Distribution of cholinesterase within the sinus node and AV node of the human heart

Morphological and membrane characteristics of spider and spindle cells isolated from rabbit sinus node

This study reports the comparative quantitative, morphological, and electrophysiological properties of two pacemaker cell types, spider and spindle-shaped cells, isolated from the rabbit sinoatrial node. Isolated nodal cells were studied with perforated and ruptured patch whole cell recording techniques. The basic spontaneous cycle length of the spider cells was 381 +/- 12 ms, and the basic spontaneous cycle length of the spindle cells was 456 +/- 17 ms (n = 12, P < 0.05). The spider cells had a more positive maximum diastolic potential (-54 +/- 1 mV) compared with the spindle cells (-68 +/- 1mV, P < 0.05). The overshoot and action potential amplitudes were also smaller in the spider cells. The hyperpolarization-activated inward (I(f)) current density, measured from their tail currents, was 15 +/- 1.3 pA/pF for the spider cells and 9 +/- 0.7 pA/pF for the spindle cells (P < 0.01). I(f) current activation voltage was more positive in the spider cells than the spindle cells. Isoproterenol (1 microM) decreased the spontaneous cycle length of the spider cells by 28 +/- 3% and the spindle cells by 20 +/- 1.5% (P < 0.05). Acetylcholine (0.5 microM) hyperpolarized the membrane potential of the spider cells to -86 +/- 0.7 mV and the spindle cells to -76 +/- 0.8 mV (P < 0.05). In summary, there are at least two distinct pacemaker cell types in the sinus node with different electrophysiological characteristics.

Beta-adrenergic and muscarinic receptor mRNA accumulation in the sinoatrial node area of adult and senescent rat hearts

The sinoatrial (SA) node is the cardiac pacemaker and changes in its adrenergic-muscarinic phenotype have been postulated as a determinant of age-associated modifications in heart rate variability. To address this question, right atria were microdissected, the SA node area was identified by acetylcholinesterase staining, and, using a RT-PCR method, the accumulation of mRNA molecules encoding beta1- and beta2-adrenergic (beta1- and beta2-AR) and muscarinic (M2-R) receptor was quantified to define the proportion between beta-AR and M2-R mRNAs within the sinoatrial area of adult (3 months) and senescent (24 months) individual rat hearts. In adult hearts, the highest M2-R/beta-AR mRNA ratio was observed within the sinoatrial area compared with adjacent atrial myocardium, while in the senescent hearts, no difference was observed between sinoatrial and adjacent areas. This change was specific of the sinoatrial area since adult and senescent whole atrial or ventricular myocardium did not differ in their M2-R/beta-AR mRNA ratio, and was associated with a fragmentation of acetylcholinesterase staining of the senescent SA node. Quantitative changes in the expression of genes encoding proteins involved in heart rate regulation specifically affect the sinoatrial area of the senescent heart.

Mipafox differential inhibition assay for heart muscle cholinesterases: substrate specificity and inhibition of three isoenzymes by physostigmine and quinidine

1. A differential inhibition assay was developed for the quantitative determination of cholinesterase isoenzymes acetylcholinesterase (AChE; EC 3.1.1.7), cholinesterase (BChE; EC 3.1.1.8), and atypical cholinesterase in small samples of left ventricular porcine heart muscle. 2. The assay is based on kinetic analysis of irreversible cholinesterase inhibition by the organophosphorus compound N,N'-di-isopropylphosphorodiamidic fluoride (mipafox). With acetylthiocholine (ASCh) as substrate (1.25 mM), hydrolytic activities (A) of cholinesterase isoenzymes were determined after preincubation (60 min, 25 degrees C) of heart muscle samples with either saline (total activity, A tau), 7 microM mipafox (AM1), or 0.8 mM mipafox (AM2): (BChE) = A tau-AM1, (AChE) = AM1-AM2, (Atypical ChE) = AM2. 3. The mipafox differential inhibition assay was used to determine the substrate hydrolysis patterns of myocardial cholinesterases with ASCh, acetyl-beta-methylthiocholine (A beta MSCh), propionylthiocholine (PSCh), and butyrylthiocholine (BSCh). The substrate specificities of myocardial AChE and BChE resemble those of erythrocyte AChE and serum BChE, respectively. Michaelis constants KM with ASCh were determined to be 0.15 mM for AChE and 1.4 mM for BChE. 4. Atypical cholinesterase, in respect to both substrate specificity and inhibition kinetics, differs from cholinesterase activities of vertebrate tissue and, up to now, could be identified exclusively in heart muscle. The enzyme's Michaelis constant with ASCh was determined to be 4.0 mM. 5. The reversible inhibitory effects of physostigmine (eserine) and quinidine on heart muscle cholinesterases were investigated using the differential inhibition assay. With all three isoenzymes, the inhibition kinetics of both substances were strictly competitive. The physostigmine inhibition of AChE was most pronounced (Ki = 0.22 microM). Quinidine most potently inhibited myocardial BChE (Ki = 35 microM).

Gross and microscopic anatomy of the canine intrinsic cardiac nervous system

BACKGROUND

A three-dimensional description of the distribution and organization of the canine intrinsic cardiac nervous system was developed in order to characterize its full extent physiologically.

METHODS

The anatomy of the canine intrinsic cardiac nervous system was investigated in 67 mongrel dogs by means of visualization following methylene blue staining as well as by light and electron microscopic analyses.

RESULTS

Collections of ganglia associated with nerves, i.e., ganglionated plexuses, were identified in specific locations in epicardial fat and cardiac tissue. Distinct epicardial ganglionated plexuses were consistently observed in four atrial and three ventricular regions, with occasional neurons being located throughout atrial and ventricular tissues. One ganglionated plexus extended from the ventral to dorsal surfaces of the right atrium. Another ganglionated plexus, with three components, was identified in fat on the left atrial ventral surface. A ganglionated plexus was located on the mid-dorsal surface of the two atria, extending ventrally in the interatrial septum. A fourth atrial ganglionated plexus was located at the origin of the inferior vena cava extending to the dorsal caudal surface of the two atria. On the cranial surface of the ventricles a ganglionated plexus that surrounded the aortic root was identified. This plexus extended to the right and left main coronary arteries and origins of the ventral descending and circumflex coronary arteries. Two other ventricular ganglionated plexuses were identified adjacent to the origins of the right and left marginal coronary arteries. Intrinsic cardiac ganglia ranged in size from ones comprising one or a few neurons along the course of a nerve to ones as large as 1 x 3 mm estimated to contain a few hundred neurons. Intrinsic cardiac neuronal somata varied in size and shape, up to 36% containing multiple nucleoli. Electron microscopic examination demonstrated typical autonomic neurons and satellite cells in intrinsic cardiac ganglia. Many of their axon profiles contained large numbers of clear, round, and dense-core vesicles. Asymmetrical axodendritic synapses were common.

CONCLUSIONS

The canine intrinsic cardiac nervous system contains a variety of neurons interconnected via plexuses of nerves, the distribution of which is wider than previously assumed.

Innervation of the human cardiac conduction system. A quantitative immunohistochemical and histochemical study

BACKGROUND

Cardiac conduction is influenced by peptidergic mechanisms as well as classic neurotransmitters. The distribution of peptide-containing nerves has not been well defined.

METHODS AND RESULTS

Immunofluorescence and histochemical techniques were used to visualize the innervation of the human conduction system and to distinguish nerve subpopulations according to their peptide and enzyme content. Nerve fibers and fascicles displaying immunoreactivity for protein gene product 9.5 (PGP 9.5) were more numerous in the sinus and atrioventricular nodes than in the penetrating bundle, bundle branches, and adjacent myocardium. The relative density of innervation was greater in the central region of the sinus node than in the peripheral regions. Nerve densities were also higher in the transitional region of the atrioventricular node compared with its compact region. Acetylcholinesterase (AChE)-positive nerves were the main subtype identified in the sinus and atrioventricular nodes, representing half to two thirds of the stained area occupied by PGP 9.5-immunoreactive nerves. Neuropeptide Y-immunoreactive nerves represented the main peptide-containing subpopulation and occurred throughout the conduction system, displaying a similar pattern of distribution and relative density to those demonstrating tyrosine hydroxylase immunoreactivity. Nerve fibers showing immunoreactivity for vasoactive intestinal polypeptide, somatostatin, substance P, or calcitonin gene-related peptide exhibited distinct patterns of distribution and comprised a relatively minor component of the innervation, the percentage of stained area being 10- to 40-fold lower than that occupied by neuropeptide Y- and PGP 9.5-immunoreactive nerves, respectively.

CONCLUSIONS

The innervation of human conduction tissues exhibits significant regional variation and comprises putative parasympathetic nerves and intrinsic neurons (AChE positive), sympathetic efferent nerves (neuropeptide Y- and tyrosine hydroxylase-immunoreactive nerves), and other peptide-containing nerves, some of which (substance P and calcitonin gene-related peptide containing) are considered to represent afferent nerves. Locally released peptides may be involved in the neural modulation of the human conduction system.

Innervation of the human cardiac conduction system at birth

OBJECTIVE

To study the pattern of innervation of the conduction system of the neonatal heart in humans.

DESIGN

A prospective analysis based on immunohistochemical and enzyme histochemical examination of newborn human hearts.

SETTING

A general district hospital.

MAIN OUTCOME MEASURES

Fresh necropsy tissue.

MATERIAL

Hearts of three neonatal humans with no cardiac anomaly, freshly taken at necropsy.

METHODS

Serial sectioning to obtain a three dimensional reconstruction of the cardiac conduction system, followed by identification of the pattern of innervation by immunohistochemical and enzyme histochemical techniques; with a panel of antisera against protein gene product (PGP) 9.5 as a general neural indicator; dopamine beta-hydroxylase (DBH) and tyrosine hydroxylase (TH) as indicators for sympathetic neural tissue; and selected neuropeptides--namely, neuropeptide Y (NPY), vasoactive intestinal polypeptide (VIP), calcitonin gene related peptide (CGRP), and substance P (SP). Gomori's technique was used for locating cholinesterase activity.

RESULTS

PGP immunoreactive (PGP-IR) nerves were present in large numbers in the sinus node, atrioventricular (AV) node, and penetrating atrioventricular bundle; in moderate numbers in the branching bundle; and occasionally in the bundle branches. Small numbers of DBH-IR and TH-IR nerves were seen in the sinus and AV nodes, mainly perivascularly; there were few in the penetrating and branching bundles and none in the bundle branches. A few perivascular NPY-IR nerves were seen only in the sinus node. VIP-IR, CGRP-IR, and SP-IR nerves were not seen. Pseudocholinesterase activity was found in the conduction tissue, whereas occasional acetylcholinesterase positive nerves were found only in the sinus and AV nodes.

CONCLUSION

A considerable innervation of the human cardiac conduction system is present at birth, although, by comparison with the results of other studies on adult tissue, the mature pattern has not yet been established. Thus it is still in the process of maturation, especially with regard to the acquisition of various neurotransmitters, including the more recently described neuropeptides.

Increase in the activities of plasma pseudocholinesterase dependent on the blood glucose level and its relation to the hypersensitivity to acetylcholine in striated muscles of KK-CAy mice with diabetes

Acetylcholinesterase activity and pseudocholinesterase activity were examined in plasma and in striated muscles (whole heart and diaphragm muscles) of diabetic KK-CAy mice. Both activities of acetylcholinesterase in heart muscle and pseudocholinesterase in plasma were significantly increased in diabetic KK-CAy mice compared to pre-diabetic KK-CAy mice. Both acetylcholinesterase and pseudocholinesterase activities in skeletal muscle were not changed by the diabetic state. The increases in activity of plasma pseudocholinesterase was significantly correlated to the increase in blood glucose level in alloxan-, streptozotocin (STZ)-diabetic ddY mice and diabetic KK-CAy mice. The increase was not correlated to the body weight in non-diabetic female-KK-CAy mice. Furthermore, the activity of heart acetylcholinesterase was significantly correlated with the activity of plasma pseudocholinesterase (r = 0.79, P less than 0.01). The activities of acetylcholinesterases in heart muscles from STZ- and alloxan-diabetic ddY mice also tended to increase. The hypersensitivity of the pulse rate to a low dose (1 mg/kg) of acetylcholine was correlated to the activity of plasma pseudocholinesterase (r = -0.51, P less than 0.05). These results demonstrate that the activities of plasma pseudocholinesterase were increased by the diabetic state being associated with the increasing alteration of cardiac sensitivity to acetylcholine in the whole body.

Morphological and electrophysiological correlates of atrioventricular nodal response to increased vagal activity

The mechanisms responsible for slowing cardiac impulse conduction through the atrioventricular (AV) node are not well understood but include anatomical architecture, presence of cells with diverse electrophysiological characteristics, and modulation by autonomic nervous system. The present study was designed to determine the site of vagally induced slowing of conduction through the AV node. We attempted to correlate the electrophysiological response of AV nodal cells to postganglionic vagal stimulation applied in different regions of the node with the morphological findings and patterns of acetylcholinesterase-positive staining of nodal tissue. This multifaceted approach revealed that vagal stimulation produced localized hyperpolarization of the cells from the N region of the AV node, which correlated with the strong acetylcholinesterase positive staining of the central nodal area. In contrast, the density of the acetylcholinesterase staining decreased toward both the AN and His bundle regions, whereas vagal stimulation had a negligible effect on the cells from these regions. These results suggest that vagal-induced depression of AV nodal conduction is produced by release of acetylcholine predominantly around the midnodal region and the depressive action of acetylcholine is concentrated on the cells occupying the same region (i.e., the N cells). Thus, there appears to be a close juxtaposition of nerve elements and effector cells in the midnodal region of the AV node. This unique combination of available neuromediator and responding cells with hyperpolarization and depressed action potential determines the midnodal region as the focus of vagal effect on AV nodal conduction.

Immunohistochemical and ultrastructural localisation of peptide-containing nerves and myocardial cells in the human atrial appendage

The innervation and myocardial cells of the human atrial appendage were investigated by means of immunocytochemical and ultrastructural techniques using both tissue sections and whole mount preparations. A dense innervation of the myocardium, blood vessels and endocardium was revealed with antisera to general neuronal (protein gene product 9.5 and synaptophysin) and Schwann cell markers (S-100). The majority of nerve fibres possessed neuropeptide Y immunoreactivity and were found associated with myocardial cells, around small arteries and arterioles at the adventitial-medial border and forming a plexus in the endocardium. Subpopulations of nerve fibres displayed immunoreactivity for vasoactive intestinal polypeptide, somatostatin, substance P and calcitonin gene-related peptide. In whole-mount preparations of endocardium, substance P and calcitonin gene-related peptide immunoreactivities were found to coexist in the same varicose nerve terminals. Ultrastructural studies revealed the presence of numerous varicose terminals associated with myocardial, vascular smooth muscle and endothelial cells. Neuropeptide Y immunoreactivity was localised to large electron-dense secretory vesicles in nerve terminals which also contained numerous small vesicles. Atrial natriuretic peptide immunoreactivity occurred exclusively in myocardial cells where it was localised to large secretory vesicles. The human atrial appendage comprises a neuroendocrine complex of peptide-containing nerves and myocardial cells producing ANP.

Congruence of adrenergic and cholinergic intrinsic innervation of human and rat atria

Right atrial biopsies from rat and human hearts were studied using combined methods for the demonstration of glyoxylic acid-induced fluorescence (GIF) of catecholamines and acetylcholinesterase (AChE) reactions in the same specimens. In specimens from the rat heart, the GIF and AChE reactions were performed either simultaneously or consecutively. In biopsies of the human right atrium, obtained at right atria cannulation during open-heart surgery, the reactions were performed consecutively. It was found that in both rat and human atria the adrenergic nerves and AChE reactive nerves, which are probably cholinergic, run partly separately and partly together. In the rat atrial specimens, close relations between adrenergic nerves and clusters of AChE reactive cells were observed. In addition, clusters of fluorescent cells were observed in the vicinity of AChE reactive nerve bundles. This indicates that there may be several possible means of peripheral interaction between the intrinsic adrenergic and cholinergic systems of the rat heart.

Acetylcholinesterase in prenatal rat heart: a marker for the early development of the cardiac conductive tissue?

In rat embryos, acetylcholinesterase (AChE, EC 3.1.1.7) activity is present in a continuous sleeve of myocytes that extends from the myocardium that is adjacent to the atrioventricular endocardial cushions via the ventricular trabeculae to the outflow tract. No activity is found in the atrial roof, in the ventricular walls and in the interventricular septum except for its subendocardial surface. AChE-positive cells are first identified in 11-day rat embryos, while the prototypical distribution is best demonstrable in 13-day embryos. Part of the AChE-positive cell system is identifiable as a precursor of the adult conduction system by topographical criteria in 16-day fetuses and by morphological criteria in 20-day fetuses. At birth (2 days later), AChE activity has disappeared from the cardiac myocytes except for a ring of tissue at the atrial side of the atrioventricular junction. These findings suggest that the embryonic heart can be divided into an upstream myocardium that has no AChE activity and a downstream myocardium that is characterized by the presence of AChE. Furthermore they suggest that an acetylcholine-dependent mechanism may be responsible for the retardation of the depolarization wave in the downstream parts of the heart. Finally they show that the adult conduction system is formed by a transdifferentiation of part of a far more extensive embryonic precursor system.

Adverse cardiovascular effects of anticholinesterase medications

Anticholinesterase medications (anti-ChEs) play a significant role in the diagnosis and treatment of myasthenia gravis (MG). The primary effect on the heart produced by a surfeit of ACh is bradyarrhythmias with consequent fall in cardiac output and hypotension; yet, adverse cardiac reactions to these agents have been reported relatively infrequently. The authors describe 12 patients with MG from a pool of more than 1,000 who suffered hypotensive episodes related to use of anti-ChEs. The 12 patients (seven male, five female) had a mean age of 62.6 years; of these, eight adverse reactions occurred after edrophonium, two after neostigmine, and two after pyridostigmine. Seven patients had a recent increase in anti-ChEs and none had a decrease in dosage. Nine patients suffered either from severe sinus bradycardia, (20 beats/min), junctional bradycardia, or complete AV dissociation. Two patients had paradoxic sinus tachycardia and all had syncopal or near-syncopal episodes. Evidence for cholinergic stimulation of other organs was generally lacking. No recurrence appeared with reduction of the dose of anti-ChEs or discontinuation of the drug. The authors believe that these agents should be given with caution to patients with inflammatory, infiltrative, or degenerative disease of the conduction systems, patients being treated with digitalis, calcium-channel antagonists or beta blockers, patients with myocardial ischemia, and elderly patients. Appropriate resuscitative equipment should be readily available.

Effects of pharmacologic autonomic blockade on atrial electrophysiologic properties in normal subjects and in patients with sinus node disease

In order to elucidate the influence of autonomic nervous system on atrial electrophysiologic properties, we studied 10 patients with sinus node dysfunction and 10 age-matched normal subjects. In each of them effective and functional refractory periods of the right atrium (near its junction with the superior caval vein) were measured, during atrial pacing (100/min) and using variable current strengths (2, 3, 4, 5, 7, 10, and 15 mA), before and after pharmacologic autonomic blockade (using intravenous propranolol 0.2 mg/kg and atropine 0.04 mg/kg). Mean values of effective and functional refractory periods at each current strength were significantly higher in patients with sinus node disease than in normal subjects both before and after autonomic blockade. Blockade did not significantly modify mean values of effective and functional refractory periods at any current strength, either in patients with sinus node disease or in normal subjects. Furthermore, autonomic blockade did not change the effects of the increase of current strength on atrial refractoriness in either group. We conclude that our data indicate a prolonged refractoriness to be present in patients with sinus node disease even in the absence of influences from the autonomic nervous system. Thus, we can suggest a "primary" involvement of atrial fibers in this pathophysiological condition. Propranolol together with atropine did not induce changes of atrial refractoriness. Indeed, they probably exerted an opposite effect. The effects of the increase of current strength on atrial excitability do not seem to be mediated by autonomic humoral agents.

Dopamine in the conscious dog with chronic heart-block. Mechanisms of chronotropic cardiac effects

The chronotropic effects of dopamine were studied in the conscious dog with chronic A-V block. Dopamine at 12.5-200 micrograms/kg and 12.5-50 micrograms/kg/min lowered atrial rate independently of dose. After blockade of muscarine receptors or alpha-adrenoceptors, it raised atrial rate. After blockade of dopamine receptors, dopamine still lowered atrial rate, and did so dose-relatedly after blockade of beta-adrenoceptors. It raised ventricular rate, and at high doses also induced ventricular rhythm disorders. Blockade of muscarine receptors enhanced the ventricular cardioaccelerator effect of dopamine (P less than 0.025) at 100 micrograms/kg, while blockade of alpha-adrenoceptors reduced it (P less than 0.05). Blockade of dopamine receptors did not modify this effect, but blockade of beta-adrenoceptors reversed it. Dopamine at 25-200 micrograms/kg raised mean blood pressure. This effect was enhanced by blockade of muscarine receptors, reversed by blockade of alpha-adrenoceptors, and was unaffected by blockade of beta-adrenoceptors or dopamine receptors. These results show that the atrial cardiomoderator effect of dopamine is a vagal reflex response to its hypertensive action, and that it is limited by its direct beta-adrenergic stimulating action. They also show that the ventricular cardioaccelerator effect of dopamine is attenuated by a reflex vagal depressor effect consequent to the induced hypertension. No evidence was found for the existence of positive chronotropic dopamine receptors in either atria or ventricles.

Dimethyl sulfoxide: inhibition of acetylcholinesterase in the mammalian heart

The heart rate of the isolated, perfused, working rat heart was significantly and equally depressed by 1 X 10(-6)M acetylcholine (ACh) and by 6 X 10(-5)M 4-ketoamyltrimethylammonium (4K), a cholinomimetic agonist. Dimethyl sulfoxide (DMSO) (10 microliter/ml, 140 mM) strongly potentiated the effect of ACh but did not alter the effect of 4K. DMSO (10 microliter/ml, 140 mM) strongly potentiated the effect of ACh but did not alter the effect of 4K. DMSO (10 microliter/ml, 140 mM final concentration) alone had no significant effect upon heart rate when added to the perfusate in incremental additions of 1 microliter X (ml perfusate)-1 X min-1 over a 10-min period. The specific activity of atrial homogenate cholinesterase was 48.8 +/- 3.46 nmoles X min-1 X (mg protein)-1 (mean +/- S.E.M.), 38.2 +/- 1.60 for butyrylcholinesterase, and 11.2 +/- 0.86 for acetylcholinesterase (AChE). True AChE activity (measured in the presence of a maximally effective concentration of tetraisopropylpyrophosphoramide) had a Vmax of 13.4 +/- 0.17 nmoles X min-1 X mg protein)-1 and an apparent Km value of 1 X 10(-4)M acetylthiocholine. At this Km substrate concentration, DMSO inhibited atrial AChE activity (I50 = 9 microliter/ml). At the concentration tested, DMSO inhibited atrial AChE and potentiated ACh effects.

Aging and atrial electrophysiologic properties in man

In order to assess the influence of age on atrial electrophysiologic properties, we studied 17 normal subjects, whose ages were homogeneously distributed between 17 and 78 years, measuring in each of them effective (ERP) and functional (FRP) refractory periods at 3 sites of the right atrium (high, middle and low in the lateral wall) at the same driven frequency (120/min). Twice threshold stimuli of 2 msec duration were applied. Dispersion of atrial refractoriness was measured as the longest minus the shortest refractory period. A significant direct correlation was observed between age and dispersion of atrial refractoriness (of ERP: r = 0.75, P less than 0.001; of FRP: r = 0.82, P less than 0.001). Moreover, age showed a significant direct correlation with refractoriness at high right atrium (ERP: r = 0.66, P less than 0.01; FRP: r = 0.76, P less than 0.001), but did not correlate with that at the other two sites. We suggest that ageing modifies atrial refractoriness in a non-uniform manner inducing a progressive increment of dispersion of atrial refractoriness. The impression is that a slow but continuous process takes place from juvenility to old age.

Parasympathetic effects on electrophysiologic properties of cardiac ventricular tissue

The physiologic importance of parasympathetic influence on the sinoatrial and atrioventricular nodes is well established, but the importance of parasympathetic modulation of ventricular function remains controversial. Recognized effects of muscarinic cholinergic stimulation on ventricular automaticity and ventricular repolarization, the ability of muscarinic cholinergic agonists to antagonize catecholamine effects in the ventricle and proposed mechanisms for these effects are described. Anatomic studies have demonstrated a great abundance of cholinergic nerve endings in association with the ventricular conducting system. Stimulation of the vagus nerve or addition of muscarinic cholinergic agonists suppresses ventricular automaticity in most species and antagonizes isoproterenol-induced action potential shortening and isoproterenol-restored slow response action potentials. In vivo, interactions between the parasympathetic and sympathetic nervous systems occur at multiple levels. Muscarinic cholinergic agonists inhibit release of norepinephrine from sympathetic nerve terminals, inhibit catecholamine-stimulated adenylate cyclase activity and alter cyclic guanosine monophosphate (GMP) and possibly cyclic adenosine monophosphate (AMP) levels. Evidence is also presented that, in vivo, parasympathetic effects on ventricular electrical function might influence the pathophysiologic milieu responsible for initiation or termination of certain ventricular arrhythmias. Vagal influences appear to be protective against certain digitalis-induced arrhythmias and protective in certain experimental acute myocardial infarctions. In human beings, there appears to be tonic vagal tone in the ventricle and vagal stimulation terminates certain types of ventricular tachycardia. The evidence presented supports a physiologic role of parasympathetic stimulation in altering ventricular electrical function.

Primary and secondary cardioneuropathies and their functional significance

For most functions of the heart its nerves are as important as its coronary arteries, but this is particularly true concerning cardiac rhythm, conduction and repolarization. It is thus paradoxical that postmortem correlative studies of sudden death virtually always include careful scrutiny of the coronary arteries but only rarely of the cardiac nerves or ganglia. In this review, abnormalities of the cardiac nerves and ganglia, collectively termed cardioneuropathies, are examined from the dual standpoint of their structural appearance and functional significance. Some cardioneuropathies are found in the absence of any other significant structural abnormality detectable in the heart and these are designated as primary cardioneuropathies. A viral etiology or some heritable disorder must rank high among possible causes. Secondary cardioneuropathies are those observed in association with almost every disease that can affect the heart; examples include myocardial infarction, infections, amyloidosis and cancer, but there are many others. Because abnormalities of the heart's nerves and ganglia not only have their own unstabilizing influence on cardiac electrical activity but can also profoundly alter a patient's responses to pharmacologic treatment, it is hoped that future clinicopathologic examinations will more often include their careful study and thereby add to our meager knowledge about these important structures.

Phasic effects of repetitive vagal stimulation on atrial contraction

The vagus nerves of anesthetized dogs were stimulated once each cardiac cycle with a brief burst of pulses, and the timing of the stimulus bursts was changed by a fixed increment on successive cardiac cycles. The effects of such vagal stimulation on atrial contraction depended on the number of pulses per stimulus burst, on the interval between pulses within the burst, and on the timing of the stimulus bursts within the cardiac cycle. The vagal stimulus bursts had the least negative inotropic effect when they were given less than 100 msec before the next atrial depolarization, and they were most effective when given about 330 msec before the next atrial depolarization. This dependence of the inotropic response on the timing of the vagal activity within the cardiac cycle indicates that the following conditions must prevail with respect to the vagal innervation of the atrium: (1) the acetylcholine released from the vagal nerve endings is hydrolyzed at a critically rapid rate in the atrial tissues, (2) the neurally released acetylcholine must exert its major influence on atrial contraction during some preferential fraction of the cardiac cycle (presumably, during depolarization), and (3) after a vagal stimulus of a given strength, the concentration of acetylcholine in the region of the myocardial cells will attain its maximum value during this critical phase of the cardiac cycle when the vagal stimuli are given at the optimal time in the cardiac cycle.

Neuropeptide tyrosine (NPY)--a major cardiac neuropeptide

A newly discovered bioactive peptide, neuropeptide tyrosine (NPY), has been found in the human cardiac nervous system. Dense concentrations of NPY-immunoreactive nerve fibres were found in association with nodal tissue (atrioventricular node 22.1 +/- 3.7 pmol/g). NPY nerve fibres were seen in close contact with cardiac muscle fibres and were also found around the coronary vessels (19.6 +/- 6.2 pmol/g). Analysis of the peptide by high-performance liquid chromatography demonstrated that it was present in a single molecular form, closely similar or identical to that of the isolated bioactive peptide. Cardiac function in man has long been known to be influenced by cholinergic and adrenergic nerves. There now appears to be a further component of the nervous system in the human heart, involving peptidergic nerves containing NPY.

Enhanced parasympathetic tone shortens atrial refractoriness in man

The purpose of this study was to determine the effects of enhanced vagal tone on human right atrial refractoriness in 12 patients. A specially built neck collar connected to a vacuum source was placed around the patient's neck and enhanced vagal tone was produced during neck suction using intracollar negative pressures of 50 to 60 mm Hg. Refractory periods were determined with a catheter electrode positioned in the high right atrium near the sinus node. Induced neck suction increased the spontaneous sinus cycle length from 837 +/- 96 to 1.136 +/- 273 ms (p less than 0.001) and shortened the atrial effective refractory period from 241 +/- 24 to 230 +/- 20 ms (p less than 0.01) and the atrial functional refractory period from 272 +/- 32 to 262 +/- 29 ms (p less than 0.01). In 2 of 2 patients, collar-induced decreases in atrial refractoriness and increases in spontaneous cycle length were prevented after atropine (0.03 mg/kg) was given intravenously. It is concluded that enhanced vagal tone mediated through muscarinic receptors shortens atrial refractory periods in man.

The sinus node in sudden infant death syndrome

The sinus node (SN) was examined histologically in 30 infants diagnosed with sudden infant death syndrome (SIDS) and in 18 age-matched controls who died of known causes. Location, size and organization of the SN did not differ significantly in the two groups Petechiae involved the SN region in 20% of SIDS and 17% of control infants and probably do not represent a primary event. In three SIDS infants (10%), intimal lesions reduced the lumen of the intranodal SN artery by 63-83% in cross-sectional area. These resembled the intimal thickenings frequently observed in main epicardial coronary arteries of infants. Whether the vascular alterations in these three cases had adverse effects upon SN function is unknown.

Electrical activity from the sinus node region in conscious dogs

In an attempt to understand the way automatic cells in the sinus node (SN) control the cardiac rhythm, we studied extracellular electrograms recorded from the SN region in conscious dogs. A SN electrode, containing 48 silver terminals arranged 1.5 mm apart, was implanted over the node, and an indifferent electrode was implanted on the superior vena cava. Through terminals of the SN electrode paired with the vena caval electrode, "unipolar" electrograms were recorded at 100 microV/cm and with a time constant of 0.1 second. Low amplitude and low frequency deflections (dV/dt less than or equal to 20 mV/sec) which resulted from electrical activity of the node could be differentiated from the more rapid deflections due to atrial electrical activity. Electrical activity due to the inherent automaticity of what appeared to be groups of automatic cells was recognized as a slow negative-going diastolic slope followed by a slow negative-going, or negative and then positive-going, SN potential. Impulse propagation toward the SN electrode terminal in groups of automatic cells appeared as a slow positive-going deflection interrupting the diastolic slope. Adjacent groups of automatic cells located near the sites of earliest atrial activation discharged asynchronously before the earliest atrial activity; this suggests that multiple groups of automatic cells might initiate atrial activation. In addition to changes in rate and in location of the pacemaking groups of automatic cells, significant beat-to-beat variation in the sinoatrial interval contributed to the changes in atrial rate in "sinus arrhythmia." These studies provide a better understanding of SN function in conscious animals.

Cardiac arrhythmias after chronic embolization of the sinus node artery: alterations in parasympathetic pacemaker control

Embolization of the sinus node artery was accomplished in dogs by injecting rapidly hardening vinyl latex into the sinus node artery. Embolization immediately shifted the pacemaker to a junctional focus; however, with time postoperatively, the pacemaker shifted to an atrial site. Variable episodes of pacemaker failure, sinoatrial block, junctional rhythm, wandering atrial pacemaker and idioventricular escape rhythms were commonly observed on Holter monitor in isolation but only rarely when the dog was in the laboratory. Severe bradycardia (38.9 +/- 3.7 beats/min) was the predominant rhythm by 3-6 months postoperatively. In addition, these same dogs had a greater overall increase in heart rate after atropine than normal dogs (17.5 +/- 13.5 vs 116.6 +/- 15.9 beats/min above control; p less than 0.02). Responses to vagal stimulation in this group were abnormal, as long periods of asystole and bradycardia were observed after stimulation was terminated. These data suggest an alteration in parasympathetic pacemaker control after chronic embolization of the sinus node artery.

Effect of acetylcholine on the norepinephrine-induced positive chronotropy and increase in cyclic nucleotides of isolated rabbit sinoatrial node

Transmural stimulation of, or application of nicotine to, the isolated rabbit sinoatrial (SA) node resulted in initial negative and late positive chronotropy. Simultaneous application of acetylcholine and norepinephrine produced a similar biphasic chronotropic effect. These procedures produced an initial increase in cyclic guanosine 3':5'-monophosphate (cyclic GMP) and a delayed elevation in cyclic adenosine 3':5'-monophosphate (cyclic AMP). The initial and late effects on rate and nucleotide levels were inhibited by pretreatment with atropine and propranolol, respectively. Pretreatment with atropine shortened the time of maximum increase in cyclic AMP level and heart rate from 3 to 1 minute after the simultaneous application of acetylcholine and norepinephrine and enhanced the positive chronotropic effect. Physostigmine prolonged the duration of the increase in cyclic GMP and negative chronotropic effect after the simultaneous application. These results suggest that when acetylocholine and norepinephrine are present simultaneously in the SA node region, the former interacts predominantly with muscarinic receptors and stimulates the cyclic GMP system, which in effect delays the cyclic AMP elevation and reduces the positive chronotropic effect of norepinephrine. However, these effects of acetylcholine cannot be explained solely on the basis of changes in the cyclic GMP level, because sodium nitroprusside produced a marked elevation of the cyclic GMP levels without decreasing the heart rate and did not affect the norepinephrine-induced increase in pacemaker rate and cyclic AMP. Sodium nitroprusside may affect cyclic GMP pools other than those susceptible to acetylcholine. These cyclic GMP pools may not exert chronotropic effects.

Studies on the mechanism of sinus node dysfunction in the sick sinus syndrome

The intrinsic heart rate (IHR) was determined in 17 patients with symptomatic sinus bradycardia by administering atropine 0.04 mg/kg and propranolol 0.2 mg/kg, i.v. In this way, sick sinus (SSS) patients with intrinsic sinus node (SN) dysfunction could be distinguished from those patients with disturbed autonomic regulation of SN function. Sick sinus syndrome patients with normal corrected sinus node recovery time (SNRTC), adjusted for the magnitude and direction of autonomic chronotrophy, consistently had normal IHRs and therefore abnormalities of autonomic regulation. Sick sinus syndrome patients with abnormal adjusted SNRTC consistently had abnormal IHRs and therefore abnormalities of intrinsic SN function. We conclude that more than one pathophysiologic mechanism can produce the clinical manifestations of sick sinus syndrome and that abnormal prolongation of SNRTC is dependent upon the underlying mechanism of sinus node dysfunction.

Analysis of secondary pauses following termination of rapid atrial pacing in man

The first ten cycles following cessation of atrial pacing were evaluated in 44 control subjects (mean age 52.9 +/- 14.88 yr) and 39 patients (mean age 62.9 +/- 15.41 yr) suspected of having sinus node dysfunction (SND). The maximal cycle length for each postpacing cycle following several pacing periods in each control subject was determined, and was normalized by dividing it by the subject's mean spontaneous control cycle length (SCL). Using the control group, a normalized maximal post-pacing response pattern (mean and SD) was derived. For each SND patient, a composite SD for each post-pacing cycle was calculated by adding the patient's SCL variance to the variance determined for each post-pacing cycle in the control group. Two composite SD above the mean value for each post-pacing cycle was selected as the upper limit of the normal recovery response and used to identify abnormal post-pacing responses in the 39 SND patients. Abnormally prolonged cycle lengths subsequent to the first escape cycle (secondary pauses) were found in 16/39 (41.0%) patients, of whom 11/39 (28.2%) had a prolonged SNRTmax. Of importance, 11/12 (91;7%) patients with documented SA block or sinus pauses prior to electrophysiologic study, demonstrated secondary pauses, while only 7/12 (58.3%) had a prolonged SNRTmax. Criteria are derived for the identification of secondary pauses during the postpacing period, and a close association between secondary pauses and the presence of spontaneous SA block or sinus pauses prior to electrophysiologic study is demonstrated.

Mechanism of the bradycardia during coronary angiography

Bradycardia occurring during coronary angiography may be due to the direct effect of dye or to reflex vagal effects on pacemaker centers. Fifteen patients were classified according to the origin of the sinus nodal and atrioventricular nodal arteries. In patients with type A anatomy, both the sinus and the atrioventricular nodal arteries arose from the right coronary artery. In those with type B anatomy, only the atrioventricular nodal artery arose from the right coronary artery. Heart rate recordings were made during coronary angiography before and after selective infusion of atropine (0.2mg) into the right coronary artery. In type A patients, the sinus bradycardia observed during right coronary dye injection was caused by a combination of both direct and reflex effects on pacemaker tissue. Sinus bradycardia occurring with left coronary dye injections was entirely reflex in nature and was completely blocked with right coronary arterial injection of atropine. In type B patients, sinus bradycardia with right coronary dye injections was produced by reflex suppression of the sinus pacemaker. A junctional rhythm was consistently produced after administration of atropine. Junctional bradycardia in type B patients was caused by direct suppression of the junctional pacemaker. Thus, angiographic dye appears to decrease heart rate by a direct effect on pacemaker tissue and by reflex vagal suppression of the sinus pacemaker.