Dissociation between cortical activation and cognitive performance under pharmacological blood pressure elevation in chronic hypotension

Hypotension with neurovascular changes and cognitive dysfunction: An epidemiological, pathobiological, and treatment review

ABSTRACT

Hypotension is a leading cause of age-related cognitive impairment. The available literature evidences that vascular factors are associated with dementia and that hypotension alters cerebral perfusion flow and can aggravate the neurodegeneration of Alzheimer's disease (AD). Despite the discovery of biomarkers and the recent progress made in neurovascular biology, epidemiology, and brain imaging, some key issues remain largely unresolved: the potential mechanisms underlying the neural deterioration observed in AD, the effect of cerebrovascular alterations on cognitive deficits, and the positive effects of hypotension treatment on cognition. Therefore, further well-designed studies are needed to unravel the potential association between hypotension and cognitive dysfunction and reveal the potential benefits of hypotension treatment for AD patients. Here, we review the current epidemiological, pathobiological, and treatment-related literature on neurovascular changes and hypotension-related cognitive dysfunction and highlight the unsettled but imminent issues that warrant future research endeavors.

Olfactory Modulation of the Contingent Negative Variation to Auditory Stimuli

Although pleasantness is intrinsically related to the perception of odors it is difficult to objectively assess odor-induced pleasantness. To evaluate the effects of odors of different valences on the contingent negative variation (CNV) in a younger and an older population. Data from 62 participants (27 men, 35 women) were included. Two age groups with Age group 1 (YOUNG) had 30 subjects within age 18-30 years and age group 2 (OLD) had 32 subjects with age >40 years. Pre-testing was performed to acquaint subjects with the experimental tasks and their environment. Subjects received "Sniffin' Sticks" odor identification tests and a standardized medical history to ascertain normosmia. In addition, they also took questionnaires relating to importance of the sense of smell and personality traits. CNV was elicited with two auditory stimuli, S1 followed by S2 at an interval of 2.4 s. Subjects were asked to push a button as fast as possible after they perceived S2. EEG was recorded from 4 positions of the 10-20 system (Fp2, Fz, Cz, and Pz). Four odors plus odorless air was presented in randomized order. The following main results emerged: (1) Consistent with the literature CNV showed a typical topographical distribution with the largest amplitude over the front-central recording sites. (2) 69% of subjects had consistent CNV for all conditions. (3) for some odor conditions CNV amplitudes exhibit a weak relation to odor pleasantness and associations with calmness. (4) CNV amplitude correlated negatively with reaction times. Overall, the results suggest the usefulness of CNV as an electrophysiological measure of cognition. However, in the present context, concomitantly applied odors of different hedonic tones exerted only minor effects on CNV. Thus, we conclude that odors have little or no effect on CNV.

Baroreceptor Modulation of the Cardiovascular System, Pain, Consciousness, and Cognition

Baroreceptors are mechanosensitive elements of the peripheral nervous system that maintain cardiovascular homeostasis by coordinating the responses to external and internal environmental stressors. While it is well known that carotid and cardiopulmonary baroreceptors modulate sympathetic vasomotor and parasympathetic cardiac neural autonomic drive, to avoid excessive fluctuations in vascular tone and maintain intravascular volume, there is increasing recognition that baroreceptors also modulate a wide range of non-cardiovascular physiological responses via projections from the nucleus of the solitary tract to regions of the central nervous system, including the spinal cord. These projections regulate pain perception, sleep, consciousness, and cognition. In this article, we summarize the physiology of baroreceptor pathways and responses to baroreceptor activation with an emphasis on the mechanisms influencing cardiovascular function, pain perception, consciousness, and cognition. Understanding baroreceptor-mediated effects on cardiac and extra-cardiac autonomic activities will further our understanding of the pathophysiology of multiple common clinical conditions, such as chronic pain, disorders of consciousness (e.g., abnormalities in sleep-wake), and cognitive impairment, which may result in the identification and implementation of novel treatment modalities. © 2021 American Physiological Society. Compr Physiol 11:1373-1423, 2021.

Autonomic Cardiovascular Dysregulation at Rest and During Stress in Chronically Low Blood Pressure

Abstract. Chronic low blood pressure (hypotension) is accompanied by symptoms such as fatigue, reduced drive, faintness, dizziness, cold limbs, and concentration difficulties. The study explored the involvement of aberrances in autonomic cardiovascular control in the origin of this condition. In 40 hypotensive and 40 normotensive subjects, impedance cardiography, electrocardiography, and continuous blood pressure recordings were performed at rest and during stress induced by mental calculation. Parameters of cardiac sympathetic control (i.e., stroke volume, cardiac output, pre-ejection period, total peripheral resistance), parasympathetic control (i.e., heart rate variability), and baroreflex function (i.e., baroreflex sensitivity) were obtained. The hypotensive group exhibited markedly lower stroke volume, heart rate, and cardiac output, as well as higher pre-ejection period and baroreflex sensitivity than the control group. Hypotension was furthermore associated with a smaller blood pressure response during stress. No group differences arose in total peripheral resistance and heart rate variability. While reduced beta-adrenergic myocardial drive seems to constitute the principal feature of the autonomic impairment that characterizes chronic hypotension, baroreflex-related mechanisms may also contribute to this state. Insufficient organ perfusion due to reduced cardiac output and deficient cardiovascular adjustment to situational requirements may be involved in the manifestation of bodily and mental symptoms.

Effects of midodrine and L-NAME on systemic and cerebral hemodynamics during cognitive activation in spinal cord injury and intact controls

We previously showed that increases in mean arterial pressure (MAP) following administration of midodrine hydrochloride (MH) and nitro‐L‐arginine methyl ester (L‐NAME) resulted in increased mean cerebral blood flow velocity (MFV) during head‐up tilt in hypotensive individuals with spinal cord injury (SCI) and question if this same association was evident during cognitive activation. Herein, we report MAP and MFV during two serial subtraction tasks (SSt) given before (predrug) and after (postdrug) administration of MH; (10 mg), L‐NAME (1 mg/kg) or no drug (ND) in 15 subjects with SCI compared to nine able‐bodied (AB) controls. Three‐way factorial analysis of variance (ANOVA) models were used to determine significant main and interaction effects for group (SCI, AB), visit (MH, L‐NAME, ND), and time (predrug, postdrug) for MAP and MFV during the two SSt. The three‐way interaction was significant for MAP (F = 4.262; P = 0.020); both MH (30 ± 26 mmHg; P < 0.05) and L‐NAME (27 ± 22 mmHg; P < 0.01) significantly increased MAP in the SCI group, but not in the AB group. There was a significant visit by time interaction for MFV suggesting an increase from predrug to postdrug following L‐NAME (6 ± 8 cm/sec; P < 0.05) and MH (4 ± 7 cm/sec; P < 0.05), regardless of study group, with little change following ND (3 ± 3 cm/sec). The relationship between change in MAP and MFV was significant in the SCI group following administration of MH (r² = 0.38; P < 0.05) and L‐NAME (r² = 0.32; P < 0.05). These antihypotensive agents, at the doses tested, raised MAP, which was associated with an increase MFV during cognitive activation in hypotensive subjects with SCI.

Autonomic cardiovascular regulation and cortical tone

This study aimed to investigate interactions between tonic cortical arousal and features of autonomic cardiovascular regulation. In 50 healthy subjects, the power spectrum of the spontaneous EEG was obtained at resting state. Concurrently, respiratory sinus arrhythmia (RSA), baroreflex sensitivity (BRS) and R-wave to pulse interval (RPI) were recorded as indices of cardiovascular control. At the bivariate level, only a negative correlation between beta power recorded at frontal electrode positions and RPI was found. However, when common variance of BRS and RSA was controlled for in multiple regression analyses, a positive association between alpha power and RSA, and an inverse relationship with BRS, also arose. The findings concerning RPI and RSA are suggestive of a relationship between higher levels of cortical tone and increased sympathetic and reduced vagal cardiac influences. The inverse association between BRS and alpha activity may reflect bottom-up modulation of cortical arousal by baroreceptor afferents.

The beneficial effects of meditation: contribution of the anterior cingulate and locus coeruleus

During functional magnetic resonance imaging studies of meditation the cortical salience detecting and executive networks become active during "awareness of mind wandering," "shifting," and "sustained attention." The anterior cingulate (AC) is activated during "awareness of mind wandering." The AC modulates both the peripheral sympathetic nervous system (SNS) and the central locus coeruleus (LC) norepinephrine systems, which form the principal neuromodulatory system, regulating in multiple ways both neuronal and non-neuronal cells to maximize adaptation in changing environments. The LC is the primary source of central norepinephrine (C-NE) and nearly the exclusive source of cortical norepinephrine. Normally activated by novel or salient stimuli, the AC initially inhibits the SNS reflexively, lowering peripheral norepinephrine and activates the LC, increasing C-NE. Moderate levels of C-NE enhance working memory through alpha 2 adrenergic receptors, while higher levels of C-NE, acting on alpha 1 and beta receptors, enhance other executive network functions such as the stopping of ongoing behavior, attentional set-shifting, and sustained attention. The actions of the AC on both the central and peripheral noradrenergic systems are implicated in the beneficial effects of meditation. This paper will explore some of the known functions and interrelationships of the AC, SNS, and LC with respect to their possible relevance to meditation.

A prospective report on the prevalence of heart rate and blood pressure abnormalities in veterans with spinal cord injuries

OBJECTIVE

Decentralized autonomic cardiovascular regulation may lead to increased prevalence of heart rate (HR) and blood pressure (BP) abnormalities in veterans with SCI. In addition, comorbid medical conditions and prescription medication use may increase HR and BP abnormalities. These abnormalities include bradycardia, and tachycardia, hypotension, hypertension as well as autonomic dysreflexia and orthostatic hypotension; the prevalence of which is unknown.

DESIGN

HR and BP data were measured during a routine annual physical examination in 64 veterans with SCI. Measurements of HR and BP were recorded in the seated and supine positions to document the influence of body position and to document intra-subject variability in these assessments.

RESULTS

All subjects were chronically injured (20 ± 14 years), 33 subjects were tetraplegic (T: C3-C8), nine had high paraplegia (HP: T1-T6), and 22 had low paraplegia (LP: T7-L2). Regardless of position, the prevalence of bradycardia was increased in the T group, whereas prevalence of tachycardia was increased in the HP and LP groups. Systolic hypotension was more common in the T and HP groups than the LP group and positional effects were most evident in the T group. Systolic hypertension was comparable in the T and HP groups but was twice as prevalent in the LP group. Increased prevalence of individuals with three or more medical conditions and prescribed three or more medications which might influence HR and BP was observed.

CONCLUSION

Decentralized autonomic regulation, comorbid medical conditions, and prescription medication use in veterans with SCI result in HR and BP abnormalities; our data suggest that these abnormalities vary depending on the level of injury and orthostatic positioning.

The behavioral impact of baroreflex function: a review

The baroreflex consists of a negative feedback loop adjusting heart activity to blood pressure fluctuations. This review is concerned with interactions between baroreflex function and behavior. In addition to changes in baroreflex cardiac control subject to behavioral manipulations, interindividual differences in reflex function predicted psychological and central nervous features. The sensitivity of the reflex was inversely related to cognitive performance, evoked potential amplitudes, experimental pain sensitivity, and the severity of clinical pain. Possible variables moderating the strength of the associations are tonic blood pressure, gender, and psychiatric disease. It is suggested that these observations reflect inhibition of higher brain function by baroreceptor afferents. While in many cases increased baroreflex function implies stronger inhibition, individual and situational factors modulate the behavioral impact of cardiac regulation.

Interactions between autonomic cardiovascular regulation and cortical activity: a CNV study

The study investigated interactions between autonomic cardiovascular regulation and cortical activity. In 54 healthy subjects, baroreflex sensitivity (BRS) and respiratory sinus arrhythmia (RSA) were assessed at resting conditions. As an EEG indicator of cortical excitability, the contingent negative variation (CNV) was induced using a constant foreperiod reaction time task. At bivariate level, only RSA showed a moderate positive correlation with the CNV recorded at frontal electrodes. However, when common variance of BRS and RSA was controlled for in multiple regression analysis, an inverse association between BRS and the frontal CNV also arose. The inverse association between BRS and the CNV is discussed as reflecting bottom-up modulation of cortical excitability by baroreceptor afferents. The positive correlation between RSA and the CNV may relate to the interplay between prefrontal processing and cardiac vagal tone.

Nocturnal cardiovascular activity in essential hypotension: evidence of differential autonomic regulation

OBJECTIVE

Essential hypotension represents a form of chronic low blood pressure (BP) not explained by medical or orthostatic conditions. The pathogenesis of essential hypotension may involve sympathetic hypoactivation and other forms of autonomic dysregulation. The aim of the current study was to investigate autonomic and cardiovascular activity during sleep in individuals with essential hypotension.

METHODS

A case-control study was conducted in 14 individuals with essential hypotension (mean [standard error] = 23.4 [0.6] years, all women) and 14 controls (mean [standard error] age = 22.2 [0.4] years, all women). The following measures were collected over a night of sleep: BP, heart rate (HR), stroke volume, cardiac output (CO), preejection period (PEP), total peripheral resistance, and time-domain measures of HR variability.

RESULTS

Hypotensive participants had consistently lower BP, HR, and CO than did normotensives. Cardiac autonomic variables revealed enhanced parasympathetic tone (proportion of adjacent normal-to-normal intervals that differed in length by more than 50 milliseconds = 40.8 [6.3] versus 23.4 [4.5], p = .03) and reduced sympathetic drive in hypotensives (PEP = 99.4 [3.6] versus 86.1 [4.3], p = .02). Analysis of temporal profiles showed that HR, stroke volume, and CO decreased throughout the night in both groups, whereas PEP and HR variability increased. Unlike controls, BP remained essentially unchanged in hypotensives, as the decrease in CO was counterbalanced by a parallel rise in total peripheral resistance.

CONCLUSIONS

These findings suggest that nocturnal cardiac sympathetic withdrawal combined with vagal hyperactivity is a characteristic of the autonomic regulation in essential hypotension.

D-camphor-crataegus berry extract combination increases blood pressure and cognitive functioning in the elderly - a randomized, placebo controlled double blind study

The present study investigated whether the D-camphor-crataegus berry extract combination Korodin elevates blood pressure and enhances cognitive performance in the elderly population. Eighty women aged between 50 and 80 years were examined based on a randomized, placebo controlled double blind design. Blood pressure was measured sphygmomanometrically and through continuous noninvasive recording. Cognitive performance was assessed by means of two tests measuring general information processing capacity and visuomotor speed. The administration of the drug led to a short term increase in blood pressure as well as in cognitive performance as compared to placebo. Potential physiological mechanisms of action mediating this effect, including hemodynamic alterations, sympathetic stimulation as well as improvement of cerebral metabolism are discussed.

Hemodynamic determinants of chronic hypotension and their modification through vasopressor application

Chronic low blood pressure is typically accompanied by symptoms such as fatigue, reduced drive, dizziness, headaches and cold limbs. Reduced cognitive performance, diminished cerebral blood flow and autonomic dysregulation have been furthermore documented in this condition. The present contribution reports two studies exploring systemic hemodynamics in chronic hypotension and their modification through vasopressor application. In study I, effects of the alpha-sympathomimetic midodrine were examined in 54 hypotensive individuals using a placebo-controlled double-blind design. Hemodynamic parameters were assessed at rest and during mental stress. They were derived from continuous blood pressure recordings using Modelflow analysis. The drug led to marked increases in blood pressure, total peripheral resistance and stroke volume. However, due to strong heart rate deceleration, cardiac output remained virtually unchanged. In study II, 40 hypotensive and 40 normotensive control persons were compared with respect to hemodynamics. While groups did not differ in total peripheral resistance, hypotensives exhibited markedly diminished stroke volume and heart rate, resulting in a reduction in cardiac output of 25% at rest and of 33% during mental stress. The data provide relevant knowledge about the hemodynamic mediation of chronic hypotension. In contrast to elevated blood pressure, which is mainly determined by increased peripheral resistance, reduced cardiac output may be the cardinal hemodynamic aberration in chronic hypotension. Midodrine proved to be effective in elevating blood pressure. However, given the cardiac origin of chronic hypotension and the lack of drug effect on cardiac output, alpha-sympathomimetic treatment may be suboptimal.

Changes in cortical potential associated with modulation of peripheral sympathetic activity in patients with epilepsy

OBJECTIVES

To examine the immediate and sustained effects of volitional sympathetic modulation, using galvanic skin response (GSR) biofeedback training on cortical excitability in patients with drug-resistant epilepsy.

METHODS

Ten patients undertook 12 sessions of GSR biofeedback training over 1 month, during which they were trained to increase sympathetic arousal, using GSR biofeedback. Contingent negative variation (CNV) (a slow cortical potential reflecting cortical arousal and excitability) and the related post imperative negative variation (PINV) were quantified before and after biofeedback treatment.

RESULTS

A significant reduction in CNV amplitude was observed in both the short-term (within the first session, after 10 minutes of GSR biofeedback) and long-term (sustained after 12 training sessions). Specifically, the change in baseline CNV amplitude after the 12 training sessions correlated with a percentage reduction in seizure frequency. Furthermore, changes in baseline amplitude of the PINV also correlated with seizure reduction.

CONCLUSIONS

Our findings demonstrate that behavioral enhancement of peripheral sympathetic tone (GSR) is associated with modulation of indices of cortical excitability. Moreover, GSR biofeedback training over repeated sessions was associated with a chronic baseline reduction in slow cortical potentials and concurrent therapeutic improvement.

Reduction in Pain Sensitivity from Pharmacological Elevation of Blood Pressure in Persons with Chronically Low Blood Pressure

Recent studies have revealed evidence for increased pain sensitivity in individuals with chronically low blood pressure. The present trial explored whether pain sensitivity can be reduced by pharmacological elevation of blood pressure. Effects of the sympathomimetic midodrine on threshold and tolerance to heat pain were examined in 52 hypotensive persons (mean blood pressure 96/61 mmHg) based on a randomized, placebo-controlled, double-blind design. Heat stimuli were applied to the forearm via a contact thermode. Confounding of drug effects on pain perception with changes in skin temperature, temperature sensitivity, and mood were statistically controlled for. Compared to placebo, higher pain threshold and tolerance, increased blood pressure, as well as reduced heart rate were observed under the sympathomimetic condition. Increases in systolic blood pressure between points of measurement correlated positively with increases in pain threshold and tolerance, and decreases in heart rate were associated with increases in pain threshold. The findings underline the causal role of hypotension in the augmented pain sensitivity related to this condition. Pain reduction as a function of heart rate decrease suggests involvement of a baroreceptor-related mechanism in the pain attrition. The increased proneness of persons with chronic hypotension toward clinical pain is discussed.

The effect of Camphor-Crataegus berry extract combination on blood pressure and mental functions in chronic hypotension--a randomized placebo controlled double blind design

A number of studies have provided evidence for reduced cognitive performance due to chronically low blood pressure. The present studies explored whether these deficits can be reduced by pharmacological blood pressure elevation. Effects of the Camphor-Crataegus berry extract combination (Korodin(®)) were investigated in two studies with 40 and 48 hypotensive women based on a randomized, placebo controlled double blind design. The participants were presented with different tasks assessing performance in attention and cognition. Blood pressure was measured repeatedly during the experiment. The administration of the drug led to positive and differential effects on blood pressure and cognitive performance as compared to placebo. These effects were already visible within the time range of 2-5 min. A positive correlation between blood pressure increase and performance enhancement could be demonstrated for two of the four tasks. The results show that the application of Korodin(®) results in beneficial effects on resting blood pressure and cognitive performance. The positive association between the increase in blood pressure and cognitive enhancement suggests that blood pressure plays a causal role in the cognitive deficits in hypotension and underlines that they can be reduced through antihypotensive treatment.