Spectral analyses of R-R interval and systolic blood pressure in diabetic autonomic neuropathy

Associations of age-adjusted coefficient of variation of R-R intervals with autonomic and peripheral nerve function in non-elderly persons with diabetes

AIMS/INTRODUCTION

Early diagnosis of diabetes-associated cardiac autonomic neuropathy using the coefficient of variation of R-R intervals (CVRR) may improve outcomes for individuals with diabetes. The present study examined the associations of decreased CVRR at rest and during deep breathing (DB) with other autonomic nerve function parameters.

MATERIALS AND METHODS

The electronic records of 141 inpatients with diabetes (22-65 years) admitted to our hospital between March 2015 and March 2019 were analyzed retrospectively. After assessment by exclusion criteria, 51 inpatients were included. All inpatients were assessed for peripheral and autonomic nerve function, clinical characteristics, and physical abilities.

RESULTS

Inpatients with decreased CVRR at rest (n = 9 (17.6%)) and during DB (n = 12 (23.5%)) had a longer duration of known diabetes, a higher prevalence of diabetic retinopathy, lower body mass index (BMI), skeletal mass index (SMI), and knee extension strength, and a higher proportion of impaired standing balance. Decreased CVRR at rest was associated with a greater fall in diastolic BP from supine to standing, higher resting HR, longer QTc, longer time of voiding, and sensory symptoms.

CONCLUSIONS

Decreased CVRR at rest and during deep breathing was associated with lower BMI, SMI, and knee strength and a higher proportion of impaired standing balance among non-elderly inpatients with diabetes. Decreased CVRR at rest appeared more strongly associated with a greater orthostatic BP decline, higher resting heart rate, longer QTc, lower urinary tract dysfunction, and sensory symptoms than a decreased CVRR during deep breathing.

Coefficient of variation of R-R interval closely correlates with glycemic variability assessed by continuous glucose monitoring in insulin-depleted patients with type 1 diabetes

AIMS

In type 1 diabetic patients, insulin secretory capacity, meals and physical activity correlate with glycemic variability. Autonomic function associated with gastrointestinal motility and counterregulatory hormone secretion is another candidate which correlates with glucose variability. The aim of this study is to clarify a new clinical parameter associated with glycemic variability in insulin-depleted patients with type 1 diabetes.

METHODS

We studied 31 inpatients with type 1 diabetes. We evaluated glycemic variability calculated by continuous glucose monitoring, clinical parameters and the coefficient of variation of R-R interval (CVR-R). Glycemic variability was also assessed during the daytime and nighttime.

RESULTS

The CVR-R showed a significant negative correlation with the whole-day standard deviation (SD) (r = -0.50, p = 0.007), mean amplitude of glycemic excursions (MAGE) (r = -0.47, p=0.011), M-value (r = -0.38, p = 0.048) and mean of daily differences (MODD) (r = -0.59, p = 0.001). The CVR-R also showed a significant negative correlation with the nighttime SD (r = -0.59, p = 0.001), MAGE (r = -0.47, p=0.011), M-value (r = -0.53, p = 0.004) and MODD (r = -0.65, p = 0.0003). And furthermore, the CVR-R also showed a significant negative correlation with the daytime SD (r = -0.44, p = 0.019) and MAGE (r = -0.50, p = 0.006), but not with the daytime M-value or MODD. The nighttime SD was significantly higher in patients with diabetic polyneuropathy than in patients without it (p = 0.016), while the CVR-R was significantly lower in patients with polyneuropathy than in patients without it (p = 0.009).

CONCLUSIONS

CVR-R is closely correlated with glycemic variability, especially during nighttime, in insulin-depleted patients with type 1 diabetes. Measuring CVR-R may help us to presume the degree of glycemic variability in those patients.

Comparable accuracy of micro-electromechanical blood flowmetry-based analysis vs. electrocardiography-based analysis in evaluating heart rate variability

BACKGROUND

Because the conventional evaluation of autonomic nervous system (ANS) function inevitably uses long-lasting uncomfortable electrocardiogram (ECG) recording, a more simplified and comfortable analysis system has been sought for this purpose. The feasibility of using a portable micro-electromechanical system (MEMS) blood flowmeter to analyze heart rate variability (HRV) for evaluating ANS function was thus examined.

METHODS AND RESULTS

Measurements of the R-R interval (TRR) derived from an ECG, simultaneously with the pulse wave interval (TPP) derived from a MEMS blood flowmeter, in 8 healthy subjects was performed and resultant HRV variables in time and frequency domains were compared. The TRR- and TPP-derived variables were strongly correlated (coefficients of regression for low frequency (LF), high frequency (HF), and LF/HF of 1.1, 0.66, and 0.35, respectively; corresponding coefficients of determination of 0.92, 0.63, and 0.91, respectively (P<0.01)). In addition, the values of LF, HF, and LF/HF, as analyzed using TPP, changed significantly from the supine to the standing position in another 6 subjects.

CONCLUSIONS

Miniaturized-MEMS blood flowmetry can be used to perform HRV analysis for the evaluation of ANS function, which is as accurate as analysis based on ECG within comparable tolerances. As MEMS blood flowmetry can more easily and comfortably record physiological variables for longer durations than ECG recording, and can further capture skin blood flow information, this device has great potential to be used in a wider area of physiological analyses.

Pathological baroreceptor sensitivity in patients suffering from somatization disorders: do they correlate with symptoms?

AIM

We conducted a study to investigate whether patients with somatization disorders (ICD-10, F45.0) show abnormal values in autonomic testing.

METHOD

35 patients with a diagnosis of somatization disorder (SP) were matched to 35 healthy volunteers (HV). International standardized autonomic testing based on heart rate variation and continuously measured blood pressure signals was used to assess autonomic activity and establish baroreceptor sensitivity (BRS). Three different statistical procedures were used to confirm the reliability of the findings.

RESULTS

There were no statistical differences between the 2 groups in age, BMI, systolic and diastolic blood pressures, and spectral values (total power, low, and high frequency power). However, heart rate was higher (p=0.044) and baroreceptor sensitivity was lower (p=0.002) in the patients compared to the healthy volunteers. Median BRS (+/-S.E.M.) of patients was 9.09+/-0.65 compared to 12.04+/-0.94 ms/mmHg in healthy volunteers. Twenty-two of the 35 patients had a BRS of -1.0S.D. below the mean of HV. SP with lower values differed from SP with normal BRS in values of total power, low-, mid-, and high-frequency bands (p<0.01 to <0.0001). No differences in psychometric testing were found between patients with lower or higher BRS. In addition, no correlation whatsoever was found in relation to autonomic variables between HV and SP, except for a higher LF/HF quotient in the latter (p<0.05).

CONCLUSION

Autonomic regulation was impaired in 62% of patients with a somatization disorder. Severity of clinical symptoms measured by psychometric instruments did not preclude autonomic function impairment. Accordingly, autonomic dysfunction may constitute an independent somatic factor in this patient group.

Correlates of the shift in heart rate variability with postures and walking by time-frequency analysis

Heart rate (HR) variability derived from electrocardiogram (ECG) can be used to assess the function of the autonomic nervous system. HR exhibits various characteristics during different physical activities attributed to the altered autonomic mediation, where it is also beneficial to reveal the autonomic shift in response to physical-activity change. In this paper, the physical-activity-related HR behaviors were delineated using a portable ECG and body acceleration recorder based on a personal digital assistant and the smoothed pseudo Wigner-Ville distribution. The results based upon eighteen subjects performing four sequential 5-min physical activities (supine, sitting, standing and spontaneous walking) showed that the high-frequency heartbeat fluctuations during supine and sitting were significantly larger than during standing, and that the ratio of low- to high-frequency fluctuation during standing was significantly higher than during supine and sitting. This could be linked with the parasympathetic predominance during supine and sitting, and a shift to sympathetic dominance while standing. During spontaneous walking, the high-frequency fluctuation was significant lower than during supine. The low- to high-frequency ratio decreased significantly from standing to spontaneous walking, which may imply an increased vagal predominance (autonomic effect) or an increased respiratory activity (mechanical effect).

Heart Rate Variability Characterization in Daily Physical Activities Using Wavelet Analysis and Multilayer Fuzzy Activity Clustering

A portable data recorder was developed to parallel measure the electrocardiogram and body accelerations. A multilayer fuzzy clustering algorithm was proposed to classify the physical activity based on body accelerations. Discrete wavelet transform was incorporated to retrieve time-varying characteristics of heart rate variability under different physical activities. Nine healthy subjects were included to investigate activity-related heart rate variability during 24 h. The results showed that the heartbeat fluctuations in high frequencies were the greatest during lying and the smallest during standing. Moreover, very-low-frequency heartbeat fluctuations during low activity level (lying) were greater than during high activity level (nonlying).

Dysfunctional baroreflex regulation of sympathetic nerve activity in remitted patients with panic disorder. A new methodological approach

BACKGROUND

Many researchers have studied the abnormalities of autonomic nervous system (ANS) such as decreased heart rate variability, which is a risk factor for sudden cardiac death, in patients with panic disorder (PD). However, no consistent abnormality has been uncovered to date. One of the reasons for this controversy may be due to the fact that most of these conventional studies have analyzed each physiological variable independent of other indices. We examined the ANS in PD patients using a new method which can more directly investigate the function of the baroreflex by examining the relation between the blood pressure (BP) and heart rate (HR).

METHODS

During rest and audiovisual stimulation (AS) as mental stress such as being exposed to video imaginary of experiences such as driving motor vehicles, cardiovascular parameters, HR and BP were consecutively measured in 13 remitted PD patients and twenty aged and gender-matched normal controls (NC). In this study, to assess the cardiovascular ANS function (baroreflex) in PD we used the power spectrum analysis as usual and the mean of lag time (tau) between the Mayer wave components, which was closely related to sympathetic nerve activity of vasomotor, of HR and BP variability as a new trial.

RESULTS

The PD patients and NC did not differ with regard to the power spectrum analysis of the heart rate. We found that tau in the PD group was significantly shorter than that in the NC both before and after AS, especially before.

CONCLUSIONS

These findings suggest that remitted PD patients may have a dysfunctional baroreflex regulation of sympathetic nerve activity.

Time- and frequency-domain estimation of early diabetic cardiovascular autonomic neuropathy

The risk related to cardiovascular autonomic neuropathy dysautonomia should lead to a specific assessment of this complication of diabetes. The aim of this study was to estimate the accuracy of a battery of blood pressure (BP) and heart rate (HR) variability indexes obtained in different subgroups of diabetic subjects classified according to the conventional laboratory autonomic function tests (Ewing scores). Blood pressure was measured continuously at the finger level with a Finapres monitor while subjects were in the supine position and again while they were standing. Pulse intervals were derived from BP recordings and were taken as surrogates for R-R intervals. Subjects with borderline or definite cardiovascular autonomic neuropathy showed a similar degree of alterations of both HR and BP variability (spectral measures) and in the relationship between BP and HR (cross-spectral and sequence analysis). Subjects with no evidence of cardiovascular autonomic neuropathy on the basis of the conventional tests showed an altered relationship between BP and HR. This baroreceptor-HR reflex dysfunction could represent an early stage of cardiovascular autonomic neuropathy undetected by the conventional tests. The areas under the receiver operating characteristic plots indicated that the high-frequency peak of pulse interval was highly discriminant in the supine and standing positions. The cross-spectral analysis showed the best discrimination for the gain in the high-frequency range. For the sequence analysis, the slope was the best discriminant factor for any degree of cardiovascular autonomic neuropathy. In conclusion, these estimates of baroreceptor-HR function may provide a powerful tool for assessing cardiovascular autonomic neuropathy at any stage, including the early stage, which is not detected by the conventional tests.

Observer variations in short period spectral analysis of heart rate variability

25% of the corresponding mean LF/HF ratio. The smallest interobserver variations were found for the 'fixed frequency' method. The data showed that it is advantageous to select the 3-min ECG periods but not to select the frequency regions. Selection of the latter led to an increase in interobserver variation. The results of this study give a realistic impression of the intrasubject and interobserver variation to be expected when measuring the LF/HF ratio. This variation is considerable.

Rationale for assessing the effects of manipulative therapy on autonomic tone by analysis of heart rate variability

BACKGROUND

For more than 100 years, chiropractors have asserted that overall health can be improved through the use of spinal manipulative therapy. The autonomic nervous system is known to control and regulate all involuntary physiologic activities by controlling the activities of the internal organs, glands, and circulation. Recent studies document a potential relationship between the vertebral subluxation complex, autonomic tone, and cardiac function.

OBJECTIVE

This discussion reviews how it is possible to use heart rate variability analysis to calculate a quantitative index of autonomic function, which accurately reflects the sympathetic and parasympathetic tone and the sympathovagal balance.

DISCUSSION

The technique of heart rate analysis known as heart rate variability could be extremely useful in assessment of treatment outcomes in clinical chiropractic practice. At present, heart rate variability is in widespread use in the fields of neurology, cardiology, psychology, psychophysiology, obstetrics, anesthesiology, and psychiatry.

CONCLUSION

Further studies in this area may lead to a better understanding of the effects of spinal manipulation on (1) the general health of an individual, (2) an individual's susceptibility to lowered immunity and recuperative capacity, and (3) conditions that lie outside the scope of musculoskeletal therapeutics and are more in line with classical chiropractic concepts. This can also contribute to a better-informed interprofessional cooperation between allopathic and chiropractic health care providers.

Early autonomic dysfunction in patients with diabetes mellitus assessed by spectral analysis of heart rate and blood pressure variability

Patients with diabetes mellitus (DM) often have alterations of the autonomic nervous system (ANS), even early in their disease course. Previous research has not evaluated whether these changes may have consequences on adaptation mechanisms in DM, e.g. to mental stress. We therefore evaluated whether patients with DM who already had early alterations of the ANS reacted with an abnormal regulatory pattern to mental stress. We used the spectral analysis technique, known to be valuable and reliable in the investigation of disturbances of the ANS. We investigated 34 patients with DM without clinical evidence of ANS dysfunction (e.g. orthostatic hypotension) and 44 normal control subjects (NC group). No patients on medication known to alter ANS responses were accepted. The investigation consisted of a resting state evaluation and a mental stress task (BonnDet). In basal values, only the 21 patients with type 2 DM were different in respect to body mass index and systolic blood pressure. In the study parameters we found significantly lower values in resting and mental stress spectral power of mid-frequency band (known to represent predominantly sympathetic influences) and of high-frequency and respiration bands (known to represent parasympathetic influences) in patients with DM (types 1 and 2) compared with NC group (5.3 +/- 1.2 ms2 vs. 6.1 +/- 1.3 ms2, and 5.5 +/- 1.6 ms2 vs. 6.2 +/- 1.5 ms2, and 4.6 +/- 1.7 ms2 vs. 6.2 +/- 1.5 ms2, for resting values respectively; 4.7 +/- 1.4 ms2 vs. 5.9 +/- 1.2 ms2, and 4.6 +/- 1.9 ms2 vs. 5.6 +/- 1.7 ms2, and 3.7 +/- 2.1 ms2 vs. 5.6 +/- 1.7 ms2, for stress values respectively; M/F ratio 6/26 vs. 30/14). These differences remained significant even when controlled for age, sex, and body weight. However, patients with DM type 2 (and significantly higher body weight) showed only significant values in mental stress modulus values. There were no specific group effects in the patients with DM in adaptation mechanisms to mental stress compared with the NC group. These findings demonstrate that power spectral examinations at rest are sufficiently reliable to diagnose early alterations in ANS in patients with DM. The spectral analysis technique is sensitive and reliable in investigation of ANS in patients with DM without clinically symptomatic autonomic dysfunction.

The trigonometric regressive spectral analysis--a method for mapping of beat-to-beat recorded cardiovascular parameters on to frequency domain in comparison with Fourier transformation

Heart rate and peripheral blood pressure as physiological recorded vegetative parameters are very often rhythmically investigated with the Fourier Transformation (FT). In contrast to the original use of FT these parameters are still stochastic with overlaying rhythmical structures. The R-R intervals as independent variables of time are not equidistant. The mathematical structure for the spectral decomposition is critically analysed. The purpose of this article is the presentation of a mathematical method, considering both the statistical and rhythmical features of such time series. On the basis of trigonometric regressions, this method is presented to eliminate the equidistance problems, arising with the usage of FT, by a new mathematical approach. This method computes more precisely the spectral power especially in the VLF range (0.003-0.04 Hz) than FT, because this method of trigonometric regression does not perform a frequency quantization. This method has been used and successfully tested for the analysis of peripheral blood pressure and R-R intervals including an effective reduction of input data.

Impairment of autonomic function induced by posture change in postmenopausal women

This study was designed to determine if there is a difference in autonomic regulation induced by posture change between postmenopausal and young women. To evaluate autonomic nervous system function, spectral analysis of heart rate variability (HRV) was done in postmenopausal women (n = 13, 46-59 years of age), age-matched men (n = 8, 45-55 years of age), and young women (n = 10, 20-37 years of age) for 3-min periods of controlled frequency breathing (15 breaths/min) in supine followed by sitting positions. In the supine position, the R-R interval variation in older persons decreased significantly compared with that during the follicular phase in young women. Furthermore, the high-frequency (HF) components of HRV, which reflect only parasympathetic activity, were lower in older subjects than in young women. Following a change of position from supine to sitting, the HF component did not change significantly in the postmenopausal women or the men, but the low/high frequency (LF/HF) component ratio, which reflects the balance of autonomic nerve activities, increased significantly in the men. These results suggest that cardiac parasympathetic tone may be reduced in older persons in comparison with young women. Furthermore, arterial baroreflex control of parasympathetic nerve activity caused by posture changes is impaired in the postmenopausal women and aged-matched men. The baroreflex control of the sympathetic component is maintained in the men but not in the postmenopausal women. These differences might result in part from changes in the level of female hormones.

Reflex control of autonomic function induced by posture change during the menstrual cycle

This study was designed to determine whether autonomic regulation induced by posture changes varies during the menstrual cycle. Heart rate variability (HRV) was analyzed in women with normal menstrual cycles (n = 10, age range 20-37 years) during 3 min periods of controlled frequency breathing (15 breaths/min) in supine followed by sitting positions. In a supine or sitting position, high frequency (HF) components of HRV, which reflects only parasympathetic activity, were significantly high in the follicular phase compared with those in the menstrual phase, suggesting that parasympathetic nerve activity increases in this phase. Following the change of position to sitting from supine, the HF component decreased significantly in the menstrual, ovulatory and luteal phases, but not the follicular or premenstrual phase. After changing the position to sitting, the low to high frequency component ratio, which reflects the balance of autonomic nerve activities, was increased significantly in the menstrual, luteal and premenstrual phases, indicating that sympathetic nerve activities in these phases became predominant by the sitting position. These results suggest that parasympathetic nerve activity is predominant in the follicular phase, resulting in an impairment of baroreflex caused by posture changes. Moreover, baroreflex control of the sympathetic component, not the parasympathetic component, increases in the premenstrual phase, while the reflex response of the sympathetic component is less in the ovulatory phase compared with the menstrual or luteal phase. We concluded that baroreflex regulation of autonomic functions induced by changing positions is modified during the menstrual cycle. A difference of a balance of ovarian hormones may be responsible for these changes of autonomic functions during the menstrual cycle.

Prolongation of QTc interval and autonomic nervous dysfunction in diabetic patients

We have attempted to clarify the relationships of the QTc interval to alpha and beta sympathetic, as well as parasympathetic function tests including spectral analyses of the R-R interval and systolic blood pressure. The QTc intervals were estimated in 76 diabetic patients and 76 age-matched healthy controls whose R-R intervals were comparable to those of the diabetic patients. We also investigated the relationships of the QTc interval to various clinical features of diabetes mellitus and to autonomic function tests. The QTc interval in diabetic patients was significantly greater than that in healthy controls. The QTc intervals were unrelated to diabetic control, retinopathy and nephropathy, but were prolonged in patients with a long duration of diabetes as compared to those with a short disease duration. There were significant correlations between the QTc interval and orthostatic hypotension, R-R variation and the Valsalva maneuver. Significant correlations were observed between the QTc interval and both the low and the high frequency component of spectral analysis of the R-R interval, whereas no correlations were found with spectral analysis of systolic blood pressure. An abnormal QTc interval is an indicator of cardiac sympathetic and parasympathetic nervous dysfunction, but not vasomotor dysfunction.