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Rousselet L, Le Rolle V, Ojeda D, Guiraud D, Hagége A, Bel A, Bonnet JL, Mabo P, Carrault G, Hernández AI. Influence of Vagus Nerve Stimulation parameters on chronotropism and inotropism in heart failure. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2016; 2014:526-9. [PMID: 25570012 DOI: 10.1109/embc.2014.6943644] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Vagus Nerve Stimulation (VNS) has been shown to be useful in heart failure patients, including antiarrhythmic effects, improvement of cardiac function and reduction of the mortality. However, the optimal configuration of VNS can be a difficult task, since there are several adjustable parameters, such as current amplitude (mA), pulse width (ms), burst frequency (Hz), number of pulses and, in the case of cardiac-triggered VNS, the delay (ms) between the R-wave and the beginning of the stimulation. The objective of this paper is to analyse the effect of these parameters, and their interaction, on the chronotropic and inotropic responses to vagal stimulation. 306 VNS sequences were tested on 12 sheep with induced heart failure. Autonomic markers of the chronotropic (changes in RR interval) and inotropic (changes in dP/dtmax) effects were extracted from the observed data. In order to analyse the influence of stimulation parameters on these markers, a sensitivity analysis method was applied. Results illustrate the strong interaction between the delay and the others parameters. The number of pulses, the current and the frequency seem to be particularly influent on chronotropism and inotropism although the effect of the frequency is highly non-linear or it depends on other parameters.
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Fernandes Serôdio J, Martins Oliveira M, Matoso Laranjo S, Tavares C, Silva Cunha P, Abreu A, Branco L, Alves S, Rocha I, Cruz Ferreira R. The arterial baroreflex effectiveness index in risk stratification of chronic heart failure patients who are candidates for cardiac resynchronization therapy. Rev Port Cardiol 2016; 35:343-50. [PMID: 27255174 DOI: 10.1016/j.repc.2015.11.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 11/22/2015] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Baroreflex function is an independent marker of prognosis in heart failure (HF). However, little is known about its relation to response to cardiac resynchronization therapy (CRT). The aim of this study is to assess arterial baroreflex function in HF patients who are candidates for CRT. METHODS The study population consisted of 25 patients with indication for CRT, aged 65±10 years, NYHA functional class ≥III in 52%, QRS width 159±15 ms, left ventricular ejection fraction (LVEF) 29±5%, left ventricular end-systolic volume (LVESV) 150±48 ml, B-type natriuretic peptide (BNP) 357±270 pg/ml, and peak oxygen consumption (peak VO2) 18.4±5.0 ml/kg/min. An orthostatic tilt test was performed to assess the baroreflex effectiveness index (BEI) by the sequence method. This group was compared with 15 age-matched healthy individuals. RESULTS HF patients showed a significantly depressed BEI during tilt (31±12% vs. 49±18%, p=0.001). A lower BEI was associated with higher BNP (p=0.038), lower peak VO2 (p=0.048), and higher LVESV (p=0.031). By applying a cut-off value of 25% for BEI, two clusters of patients were identified: lower risk cluster (BEI >25%) QRS 153 ms, LVESV 129 ml, BNP 146 pg/ml, peak VO2 19.0 ml/kg/min; and higher risk cluster (IEB ≤25%) QRS 167 ms, LVESV 189 ml, BNP 590 pg/ml, peak VO2 16.2 ml/kg/min. CONCLUSIONS Candidates for CRT show depressed arterial baroreflex function. Lower BEI was observed in high-risk HF patients. Baroreflex function correlated closely with other clinical HF parameters. Therefore, BEI may improve risk stratification in HF patients undergoing CRT.
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Affiliation(s)
| | - Mário Martins Oliveira
- Institute of Physiology, Faculty of Medicine, University of Lisbon, Lisbon, Portugal; Department of Cardiology, Santa Marta Hospital, Lisbon, Portugal
| | - Sérgio Matoso Laranjo
- Institute of Physiology, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Cristiano Tavares
- Institute of Physiology, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | | | - Ana Abreu
- Department of Cardiology, Santa Marta Hospital, Lisbon, Portugal
| | - Luísa Branco
- Department of Cardiology, Santa Marta Hospital, Lisbon, Portugal
| | - Sandra Alves
- Department of Cardiology, Santa Marta Hospital, Lisbon, Portugal
| | - Isabel Rocha
- Institute of Physiology, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
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Fernandes Serôdio J, Martins Oliveira M, Matoso Laranjo S, Tavares C, Silva Cunha P, Abreu A, Branco L, Alves S, Rocha I, Cruz Ferreira R. The arterial baroreflex effectiveness index in risk stratification of chronic heart failure patients who are candidates for cardiac resynchronization therapy. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.repce.2015.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Smith S, Rossignol P, Willis S, Zannad F, Mentz R, Pocock S, Bisognano J, Nadim Y, Geller N, Ruble S, Linde C. Neural modulation for hypertension and heart failure. Int J Cardiol 2016; 214:320-30. [PMID: 27085120 DOI: 10.1016/j.ijcard.2016.03.078] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 03/19/2016] [Indexed: 01/08/2023]
Abstract
Hypertension (HTN) and heart failure (HF) have a significant global impact on health, and lead to increased morbidity and mortality. Despite recent advances in pharmacologic and device therapy for these conditions, there is a need for additional treatment modalities. Patients with sub-optimally treated HTN have increased risk for stroke, renal failure and heart failure. The outcome of HF patients remains poor despite modern pharmacological therapy and with established device therapies such as CRT and ICDs. Therefore, the potential role of neuromodulation via renal denervation, baro-reflex modulation and vagal stimulation for the treatment of resistant HTN and HF is being explored. In this manuscript, we review current evidence for neuromodulation in relation to established drug and device therapies and how these therapies may be synergistic in achieving therapy goals in patients with treatment resistant HTN and heart failure. We describe lessons learned from recent neuromodulation trials and outline strategies to improve the potential for success in future trials. This review is based on discussions between scientists, clinical trialists, and regulatory representatives at the 11th annual CardioVascular Clinical Trialist Forum in Washington, DC on December 5-7, 2014.
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Affiliation(s)
- S Smith
- The Ohio State University Wexner Medical Center, Department of Internal Medicine and Division of Cardiology, Columbus, OH, USA.
| | - P Rossignol
- Inserm, CIC 1433, Centre Hospitalier Universitaire, Universite´ de Lorraine, F-CRIN INI-CRCT, Nancy, France
| | - S Willis
- The Ohio State University Wexner Medical Center, Department of Internal Medicine and Division of Cardiology, Columbus, OH, USA
| | - F Zannad
- Inserm, CIC 1433, Centre Hospitalier Universitaire, Universite´ de Lorraine, F-CRIN INI-CRCT, Nancy, France
| | - R Mentz
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - S Pocock
- Medical Statistics Unit LSHTM, London, UK
| | - J Bisognano
- University of Rochester Medical Center, Department of Medicine, Cardiology, Rochester, NY, USA
| | - Y Nadim
- CVRx, Inc, Minneapolis, MN, USA
| | - N Geller
- Office of Biostatistics Research, Division of Cardiovascular Sciences, NHLBI, National Institutes of Health, Bethesda, MD, USA
| | - S Ruble
- Boston Scientific CRV, St. Paul, MN, USA
| | - C Linde
- Institution of Internal Medicine, Karolinska Institutet and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
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Abstract
Sympathovagal imbalance contributes to progressive worsening of heart failure (HF) and is associated with untoward clinical outcomes. Based on compelling pre-clinical studies that supported the role of autonomic modulation in HF models, a series of clinical studies were initiated using spinal cord stimulation, vagus nerve stimulation, and baroreceptor activation therapy in patients with HF with a reduced ejection fraction. Whereas the phase II studies with baroreceptor activation therapy remain encouraging, the larger clinical studies with spinal cord stimulation and vagus nerve stimulation have yielded disappointing results. Here we will focus on the pre-clinical studies that supported the role of neuromodulation in the failing heart, as well provide a critical review of the recent clinical trials that have sought to modulate autonomic tone in HF patients. This review will conclude with an analysis of some of the difficulties in translating device-based modulation of the autonomic nervous system from pre-clinical models into successful clinical trials, as well as provide suggestions for how to move the field of neuromodulation forward.
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Affiliation(s)
- Mirnela Byku
- Center for Cardiovascular Research, Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, MO 63110
| | - Douglas L Mann
- Center for Cardiovascular Research, Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, MO 63110
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Daniłowicz-Szymanowicz L, Suchecka J, Niemirycz-Makurat A, Rozwadowska K, Raczak G. Autonomic Predictors of Hospitalization Due to Heart Failure Decompensation in Patients with Left Ventricular Systolic Dysfunction. PLoS One 2016; 11:e0152372. [PMID: 27015089 PMCID: PMC4807762 DOI: 10.1371/journal.pone.0152372] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 03/14/2016] [Indexed: 01/01/2023] Open
Abstract
Introduction Autonomic nervous system balance can be significantly deteriorated during heart failure exacerbation. However, it is still unknown whether these changes are only the consequence of heart failure decompensation or can also predict development thereof. Objectives were to verify if simple, non-invasive autonomic parameters, such as baroreflex sensitivity and short-term heart rate variability can provide independent of other well-known clinical parameters information on the risk of heart failure decompensation in patients with left ventricular systolic dysfunction. Methods In 142 stable patients with left ventricular ejection fraction ≤ 40%, baroreflex sensitivity and short-term heart rate variability, as well as other well-known clinical parameters, were analyzed. During 23 ± 9 months of follow-up 19 patients were hospitalized due to the heart failure decompensation (EVENT). Results Pre-specified cut-off values of baroreflex sensitivity (≤2.4 ms/mmHg) and low frequency power index of heart rate variability (≤19 ms2) were significantly associated with the EVENTs (hazard ratio 4.43, 95% confidence interval [CI] 1.35–14.54 and 5.41, 95% CI 1.87–15.65 respectively). EVENTs were also associated with other parameters, such as left ventricular ejection fraction, NYHA class, diuretic use, renal function, brain natriuretic peptide and hemoglobin level, left atrial size, left and right ventricular heart failure signs. After adjusting baroreflex sensitivity and low frequency power index for each of the abovementioned parameters, autonomic parameters were still significant predictors of hospitalization due to the heart failure decompensation. Conclusion Simple, noninvasive autonomic indices can be helpful in identifying individuals with increased risk of hospitalization due to the heart failure decompensation among clinically stable patients with left ventricular systolic dysfunction, even when adjusted for other well-known clinical parameters.
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Affiliation(s)
| | - Justyna Suchecka
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Gdansk, Poland
| | | | - Katarzyna Rozwadowska
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Gdansk, Poland
| | - Grzegorz Raczak
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Gdansk, Poland
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Viehweg J, Reimann M, Gasch J, Rüdiger H, Ziemssen T. Comparison of baroreflex sensitivity estimated from ECG R–R and inter-systolic intervals obtained by finger plethysmography and radial tonometry. J Neural Transm (Vienna) 2016; 123:481-90. [DOI: 10.1007/s00702-016-1535-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 02/23/2016] [Indexed: 11/29/2022]
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Abstract
Circulatory homeostasis is associated with interactions between multiple organs, and the disruption of dynamic circulatory homeostasis could be considered as heart failure. The brain is the central unit integrating neural and neurohormonal information from peripheral organs and controlling peripheral organs using the autonomic nervous system. Heart failure is worsened by abnormal sympathoexcitation associated with baroreflex failure and/or chemoreflex activation, and by vagal withdrawal, and autonomic modulation therapies have benefits for heart failure. Recently, we showed that baroreflex failure induces striking volume intolerance independent of left ventricular dysfunction. Many studies have indicated that an overactive renin-angiotensin system, excess oxidative stress and excess inflammation, and/or decreased nitric oxide in the brain cause sympathoexcitation in heart failure. We have demonstrated that angiotensin II type 1 receptor (AT1R)-induced oxidative stress in the rostral ventrolateral medulla (RVLM), which is known as a vasomotor center, causes prominent sympathoexcitation in heart failure model rats. Interestingly, systemic infusion of angiotensin II directly affects brain AT1R with sympathoexcitation and left ventricular diastolic dysfunction. Moreover, we have demonstrated that targeted deletion of AT1R in astrocytes strikingly improved survival with prevention of left ventricular remodeling and sympathoinhibition in myocardial infarction-induced heart failure. From these results, we believe it is possible that AT1R in astrocytes, not in neurons, have a key role in the pathophysiology of heart failure. We would like to propose a novel concept that the brain works as a central processing unit integrating neural and hormonal input, and that the disruption of dynamic circulatory homeostasis mediated by the brain causes heart failure.
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Affiliation(s)
- Takuya Kishi
- Collaborative Research Institute of Innovation for Cardiovascular Diseases, Kyushu University Center for Disruptive Cardiovascular Medicine
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Giannoni A, Mirizzi G, Aimo A, Emdin M, Passino C. Peripheral reflex feedbacks in chronic heart failure: Is it time for a direct treatment? World J Cardiol 2015; 7:824-828. [PMID: 26730288 PMCID: PMC4691809 DOI: 10.4330/wjc.v7.i12.824] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 09/21/2015] [Accepted: 10/27/2015] [Indexed: 02/07/2023] Open
Abstract
Despite repeated attempts to develop a unifying hypothesis that explains the clinical syndrome of heart failure (HF), no single conceptual paradigm for HF has withstood the test of time. The last model that has been developed, the neurohormonal model, has the great virtue of highlighting the role of the heart as an endocrine organ, as well as to shed some light on the key role on HF progression of neurohormones and peripheral organs and tissues beyond the heart itself. However, while survival in clinical trials based on neurohormonal antagonist drugs has improved, HF currently remains a lethal condition. At the borders of the neurohormonal model of HF, a partially unexplored path trough the maze of HF pathophysiology is represented by the feedback systems. There are several evidences, from both animal studies and humans reports, that the deregulation of baro-, ergo- and chemo-reflexes in HF patients elicits autonomic imbalance associated with parasympathetic withdrawal and increased adrenergic drive to the heart, thus fundamentally contributing to the evolution of the disease. Hence, on top of guideline-recommended medical therapy, mainly based on neurohormonal antagonisms, all visceral feedbacks have been recently considered in HF patients as additional potential therapeutic targets.
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60
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Gronda E, Vanoli E. Baroreflex activation therapy for the treatment of heart failure. Interv Cardiol 2015. [DOI: 10.2217/ica.15.44] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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He X, Zhao M, Bi X, Sun L, Yu X, Zhao M, Zang W. Novel strategies and underlying protective mechanisms of modulation of vagal activity in cardiovascular diseases. Br J Pharmacol 2015; 172:5489-500. [PMID: 25378088 PMCID: PMC4667861 DOI: 10.1111/bph.13010] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 10/21/2014] [Accepted: 10/31/2014] [Indexed: 01/14/2023] Open
Abstract
Cardiovascular disease remains a major cause of disability and death worldwide. Autonomic imbalance, characterized by suppressed vagal (parasympathetic) activity and increased sympathetic activity, correlates with various pathological conditions, including heart failure, arrhythmia, ischaemia/reperfusion injury and hypertension. Conventionally, pharmacological interventions, such as β-blocker treatment, have primarily targeted suppressing sympathetic over-activation, while vagal modulation has always been neglected. Emerging evidence has documented the improvement of cardiac and vascular function mediated by the vagal nerve. Many investigators have tried to explore the effective ways to enhance vagal tone and normalize the autonomic nervous system. In this review, we attempt to give an overview of these therapeutic strategies, including direct vagal activation (electrical vagal stimulation, ACh administration and ACh receptor activation), pharmacological modulation (adenosine, cholinesterase inhibitors, statins) and exercise training. This overview provides valuable information for combination therapy, contributing to establishment of a comprehensive system on vagal modulation from the aspects of clinical application and lifestyle improvement. In addition, the mechanisms contributing to the benefits of enhancing vagal tone are diverse and have not yet been fully defined. We endeavour to outline the recent findings that advance our knowledge regarding the many favourable effects exerted by vagal activation: anti-inflammatory pathways, modulation of NOS and NO signalling, regulation of redox state, improvement of mitochondrial biogenesis and function, and potential calcium regulation. This review may help to develop novel therapeutic strategies targeting enhancing vagal activity for the treatment of cardiovascular diseases.
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Affiliation(s)
- Xi He
- Department of PharmacologyXi'an Jiaotong University Health Science CenterXi'anChina
| | - Ming Zhao
- Department of PharmacologyXi'an Jiaotong University Health Science CenterXi'anChina
| | - Xueyuan Bi
- Department of PharmacologyXi'an Jiaotong University Health Science CenterXi'anChina
| | - Lei Sun
- Department of PharmacologyXi'an Jiaotong University Health Science CenterXi'anChina
| | - Xiaojiang Yu
- Department of PharmacologyXi'an Jiaotong University Health Science CenterXi'anChina
| | - Mei Zhao
- Department of PharmacologyXi'an Jiaotong University Health Science CenterXi'anChina
| | - Weijin Zang
- Department of PharmacologyXi'an Jiaotong University Health Science CenterXi'anChina
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Spontaneous baroreceptor reflex sensitivity for risk stratification of heart failure patients: optimal cut-off and age effects. Clin Sci (Lond) 2015; 129:1163-72. [DOI: 10.1042/cs20150341] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 10/01/2015] [Indexed: 11/17/2022]
Abstract
This study provides statistical support for 3 ms/mmHg as a cut-off value that is the identifier of a homogeneous group of patients with depressed BRS, and highlights the robustness of this threshold in risk stratification due to its age-independent prognostic value.
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63
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Mortara A, Vanoli E. Baroreceptor activation therapy: The importance of targeting the right patient: who needs to be treated? Eur J Heart Fail 2015; 17:1000-2. [PMID: 26417677 DOI: 10.1002/ejhf.328] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 06/29/2015] [Accepted: 06/30/2015] [Indexed: 11/06/2022] Open
Affiliation(s)
- Andrea Mortara
- Department of Cardiology, Heart failure Clinic, Policlinico di Monza, Via Amati 111, 20900, Monza MB, Italy
| | - Emilio Vanoli
- Cardiovascular Department, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy.,Department of Molecular Medicine, University of Pavia, Italy
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65
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Zile MR, Abraham WT, Weaver FA, Butter C, Ducharme A, Halbach M, Klug D, Lovett EG, Müller‐Ehmsen J, Schafer JE, Senni M, Swarup V, Wachter R, Little WC. Baroreflex activation therapy for the treatment of heart failure with a reduced ejection fraction: safety and efficacy in patients with and without cardiac resynchronization therapy. Eur J Heart Fail 2015; 17:1066-74. [DOI: 10.1002/ejhf.299] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 05/13/2015] [Accepted: 05/14/2015] [Indexed: 01/19/2023] Open
Affiliation(s)
- Michael R. Zile
- Division of Cardiology, Department of Medicine Medical University of South Carolina 114 Doughty Street, Thurmond/Gazes, 323, Charleston, SC 29425, USA and Ralph H. Johnson Department of Veterans Affairs Medical Center Charleston SC USA
| | - William T. Abraham
- Division of Cardiovascular Medicine The Ohio State University Columbus OH USA
| | - Fred A. Weaver
- Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine University of Southern California Los Angeles CA USA
| | - Christian Butter
- Department of Cardiology Immanuel Heart Center Bernau—Medical School Brandenburg Bernau Germany
| | - Anique Ducharme
- Montreal Heart Institute University of Montréal Montreal Quebec Canada
| | - Marcel Halbach
- Department of Internal Medicine III University Hospital of Cologne Cologne Germany
| | - Didier Klug
- Department of Cardiology A University Hospital Lille France
| | | | | | | | - Michele Senni
- Cardiovascular Department Ospedale Papa Giovanni XXIII Bergamo Italy
| | - Vijay Swarup
- Department of Electrophysiology Arizona Heart Hospital Phoenix AZ USA
| | - Rolf Wachter
- Clinic for Cardiology and Pneumology University Medicine Göttingen and German Cardiovascular Research Center (DZHK) Göttingen Germany
| | - William C. Little
- Division of Cardiology University of Mississippi Medical Center Jackson MS USA
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Schwartz PJ, La Rovere MT, De Ferrari GM, Mann DL. Autonomic Modulation for the Management of Patients with Chronic Heart Failure. Circ Heart Fail 2015; 8:619-28. [DOI: 10.1161/circheartfailure.114.001964] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Peter J. Schwartz
- From the Center for Cardiac Arrhythmias of Genetic Origin, IRCCS Istituto Auxologico Italiano, Milan, Italy (P.J.S.); Department of Cardiology, Fondazione “Salvatore Maugeri”, IRCCS Istituto Scientifico di Montescano, Montescano, Pavia, Italy (M.T.L.R.); Department of Cardiology and Cardiovascular Clinical Research Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (G.M.D.F.); Department of Molecular Medicine, University of Pavia, Pavia, Italy (G.M.D.F.); and Cardiovascular Division,
| | - Maria Teresa La Rovere
- From the Center for Cardiac Arrhythmias of Genetic Origin, IRCCS Istituto Auxologico Italiano, Milan, Italy (P.J.S.); Department of Cardiology, Fondazione “Salvatore Maugeri”, IRCCS Istituto Scientifico di Montescano, Montescano, Pavia, Italy (M.T.L.R.); Department of Cardiology and Cardiovascular Clinical Research Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (G.M.D.F.); Department of Molecular Medicine, University of Pavia, Pavia, Italy (G.M.D.F.); and Cardiovascular Division,
| | - Gaetano M. De Ferrari
- From the Center for Cardiac Arrhythmias of Genetic Origin, IRCCS Istituto Auxologico Italiano, Milan, Italy (P.J.S.); Department of Cardiology, Fondazione “Salvatore Maugeri”, IRCCS Istituto Scientifico di Montescano, Montescano, Pavia, Italy (M.T.L.R.); Department of Cardiology and Cardiovascular Clinical Research Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (G.M.D.F.); Department of Molecular Medicine, University of Pavia, Pavia, Italy (G.M.D.F.); and Cardiovascular Division,
| | - Douglas L. Mann
- From the Center for Cardiac Arrhythmias of Genetic Origin, IRCCS Istituto Auxologico Italiano, Milan, Italy (P.J.S.); Department of Cardiology, Fondazione “Salvatore Maugeri”, IRCCS Istituto Scientifico di Montescano, Montescano, Pavia, Italy (M.T.L.R.); Department of Cardiology and Cardiovascular Clinical Research Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (G.M.D.F.); Department of Molecular Medicine, University of Pavia, Pavia, Italy (G.M.D.F.); and Cardiovascular Division,
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The autonomic nervous system and cardiovascular disease: role of n-3 PUFAs. Vascul Pharmacol 2015; 71:1-10. [PMID: 25869497 DOI: 10.1016/j.vph.2015.02.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 02/04/2015] [Accepted: 02/07/2015] [Indexed: 02/05/2023]
Abstract
In the last decades, a large body of experimental and clinical evidence has been accumulated showing that cardiovascular diseases are often accompanied by an imbalance in the sympathetic-vagal outflow to the heart, resulting in a chronic adrenergic activation. The arterial baroreceptor system is a key component of mechanisms contributing to the neural regulation of the cardiovascular system. Several methods have been proposed to assess autonomic activity by analyzing heart rate and blood pressure changes either spontaneously occurring or following provocations. The autonomic nervous system has been regarded as one of the putative mechanisms involved into the beneficial effects of exposure to n-3 fatty acids observed in epidemiological studies. The aim of the present review is to provide an update on the clinical evidence proposed so far linking exposure to n-3 fatty acids to autonomic nervous system modulation.
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Horsman HM, Tzeng YC, Galletly DC, Peebles KC. The repeated sit-to-stand maneuver is a superior method for cardiac baroreflex assessment: a comparison with the modified Oxford method and Valsalva maneuver. Am J Physiol Regul Integr Comp Physiol 2014; 307:R1345-52. [DOI: 10.1152/ajpregu.00376.2014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Baroreflex assessment has diagnostic and prognostic utility in the clinical and research environments, and there is a need for a reliable, simple, noninvasive method of assessment. The repeated sit-to-stand method induces oscillatory changes in blood pressure (BP) at a desired frequency and is suitable for assessing dynamic baroreflex sensitivity (BRS). However, little is known about the reliability of this method and its ability to discern fundamental properties of the baroreflex. In this study we sought to: 1) evaluate the reliability of the sit-to-stand method for assessing BRS and compare its performance against two established methods (Oxford method and Valsalva maneuver), and 2) examine whether the frequency of the sit-to-stand method influences hysteresis. Sixteen healthy participants underwent three trials of each method. For the sit-to-stand method, which was performed at 0.1 and 0.05 Hz, BRS was quantified as an integrated response (BRSINT) and in response to falling and rising BP (BRSDOWN and BRSUP, respectively). Test retest reliability was assessed using the intraclass correlation coefficient (ICC). Irrespective of frequency, the ICC for BRSINT during the sit-to-stand method was ≥0.88. The ICC for a rising BP evoked by phenylephrine (PEGAIN) in the Oxford method was 0.78 and ≤0.5 for the remaining measures. During the sit-to-stand method, hysteresis was apparent in all participants at 0.1 Hz but was absent at 0.05 Hz. These findings indicate the sit-to-stand method is a statistically reliable BRS assessment tool and suitable for the examination of baroreflex hysteresis. Using this approach we showed that baroreflex hysteresis is a frequency-dependent phenomenon.
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Affiliation(s)
- H. M. Horsman
- Cardiovascular Systems Laboratory
- Centre for Translational Physiology, University of Otago, Wellington, New Zealand
| | - Y. C. Tzeng
- Cardiovascular Systems Laboratory
- Centre for Translational Physiology, University of Otago, Wellington, New Zealand
| | - D. C. Galletly
- Cardiovascular Systems Laboratory
- Centre for Translational Physiology, University of Otago, Wellington, New Zealand
| | - K. C. Peebles
- Cardiovascular Systems Laboratory
- Centre for Translational Physiology, University of Otago, Wellington, New Zealand
- Department of Physiology, University of Otago, Dunedin, New Zealand; and
- Department of Human Sciences, Macquarie University, Sydney, Australia
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69
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Haack KKV, Zucker IH. Central mechanisms for exercise training-induced reduction in sympatho-excitation in chronic heart failure. Auton Neurosci 2014; 188:44-50. [PMID: 25458427 DOI: 10.1016/j.autneu.2014.10.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 08/19/2014] [Accepted: 10/13/2014] [Indexed: 11/17/2022]
Abstract
The control of sympathetic outflow in the chronic heart failure (CHF) state is markedly abnormal. Patients with heart failure present with increased plasma norepinephrine and increased sympathetic nerve activity. The mechanism for this sympatho-excitation is multiple and varied. Both depression in negative feedback sensory control mechanisms and augmentation of excitatory reflexes contribute to this sympatho-excitation. These include the arterial baroreflex, cardiac reflexes, arterial chemoreflexes and cardiac sympathetic afferent reflexes. In addition, abnormalities in central signaling in autonomic pathways have been implicated in the sympatho-excitatory process in CHF. These mechanisms include increases in central Angiotensin II and the Type 1 receptor, increased in reactive oxygen stress, upregulation in glutamate signaling and NR1 (N-methyl-D-aspartate subtype 1) receptors and others. Exercise training in the CHF state has been shown to reduce sympathetic outflow and result in increased survival and reduced cardiac events. Exercise training has been shown to reduce central Angiotensin II signaling including the Type 1 receptor and reduce oxidative stress by lowering the expression of many of the subunits of NADPH oxidase. In addition, there are profound effects on the central generation of nitric oxide and nitric oxide synthase in sympatho-regulatory areas of the brain. Recent studies have pointed to the balance between Angiotensin Converting Enzyme (ACE) and ACE2, translating into Angiotensin II and Angiotensin 1-7 as important regulators of sympathetic outflow. These enzymes appear to be normalized following exercise training in CHF. Understanding the precise molecular mechanisms by which exercise training is sympatho-inhibitory will uncover new targets for therapy.
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Affiliation(s)
- Karla K V Haack
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, United States
| | - Irving H Zucker
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, United States.
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70
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Schwartz PJ. Can we Modulate the Autonomic Nervous System to Improve the Life of Patients with Heart Failure? The Case of Vagal Stimulation. Arrhythm Electrophysiol Rev 2014; 3:120-2. [PMID: 26835078 PMCID: PMC4711534 DOI: 10.15420/aer.2014.3.2.120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Accepted: 07/29/2014] [Indexed: 01/08/2023] Open
Abstract
An imbalance of the autonomic nervous system, with reduced vagal and increased sympathetic activity, contributes to pathogenesis and clinical deterioration in heart failure (HF). Experimental studies have demonstrated that vagal stimulation (VS) has an antifibrillatory effect that has proved beneficial in animal models of HF. The potential value of chronic VS in man was first investigated with an implantable neuro-stimulator capable of delivering low current pulses with adjustable parameters to stimulate the right vagus. The results of a pilot study and a small multicentre clinical trial of VS in HF patients appeared to show a favourable clinical effect, and feasibility and safety data were encouraging. An ongoing pivotal clinical trial will provide a definitive assessment of the efficacy and usefulness of chronic VS in HF patients.This approach represents a new and exciting possibility for the management of HF that will provide clinicians with a novel tool to modulate non-pharmacologically the autonomic nervous system in patients with moderate-to-advanced HF.
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Affiliation(s)
- Peter J Schwartz
- Professor and Head, Centre for Cardiac Arrhythmias of Genetic Origin, IRCCS Istituto Auxologico Italiano, Milan, Italy
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71
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Gronda E, Seravalle G, Brambilla G, Costantino G, Casini A, Alsheraei A, Lovett EG, Mancia G, Grassi G. Chronic baroreflex activation effects on sympathetic nerve traffic, baroreflex function, and cardiac haemodynamics in heart failure: a proof-of-concept study. Eur J Heart Fail 2014; 16:977-83. [PMID: 25067799 PMCID: PMC4237551 DOI: 10.1002/ejhf.138] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 05/23/2014] [Accepted: 06/06/2014] [Indexed: 12/20/2022] Open
Abstract
Aims Heart failure (HF) pathophysiology is believed to be mediated by autonomic dysfunction, including chronic sympathoexcitation and diminished baroreflex sensitivity, which correlate with mortality risk. Baroreflex activation therapy (BAT) is a device-based treatment providing chronic baroreflex activation through electrical stimulation of the carotid sinus. BAT chronically reduces sympathetic activity in resistant hypertension. The purpose of this investigation is to determine BAT effects in clinical HF. Methods and results In a single-centre, open-label evaluation, patients with NYHA class III HF, EF <40%, optimized medical therapy, and ineligible for cardiac resynchronization received BAT for 6 months. Efficacy was assessed with serial measurement of muscle sympathetic nerve activity (MSNA) and clinical measures of quality of life and functional capacity. Eleven patients participated in the trial. MSNA was reduced over 6 months from 45.1 ± 7.7 to 31.3 ± 8.3 bursts/min and from 67.6 ± 12.7 to 45.1 ± 11.6 bursts/100 heartbeats, decreases of 31% and 33%, respectively (P < 0.01). Concomitant improvements occurred in baroreflex sensitivity, EF, NYHA class, quality of life and 6 min hall walk (6MHW) distance (P ≤ 0.05 each). On an observational basis, hospitalization and emergency department visits for worsening HF were markedly reduced. One complication, perioperative anaemia requiring transfusion, occurred during the study. Conclusion BAT was safe and provided chronic improvement in MSNA and clinical variables. Based on present understanding of HF pathophysiology, these results suggest that BAT may improve outcome in HF by modulating autonomic balance. Prospective, randomized trials to test the hypothesis are warranted.
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Affiliation(s)
- Edoardo Gronda
- Cardiovascular Department, IRCCS MultiMedica, Sesto San Giovanni (Milan), Italy
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72
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Abstract
The pathophysiology of heart failure (HF) is characterized by hemodynamic abnormalities that result in neurohormonal activation and autonomic imbalance with increase in sympathetic activity and withdrawal of vagal activity. Alterations in receptor activation from this autonomic imbalance may have profound effects on cardiac function and structure. Inhibition of the sympathetic drive to the heart through β-receptor blockade has become a standard component of therapy for HF with a dilated left ventricle because of its effectiveness in inhibiting the ventricular structural remodeling process and in prolonging life. Several devices for selective modulation of sympathetic and vagal activity have recently been developed in an attempt to alter the natural history of HF. The optimal counteraction of the excessive sympathetic activity is still unclear. A profound decrease in adrenergic support with excessive blockade of the sympathetic nervous system may result in adverse outcomes in clinical HF. In this review, we analyze the data supporting a contributory role of the autonomic functional alterations on the course of HF, the techniques used to assess autonomic nervous system activity, the evidence for clinical effectiveness of pharmacological and device interventions, and the potential future role of autonomic nervous system modifiers in the management of this syndrome.
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Affiliation(s)
- Viorel G Florea
- From the Minneapolis VA Health Care System, Section of Cardiology (V.G.F.) and Rasmussen Center for Cardiovascular Disease Prevention, Department of Medicine (J.N.C.), University of Minnesota Medical School
| | - Jay N Cohn
- From the Minneapolis VA Health Care System, Section of Cardiology (V.G.F.) and Rasmussen Center for Cardiovascular Disease Prevention, Department of Medicine (J.N.C.), University of Minnesota Medical School.
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73
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Wellens HJJ, Schwartz PJ, Lindemans FW, Buxton AE, Goldberger JJ, Hohnloser SH, Huikuri HV, Kääb S, La Rovere MT, Malik M, Myerburg RJ, Simoons ML, Swedberg K, Tijssen J, Voors AA, Wilde AA. Risk stratification for sudden cardiac death: current status and challenges for the future. Eur Heart J 2014; 35:1642-51. [PMID: 24801071 PMCID: PMC4076664 DOI: 10.1093/eurheartj/ehu176] [Citation(s) in RCA: 269] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 12/17/2013] [Accepted: 01/27/2014] [Indexed: 01/09/2023] Open
Abstract
Sudden cardiac death (SCD) remains a daunting problem. It is a major public health issue for several reasons: from its prevalence (20% of total mortality in the industrialized world) to the devastating psycho-social impact on society and on the families of victims often still in their prime, and it represents a challenge for medicine, and especially for cardiology. This text summarizes the discussions and opinions of a group of investigators with a long-standing interest in this field. We addressed the occurrence of SCD in individuals apparently healthy, in patients with heart disease and mild or severe cardiac dysfunction, and in those with genetically based arrhythmic diseases. Recognizing the need for more accurate registries of the global and regional distribution of SCD in these different categories, we focused on the assessment of risk for SCD in these four groups, looking at the significance of alterations in cardiac function, of signs of electrical instability identified by ECG abnormalities or by autonomic tests, and of the progressive impact of genetic screening. Special attention was given to the identification of areas of research more or less likely to provide useful information, and thereby more or less suitable for the investment of time and of research funds.
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Affiliation(s)
| | - Peter J Schwartz
- IRCCS Istituto Auxologico Italiano, Center for Cardiac Arrhythmias of Genetic Origin, Milan, Italy
| | | | - Alfred E Buxton
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jeffrey J Goldberger
- Division of Cardiology, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stefan H Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, J. W. Goethe University, Frankfurt, Germany
| | - Heikki V Huikuri
- Medical Research Center Oulu, University and University Hospital of Oulu, Oulu, Finland
| | - Stefan Kääb
- Department of Medicine I, University Hospital, Ludwig-Maximilians-University, Münich, Germany DZHK (German Centre for Cardiovascular Research), Partner Site Münich Heart Alliance, Münich, Germany
| | - Maria Teresa La Rovere
- Department of Cardiology, Fondazione 'Salvatore Maugeri', IRCCS, Istituto Scientifico di Montescano, Montescano, Pavia, Italy
| | - Marek Malik
- St Paul's Cardiac Electrophysiology, University of London and Imperial College, London, UK
| | - Robert J Myerburg
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | | | - Jan Tijssen
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Adriaan A Voors
- University Medical Center Groningen, Groningen, The Netherlands
| | - Arthur A Wilde
- Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, The Netherlands Princess Al Jawhara Albrahim Centre of Excellence in Research of Hereditary Disorders, King Abdulaziz University, Jeddah, Saudi Arabia
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74
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Taylor CE, Willie CK, Ainslie PN, Tzeng YC. Assessment of human baroreflex function using carotid ultrasonography: what have we learnt? Acta Physiol (Oxf) 2014; 211:297-313. [PMID: 24739079 DOI: 10.1111/apha.12302] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 04/09/2014] [Indexed: 12/13/2022]
Abstract
The arterial baroreflex is critical to both short- and long-term regulation of blood pressure. However, human baroreflex research has been largely limited to the association between blood pressure and cardiac period (or heart rate) or indices of vascular sympathetic function. Over the past decade, emerging techniques based on carotid ultrasound imaging have allowed new means of understanding and measuring the baroreflex. In this review, we describe the assessment of the mechanical and neural components of the baroreflex through the use of carotid ultrasound imaging. The mechanical component refers to the change in carotid artery diameter in response to changes in arterial pressure, and the neural component refers to the change in R-R interval (cardiac baroreflex) or muscle sympathetic nerve activity (sympathetic baroreflex) in response to this barosensory vessel stretch. The key analytical concepts and techniques are discussed, with a focus on the assessment of baroreflex sensitivity via the modified Oxford method. We illustrate how the application of carotid ultrasound imaging has contributed to a greater understanding of baroreflex physiology in humans, covering topics such as ageing and diurnal variation, and physiological challenges including exercise, postural changes and mental stress.
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Affiliation(s)
- C. E. Taylor
- School of Science and Health; University of Western Sydney; Sydney NSW Australia
| | - C. K. Willie
- School of Health and Exercise Sciences; Centre for Heart Lung and Vascular Health; University of British Columbia Okanagan; Kelowna BC Canada
| | - P. N. Ainslie
- School of Health and Exercise Sciences; Centre for Heart Lung and Vascular Health; University of British Columbia Okanagan; Kelowna BC Canada
| | - Y.-C. Tzeng
- Cardiovascular Systems Laboratory; Centre for Translational Physiology; University of Otago; Wellington New Zealand
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Mechanisms underlying the autonomic modulation of ventricular fibrillation initiation--tentative prophylactic properties of vagus nerve stimulation on malignant arrhythmias in heart failure. Heart Fail Rev 2014; 18:389-408. [PMID: 22678767 PMCID: PMC3677978 DOI: 10.1007/s10741-012-9314-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Classical physiology teaches that vagal post-ganglionic nerves modulate the heart via acetylcholine acting at muscarinic receptors, whilst it is accepted that vagus nerve stimulation (VNS) slows heart rate, atrioventricular conduction and decreases atrial contraction; there is continued controversy as to whether the vagus has any significant direct effect on ventricular performance. Despite this, there is a significant body of evidence from experimental and clinical studies, demonstrating that the vagus nerve has an anti-arrhythmic action, protecting against induced and spontaneously occurring ventricular arrhythmias. Over 100 years ago Einbrodt first demonstrated that direct cervical VNS significantly increased the threshold for experimentally induced ventricular fibrillation. A large body of evidence has subsequently been collected supporting the existence of an anti-arrhythmic effect of the vagus on the ventricle. The development of prognostic indicators of heart rate variability and baroreceptor reflex sensitivity—measures of parasympathetic tone and reflex activation respectively—and the more recent interest in chronic VNS therapy are a direct consequence of the earlier experimental studies. Despite this, mechanisms underlying the anti-arrhythmic actions of the vagus nerve have not been fully characterised and are not well understood. This review summarises historical and recently published data to highlight the importance of this powerful endogenous protective phenomenon.
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76
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Dimitropoulos G, Tahrani AA, Stevens MJ. Cardiac autonomic neuropathy in patients with diabetes mellitus. World J Diabetes 2014; 5:17-39. [PMID: 24567799 PMCID: PMC3932425 DOI: 10.4239/wjd.v5.i1.17] [Citation(s) in RCA: 177] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 12/02/2013] [Accepted: 12/12/2013] [Indexed: 02/05/2023] Open
Abstract
Cardiac autonomic neuropathy (CAN) is an often overlooked and common complication of diabetes mellitus. CAN is associated with increased cardiovascular morbidity and mortality. The pathogenesis of CAN is complex and involves a cascade of pathways activated by hyperglycaemia resulting in neuronal ischaemia and cellular death. In addition, autoimmune and genetic factors are involved in the development of CAN. CAN might be subclinical for several years until the patient develops resting tachycardia, exercise intolerance, postural hypotension, cardiac dysfunction and diabetic cardiomyopathy. During its sub-clinical phase, heart rate variability that is influenced by the balance between parasympathetic and sympathetic tones can help in detecting CAN before the disease is symptomatic. Newer imaging techniques (such as scintigraphy) have allowed earlier detection of CAN in the pre-clinical phase and allowed better assessment of the sympathetic nervous system. One of the main difficulties in CAN research is the lack of a universally accepted definition of CAN; however, the Toronto Consensus Panel on Diabetic Neuropathy has recently issued guidance for the diagnosis and staging of CAN, and also proposed screening for CAN in patients with diabetes mellitus. A major challenge, however, is the lack of specific treatment to slow the progression or prevent the development of CAN. Lifestyle changes, improved metabolic control might prevent or slow the progression of CAN. Reversal will require combination of these treatments with new targeted therapeutic approaches. The aim of this article is to review the latest evidence regarding the epidemiology, pathogenesis, manifestations, diagnosis and treatment for CAN.
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77
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De Ferrari GM. Vagal Stimulation in Heart Failure. J Cardiovasc Transl Res 2014; 7:310-20. [DOI: 10.1007/s12265-014-9540-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 01/03/2014] [Indexed: 01/09/2023]
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78
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Pathophysiology and Potential Clinical Applications for Testing of Peripheral Chemosensitivity in Heart Failure. Curr Heart Fail Rep 2014; 11:126-33. [DOI: 10.1007/s11897-014-0188-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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79
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Patel HC, Rosen SD, Lindsay A, Hayward C, Lyon AR, di Mario C. Targeting the autonomic nervous system: Measuring autonomic function and novel devices for heart failure management. Int J Cardiol 2013; 170:107-17. [DOI: 10.1016/j.ijcard.2013.10.058] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 09/03/2013] [Accepted: 10/19/2013] [Indexed: 01/08/2023]
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80
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Labrunée M, Despas F, Marque P, Guiraud T, Galinier M, Senard JM, Pathak A. Acute electromyostimulation decreases muscle sympathetic nerve activity in patients with advanced chronic heart failure (EMSICA Study). PLoS One 2013; 8:e79438. [PMID: 24265770 PMCID: PMC3827140 DOI: 10.1371/journal.pone.0079438] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 09/23/2013] [Indexed: 11/25/2022] Open
Abstract
Background Muscle passive contraction of lower limb by neuromuscular electrostimulation (NMES) is frequently used in chronic heart failure (CHF) patients but no data are available concerning its action on sympathetic activity. However, Transcutaneous Electrical Nerve Stimulation (TENS) is able to improve baroreflex in CHF. The primary aim of the present study was to investigate the acute effect of TENS and NMES compared to Sham stimulation on sympathetic overactivity as assessed by Muscle Sympathetic Nerve Activity (MSNA). Methods We performed a serie of two parallel, randomized, double blinded and sham controlled protocols in twenty-two CHF patients in New York Heart Association (NYHA) Class III. Half of them performed stimulation by TENS, and the others tested NMES. Results Compare to Sham stimulation, both TENS and NMES are able to reduce MSNA (63.5 ± 3.5 vs 69.7 ± 3.1 bursts / min, p < 0.01 after TENS and 51.6 ± 3.3 vs 56.7 ± 3.3 bursts / min, p < 0, 01 after NMES). No variation of blood pressure, heart rate or respiratory parameters was observed after stimulation. Conclusion The results suggest that sensory stimulation of lower limbs by electrical device, either TENS or NMES, could inhibit sympathetic outflow directed to legs in CHF patients. These properties could benefits CHF patients and pave the way for a new non-pharmacological approach of CHF.
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Affiliation(s)
- Marc Labrunée
- National Institute of Health and Medical ResearchTeam Institut des maladies métaboliques et cardiovasculaires, Toulouse, France
- Faculty of Medicine, University of Toulouse III Paul Sabatier F-31432, Toulouse, France
- Federation of Cardiology, Universitary Hospital of Toulouse, F-31073, Toulouse, France
- Physical Medicine and Rehabilitation unit, Universitary Hospital of Toulouse, F-31073, Toulouse, France
- * E-mail:
| | - Fabien Despas
- National Institute of Health and Medical ResearchTeam Institut des maladies métaboliques et cardiovasculaires, Toulouse, France
- Faculty of Medicine, University of Toulouse III Paul Sabatier F-31432, Toulouse, France
- Clinical Pharmacology unit, Universitary Hospital of Toulouse, F-31073, Toulouse, France
| | - Philippe Marque
- Faculty of Medicine, University of Toulouse III Paul Sabatier F-31432, Toulouse, France
- Physical Medicine and Rehabilitation unit, Universitary Hospital of Toulouse, F-31073, Toulouse, France
| | - Thibaut Guiraud
- National Institute of Health and Medical ResearchTeam Institut des maladies métaboliques et cardiovasculaires, Toulouse, France
- Cardiopulmonary rehabilitation center, Saint-Orens de Gameville, France
| | - Michel Galinier
- Faculty of Medicine, University of Toulouse III Paul Sabatier F-31432, Toulouse, France
- Federation of Cardiology, Universitary Hospital of Toulouse, F-31073, Toulouse, France
| | - Jean Michel Senard
- National Institute of Health and Medical ResearchTeam Institut des maladies métaboliques et cardiovasculaires, Toulouse, France
- Faculty of Medicine, University of Toulouse III Paul Sabatier F-31432, Toulouse, France
- Clinical Pharmacology unit, Universitary Hospital of Toulouse, F-31073, Toulouse, France
| | - Atul Pathak
- National Institute of Health and Medical ResearchTeam Institut des maladies métaboliques et cardiovasculaires, Toulouse, France
- Faculty of Medicine, University of Toulouse III Paul Sabatier F-31432, Toulouse, France
- Federation of Cardiology, Universitary Hospital of Toulouse, F-31073, Toulouse, France
- Clinical Pharmacology unit, Universitary Hospital of Toulouse, F-31073, Toulouse, France
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81
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Systemic Effects of a High-Flow Arteriovenous Fistula for Hemodialysis. J Vasc Access 2013; 15:163-8. [DOI: 10.5301/jva.5000196] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2013] [Indexed: 12/20/2022] Open
Abstract
Purpose Absolute treatment criteria for reducing the access volume of a high-flow access (HFA, access flow >2 L/min) are absent. Previous studies suggested that a HFA may influence the systemic circulation including blood pressure (BP) and heart rate (HR). The aim of this study was to determine these parameters after access clamping in hemodialysis patients undergoing flow-reducing access surgery. Methods Systolic BP (SBP), diastolic BP (DBP) and HR in HFA patients undergoing flow-reducing surgery were measured intraoperatively before and after access clamping. Data were compared to values obtained in patients receiving surgery for severe hand ischemia due to an access (HAIDI, hemodialysis access-induced distal ischemia). Results In 8 years, 34 patients underwent surgery for HFA (n=23) or HAIDI (n=11). Preoperative access flows in HFA were larger compared to HAIDI (3,026±147 vs 1,078±139 mL/min, respectively, p<0.001). Temporary clamping (15 sec) caused a 12±2 mm Hg increase in SBP (111±6 to 123±6 mm Hg, p<0.05) and a 6±1 mm Hg rise in DBP (57±4 to 63±5 mm Hg, p<0.05) in HFA patients. In contrast, SBP and DBP increases were not significant in HAIDI patients (+6±3 and +2±2 mm Hg, respectively, p=0.37). HR was modestly reduced in both groups following access clamping (–3±1 beats/min). The relationship between access flow volume and alterations in SBP best fitted a quadratic regression model, suggesting cardiovascular exhaustion with progressively higher access flows > 2-2.5 L/min. Conclusions HFA may influence systemic hemodynamics in some hemodialysis patients. The findings of this study may contribute to a tailored management of a high-flow fistula in this population.
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Borgers AJ, van den Born BJH, Alkemade A, Eeftinck Schattenkerk DW, van Lieshout JJ, Wesseling KH, Bisschop PH, Westerhof BE. Determinants of vascular and cardiac baroreflex sensitivity values in a random population sample. Med Biol Eng Comput 2013; 52:65-73. [DOI: 10.1007/s11517-013-1111-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 09/01/2013] [Indexed: 10/26/2022]
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83
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Mirizzi G, Giannoni A, Bramanti F, Ripoli A, Varanini M, Bernardi L, Emdin M, Passino C. A simple method for measuring baroreflex sensitivity holds prognostic value in heart failure. Int J Cardiol 2013; 169:e9-11. [PMID: 24067599 DOI: 10.1016/j.ijcard.2013.08.120] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Accepted: 08/29/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Gianluca Mirizzi
- Division of Cardiovascular Medicine, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
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84
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Impaired cardiac baroreflex sensitivity predicts response to renal sympathetic denervation in patients with resistant hypertension. J Am Coll Cardiol 2013; 62:2124-30. [PMID: 23973686 DOI: 10.1016/j.jacc.2013.07.046] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 07/11/2013] [Accepted: 07/16/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVES This study sought to evaluate cardiac baroreflex sensitivity (BRS) as a predictor of response to renal sympathetic denervation (RDN). BACKGROUND Catheter-based RDN is a novel treatment option for patients with resistant arterial hypertension. It is assumed that RDN reduces efferent renal and central sympathetic activity. METHODS Fifty patients (age 60.3 ± 13.8 years [mean ± SD mean systolic blood pressure (BP) on ambulatory blood pressure monitoring (ABPM) 157 ± 22 mm Hg, despite medication with 5.4 ± 1.4 antihypertensive drugs) underwent RDN. Prior to RDN, a 30-min recording of continuous arterial BP (Finapres; TNO-TPD Biomedical Instrumentation, Amsterdam, the Netherlands) and high-resolution electrocardiography (1.6 kHz in orthogonal XYZ leads) was performed in all patients under standardized conditions. Cardiac BRS was assessed by phase-rectified signal averaging (BRSPRSA) according to previously published technologies. Response to RDN was defined as a reduction of mean systolic BP on ABPM by 10 mm Hg or more at 6 months after RDN. RESULTS Six months after RDN, mean systolic BP on ABPM was significantly reduced from 157 ± 22 mm Hg to 149 ± 20 mm Hg (p = 0.003). Twenty-six of the 50 patients (52%) were classified as responders. BRSPRSA was significantly lower in responders than nonresponders (0.16 ± 0.75 ms/mm Hg vs. 1.54 ± 1.73 ms/mm Hg; p < 0.001). Receiver-operator characteristics analysis revealed an area under the curve for prediction of response to RDN by BRSPRSA of 81.2% (95% confidence interval: 70.0% to 90.1%; p < 0.001). On multivariable logistic regression analysis, reduced BRSPRSA was the strongest predictor of response to RDN, which was independent of all other variables tested. CONCLUSIONS Impaired cardiac BRS identifies patients with resistant hypertension who respond to RDN.
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Pathak A, Lebrin M, Vaccaro A, Senard JM, Despas F. Pharmacology of levosimendan: inotropic, vasodilatory and cardioprotective effects. J Clin Pharm Ther 2013; 38:341-9. [PMID: 23594161 DOI: 10.1111/jcpt.12067] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 03/20/2013] [Indexed: 01/15/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Positive inotropic agents are frequently used in acute decompensated heart failure (ADHF) due to left ventricular systolic dysfunction. These agents are known to improve cardiac performance and peripheral perfusion in the short-term treatment. However, several preclinical and clinical studies emphasized detrimental effects of these drugs on myocardial oxygen demand and on sympathetic tone entailing arrhythmogenesis. Levosimendan is an inotropic agent with an original mechanism of action. This review focuses on major data available for levosimendan. METHODS A literature search was conducted in the PubMed database by including studies published in English using combinations of the following key words, levosimendan, inotropic drugs and acute heart failure. Furthermore, bibliographies of selected references were also evaluated for relevant articles. The collection for this review was limited to the most recently available human and animal data. RESULTS AND DISCUSSION Levosimendan's vasodilatory and cardioprotective effects are mediated by calcium sensitization of contractile proteins and opening of adenosine triphosphate (ATP)-dependent K+ channels in vascular smooth muscle cells and on mitochondrial ATP-sensitive potassium [mito.K(ATP)] channels. This inotropic agent has mild PDE inhibitory action. Unlike other inotropic agents, levosimendan improves cardiac performance without activating the sympathetic nervous system. Moreover, there are evidences that levosimendan has additional anti-inflammatory and anti-apoptotic properties that prevent cardiac toxicity and contributes to positive hemodynamic response of the drug. Four randomized trials evaluated the effects of levosimendan on mortality in patients with acute decompensated chronic heart failure; nevertheless, a clear benefit has not been demonstrated so far. Although levosimendan is indicated for the treatment of ADHF (class of recommendation IIa, level of evidence B), it is has not been approved in all countries. WHAT IS NEW AND CONCLUSION This review summarizes the characteristics and the current knowledge of the literature on levosimendan and its active metabolite OR-1896.
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Affiliation(s)
- A Pathak
- Institut National de Sante et de Recherche Médicale (INSERM), UMR-1048, Institut des maladies métaboliques et cardiovasculaires I2MC, Toulouse, France
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La Rovere MT, Staszewsky L, Barlera S, Maestri R, Mezzani A, Midi P, Marchioli R, Maggioni AP, Tognoni G, Tavazzi L, Latini R. n-3PUFA and Holter-derived autonomic variables in patients with heart failure: Data from the Gruppo Italiano per lo Studio della Sopravvivenza nell’Insufficienza Cardiaca (GISSI-HF) Holter substudy. Heart Rhythm 2013; 10:226-32. [DOI: 10.1016/j.hrthm.2012.10.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Indexed: 10/27/2022]
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Mello PR, Guerra GM, Borile S, Rondon MU, Alves MJ, Negrão CE, Dal Lago P, Mostarda C, Irigoyen MC, Consolim-Colombo FM. Inspiratory muscle training reduces sympathetic nervous activity and improves inspiratory muscle weakness and quality of life in patients with chronic heart failure: a clinical trial. J Cardiopulm Rehabil Prev 2013; 32:255-61. [PMID: 22785143 DOI: 10.1097/hcr.0b013e31825828da] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE To evaluate the effect of inspiratory muscle training (IMT) on cardiac autonomic modulation and on peripheral nerve sympathetic activity in patients with chronic heart failure (CHF). METHODS Functional capacity, low-frequency (LF) and high-frequency (HF) components of heart rate variability, muscle sympathetic nerve activity inferred by microneurography, and quality of life were determined in 27 patients with CHF who had been sequentially allocated to 1 of 2 groups: (1) control group (with no intervention) and (2) IMT group. Inspiratory muscle training consisted of respiratory exercises, with inspiratory threshold loading of seven 30-minute sessions per week for a period of 12 weeks, with a monthly increase of 30% in maximal inspiratory pressure (PI(max)) at rest. Multivariate analysis was applied to detect differences between baseline and followup period. RESULTS Inspiratory muscle training significantly increased PI(max) (59.2 ± 4.9 vs 87.5 ± 6.5 cmH(2)O, P = .001) and peak oxygen uptake (14.4 ± 0.7 vs 18.9 ± 0.8 mL·kg(-1)·min(-1), P = .002); decreased the peak ventilation (VE)/carbon dioxide production (VCO(2)) ratio (35.8 ± 0.8 vs 32.5 ± 0.4, P = .001) and the VE/VCO(2) slope (37.3 ± 1.1 vs 31.3 ± 1.1, P = .004); increased the HF component (49.3 ± 4.1 vs 58.4 ± 4.2 normalized units, P = .004) and decreased the LF component (50.7 ± 4.1 vs 41.6 ± 4.2 normalized units, P = .001) of heart rate variability; decreased muscle sympathetic nerve activity (37.1 ± 3 vs 29.5 ± 2.3 bursts per minute, P = .001); and improved quality of life. No significant changes were observed in the control group. CONCLUSION Home-based IMT represents an important strategy to improve cardiac and peripheral autonomic controls, functional capacity, and quality of life in patients with CHF.
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Abstract
The arterial baroreflex is an important determinant of the neural regulation of the cardiovascular system. It has been recognised that baroreflex-mediated sympathoexcitation contributes to the development and progression of many cardiovascular disorders. Accordingly, the quantitative estimation of the arterial baroreceptor-heart rate reflex (baroreflex sensitivity, BRS), has been regarded as a synthetic index of neural regulation at the sinus atrial node. The evaluation of BRS has been shown to provide clinical and prognostic information in a variety of cardiovascular diseases, including myocardial infarction and heart failure that are reviewed in the present article.
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Vagal stimulation for heart diseases: from animals to men. An example of translational cardiology. Neth Heart J 2013; 21:82-4. [PMID: 23250848 DOI: 10.1007/s12471-012-0368-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
A significant series of experimental and clinical studies have demonstrated the close association between reduced vagal reflexes (baroreflex sensitivity, BRS) and increased sudden and non-sudden cardiovascular mortality. Subsequently, evidence was provided that, also among chronic heart failure (HF) patients, depressed BRS is associated with a poorer outcome. At the same time, the encouraging results with experimental and clinical attempts to increase cardiac vagal activity led to a few experimental studies with vagal stimulation (VS) in different models for HF. We first performed a pilot study for VS in HF patients, and then in 2011 we reported the results of a small size multicentre clinical trial. The 6-month and 1-year results are encouraging for feasibility, safety and appear to have a favourable clinical effect. An ongoing large clinical trial will provide a definitive assessment of the efficacy and usefulness of chronic VS in HF patients.
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90
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Karayannis G, Giamouzis G, Cokkinos DV, Skoularigis J, Triposkiadis F. Diabetic cardiovascular autonomic neuropathy: clinical implications. Expert Rev Cardiovasc Ther 2013; 10:747-65. [PMID: 22894631 DOI: 10.1586/erc.12.53] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Diabetic cardiovascular autonomic neuropathy (DCAN), the impairment of the autonomic balance of the cardiovascular system in the setting of diabetes mellitus (DM), is frequently observed in both Type 1 and 2 DM, has detrimental effects on the quality of life and portends increased mortality. Clinical manifestations include: resting heart rate disorders, exercise intolerance, intraoperative cardiovascular lability, orthostatic alterations in heart rate and blood pressure, QT-interval prolongation, abnormal diurnal and nocturnal blood pressure variation, silent myocardial ischemia and diabetic cardiomyopathy. Clinical tests for autonomic nervous system evaluation, heart rate variability analysis, autonomic innervation imaging techniques, microneurography and baroreflex analysis are the main diagnostic tools for DCAN detection. Aldose reductase inhibitors and antioxidants may be helpful in DCAN therapy, but a regular, more generalized and multifactorial approach should be adopted with inclusion of lifestyle modifications, strict glycemic control and treatment of concomitant traditional cardiovascular risk factors, in order to achieve the best therapeutic results. In the present review, the authors provide aspects of DCAN pathophysiology, clinical presentation, diagnosis and an algorithm regarding the evaluation and management of DCAN in DM patients.
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Pop-Busui R, Cleary PA, Braffett BH, Martin CL, Herman WH, Low PA, Lima JAC, Bluemke DA. Association between cardiovascular autonomic neuropathy and left ventricular dysfunction: DCCT/EDIC study (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications). J Am Coll Cardiol 2012; 61:447-454. [PMID: 23265339 DOI: 10.1016/j.jacc.2012.10.028] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 10/23/2012] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The goal of these studies was to determine the association between cardiovascular autonomic neuropathy (CAN) and indices of left ventricle (LV) structure and function in patients with type 1 diabetes (T1DM) in the DCCT/EDIC (Diabetes Control and Complications Trial /Epidemiology of Diabetes Interventions and Complications) study. BACKGROUND The pathophysiology of LV dysfunction in T1DM remains unclear, especially when the LV ejection fraction (EF) is preserved. Whether CAN is associated with LV dysfunction is unclear. METHODS Indices of LV structure and function were obtained by cardiac magnetic resonance imaging (CMRI). CAN was assessed by cardiovascular reflex testing (R-R response to paced breathing, Valsalva ratio, and blood pressure response to standing). Analyses were performed in 966 DCCT/EDIC participants with valid CMRI and CAN data (mean age 51 years, 52% men, mean diabetes duration 29 years, and mean glycosylated hemoglobin 7.9%). RESULTS Systolic function (EF, end-systolic and end-diastolic volumes, stroke volumes) was not different in 371 subjects with CAN compared with 595 subjects without CAN. In multiple-adjusted analyses, participants with either abnormal R-R variation or a composite of abnormal R-R variation, abnormal Valsalva ratio, and postural blood pressure changes had significantly higher LV mass, mass-to-volume-ratio, and cardiac output compared with those with normal tests (p < 0.0001 for all). After further adjustment for traditional cardiovascular risk factors, subjects with abnormal R-R variation had higher LV mass and cardiac output compared with those with a normal R-R variation (p < 0.05). CONCLUSIONS In this large cohort of patients with T1DM, CAN is associated with increased LV mass and concentric remodeling as assessed by CMRI independent of age, sex, and other factors. (Diabetes Control and Complications Trial [DCCT]; NCT00360815) (Epidemiology of Diabetes Interventions and Complications [EDIC]; NCT00360893).
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Affiliation(s)
- Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan.
| | - Patricia A Cleary
- Biostatistics Center, George Washington University, Rockville, Maryland
| | | | - Catherine L Martin
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan
| | - William H Herman
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan
| | - Phillip A Low
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Joao A C Lima
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland
| | - David A Bluemke
- Radiology and Imaging Sciences, National Center for Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, Maryland
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Simula S, Laitinen T, Vanninen E, Pajunen P, Syvänne M, Hedman A, Hartikainen J. Baroreflex sensitivity in asymptomatic coronary atherosclerosis. Clin Physiol Funct Imaging 2012; 33:70-4. [PMID: 23216768 DOI: 10.1111/j.1475-097x.2012.01165.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 08/10/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Baroreflex sensitivity (BRS) reflects the effectiveness of cardiac parasympathetic regulation. BRS becomes impaired in stable coronary artery disease (CAD) and after myocardial infarction and carries prognostic information in these patients. Whether impaired BRS is found already in asymptomatic subjects, with subclinical coronary atherosclerosis, has remained elusive. METHODS The relationship between BRS and coronary atherosclerosis was evaluated in 31 subjects with high familial risk for CAD but without evidence of angina pectoris or myocardial ischaemia. Single photon emission tomography was performed with (99m) Tc-sestamibi to rule out myocardial perfusion defects at rest and during exercise. BRS was assessed by phenylephrine technique. Coronary atherosclerosis was analysed by quantitative coronary angiography (QCA). Percentage of diameter stenosis (PDS) was calculated separately for LAD, LCX, RCA coronary arteries as well as for proximal (PROX), middle (MID) and distal (DIST) coronary artery regions; and for all coronary artery regions (global PDS). RESULTS Baroreflex sensitivity averaged 7·8 ± 5·4 ms mmHg(-1) . BRS showed inverse correlation to PDS of the proximal coronary artery segments (r = -0·315; P<0·05) and with the most severe single coronary artery stenosis (r = -0·374; P<0·05). Five (16%) subjects had BRS ≤ 3 ms mmHg(-1) . They had more severe PDS of proximal coronary artery segment than subjects with BRS > 3 ms mmHg(-1) (24 ± 7% versus 13 ± 11%, P<0·05, respectively). CONCLUSIONS Impairment of BRS was found to be associated with the severity of subclinical coronary atherosclerosis in healthy asymptomatic subjects with familial risk of CAD. Asymptomatic subjects with severely blunted BRS may have advanced coronary atherosclerosis.
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Affiliation(s)
- Sakari Simula
- Department of Neurology, Mikkeli Central Hospital, Mikkeli, Finland
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Pop-Busui R. What do we know and we do not know about cardiovascular autonomic neuropathy in diabetes. J Cardiovasc Transl Res 2012; 5:463-78. [PMID: 22644723 DOI: 10.1007/s12265-012-9367-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 04/12/2012] [Indexed: 12/16/2022]
Abstract
Cardiovascular autonomic neuropathy (CAN) in diabetes is generally overlooked in practice, although awareness of its serious consequences is emerging. Challenges in understanding the complex, dynamic changes in the modulation of the sympathetic/parasympathetic systems' tone and their interactions with physiologic mechanisms regulating the control of heart rate, blood pressure, and other cardiovascular functions in the presence of acute hyper-or-hypoglycemic stress, other stressors or medication, and challenges with sensitive evaluations have contributed to lower CAN visibility compared with other diabetes complications. Yet, CAN is a significant cause of morbidity and mortality, due to a high-risk of cardiac arrhythmias, silent myocardial ischemia and sudden death. While striving for aggressive risk factor control in diabetes practice seemed intuitive, recent reports of major clinical trials undermine established thinking concerning glycemic control and cardiovascular risk. This review covers current understanding and gaps in that understanding of the clinical implications of CAN and prevention and treatment of CAN.
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Affiliation(s)
- Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
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Ueno LM, Drager LF, Rodrigues ACT, Rondon MUPB, Mathias W, Krieger EM, Júnior RF, Negrão CE, Lorenzi-Filho G. Day-night pattern of autonomic nervous system modulation in patients with heart failure with and without sleep apnea. Int J Cardiol 2012; 148:53-8. [PMID: 19923017 DOI: 10.1016/j.ijcard.2009.10.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Revised: 10/13/2009] [Accepted: 10/17/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Among patients with congestive heart failure (CHF) both obstructive and central sleep apnea (SA) are associated with increased sympathetic activity. However, the day-night pattern of cardiac autonomic nervous system modulation in CHF patients with and without sleep apnea is unknown. MATERIAL AND METHODS Twenty-five CHF patients underwent polysomnography with simultaneous beat-to-beat blood pressure (Portapres), respiration and electrocardiogram monitoring. Patients were divided according to the presence (SA, n=17) and absence of SA (NoSA, n=8). Power spectral analyses of heart rate variability (HRV) and spontaneous baroreflex sensitivity (BRS) were determined in periods with stable breathing while awake at 6 am, 10 am, 10 pm, as well as during stage 2 sleep. In addition, muscle sympathetic nerve activity (MSNA) was evaluated at 10 am. RESULTS RR variance, low-frequency (LF), high-frequency (HF) powers of HRV, and BRS were significantly lower in patients with SA compared with NoSA in all periods. HF power, a marker of vagal activity, increased during sleep in patients with NoSA but in contrast did not change across the 24-hour period in patients with SA. MSNA was significantly higher in patients with SA compared with NoSA. RR variance, LF and HF powers correlated inversely with simultaneous MSNA (r=-0.64, -0.61, and -0.61 respectively; P<0.01). CONCLUSIONS Patients with CHF and SA present a reduced and blunted cardiac autonomic modulation across the 24-hour period. These findings may help to explain the increased cardiovascular risk in patients with CHF and SA.
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Affiliation(s)
- Linda M Ueno
- School of Arts, Sciences and Humanities, University of São Paulo, São Paulo, Brazil.
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Bivariate phase-rectified signal averaging for assessment of spontaneous baroreflex sensitivity: normalization of the results. J Electrocardiol 2012; 45:77-81. [DOI: 10.1016/j.jelectrocard.2011.07.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Indexed: 11/21/2022]
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Carvalho TD, Mara LSD, Ulbrich A. Reposição hormonal e exercício físico no tratamento da insuficiência cardíaca: revisão sistemática. REV BRAS MED ESPORTE 2011. [DOI: 10.1590/s1517-86922011000600013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
FUNDAMENTAÇÃO: A despeito do pleno uso da terapia farmacológica e não farmacológica, persistem as expressivas morbidade e mortalidade decorrentes da insuficiência cardíaca (IC). No contexto terapêutico é relevante a inibição das inadequadas adaptações neuro-hormonais e metabólicas, sendo bem conhecida a deficiência anabólica que se instala na IC. Mas somente recentemente surgiram alguns estudos sobre os benefícios que adviriam da terapia de reposição ou suplementação de testosterona (TRT). OBJETIVOS: Pesquisar estudos que abordem a TRT na insuficiência cardíaca (IC), em especial os desenvolvidos no cenário ideal de tratamento clínico, que inclui programa de exercício físico. MÉTODOS: Foram consultadas as bases de dados SciELO e PubMed, a base de dados Cochrane de Revisões Sistemáticas e o Registro de Ensaios Controlados da Colaboração Cochrane. RESULTADOS: Os poucos estudos sobre TRT em pacientes com IC evidenciaram melhora da função hemodinâmica, da resistência à insulina, da capacidade funcional e das respostas neuro-hormonal e neuromuscular, evidenciaram as controvérsias quanto à influência sobre o perfil inflamatório, e não constataram mudanças na função e na estrutura cardiovascular central. Entretanto, não foi encontrado nenhum estudo sobre TRT concomitante ao programa de exercícios físicos. CONCLUSÕES: O estágio atual de conhecimento, embora baseado em poucos estudos, permite considerar a TRT no tratamento de pacientes com IC. Não está bem definida a forma ideal da TRT, no que diz respeito à duração do tratamento, critérios de inclusão e exclusão etc. Existe uma grande lacuna na literatura, chamando atenção à inexistência de estudos sobre a TRT concomitante ao tratamento clínico pleno, que inclui um programa de exercícios físicos.
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Affiliation(s)
- Tales de Carvalho
- Universidade do Estado de Santa Catarina; Clínica de Prevenção e Reabilitação Cardiosport
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Truijen J, de Peuter OR, Kim YS, van den Bogaard B, Kok WE, Kamphuisen PW, van Lieshout JJ. β2-adrenergic receptor genotype influences the effect of nonselective vs. selective β-blockade on baroreflex function in chronic heart failure. Int J Cardiol 2011; 153:230-2. [PMID: 21996419 DOI: 10.1016/j.ijcard.2011.09.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Accepted: 09/17/2011] [Indexed: 10/16/2022]
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Gademan MG, Sun Y, Han L, Valk VJ, Schalij MJ, van Exel HJ, Lucas CM, Maan AC, Verwey HF, van de Vooren H, Pinna GD, Maestri R, La Rovere MT, van der Wall EE, Swenne CA. Rehabilitation: Periodic somatosensory stimulation increases arterial baroreflex sensitivity in chronic heart failure patients. Int J Cardiol 2011; 152:237-41. [DOI: 10.1016/j.ijcard.2010.07.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Revised: 06/17/2010] [Accepted: 07/04/2010] [Indexed: 11/25/2022]
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Bernardi L, Spallone V, Stevens M, Hilsted J, Frontoni S, Pop-Busui R, Ziegler D, Kempler P, Freeman R, Low P, Tesfaye S, Valensi P. Methods of investigation for cardiac autonomic dysfunction in human research studies. Diabetes Metab Res Rev 2011; 27:654-64. [PMID: 21695761 DOI: 10.1002/dmrr.1224] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 06/06/2011] [Indexed: 12/16/2022]
Abstract
This consensus document provides evidence-based guidelines regarding the evaluation of diabetic cardiovascular autonomic neuropathy (CAN) for human research studies; the guidelines are the result of the work of the CAN Subcommittee of the Toronto Diabetic Neuropathy Expert Group. The subcommittee critically reviewed the limitations and strengths of the available diagnostic approaches for CAN and the need for developing new tests for autonomic function. It was concluded that the most sensitive and specific approaches currently available to evaluate CAN in clinical research are: (1) heart rate variability, (2) baroreflex sensitivity, (3) muscle sympathetic nerve activity, (4) plasma catecholamines, and (5) heart sympathetic imaging. It was also recommended that efforts should be undertaken to develop new non-invasive and safe CAN tests to be used in clinical research, with higher sensitivity and specificity, for studying the pathophysiology of CAN and evaluating new therapeutic approaches.
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Affiliation(s)
- Luciano Bernardi
- Department of Internal Medicine, IRCCS S.Matteo and University of Pavia, Pavia, Italy.
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Clinical and haemodynamic correlates of heart rate turbulence as a non-invasive index of baroreflex sensitivity in chronic heart failure. Clin Sci (Lond) 2011; 121:279-84. [PMID: 21526982 PMCID: PMC3193846 DOI: 10.1042/cs20110063] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
HRT (heart rate turbulence), describing the heart rate changes following a premature ventricular contraction, has been regarded as an indirect index of baroreflex function. However, limited data are available on its relationship with invasive assessment by phenylephrine injection (Phe-slope). In the present study, we therefore compared these methodologies in a series of patients with HF (heart failure) in which both measures together with clinical and haemodynamic data were available. HRT parameters [TO (turbulence onset) and TS (turbulence slope)] were measured from 24-h Holter recordings obtained within 1 week of baroreflex sensitivity assessment and right heart haemodynamic evaluation (Swan-Ganz catheter). HRT was computable in 135 out of 157 (86%) patients who had both a phenylephrine test and haemodynamic evaluation. TO and TS significantly correlated with Phe-slope (r=−0.39, P<0.0001 and r=0.66, P<0.0001 respectively). Age, baseline heart rate, LVEF (left ventricular ejection fraction), PCP (pulmonary capillary pressure), CI (cardiac index) and sodium were significant and independent predictors of Phe-slope, accounting for 51% of its variability. Similarly, age, baseline heart rate and PCP, and NYHA (New York Heart Association) classes III–IV were independent predictors for TS and explained 48% of its variability, whereas only CI and LVEF were found to be significantly related to TO and explained a very limited proportion (20%) of the variability. In conclusion, these results suggest that HRT may be regarded as a surrogate measure of baroreflex sensitivity in clinical and prognostic evaluation in patients with HF.
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