right atrial pressure physiologically increases because of the rise in intrathoracic pressure.This in vivo demonstration of paradoxic embolism makes the case interesting.Furthermore, the relationship between ASD and cerebral ischemia, which can be considered to be established in young-adult subjects, is not obvious in elderly people.4,[6][7][8][9][10] In conclusion, the finding of paradoxic embolism through an ASD lends support to the view that such a mechanism could underlie otherwise unexplained cerebral ischemia at any age.It also suggests that patients with pulmonary hypertension should be screened for atrial or ventricular right to left shunt driven by increased pressures in the right heart cavities.