Age and gender dependency of baroreflex sensitivity in healthy subjects

The concentration-dependent effects of general anesthesia on spontaneous baroreflex indices and their correlations with pharmacological gains

Beat-to-beat assessment of spontaneously occurring fluctuations in heart rate and arterial blood pressure allows noninvasive determination of cardiovagal function, but little is known regarding the effects of general anesthesia on spontaneous baroreflex (SBR) indices. We examined (a) concentration-dependent effects of sevoflurane on SBR indices, heart rate variability (HRV), and blood pressure variability and (b) correlation and agreement between pharmacological baroreflex gains and SBR indices during sevoflurane anesthesia. Continuous electrocardiogram and invasive arterial blood pressure were monitored in nine healthy volunteers before, during, and for 3 h after sevoflurane anesthesia, during which end-tidal sevoflurane was maintained at 0.7%, 1.4%, and 2.0% in random sequences. We derived three SBR indices (sequence method, alpha-index, and low-frequency transfer function) and compared them with pressor and depressor test gains by the pharmacological method. HRV and blood pressure variability were analyzed at a fixed respiratory rate (12 breaths/min) in awake and anesthetized conditions. Except for low-frequency transfer function, SBR indices were depressed by sevoflurane and remained depressed for 30 min after emergence from anesthesia, compared with the conscious baseline value. Spontaneous sequence indices and high- and low-frequency powers of HRV demonstrated concentration-dependent depression. Pharmacological gains and SBR indices during anesthesia generally correlated well, but Bland-Altman analysis revealed that SBR indices had limits of agreement as large as the baroreflex gain itself. These data suggest that spontaneous indices are inadequate estimates of, and are inconsistent with, the pharmacological baroreflex gain during sevoflurane anesthesia.

Interval training in elderly men increases both heart rate variability and baroreflex activity

AIMS

Autonomic nervous system activity decreases continuously with age and appears to be a powerful predictor of disease and death. Attempts are thus made to reactivate autonomic drive with the intent of improving health.

METHODS

We assessed maximal oxygen consumption (VO2max), autonomic nervous system activity by heart rate variability (HRV) analysis and spontaneous cardiac baroreflex activity (SBR) in eleven elderly men (73.5+/-4.2 years) before and after a 14-week program of intensive cycloergometer interval training. The standard HRV indices were calculated using time domain (mean RR, PNN50, RMSSD, SDNN, SDANN and SDNNIDX), and Fourier transform (total power, ULF,VLF, LF, LFnu, HF, HFnu and LF/HF) analyses of 24-hour, daytime and nighttime Holter recordings. The SBR was calculated from 15-minute recordings of spontaneous blood pressure and RR interval variations using the sequence (slope, slSBR) and cross-spectral (alphaSBRHF and alphaSBRLF) methods.

RESULTS

After the training period,VO2max increased by 18.6 % (26.8+/-4.4 to 31.8+/-5.2 ml.kg(-1).min(-1), p<0.01). The nocturnal parasympathetic indices of HRV increased (PNN50: 3.05+/-2.21 to 5.00+/-2.87%, RMSSD: 29.1+/-7.6 to 38.8+/-10.9 ms, HF: 117+/-54 to 194+/-116 ms2/Hz, all p<0.05) as did the SBR indices (slSBR: 7.0+/-1.8 to 9.8+/-2.1 ms.mmHg(-1), p<0.01; alphaSBRHF: 6.9+/-2.2 to 10.5+/-3.7 ms.mmHg(-1), p<0.05; alphaSBRLF: 5.3+/-2.3 to 6.9+/-3.1 ms.mmHg(-1), p=0.22).

CONCLUSION

Intensive endurance training in elderly men enhanced parasympathetic parameters of HRV and, interestingly, of SBR. Physiological mechanisms and long-term clinical effects on health status should be further investigated.

Effect of testosterone replacement or duration of castration on baroreflex bradycardia in conscious rats

Background

In this study, we tested the hypothesis that 17β-estradiol contributes to testosterone-mediated restoration of baroreflex-mediated bradycardia in short-term (3 weeks) castrated rats. Further, a reported increase in serum testosterone after long-term (6 weeks) castration constituted a basis for testing the hypothesis that a spontaneous increase in serum testosterone or androstenedione in this model causes a commensurate increase in baroreflex-mediated bradycardia.

Results

Testosterone (1 week) replacement enhanced baroreflex-mediated bradycardia in short-term castrated rats without changing 17β-estradiol level. A spontaneous recovery of baroreflex-mediated bradycardia occurred following long-term castration, although circulating testosterone and androstenedione remained suppressed.

Conclusion

The data suggest: 1) 17β-Estradiol does not contribute to testosterone restoration of the baroreflex-mediated bradycardia in short-term castrated rats. 2) The long-term modulation of baroreflex-mediated bradycardia occurs independent of androgens, or the baroreflex mechanism may become adapted to low levels of circulating androgens.

Role of estrogen in nitric oxide- and prostaglandin-dependent modulation of vascular conductance during treadmill locomotion in rats

Endothelial production of nitric oxide (NO) and prostaglandins (PG) may be greater in females than in males, increasing vasodilatory responses in females. Does sex influence the cardiovascular responses to dynamic exercise through estrogen-dependent modulation of NO and PG vasodilatory pathways? After the administration of hexamethonium, we assessed terminal aortic blood flow (TAQ), mean arterial pressure (MAP), and hindlimb vascular conductance (VC) in four groups of rats (6 males, 5 females, 5 ovariectomized females, and 6 ovariectomized females with chronic estrogen supplementation) during graded mild-intensity treadmill locomotion (5-15 m/min, 0 degrees grade, 2 min). All rats repeated exercise after cyclooxygenase inhibition (indomethacin) and then again after NO synthase inhibition (nitro-l-arginine methyl ester) to examine the roles of NO and PG. Regression analysis was used to determine the influence of sex and plasma 17beta-estradiol on TAQ, MAP, and VC. The analysis revealed that female sex did not influence TAQ but reduced MAP and increased VC at rest and during exercise conditions. Plasma 17beta-estradiol (measured by immunoassay) significantly decreased MAP and increased TAQ and VC, irrespective of sex. Cyclooxygenase inhibition eliminated the significant association between MAP and estrogen, suggesting that estrogenic modulation occurred through PG-dependent processes. In contrast, the significant influence of estrogen on TAQ and VC was eliminated after NO synthase inhibition. On the basis of the overall findings of this study, estrogen influenced the vascular responses to dynamic exercise through PG- and NO-dependent pathways, but this occurred independent of sex.

How Does Deep Breathing Affect Office Blood Pressure and Pulse Rate?

Little is known about the relation between deep breathing (DB) and blood pressure (BP). We studied the relationship between DB and BP in a large Japanese population. The subjects were recruited from randomly selected clinics and hospitals that were members of a medical association, and divided into two groups. In one group, BP was measured before and after taking 6 DB over a period of 30 s, and in the other group BP was measured before and after a 30-s rest in a sitting position without DB. Before these measurements, all patients rested 10 min or more in the waiting room and another 2 min or more in the doctor's office. Analyses were performed on data collected from 21,563 subjects. In both groups, systolic blood pressure (SBP), diastolic blood pressure (DBP) and pulse rate (PR) were significantly reduced after DB or a 30-s rest compared with the baseline measurements (p < 0.001). SBP reductions were greater in the DB group than in the 30-s rest group (normotensives: -6.4 +/- 8.3 vs. -3.0 +/- 7.4 mmHg, p < 0.001; untreated hypertensives: -9.6 +/- 10.2 vs. -5.9 +/- 9.1 mmHg, p < 0.001; treated hypertensives: -8.3 +/- 9.6 vs. -4.4 +/- 8.3 mmHg, p < 0.001). Greater BP reductions were found in patients with a higher baseline BP in both the DB and 30-s rest groups. In conclusion, the present study showed a baseline BP-dependent BP reduction by DB, suggesting that BP measurement should be done without DB in the office because DB lowers BP.

Maturation of cardiovagal autonomic function from childhood to young adult age

BACKGROUND

Cardiovagal autonomic control declines with age in adult subjects, which is related in part to increasing stiffness of the barosensory vessel wall. It is not known, however, whether autonomic function changes with age in children.

METHODS AND RESULTS

We studied 137 healthy subjects divided into 4 age groups: group 1, 7 to 14 years; group 2, 11 to 14 years; group 3, 15 to 18 years; and group 4, 19 to 22 years. Brachial artery pressure was measured by sphygmomanometry and continuous radial artery pressure and carotid artery pulse pressure (DeltaP) by applanation tonometry. The R-R interval was derived from the ECG. Autonomic function was assessed by spontaneous sequence and frequency-domain indices, which indicate the extent of coupling between fluctuations in heart rate and systolic pressure. Carotid artery diastolic diameter (DD) and pulsatile distension (DeltaD) were measured by echo wall tracking; carotid compliance coefficient (CC) was defined as DeltaD/DeltaP and distensibility coefficient as 2DeltaD/DD . DeltaP. From group 1 to group 3, spontaneous indices increased significantly (18.1+/-1.7 versus 33.3+/-4.0; 14.4+/-1.1 versus 25.5+/-22; 12.9+/-1.1 versus 20.8+/-2.0; and 6.4+/-0.6 versus 16.2+/-1.4 ms/mm Hg [mean+/-SEM] for Seq+, Seq-, LFalpha, and LF(gain), respectively), with no significant changes afterward. CC and DC were inversely proportional to age (r=-0.49 and -0.62, respectively, P<0.001). The efficiency of neural integrative mechanisms, estimated as the ratio of spontaneous indices and CC, more than doubled from group 1 to group 3. Spontaneous indices were linearly related to measures of cardiac vagal activity.

CONCLUSIONS

The increase in spontaneous indices from early childhood to adolescence, despite gradual stiffening of the carotid artery, may indicate improved cardiovagal autonomic function, which is most likely a result of maturation of neural mechanisms, attaining peak level at adolescence.

Relations between insulin sensitivity, fitness and autonomic cardiac regulation in healthy, young men

OBJECTIVES

We hypothesized that insulin sensitivity and vagal cardiac control are independently related in young men after adjustment for fitness and other confounding variables.

DESIGN

Male volunteers aged 21-24 years with high (borderline hypertensive; n = 20) and low-normal (normotensive; n = 21) screening blood pressure (BP) were studied cross-sectionally.

METHODS

Mean R-R interval (RR) and heart rate variability (HRV) were computed from 30-min ECGs, and baroreflex sensitivity (BRS) and latency (phase shift) from 15-min beat-to-beat finger blood pressure (BP) and heart rate recordings. Insulin-adjusted glucose disposal rate (GDR/I) was measured with a 90-min hyperinsulinaemic glucose clamp and fitness by peak oxygen uptake (VO2peak) during a treadmill test.

RESULTS

HRV, baroreflex function, GDR/I, and VO2peak did not differ between the groups. GDR/I correlated positively with time and frequency domain HRV, including high-frequency power (HF) (r = 0.40, P = 0.01) and root-mean squared successive differences (RMSSD) (r = 0.43, P = 0.005), but not BRS or phase shift. GDR/I correlated with VO2peak (r = 0.70, P < 0.0001) and was explained (R = 0.56) by VO2peak (beta = 0.57, P < 0.0001) and RR (beta = 0.29, P = 0.03), independently of HRV and measures of obesity. Conversely, RR (beta = 0.55, P = 0.0004) and HRV, including HF (beta = 0.44, P = 0.006) and RMSSD (beta = 0.46, P = 0.004) were explained by GDR/I, independently of VO2peak.

CONCLUSIONS

Insulin sensitivity and autonomic cardiac control are related independently of physical fitness in young men.

Effects of nitrous oxide on baroreflex gain and heart rate variability

BACKGROUND

Spontaneous baroreflex method allows continuous assessment of cardiovagal reflex function within resting blood pressure, but effects of nitrous oxide, per se, on the spontaneous baroreflex response remain unknown. This study was designed to determine the effects of nitrous oxide on spontaneous baroreflex gain and heart rate variability assessed by power spectral analysis in humans.

METHODS

Electrocardiogram and non-invasive blood pressure were monitored in 12 healthy volunteers before and during a 15-min inhalation of 67% nitrous oxide in oxygen, while spontaneous respiration was maintained. Least-square regression analysis relating R-R interval and systolic blood pressure was performed to obtain spontaneous baroreflex gains. Heart rate variability was analyzed using fast Fourier transformation.

RESULTS

Nitrous oxide did not significantly alter spontaneous baroreflex gains, which correlated well with high-frequency power (0.15-0.4 Hz) of heart rate variability before and during nitrous oxide inhalation.

CONCLUSION

Our results indicate that (a) cardiovagal reflex response is not affected by nitrous oxide, per se, and (b) spontaneous baroreflex responses closely reflect beat-to-beat dynamic modulation of the cardiac cycle by the parasympathetic nervous system during inhalation of 67% nitrous oxide.

Cardiovascular responses to orthostatic and other stressors in men and women are independent of sex

1. Cardiovascular responses to the stress of orthostasis, forearm (FA) ischaemia (reactive hyperaemia) and FA exercise (postexercise hyperaemia) are well described. Although sex differences in responses to orthostatic stress have been reported, few studies have examined the impact of sex on reactive hyperaemia and none has commented with regard to postexercise hyperaemia. 2. We investigated 11 men (mean (+/-SEM) age 18.5 +/- 0.3 years) and 10 women (18.8 +/- 0.8 years), all of whom were sedentary, with women being studied in the mid-follicular phase of their menstrual cycle. We measured blood pressure (BP), heart rate (HR) and forearm blood flow (FBF) in response to a fixed sequence of orthostatic, ischaemic and exercise stressors. 3. Orthostatic stress (10 min at -50 mmHg lower body negative pressure; LBNP) induced presyncopal signs in one man and three women. In all other subjects, BP was well maintained, with FBF decreasing and HR increasing similarly in both sexes. The tachycardia was earlier in onset in men and reached significantly higher absolute levels in women during the final 5 min of LBNP, but the percentage changes and integrated responses of both HR and FBF were not different between sexes. 4. The increases in FBF following either 10 min FA ischaemia or 10 min FA exercise were similar in men and women in terms of peak blood flow, percentage change, rate of recovery and total blood flow response. 5. In conclusion, although women were less tolerant of orthostatic stress than men, the cardiovascular responses to this and the other stressors appeared essentially independent of sex.

The Effects of Cervical and Lumbar Epidural Anesthesia on Heart Rate Variability and Spontaneous Sequence Baroreflex Sensitivity

A high level of neuroaxial block may produce profound bradycardia and hypotension, possibly as a result of an imbalance between sympathetic and parasympathetic control of heart rate. We designed this study to test the hypothesis that cervical epidural anesthesia would increase the high-frequency (HF) component of heart rate variability (HRV) as a result of cardiac sympathectomy, whereas lumbar epidural anesthesia would cause sympathetic predominance. HRV and spontaneous baroreflex (SBR) sensitivity were assessed before and after cervical and lumbar epidural anesthesia by using plain 1.5% lidocaine (median upper/lower sensory block: C3/T8 for cervical and T11/L5 for lumbar) in healthy patients (n = 10 each). Electrocardiogram and noninvasive beat-to-beat arterial blood pressure were monitored. HRV was analyzed by using fast Fourier transformation. Least-square regression analysis relating R-R interval and systolic blood pressure during spontaneous fluctuation was performed to obtain SBR sensitivities. Cervical epidural group patients were significantly older (P < 0.01) and taller (P < 0.01). Cervical epidural anesthesia attenuated HF (0.15-0.4 Hz) and low-frequency (0.04-0.15 Hz) power of HRV with concomitant reductions in up- and down-sequence SBR sensitivities, suggesting decreased vagal modulation of heart rate. Lumbar epidural anesthesia resulted in a significant increase in the low-frequency/HF ratio of HRV and unchanged SBR indices, suggesting sympathetic predominance. HF power correlated well with SBR sensitivities under most of our study conditions. Respiratory rates and Paco(2) were unchanged by either epidural technique. Our results indicate that cervical, but not lumbar, epidural anesthesia depresses phasic and tonic dynamic modulation of the cardiac cycle by the vagal nerve in conscious humans.

Heart rate variability following coronary artery bypass graft surgery as a function of recovery time, posture, and exercise

This study examined the claim made by Niemela et al. (1992) that the decline in heart rate variability after coronary artery bypass graft surgery is irreversible. We tested six women and 16 men six and 12 weeks postoperative in three postures: in the supine position, in the standing position, and during low-intensity steady-state exercise. Beat-by-beat arterial blood pressure and electrocardiographic R–R interval data were collected continuously for 10 min in each condition. R–R interval data were analyzed with spectral analysis; baroreflex data were analyzed using the sequence method. Our results show that the indices of parasympathetic modulation improved over time, as seen by an | increased spontaneous baroreflex sensitivity and parasympathetic indicator, that both indices were affected by posture, and that spontaneous baroreflex sensitivity was also affected by low-intensity exercise. The effects of posture are consistent with attenuated responses of healthy older subjects to orthostatic stress. Similarly, the effects of low-intensity exercise are consistent with findings in healthy subjects. We found that spontaneous baroreflex sensitivity declined during exercise, whereas, in healthy subjects, this is maintained during low-intensity steady-state exercise. Our results of significant functional recovery between six and 12 weeks postoperative suggest that at least some of the autonomic dysfunction following surgery is temporary. Previously, no such duration of study has lasted longer than four or six weeks following cardiac surgery, which may not have been long enough to show significant functional restoration in heart rate variability.Key words: heart rate variability, spontaneous baroreflex sensitivity, CABG surgery, posture, exercise.

Age dependency of cardiovascular autonomic responses to head-up tilt in healthy subjects

In elderly subjects, heart rate responses to postural change are attenuated, whereas their vascular responses are augmented. Altered strategy in maintaining blood pressure homeostasis during upright position may result from various cardiovascular changes, including age-related cardiovascular autonomic dysfunction. This exploratory study was conducted to evaluate impact of age on cardiovascular autonomic responses to head-up tilt (HUT) in healthy subjects covering a wide age range. The study population consisted of 63 healthy, normal-weight, nonsmoking subjects aged 23–77 yr. Five-minute electrocardiogram and finger blood pressure recordings were performed in the supine position and in the upright position 5 min after 70° HUT. Stroke volume was assessed from noninvasive blood pressure signals by the arterial pulse contour method. Heart rate variability (HRV) and systolic blood pressure variability (SBPV) were analyzed by using spectral analysis, and baroreflex sensitivity (BRS) was assessed by using sequence and cross-spectral methods. Cardiovascular autonomic activation during HUT consisted of decreases in HRV and BRS and an increase in SBPV. These changes became attenuated with aging. Age correlated significantly with amplitude of HUT-stimulated response of the high-frequency component ( r = -0.61, P < 0.001) and the ratio of low-frequency to high-frequency power of HRV ( r = -0.31, P < 0.05) and indexes of BRS (local BRS: r = -0.62, P < 0.001; cross-spectral baroreflex sensitivity in the low-frequency range: r = -0.38, P < 0.01). Blood pressure in the upright position was maintained well irrespective of age. However, the HUT-induced increase in heart rate was more pronounced in the younger subjects, whereas the increase in peripheral resistance was predominantly observed in the older subjects. Thus it is likely that whereas the dynamic capacity of cardiac autonomic regulation decreases, vascular responses related to vasoactive mechanisms and vascular sympathetic regulation become augmented with increasing age.

Effect of lignocaine injection in carotid sinus on baroreceptor sensitivity during carotid endarterectomy

OBJECTIVES

This study was undertaken to test the hypothesis that there is a neural basis for baroreceptor deterioration during carotid endarterectomy (CEA), by investigating intraoperative hemodynamic changes induced by intraluminal carotid stretch stimulation, before and after application of local anesthetic to the adventitial layer of the carotid sinus region.

METHODS

This was a prospective study of 20 patients undergoing elective CEA. During CEA, before removal of the atheroma, intraluminal stretch simulation of the carotid baroreceptors (rub test) was performed before and after injection of 1% lignocaine into adventitial tissue of the artery in the region of the carotid sinus. Continuous measurements of mean arterial blood pressure (MAP), electrocardiographic r-r intervals (R-R), heart rate, cardiac vagal tone, and carotid sinus baroreflex were recorded to determine alterations in baroreceptor function.

RESULTS

Rub test before injection of lignocaine was associated with a decrease in MAP and heart rate and an increase in R-R, cardiac vagal tone, and carotid baroreflex response, indicating a functioning baroreflex. After lignocaine injection and repetition of the rub test, no significant change was seen in MAP, heart rate, R-R, cardiac vagal tone, or carotid baroreflex response, indicating a nonfunctioning baroreflex. Comparing the peak responses to the rub test stimulus before and after lignocaine injection showed significant differences for all variables (P <.05), with carotid baroreflex response and heart rate being highly significant (P <.0005).

CONCLUSIONS

The baroreflex response to intraluminal stretch stimulation of the carotid sinus area is operational in patients undergoing CEA, and this response is abolished by infiltration of local anesthetic into the periadventitial tissue around the carotid sinus.

Oxidative stress and baroreflex sensitivity in healthy subjects and patients with mild-to-moderate hypertension

Decreased baroreflex sensitivity (BRS) is a prognostic marker in essential hypertension. Animal experiments suggest that decreased BRS is related to increased oxidative stress. Our study was aimed at testing whether oxidative stress, estimated by isoprostane 15-F(2t)-IsoP urinary levels, is correlated to BRS variation in healthy subjects as well as in patients suffering from essential hypertension. Urinary 15-F(2t)-IsoP levels and BRS were evaluated in two groups of subjects: healthy volunteers (n=64) and patients with untreated mild-to-moderate hypertension (n=33). Data were analysed in 61 and 31 subjects, respectively, BRS analysis being impossible in three and two subjects, respectively. 15-F(2t)-IsoP levels were measured using gas chromatography/mass spectrometry. BRS was measured using the sequence method [PS+/RR+ and PS-/RR-] and crossspectral analysis (CSP) (MF gain) at rest, lying down. No significant correlation was found between basal urinary 15-F(2t)-IsoP levels and BRS (sequence method and CSP) in either healthy controls or hypertensive patients. Our study shows that oxidative stress is not involved in interindividual variations of BRS in healthy subjects and patients suffering from mild-to-moderate hypertensionJournal of Human Hypertension (2004) 18, 517-521. doi:10.1038/sj.jhh.1001684 Published online 12 February 2004

Heart rate variability in long-term risk assessment in middle-aged women with coronary heart disease: The Stockholm Female Coronary Risk Study

OBJECTIVES

Low heart rate variability (HRV) is associated with poor prognosis after acute coronary events in men. In women, the prognostic impact is not well documented. The objective of this study was to assess the long-term predictive power of HRV on mortality amongst middle-aged women with coronary heart disease (CHD). DESIGN, SETTINGS AND SUBJECTS: Consecutive women below 65 years hospitalized for an acute coronary syndrome during a 3-year period in Stockholm were examined for cardiovascular prognostic factors including HRV, and followed for a median of 9 years. An ambulatory 24-h electrocardiograph was recorded during normal activities, 3-6 months after hospitalization. SDNN index (mean of the standard deviations of all normal to normal intervals for all 5-min segments of the entire recording) and the following frequency domain parameters were assessed: total power, high-frequency (HF) power, low-frequency (LF) power, very-low frequency (VLF) power and LF/HF ratio. Using Cox proportional hazards regression, the hazard ratios (HR) for each 25% decrease of the HRV parameters were assessed.

RESULTS

After controlling for the independent, significant predictors of mortality amongst the clinical variables, the following HRV parameters were found to be significant predictors of all-cause mortality: SDNN index [HR 1.56, 95% confidence intervals (CI) 1.19-2.05], total power (HR 1.21, 95% CI 1.08-1.35), VLF power (HR 1.22, 95% CI 1.09-1.36), LF power (HR 1.18 95%, CI 1.07-1.30) and HF power (HR 1.18, 95% CI 1.05-1.33). The results were essentially the same when cardiovascular mortality was used as end-points. The HRV parameters were stronger predictors of mortality in the first 5 years following the index event.

CONCLUSION

Low HRV is a predictor of long-term mortality amongst middle-aged women with CHD when measured 3-6 months after hospitalization for an acute coronary syndrome, even after controlling for established clinical prognostic markers.

Interactions between grapefruit juice and cardiovascular drugs

Grapefruit juice can alter oral drug pharmacokinetics by different mechanisms. Irreversible inactivation of intestinal cytochrome P450 (CYP) 3A4 is produced by commercial grapefruit juice given as a single normal amount (e.g. 200-300 mL) or by whole fresh fruit segments. As a result, presystemic metabolism is reduced and oral drug bioavailability increased. Enhanced oral drug bioavailability can occur 24 hours after juice consumption. Inhibition of P-glycoprotein (P-gp) is a possible mechanism that increases oral drug bioavailability by reducing intestinal and/or hepatic efflux transport. Recently, inhibition of organic anion transporting polypeptides by grapefruit juice was observed in vitro; intestinal uptake transport appeared decreased as oral drug bioavailability was reduced. Numerous medications used in the prevention or treatment of coronary artery disease and its complications have been observed or are predicted to interact with grapefruit juice. Such interactions may increase the risk of rhabdomyolysis when dyslipidemia is treated with the HMG-CoA reductase inhibitors atorvastatin, lovastatin, or simvastatin. Potential alternative agents are pravastatin, fluvastatin, or rosuvastatin. Such interactions might also cause excessive vasodilatation when hypertension is managed with the dihydropyridines felodipine, nicardipine, nifedipine, nisoldipine, or nitrendipine. An alternative agent could be amlodipine. In contrast, the therapeutic effect of the angiotensin II type 1 receptor antagonist losartan may be reduced by grapefruit juice. Grapefruit juice interacting with the antidiabetic agent repaglinide may cause hypoglycemia, and interaction with the appetite suppressant sibutramine may cause elevated BP and HR. In angina pectoris, administration of grapefruit juice could result in atrioventricular conduction disorders with verapamil or attenuated antiplatelet activity with clopidrogel. Grapefruit juice may enhance drug toxicity for antiarrhythmic agents such as amiodarone, quinidine, disopyramide, or propafenone, and for the congestive heart failure drug, carvediol. Some drugs for the treatment of peripheral or central vascular disease also have the potential to interact with grapefruit juice. Interaction with sildenafil, tadalafil, or vardenafil for erectile dysfunction, may cause serious systemic vasodilatation especially when combined with a nitrate. Interaction between ergotamine for migraine and grapefruit juice may cause gangrene or stroke. In stroke, interaction with nimodipine may cause systemic hypotension. If a drug has low inherent oral bioavailability from presystemic metabolism by CYP3A4 or efflux transport by P-gp and the potential to produce serious overdose toxicity, avoidance of grapefruit juice entirely during pharmacotherapy appears mandatory. Although altered drug response is variable among individuals, the outcome is difficult to predict and avoiding the combination will guarantee toxicity is prevented. The elderly are at particular risk, as they are often prescribed medications and frequently consume grapefruit juice.

Influence of menstrual cycle on baroreflex control of heart rate: comparison with male volunteers

This study was designed to determine baroreflex control of heart rate (HR) to hypotensive and hypertensive stimuli during the early follicular (EF), preovulation (PreOV), and midluteal (ML) phases of the menstrual cycle and to test the hypothesis that cardiovagal reflex responses to hypertensive stimuli would be altered depending on the plasma estradiol levels in healthy women. In addition, these results were compared with those of male volunteers. Fifteen healthy women with regular menstrual cycles and thirteen male volunteers were recruited. Cardiovagal baroreflex sensitivity was defined as the slope of the linear portion relating R-R interval and systolic blood pressure triggered by bolus injections of nitroprusside and phenylephrine, from the overshoot phase of the Valsalva maneuver, and during spontaneous fluctuations. Three measurements were averaged in each test as a representative at each phase, and the order of phases was counterbalanced. Baroreflex sensitivities by the phenylephrine pressor test and Valsalva maneuver during the PreOV phase were significantly greater than those during the EF and ML phases but were similar to those of men. Depressor test sensitivities by nitroprusside and down-sequence spontaneous cardiac baroreflex sensitivity during the EF phase were significantly greater than those of the ML phase and of men. Significant correlations were observed between plasma estradiol concentrations and baroreflex sensitivities assessed by phenylephrine and the Valsalva maneuver. Our results indicate that baroreflex control of HR is altered during the regular menstrual cycle, and estradiol appears to exert cardiovagal modulation in healthy women.

Spontaneous baroreflex sensitivity after coronary artery bypass graft surgery as a function of gender and age

The effects of coronary artery bypass graft (CABG) surgery on spontaneous baroreflex (SBR) sensitivity and heart rate variability were examined in 11 women and 23 men preoperatively and 5 days postoperatively. Electrocardiograph R–R interval and beat-by-beat arterial blood pressure data were collected continuously for 20 min in the supine and standing postures. Coarse graining spectral analysis was performed on the heart rate variability data. Spontaneous baroreflex sensitivity declined after surgery with a differential influence of gender. Men showed a decrease in SBR slope following surgery, with a greater decrease in the standing posture; the parasympathetic (PNS) indicator was lower postoperatively and in the standing posture; the reduction in low-frequency (LF) power was greater for the younger men. In women, the PNS indicator was lower in the standing posture. Both men and women showed a decrease in high-frequency power following CABG surgery, which decreased the sensitivity of the short-term cardiac control mechanisms that modulate heart rate, with the greater effects occurring in men. The reduction in SBR sensitivity indicates that the ability of the cardiovascular system to respond rapidly to changing stimuli was compromised. The decline in the PNS indicator implies that patients were vulnerable to the risks of myocardial ischemia, sympathetically mediated cardiac dysrhythmias, and sudden cardiac death.Key words: spectral analysis, spontaneous baroreflex sensitivity, CABG surgery, gender, age, posture.

Reflex cardiac activity in ischemia and reperfusion: heart rate turbulence in patients undergoing direct percutaneous coronary intervention for acute myocardial infarction

BACKGROUND

Abnormal heart rate turbulence (HRT) is associated with an increased risk of mortality in the chronic phase of myocardial infarction (MI) in the prethrombolytic and thrombolytic eras. However, the impact of direct percutaneous coronary intervention (PCI) on HRT in the acute phase of MI and its association to the epicardial infarct-related arterial flow has not been examined.

METHODS AND RESULTS

We investigated HRT in 126 patients undergoing direct PCI for a first MI. Turbulence onset and turbulence slope were determined before reperfusion, during the initial 2 hours after reperfusion, and during hours 6 to 24 after reperfusion. HRT significantly improved after PCI. There were no significant differences in baseline clinical characteristics between Thrombolysis in Myocardial Infarction Trial classification (TIMI) 2 (n=28) and TIMI 3 (n=98) flow. After PCI, turbulence slope increased (13.2+/-11 to 18.1+/-12 ms/beat, P<0.001) and turbulence onset decreased (-0.008+/-0.04% to -0.023+/-0.04%, P<0.01) in patients with TIMI 3 flow after PCI, whereas there were no significant alterations of turbulence slope (12.2+/-10 to 12.8+/-6.5 ms/beat) and turbulence onset (-0.009+/-0.05% to -0.003+/-0.03%) in patients with TIMI 2 flow.

CONCLUSIONS

The improvement of HRT after successful reperfusion is a previously unreported effect of direct PCI for acute MI, reflecting rapid restoration of baroreceptor response. The persistent impairment of HRT after PCI in patients with TIMI 2 flow indicates a sustained blunted baroreflex response and may reflect a more severe microvascular dysfunction.

Effect of endurance exercise on autonomic control of heart rate

Long-term endurance training significantly influences how the autonomic nervous system controls heart function. Endurance training increases parasympathetic activity and decreases sympathetic activity in the human heart at rest. These two training-induced autonomic effects, coupled with a possible reduction in intrinsic heart rate, decrease resting heart rate. Long-term endurance training also decreases submaximal exercise heart rate by reducing sympathetic activity to the heart. Physiological ageing is associated with a reduction in parasympathetic control of the heart; this decline in parasympathetic activity can be reduced by regular endurance exercise. Some research has indicated that females have increased parasympathetic and decreased sympathetic control of heart rate. These gender-specific autonomic differences probably contribute to a decreased cardiovascular risk and increased longevity observed in females.

Estrogen modulation of baroreflex function in conscious mice

It has been suggested that estrogen modulates baroreflex regulation of autonomic function. The present study evaluated the effects of estrogen on baroreflex regulation of heart rate in response to changes in blood pressure with phenylephrine (PE), ANG II, and sodium nitroprusside (SNP) in a conscious mouse model. Males and ovariectomized females with (OvxE+) and without (OvxE-) estradiol replacement chronically implanted with arterial and venous catheters were used in these studies. The slope of the baroreflex bradycardic responses to PE was significantly facilitated in OvxE+ females (-7.65 +/- 1.37) compared with OvxE- females (-4.5 +/- 0.4). Likewise, the slope of the baroreflex bradycardic responses to ANG II was significantly facilitated in OvxE+ females (-7.97 +/- 1.06) compared with OvxE- females (-4.8 +/- 1.6). Reflex tachycardic responses to SNP were comparable in all the groups. Finally, in male mice, the slope of ANG II-induced baroreflex bradycardia (-5.17 +/- 0.95) was significantly less than that induced by PE (-8.50 +/- 0.92), but this ANG II-mediated attenuation of reflex bradycardia was not observed in the female mice. These data support the hypothesis that estrogen facilitates baroreflex function in female mice and suggest that ANG II-mediated acute blunting of baroreflex regulation of heart rate may be sex dependent.

Measures of cardiovascular autonomic regulation derived from spontaneous methods and the Valsalva maneuver

The response of heart rate to a given change of systolic blood pressure is a fundamental characteristic of the cardiovascular system. The assessment of baroreflex gain (BRS) as an index of baroreflex function is based on the quantification of RR interval changes related to blood pressure changes. The spontaneous sequence and cross spectral methods describe baroreflex gain derived from spontaneous fluctuations of these parameters, yielding the up sequence and down sequence BRS and the alfa index. Phase IV of the Valsalva maneuver is also used to calculate cardiac vagal baroreflex gain. In this study, we compared the two spontaneous methods and the Valsalva maneuver in assessing baroreflex gain in 56 healthy volunteers. The BRS values calculated from different methods were as follows: up sequence BRS 12 +/- 8.6 ms/mm Hg, down sequence BRS 10 +/- 6.1 ms/mm Hg, low frequency alfa index 12.1 +/- 8.2 ms/mm Hg, Valsalva BRS 9.7 +/- 7.2 ms/mm Hg. We found close relationship between baroreflex gain derived from up and down sequences (R = 0.91, p < 0.001), down sequence BRS and low frequency alfa index (R = 0.81, p < 0.001); significant correlation between up sequence BRS and low frequency alfa index (R = 0.65, p < 0.001), the Valsalva-derived BRS and down sequence BRS (R = 0.37, p = 0.043), but no correlation between the Valsalva BRS and up sequence BRS, the Valsalva BRS and low frequency alfa index. BRS values calculated by different methods decreased with increasing age. There was no influence of age on mean arterial blood pressure elevation in late phase II of the Valsalva maneuver, nor any indication that the Valsalva BRS was related to the MAP changes. We concluded that all of these methods are useful in calculating baroreflex gain, but owing to the differences in underlying physiological mechanisms, they are not necessarily in correlation with each other.

Cardiovascular autonomic nervous system tests: reference values in young people (15-19 years) and influence of age and gender

OBJECTIVE

The aim of this study was to determine values of the deep breathing test (DB), orthostatic test (OT) and Valsalva manoeuvre (VM) parameters in young people and influence of age and gender.

METHODS

A total of 206 healthy subjects (100 girls, 106 boys) at the age of 15-19 years, BMI 21.3+/-2.3 (mean +/- SD) were examined by system Varia Pulse TF3.

RESULTS

Reference values of DB, OT, VM parameters are presented as arithmetic mean +/- SD and percentiles (P90, P75, P50, P25, P10). In the whole group HRrest was lower in 19-year-old group, in OT this difference was significant already in 18-year-old group compared with 15-year-old group. DB: I/E was significantly increased in 19-year-old group compared with 15-year-old group. HRrest was higher in girls compared with boys in the whole group. DB: I/E was significantly lower in girls compared with boys. OT: 30:15 and HRmax/HRrest were significantly decreased in girls compared with boys.

CONCLUSION

Reference values of DB, OT, VM parameters were determined in young people at the age of 15-19 years. The most sensitive test for ascertainment of developmental changes was test of deep breathing. I/E was increased in the 19-year-old group compared with 15-year-old group indicating an increase of vagal activity. Girls had decreased some parameters of deep breathing and orthostatic test compared with boys in the same group (15-19 years).

Impaired baroreflex function during pregnancy is associated with stiffening of the carotid artery

OBJECTIVE

The baroreflex sensitivity and the distensibility of the carotid artery were measured during normotensive pregnancy to test the hypothesis that changes in baroreflex sensitivity are related to carotid artery stiffening.

DESIGN

Data were obtained from pregnant subjects during each trimester (T1, T2, T3; n = 23) and postpartum (n = 11). End-diastolic diameter and pulsatile distension of the carotid artery were measured with an ultrasound wall-tracking system, and the distensibility coefficient was calculated. Spontaneous fluctuations in cardiac interval and systolic pressure were used to determine baroreflex sensitivity.

RESULTS

Both distensibility coefficient and baroreflex sensitivity were reduced from T1 to T3 (5.1 +/- 1.6 vs. 3.7 +/- 0.9 10(-3)/mmHg and 10.1 +/- 2.9 vs. 5.7 +/- 1.8 ms/mmHg, respectively). Baroreflex sensitivity and carotid distensibility coefficient were linearly related in each subject (r = 0.62 +/- 0.12). Augmentation index and return time changes indicated a global increase in arterial distensibility.

CONCLUSIONS

Stiffening of the carotid artery significantly contributes to the impairment of baroreflex sensitivity during pregnancy, and represents a region specific change as global arterial distensibility was found to increase during pregnancy.

Orthostatic tolerance and spontaneous baroreflex sensitivity in men versus women after 7 days of head-down bed rest

Many factors are involved in the development of orthostatic intolerance after real or simulated weightlessness. The aim of our study was to compare the effects of 7-day head-down bed rest (HDBR) in eight women and eight men on the spontaneous baroreflex sensitivity (standard spectral method and new time-frequency algorithm) during lower body negative pressure (LBNP) tests. Results obtained before HDBR have shown in women, compared to men, higher heart rate, lower blood pressure, higher parasympathetic modulation at rest and greater decrease in baroreflex sensitivity with greater increase in sympathetic activity during LBNP. After HDBR, we observed in both men and women a dramatic decrease in orthostatic tolerance (7.0 min at R + 1 vs. 10.0 min, p<0.05, at BDC-1 in men; 5.4 vs. 9.0 min, p<0.05, in women) together with a decrease in plasma volume (-9.1 +/- 0.9% in men, -9.5 +/- 1.4% in women) and in spontaneous baroreflex sensitivity without gender effect. After HDBR, at the highest level of LBNP, diastolic blood pressure increased in men (+5.6 +/- 1.3 mm Hg) and decreased in women (-1.0 +/- 2.7 mm Hg) with a gender difference (p<0.05). This result suggests impaired vasoconstriction in women after HDBR. Neither endocrine response nor alterations to the cardiac baroreflex can explain gender differences in orthostatic tolerance after HDBR as reported by previous studies. Further studies need to be conducted in order to obtain a more precise analysis of gender difference in arteriolar vasoconstriction after HDBR. The time frequency method we developed to study changes in spontaneous baroreflex might be applied to the analysis of LBNP tests.

Greater intima-media thickness in the carotid bulb is associated with reduced baroreflex sensitivity

The aim of this study was to evaluate the association between resting baroreflex sensitivity (BRS) and carotid intima-media thickness (IMT), a putative marker of subclinical atherosclerosis. Participants were 64 men and 18 women (median age, 57 years; range, 40 to 70 years), who did not have a previous history of coronary artery disease or treatment for hypertension. Resting BRS was measured during a 9-min baseline period using the noninvasive sequence technique; carotid IMT was subsequently determined using ultrasonography. Hierarchical multiple regression analyses showed that greater IMT in the carotid bulb (an area with a high density of baroreceptors) was associated with reduced BRS. These findings remained after adjusting BRS for resting mean arterial pressure, age, body mass index, gender, and smoking history, R2 = 0.06, P = .03. In contrast, IMT in the common and internal carotid regions (areas with presumably lower baroreceptor densities) did not account for a significant proportion of the variance in BRS. These results suggest that subclinical atherosclerosis, specifically in a region with high baroreceptor density, is associated with a reduced sensitivity of the baroreflex.

Gender influence on vasoactive hormones at rest and during a 70 degrees head-up tilt in healthy humans

To evaluate the influence of age and gender on the neuroendocrine control of blood pressure in normal subjects, a 13-min 70 degrees head-up tilt (HUT) was applied after 3 h of recumbency to 109 healthy men and women aged 23-50 yr (age group I) and 51-77 yr (age group II). We found that age and gender had a significant influence on plasma norepinephrine (PNE) concentration at baseline and in the upright position. PNE was significantly higher in older men compared with the younger men and women of both age groups, suggesting a divergent age-related activation of the sympathetic nervous system between genders at baseline as well as during a sustained orthostatic challenge. There was no significant influence of age or gender on plasma epinephrine at baseline or during HUT. Plasma renin activity was significantly higher at baseline as well as in the upright position during HUT in elderly men than in women. Age or gender had no influence on plasma vasopressin (PAVP), and, regardless of age, nonhypotensive HUT induced an extremely modest increase in PAVP. The syncopal subjects displayed a hormonal pattern associating increased PNE and a surge in plasma epinephrine and PAVP minutes before syncope during HUT. The orthostatic intolerance appears not to be a feature of healthy aging per se. In healthy subjects, both age and gender modulate markedly the cardiovascular and neuroendocrine responses to an orthostatic challenge and must be taken into consideration, particularly when catecholamine responses are studied.

Does postmenopausal hormone replacement therapy affect cardiac autonomic regulation in osteoporotic women?

OBJECTIVE

Postmenopausal hormone replacement therapy (HRT) has been associated with reduced risk of cardiovascular disease; however, the mechanisms remain obscure, and it is not known whether this applies to regimens containing both estrogen and progestin. One possibility is that estrogen would act via enhancement of cardiac autonomic regulation.

DESIGN

In this prospective, controlled study of 6-months duration, 22 osteoporotic, postmenopausal women in the intervention group were treated with combined estradiol hemihydrate corresponding to estradiol 2 mg and norethisterone acetate 1 mg with or without clodronate (HRT group). Nine women in the control group received clodronate only. Indices of heart rate variability (HRV) by power spectral analyses and baroreceptor sensitivity (BRS) by phenylephrine test were measured before and after 3 and 6 months of treatment.

RESULTS

The total power of HRV remained identical within the groups, although it was higher at 3 and 6-month measurements in the control group than the HRT group. This was mainly due to lower very low frequency and high frequency power in the HRT group. However, no changes in the low frequency/high frequency-ratio of HRV, an index of sympathovagal balance, were observed between and within the groups. Further, during the intervention, no significant changes in BRS (baseline and 6 months: 5.0 +/- 2.1 and 5.1 +/- 2.5 ms/mmHg) within the HRT group was observed.

CONCLUSIONS

The impact of estrogen and progesterone on cardiac autonomic regulation seems to be quite modest. Therefore, cardiac morbidity and mortality are probably not mediated by their effects on cardiac autonomic regulation. However, the effects of estrogen alone or more selective estrogen receptor modulators need yet to be clarified in future studies.

Gender difference in cardiovagal baroreflex gain in humans

We tested the hypothesis that women would demonstrate lower cardiovagal baroreflex gain compared with men. If so, we further hypothesized that the lower cardiovagal baroreflex gain in women would be associated with their lower aerobic fitness and higher body fat percentage compared with men. To accomplish this, we measured cardiovagal baroreflex gain (modified Oxford technique) in sedentary, nonobese (body mass index < 25 kg/m2) men (age = 26.0 +/- 2.1 yr, n = 11) and women (age = 26.9 +/- 1.6 yr, n = 14). Resting R-R interval and diastolic blood pressure were similar in the two groups, but systolic blood pressure was lower (P < 0.05) in the women. Cardiovagal baroreflex gain was significantly lower in the women compared with the men (13.3 +/- 1.5 vs. 20.0 +/- 2.8 ms/mmHg, P < 0.05). The lower cardiovagal baroreflex gain in the women was not related (P > 0.05) to their lower aerobic fitness and was only marginally related to their higher body fat percentage (r = -0.34, P < 0.05). There were no gender differences in the threshold and saturation, operating range, or operating point (all P > 0.05), although the operating point fell significantly to left (i.e., at a lower systolic blood pressure) compared with men. Therefore, the findings of this study suggest that the gain of the cardiovagal baroreflex is reduced whereas other parameters were similar in women compared with men. The mechanisms responsible for the reduced cardiovagal baroreflex gain remain unclear.

Effects of gender and age on the cardiac baroreceptor reflex in hypertension

The present study examined whether alterations in the cardiac baroreceptor reflex in hypertension may be a function of constitutional differences associated with gender and age. These hypotheses were tested using a cross-sectional design that compared 20 normotensive and 21 hypertensive men and women of varying age for differences in baroreceptor reflex sensitivity and response latency for heart rate, obtained using a modified bolus phenylephrine (Oxford) method. Relative to their respective normotensive controls, baroreceptor reflex sensitivity was reduced in hypertensive men, but not in hypertensive women. Among normotensive subjects, men had greater baroreceptor reflex sensitivity than women. Independent from the effects associated with differences in blood pressure, age was not a significant predictor of reduction in baroreceptor reflex sensitivity. However, a combination of high blood pressure and older age was associated with a significant increase in baroreceptor reflex response time. In summary, gender and aging interacted with hypertension to alter two different aspects of the baroreceptor reflex. These results provide a preliminary indication that a decline in arterial baroreflex sensitivity may be more specific to hypertension in men than in women. Prolongation in baroreflex response latency in older hypertensive subjects also suggested that aging and hypertension may have a synergistic effect on cardiac parasympathetic function.

Gender differences in cardiovascular regulation during recovery from exercise

Are women more susceptible to acute postexercise orthostatic hypotension compared with men? We hypothesized that decreases in arterial pressure during recovery from dynamic exercise are greater in women compared with men. We studied 8 men and 11 women during inactive and active recovery from cycling exercise. Heart rate, stroke volume (SV), cardiac output, mean arterial pressure (MAP), and total peripheral resistance (TPR) were measured during and after 3 min of exercise at 60% of calculated maximum heart rate. At 1 min after exercise, MAP decreased less (P < 0.05) during inactive recovery in men (-18 +/- 2 mmHg) compared with women (-30 +/- 2 mmHg). This difference was due to greater decreases in SV and less increase in TPR during inactive recovery from exercise in women compared with men. These differences persisted for 5 min after exercise. MAP decreased less during active recovery in men compared with women. These findings suggest that women may have increased risk of postexercise orthostatic hypotension and that active recovery from exercise may reduce this risk.

Heart rate variability and its determinants in patients with severe or mild essential hypertension

How cardiac autonomic nervous control is related to the severity of essential hypertension in patients receiving long-term antihypertensive therapy is not well known. The aim of this study was to examine heart rate variability (HRV), a non-invasive measure of cardiac autonomic function, in patients with long-term and medically treated mild and severe essential hypertension and healthy control subjects, and to assess the clinical determinants of HRV in these patients. Thirty-four patients with severe essential hypertension (SEHT) and 29 with mild essential hypertension (MEHT) as well as healthy age- and sex-matched control subjects were studied. HRV was assessed from 10 min ECG-recordings during paced (0.2 Hz) breathing at rest and expressed as time and frequency domain measures. In the SEHT group time (SDNN, RMSSD) and frequency domain measures (total power, low-frequency (LF) power and high-frequency (HF) power of HRV in absolute units, and LF and HF power of HRV in normalized units) of HRV were significantly lower when compared with those of the control group. The MEHT and control groups did not differ from each other with respect to time or frequency domain measures of HRV. Comparison between the hypertensive groups showed that SDNN, total power, LF power and HF power were lower in the SEHT group compared with the MEHT group (P<0.05 for all). Among hypertensive patients RR-interval, age, gender, systolic finger blood pressure and diastolic office blood pressure as well as 24-h blood pressure were significant determinants of HRV. In conclusion, we found that the severity of chronic essential hypertension seems to be related to the severity of impairment of cardiac autonomic control.

Age-associated changes in cardiovagal baroreflex sensitivity are related to central arterial compliance

Cardiovagal baroreflex sensitivity (BRS) declines with advancing age in humans, but the underlying mechanism has not been established. Using two different approaches, we determined the relation between age-associated decline in cardiovagal BRS and the compliance of an artery in which arterial baroreceptors are located. First, we measured carotid artery compliance (via the simultaneous application of ultrasonography and arterial applanation tonometry) and cardiovagal BRS (phase IV of the Valsalva maneuver) in 47 healthy sedentary men that varied widely in age (19--76 yr). Cardiovagal BRS declined progressively with age (r = -0.69; P < or = 0.001) and was positively related to carotid artery compliance (r = 0.71; P < or = 0.001). Stepwise multiple-regression analysis revealed that carotid artery compliance was the strongest independent physiological correlate of cardiovagal BRS and that it explained 51% of the total variance. Second, we studied 13 middle-aged and older previously sedentary men (age 56 +/- 2 yr) before and after 13 wk of aerobic exercise intervention. Regular exercise increased both cardiovagal BRS and carotid artery compliance (P < 0.05) and the two events were strongly and positively related (r = 0.72; P < 0.01). We conclude that reduced carotid artery compliance may play an important mechanistic role in age-associated decrease in cardiovagal BRS in healthy sedentary humans.

Autonomic function in hypertensive and normotensive subjects: the importance of gender

Baroreceptor reflex sensitivity (BRS) has been found lower and heart rate variability (HRV) parasympathetic markers have been found higher in healthy women than in healthy men. Thus, in the present study we hypothesized gender differences in the autonomic function among hypertensive subjects. Forty-one hypertensive patients and 34 normotensive subjects, age 53+/-1 years, were examined. Four weeks after cessation of antihypertensive therapy, HRV was assessed in 24-hour Holter ECGs, and BRS was calculated with the transfer technique. A t test was performed after log transformation of spectral values. Resting blood pressure and heart rate in the hypertensive and the normotensive groups were 150+/-2/100+/-1 (mean+/-SEM) and 121+/-2/81+/-1 mm Hg, respectively, and 68+/-1 and 60+/-1 bpm, respectively (P<0.0005). Compared with normotensive controls, hypertensive patients had lower total power (1224+/-116 versus 1797+/-241 ms(2); P=0.03), lower low frequency power (550+/-57 versus 813+/-115 ms(2); P=0.04), lower high frequency power (141+/-23 versus 215+/-38 ms(2); P=0.06), lower root mean square successive difference (28.7+/-2.7 versus 35.7+/-3.0 ms; P=0.03), and PNN50 (4.9+/-0.6% versus 9.8+/-1.5%; P=0.003). BRS was also lower in the hypertensive subjects (7.6+/-0.6 versus 10.4+/-0.8 ms/mm Hg; P=0.005). When comparing the same parameters between normotensive subjects and hypertensive subjects within the same gender group, we found significant reduction (P<0.05) only within the female group. The difference in BRS within the female group was twice that within the male group. Stepwise multiple regression analysis revealed gender, age, HDL cholesterol, and blood pressure as independent explanatory variables of BRS and HRV. Our results suggest that gender is an important determinant of BRS and HRV. Autonomic function parameters were especially impaired in hypertensive women compared with hypertensive men.

Does Reduced Vascular Stiffening Fully Explain Preserved Cardiovagal Baroreflex Function in Older, Physically Active Men?

Background —We measured cardiovagal baroreflex gain and its vascular mechanical and neural components during dynamic baroreflex engagement in 10 young untrained men, 6 older untrained men, and 12 older, physically active men.

Methods and Results —Our newly developed assessment of beat-to-beat carotid diameters during baroreflex engagement estimates the mechanical transduction of pressure into barosensory stretch (Δdiameter/Δpressure), the neural transduction of stretch into vagal outflow (ΔR-R interval/Δdiameter), and conventional integrated cardiovagal baroreflex gain (ΔR-R interval/Δpressure). Integrated gain was lower in older untrained men than in young untrained men (6.8±1.2 versus 15.7±1.8 ms/mm Hg) due to both lower mechanical (9.1±1.0 versus 17.1±2.4 mm Hg/μm) and lower neural (0.57±0.10 versus 0.90±0.10 ms/μm) transduction. Integrated gain in older active men (13.3±2.7 ms/mm Hg) was comparable to that in young untrained men. This was achieved through mechanical transduction (12.1±1.4 mm Hg/μm) that was modestly higher than that in older untrained men and neural transduction (1.00±0.20 ms/μm) comparable to that in young untrained men. Across groups, both mechanical and neural components were related to integrated gain; however, the neural component carried greater predictive weight (β=0.789 versus 0.588).

Conclusions —Both vascular and neural deficits contribute to age-related declines in cardiovagal baroreflex gain; however, long-term physical activity attenuates this decline by maintaining neural vagal control.

Renal function and renal disease in the elderly: Part I

In all industrialized countries, life expectancy has risen in the past 100 years. The incidence of elderly patients reaching end-stage renal disease (ESRD) and requiring renal replacement therapy has also increased. During the past few decades, the pattern of ESRD has changed significantly with the emerging predominance of elderly patients. The causes of this phenomenon are manifold and include an increasing number of chronic diseases typical of the 'third age', such as type 2 diabetes mellitus and vascular disease. In many species, a consequence of aging includes deterioration of renal function, partly due to structural alterations, and partly as the result of a diminishing blood flow. In humans, the aging kidney is characterized by modifications resulting from organic and functional disturbances. In particular, type 2 diabetes mellitus has emerged as an important condition, the microvascular and macrovascular complications of which are a common cause of morbidity and mortality in older patients. In part I of this review, the morphological and functional changes of the aging kidney will be reviewed, as well as the pathological conditions leading to the loss of renal function in the elderly.

Determinants of spontaneous baroreflex sensitivity in a healthy working population

Baroreflex sensitivity (BRS) by the spontaneous sequence technique has been widely used as a cardiac autonomic index for a variety of pathological conditions. However, little information is available on determinants of the variability of spontaneous BRS and on age-related reference values of this measurement in a healthy population. We evaluated BRS as the slope of spontaneous changes in systolic blood pressure (BP) and pulse interval from 10 minutes BP (Finapres) and ECG recordings in 1134 healthy volunteers 18 to 60 years of age. Measurement of BRS could be obtained in 90% of subjects. Those with unmeasurable spontaneous BRS had a slightly lower heart rate but were otherwise not different from the rest of the population. BRS was inversely related to age (lnBRS, 3.24-0.03xage; r(2)=0.23; P:<0.0001) in both genders. In addition, univariate analysis revealed a significant inverse correlation between BRS and heart rate, body mass index, and BP. Sedentary lifestyle and regular alcohol consumption were also associated with lower BRS. However, only age, heart rate, systolic and diastolic BP, body mass index, smoking, and gender were independent predictors of BRS in a multivariate model, accounting for 47% of the variance of BRS. The present study provides reference values for spontaneous BRS in a healthy white population. Only approximately half of the variability of BRS could be explained by anthropometric variables and common risk factors, which suggests that a significant proportion of interindividual differences may reflect genetic heterogeneity.

The effect of systemic blood pressure on cardio-vascular reflexes in elderly subjects

The evidence for impairment of cardiovascular reflexes by hypertension in elderly subjects is mixed. This study tested the hypothesis that baroreceptor- and non-baroreceptor-mediated responses in elderly subjects differed with hypertension. 54 elderly subjects were studied: 16 with combined hypertension (CT) (blood pressure 184 +/- 4/102 +/- 2 mmHg), 16 with isolated systolic hypertension (180 +/- 3/85 +/- 1 mmHg) and 22 normotensives (NT) (138 +/- 2/76 +/- 1 mmHg). All subjects performed isometric exercise with a handgrip dynamometer. Heart rate (HR), blood pressure and forearm vascular resistance (FVR) responses were then studied to 60 degrees head-up tilt and the cold face stimulus. Baseline FVR, and the response to isometric handgrip, were similar in all groups. Subjects with isolated systolic hypertension manifested greater increases in FVR with tilt (P<0.001), whilst the HR increment was greater in the NT group (P<0.001). Blood pressure changes with tilt were similar in the three groups. With the cold face stimulus (CFS) a rise in FVR of approximately 30% was seen in all groups and blood pressure rose modestly, with the largest increases being seen in the combined hypertensives. This study in elderly subjects indicates significant differences with hypertension in the response to tilt, with an impaired baroreceptor-cardiac reflex being compensated by an augmented baroreceptor-vascular response.

Regular aerobic exercise modulates age-associated declines in cardiovagal baroreflex sensitivity in healthy men

1. Cardiovagal baroreflex sensitivity (BRS), the arterial baroreflex-mediated change in the R-R interval per unit change in systolic blood pressure, decreases with advancing age in sedentary adult humans. We determined the effects of regular aerobic exercise on the age-related decline in cardiovagal BRS. 2. In the cross-sectional study, 133 healthy men 18-79 years of age who were either sedentary, performing moderate aerobic exercise, or endurance exercise trained were studied. Among the sedentary men, cardiovagal BRS (phase IV of Valsalva's manoeuvre) was progressively lower (P < 0.05) in the middle-aged ( approximately 33 %) and older ( approximately 60 %) groups compared with the young group. In contrast, cardiovagal BRS was similar in the young and middle-aged men in the moderate exercise and endurance-trained groups. Cardiovagal BRS was lower (P < 0.05) in the older exercising men, but the magnitude of decline across age ( approximately 30 %) was only half as great as that in sedentary men. Cardiovagal BRS was 40-75 % greater (P < 0.05) in middle-aged and older men who exercised regularly compared with their sedentary peers. 3. In the intervention study, a 3 month aerobic exercise intervention (primarily walking) increased cardiovagal BRS by an average of 25 % (P < 0.05) in 13 previously sedentary middle-aged and older (56 +/- 1 years) healthy men. 4. Our results demonstrate for the first time that regular aerobic exercise: (1) attenuates the age-associated decline in cardiovagal BRS; and (2) partially restores the loss of cardiovagal BRS in previously sedentary middle-aged and older healthy men.

Relationship of baroreflex sensitivity and blood pressure in an older population

OBJECTIVES

Ageing and hypertension are associated with reduced baroreflex sensitivity (BRS) in young and middle-aged populations. The effects of blood pressure level on BRS in the older population are unclear. We examined the association between blood pressure and BRS in older persons with blood pressure below 180 mmHg.

METHODS

BRS, high (alphaHF 0.15-0.4 Hz) and low (alphaLF 0.04-0.15 Hz) frequency alpha-index, was determined in 75 normotensive subjects (aged 75 +/- 4 years, 41% female, 131 +/- 10/74 +/- 7 mmHg) and 64 untreated hypertensive subjects (aged 76 +/- 5 years, 48% female, 165 +/- 7/ 88 +/- 7 mmHg) by spectral analysis of 20 min continuous blood pressure and heart rate recordings using finger plethysmography. Subjects were recruited from 10 general practices and were taking no cardiovascular medications.

RESULTS

High but not low frequency alpha-index was significantly blunted in hypertensive subjects (alphaHF 5.1 +/- 3.1 versus 8.4 +/- 7.4 ms/mmHg, P< 0.001 and alphaLF 4.7 +/- 3.0 versus 5.8 +/- 3.9 ms/mmHg, P= 0.07). Multivariate analysis of the relationship between age and blood pressure demonstrated systolic and to a lesser extent diastolic blood pressure were significant predictors of variance in BRS for alphaHF [systolic blood pressure (SBP) P< 0.0001, diastolic blood pressure (DBP) P< 0.05, r2 = 0.1] and alphaLF (SBP P=0.01, DBP P<0.05, r2 = 0.04). Age was not a significant predictor for either measure, in the 20 year range studied.

CONCLUSIONS

In an older population blood pressure is associated with reduced BRS, particularly for the high frequency component. Such a change may place older subjects with hypertension at increased risk of orthostatic hypotension, vasovagal syncope and sudden cardiac death.

Age effect on phase relations between respiratory oscillations of the RR interval and systolic pressure

Spectral analysis may allow the evaluation of (baroreflex) gain and phase between the RR interval and systolic pressure oscillations synchronous with respiration but, unlike baroreflex gain, the determinants of phase are not completely understood. We evaluated the correlates of spectral phase in 92 healthy subjects (44 men) aged 10-80 years. To do so, the cardiorespiratory signals during paced breathing at 16 breaths/min were continuously recorded and analyzed. In addition, respiratory sinus arrhythmia and baroreflex gain (two indices of cardiac vagal activity) and phase were calculated by using an autoregressive spectral technique. At univariate analysis, the phase correlated with age (r = 0.48, P < 0.001), the RR interval (r = 0.32, P < 0.01), respiratory sinus arrhythmia (r = -0.3, P < 0.01), baroreflex gain (r = -0.29, P < 0.01), and body mass index (r = 0.25, P < 0.05). At multivariate analysis, age was the most important physiological correlate of phase, accounting for 23% of interindividual phase variation. Cardiac vagal activity measures (which were higher in women than men) and the RR interval were also significant independent correlates of phase. We conclude that in addition to the RR interval and cardiac vagal activity, age has a significant impact on the phase relationship between respiratory related oscillations of the RR interval and systolic blood pressure. This spectral measure may contain additional information concerning the mechanisms that influence cardiovascular rhythms.

Inhalation of amyl nitrite and the measurement of left ventricular outflow velocity: studies in normal, young adults

Amyl nitrite inhalation is useful in the identification of patients with provocable left ventricular (LV) outflow tract obstruction. However, there are no prospective studies that assess the normal change in LV outflow velocity during this intervention. Eighteen normal subjects (mean age, 34+/-5 years; 9 men and 9 women) inhaled amyl nitrite during measurement of LV outflow velocity. Peak velocity increased from 109+/-16 cm/s to 144+/-24 cm/s (P<0.001). There were no significant gender differences in velocity measurements at baseline or at peak. Our study provides prospective data that may be useful when evaluating young adults for LV outflow tract obstruction with Doppler echocardiography during amyl nitrite inhalation.

Influence of demographic, anthropometric and lifestyle characteristics on heart rate and its variability in the population

OBJECTIVE

The purpose of this investigation was to assess the effects of age, gender, posture and their interactions, and of body mass index and lifestyle factors, on heart rate, its total variance and its variability in the frequency domain in a population-based sample of healthy subjects.

METHODS

RR interval and respiration were registered in the supine and in the standing position in 302 men and 312 women, aged 25-89 years; 424 subjects were healthy and had recordings suitable for analysis. Power spectral analysis was performed by use of autoregressive modelling and by fast Fourier transform, and the low-frequency (LF) and high-frequency (HF) components were expressed in both absolute (ms2) and normalized units

RESULTS

In the supine position, heart rate was higher in women than in men (P<0.001) and was not affected by age. Total variance and absolute LF and HF power markedly declined with age in each gender (P<0.001). Men had higher absolute LF power than women (P<0.001), whereas HF power was similar by gender; the age-related decline of HF power tended to be steeper in women (P = 0.06). The normalized LF and HF powers also decreased with age (P<0.01), except for the LF component in women; young men had higher LF power and lower HF power than young women, but the gender difference disappeared in the sixth decade of life. The LF: HF ratio was not influenced by age in supine men; the ratio was lower in women at young age, but increased to the level of men at greater age. Heart rate increased on standing, whereas its total variance was reduced; HF power declined, irrespective of the units, normalized LF power and the LF: HF ratio increased, whereas absolute LF power decreased (P<0.001). The postural changes of heart rate and of the frequency components did not differ by gender, but were attenuated with increasing age (P<0.05). Alcohol consumption did not influence heart rate and its variability, whereas independent effects of habitual physical activity, smoking habits and body mass index explained no more than 4% of the variance of some measures of heart rate variability.

CONCLUSIONS

Age, gender and/or some lifestyle factors significantly affect heart rate and various components of its variability in the supine position and in response to standing. The results are similar for autoregressive modelling and fast Fourier transform, but may differ according to the units in which the spectral components are expressed.

Sympathovagal balance is major determinant of short-term blood pressure variability in healthy subjects

Short-term blood pressure variability (BPV) has been suggested to provide important information about cardiovascular regulation. However, the background of BPV, its determinants, and physiological correlates have remained obscure. The aim of this study was to characterize physiological correlates of BPV and to investigate associations between BPV and neural and hormonal regulatory systems at rest in healthy subjects. We studied 117 healthy, normal-weight, nonsmoking male and female subjects aged 23-77 yr. Spectral analysis of BPV and heart rate variability (HRV) was performed from 5-min blood pressure (Finapres) and electrocardiogram recordings during controlled breathing. Baroreflex sensitivity (BRS) was measured using the phenylephrine method. In addition, plasma concentrations of norepinephrine, epinephrine, and arginine vasopressin and plasma renin activity were measured. We found that the ratio between the low- and high-frequency components of HRV, an index of cardiac sympathovagal balance, correlated positively with total power and very low- and low-frequency components of systolic and diastolic BPV and inversely with high-frequency components of systolic and diastolic BPV. BRS, predominantly a measure of cardiac vagal regulation, correlated inversely with BPV. Furthermore, age, gender, body mass index, and systolic blood pressure contributed to BPV. Vasoactive hormones were not significant correlates of BPV. We conclude that sympathovagal balance of cardiovascular regulation is the major determinant of BPV. Other factors associated with BPV are age, gender, body mass index, blood pressure, and BRS.