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Bricher Choque PN, Porter MH, Teixeira MS, Dellê H, Elias RM, Durante B, Dutra MRH, Metz CN, Pavlov VA, Consolim Colombo FM. Cholinergic Stimulation Exerts Cardioprotective Effects and Alleviates Renal Inflammatory Responses after Acute Myocardial Infarction in Spontaneous Hypertensive Rats (SHRs). Pharmaceuticals (Basel) 2024; 17:547. [PMID: 38794117 PMCID: PMC11124479 DOI: 10.3390/ph17050547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND In this investigation, we explored the effects of pharmacological cholinergic stimulation on cardiac function and renal inflammation following acute myocardial infarction (AMI) in spontaneously hypertensive rats (SHRs). METHODS Adult male SHRs were randomized into three experimental groups: sham-operated; AMI + Veh (infarcted, treated with vehicle); and AMI + PY (infarcted, treated with the cholinesterase inhibitor, pyridostigmine bromide (PY)-40 mg/kg, once daily for seven days). Rats were euthanized 7 or 30 days post-surgery. The clinical parameters were assessed on the day before euthanasia. Subsequent to euthanasia, blood samples were collected and renal tissues were harvested for histological and gene expression analyses aimed to evaluate inflammation and injury. RESULTS Seven days post-surgery, the AMI + PY group demonstrated improvements in left ventricular diastolic function and autonomic regulation, and a reduction in renal macrophage infiltration compared to the AMI + Veh group. Furthermore, there was a notable downregulation in pro-inflammatory gene expression and an upregulation in anti-inflammatory gene expression. Analysis 30 days post-surgery showed that PY treatment had a sustained positive effect on renal gene expression, correlated with a decrease in biomarkers, indicative of subclinical kidney injury. CONCLUSIONS Short-term cholinergic stimulation with PY provides both cardiac and renal protection by mitigating the inflammatory response after AMI.
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Affiliation(s)
- Pamela Nithzi Bricher Choque
- Department of Medicine, Universidade Nove de Julho (Uninove), São Paulo 01504-001, SP, Brazil; (P.N.B.C.); (M.H.P.); (H.D.); (R.M.E.); (M.R.H.D.)
| | - Maria Helena Porter
- Department of Medicine, Universidade Nove de Julho (Uninove), São Paulo 01504-001, SP, Brazil; (P.N.B.C.); (M.H.P.); (H.D.); (R.M.E.); (M.R.H.D.)
| | - Manuella S. Teixeira
- Hypertension Unit, Heart Institute, Medical School, University of São Paulo, São Paulo 05403-900, SP, Brazil; (M.S.T.); (B.D.)
| | - Humberto Dellê
- Department of Medicine, Universidade Nove de Julho (Uninove), São Paulo 01504-001, SP, Brazil; (P.N.B.C.); (M.H.P.); (H.D.); (R.M.E.); (M.R.H.D.)
| | - Rosilene Motta Elias
- Department of Medicine, Universidade Nove de Julho (Uninove), São Paulo 01504-001, SP, Brazil; (P.N.B.C.); (M.H.P.); (H.D.); (R.M.E.); (M.R.H.D.)
| | - Bruno Durante
- Hypertension Unit, Heart Institute, Medical School, University of São Paulo, São Paulo 05403-900, SP, Brazil; (M.S.T.); (B.D.)
| | - Marina Rascio Henriques Dutra
- Department of Medicine, Universidade Nove de Julho (Uninove), São Paulo 01504-001, SP, Brazil; (P.N.B.C.); (M.H.P.); (H.D.); (R.M.E.); (M.R.H.D.)
| | - Christine N. Metz
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, USA; (C.N.M.); (V.A.P.)
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11550, USA
| | - Valentin A. Pavlov
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, USA; (C.N.M.); (V.A.P.)
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11550, USA
| | - Fernanda M. Consolim Colombo
- Department of Medicine, Universidade Nove de Julho (Uninove), São Paulo 01504-001, SP, Brazil; (P.N.B.C.); (M.H.P.); (H.D.); (R.M.E.); (M.R.H.D.)
- Hypertension Unit, Heart Institute, Medical School, University of São Paulo, São Paulo 05403-900, SP, Brazil; (M.S.T.); (B.D.)
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Pichot V, Corbier C, Chouchou F, Barthélémy JC, Roche F. CVRanalysis: a free software for analyzing cardiac, vascular and respiratory interactions. Front Physiol 2024; 14:1224440. [PMID: 38250656 PMCID: PMC10797906 DOI: 10.3389/fphys.2023.1224440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 12/13/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction: Simultaneous beat-to-beat R-R intervals, blood pressure and respiration signals are routinely analyzed for the evaluation of autonomic cardiovascular and cardiorespiratory regulations for research or clinical purposes. The more recognized analyses are i) heart rate variability and cardiac coherence, which provides an evaluation of autonomic nervous system activity and more particularly parasympathetic and sympathetic autonomic arms; ii) blood pressure variability which is mainly linked to sympathetic modulation and myogenic vascular function; iii) baroreflex sensitivity; iv) time-frequency analyses to identify fast modifications of autonomic activity; and more recently, v) time and frequency domain Granger causality analyses were introduced for assessing bidirectional causal links between each considered signal, thus allowing the scrutiny of many physiological regulatory mechanisms. Methods: These analyses are commonly applied in various populations and conditions, including mortality and morbidity predictions, cardiac and respiratory rehabilitation, training and overtraining, diabetes, autonomic status of newborns, anesthesia, or neurophysiological studies. Results: We developed CVRanalysis, a free software to analyze cardiac, vascular and respiratory interactions, with a friendly graphical interface designed to meet laboratory requirements. The main strength of CVRanalysis resides in its wide scope of applications: recordings can arise from beat-to-beat preprocessed data (R-R, systolic, diastolic and mean blood pressure, respiration) or raw data (ECG, continuous blood pressure and respiratory waveforms). It has several tools for beat detection and correction, as well as setting of specific areas or events. In addition to the wide possibility of analyses cited above, the interface is also designed for easy study of large cohorts, including batch mode signal processing to avoid running repetitive operations. Results are displayed as figures or saved in text files that are easily employable in statistical softwares. Conclusion: CVRanalysis is freely available at this website: anslabtools.univ-st-etienne.fr. It has been developed using MATLAB® and works on Windows 64-bit operating systems. The software is a standalone application avoiding to have programming skills and to install MATLAB. The aims of this paper area are to describe the physiological, research and clinical contexts of CVRanalysis, to introduce the methodological approach of the different techniques used, and to show an overview of the software with the aid of screenshots.
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Affiliation(s)
- Vincent Pichot
- SAINBIOSE U1059, Inserm, Saint-Etienne Jean-Monnet University, Clinical Physiology and Exercise, CHU of Saint-Etienne, Saint-Etienne, France
| | - Christophe Corbier
- LASPI EA3059, Saint-Etienne Jean-Monnet University, Roanne Technology University Institute, Roanne, France
| | - Florian Chouchou
- IRISSE EA4075, UFR SHE, University of La Réunion, Le Tampon, France
| | - Jean-Claude Barthélémy
- SAINBIOSE U1059, Inserm, Saint-Etienne Jean-Monnet University, Clinical Physiology and Exercise, CHU of Saint-Etienne, Saint-Etienne, France
| | - Frédéric Roche
- SAINBIOSE U1059, Inserm, Saint-Etienne Jean-Monnet University, Clinical Physiology and Exercise, CHU of Saint-Etienne, Saint-Etienne, France
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Triposkiadis F, Briasoulis A, Sarafidis P, Magouliotis D, Athanasiou T, Paraskevaidis I, Skoularigis J, Xanthopoulos A. The Sympathetic Nervous System in Hypertensive Heart Failure with Preserved LVEF. J Clin Med 2023; 12:6486. [PMID: 37892623 PMCID: PMC10607346 DOI: 10.3390/jcm12206486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023] Open
Abstract
The neurohormonal model of heart failure (HF) pathogenesis states that a reduction in cardiac output caused by cardiac injury results in sympathetic nervous system (SNS) activation, that is adaptive in the short-term and maladaptive in the long-term. This model has proved extremely valid and has been applied in HF with a reduced left ventricular (LV) ejection fraction (LVEF). In contrast, it has been undermined in HF with preserved LVEF (HFpEF), which is due to hypertension (HTN) in the vast majority of the cases. Erroneously, HTN, which is the leading cause of cardiovascular disease and premature death worldwide and is present in more than 90% of HF patients, is tightly linked with SNS overactivity. In this paper we provide a contemporary overview of the contribution of SNS overactivity to the development and progression of hypertensive HF (HHF) as well as the clinical implications resulting from therapeutic interventions modifying SNS activity. Throughout the manuscript the terms HHF with preserved LVEF and HfpEF will be used interchangeably, considering that the findings in most HFpEF studies are driven by HTN.
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Affiliation(s)
| | - Alexandros Briasoulis
- Department of Therapeutics, Heart Failure and Cardio-Oncology Clinic, National and Kapodistrian University of Athens, 115 27 Athens, Greece;
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece;
| | - Dimitrios Magouliotis
- Unit of Quality Improvement, Department of Cardiothoracic Surgery, University of Thessaly, 411 10 Biopolis, Greece;
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital, London W2 1NY, UK;
| | | | - John Skoularigis
- Department of Cardiology, University Hospital of Larissa, 411 10 Larissa, Greece;
| | - Andrew Xanthopoulos
- Department of Cardiology, University Hospital of Larissa, 411 10 Larissa, Greece;
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Wu Z, Liao J, Liu Q, Zhou S, Chen M. Chronic vagus nerve stimulation in patients with heart failure: challenge or failed translation? Front Cardiovasc Med 2023; 10:1052471. [PMID: 37534273 PMCID: PMC10390725 DOI: 10.3389/fcvm.2023.1052471] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 05/31/2023] [Indexed: 08/04/2023] Open
Abstract
Autonomic imbalance between the sympathetic and parasympathetic nervous systems contributes to the progression of chronic heart failure (HF). Preclinical studies have demonstrated that various neuromodulation strategies may exert beneficial cardioprotective effects in preclinical models of HF. Based on these encouraging experimental data, vagus nerve stimulation (VNS) has been assessed in patients with HF with a reduced ejection fraction. Nevertheless, the main trials conducted thus far have yielded conflicting findings, questioning the clinical efficacy of VNS in this context. This review will therefore focus on the role of the autonomic nervous system in HF pathophysiology and VNS therapy, highlighting the potential reasons behind the discrepancy between preclinical and clinical studies.
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Affiliation(s)
- Zhihong Wu
- Department of Cardiovascular, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jiaying Liao
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Qiming Liu
- Department of Cardiovascular, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Shenghua Zhou
- Department of Cardiovascular, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Mingxian Chen
- Department of Cardiovascular, The Second Xiangya Hospital of Central South University, Changsha, China
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Respiratory patterns and baroreflex function in heart failure. Sci Rep 2023; 13:2220. [PMID: 36755066 PMCID: PMC9908869 DOI: 10.1038/s41598-023-29271-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 02/01/2023] [Indexed: 02/10/2023] Open
Abstract
Little is known on the effects of respiratory patterns on baroreflex function in heart failure (HF). Patients with HF (n = 30, age 61.6 ± 10 years, mean ± SD) and healthy controls (CNT, n = 10, age 58.9 ± 5.6 years) having their R-R interval (RRI, EKG), systolic arterial blood pressure (SBP, Finapres) and respiratory signal (RSP, Respitrace) monitored, were subjected to three recording sessions: free-breathing, fast- (≥ 12 bpm) and slow- (6 bpm) paced breathing. Baroreflex sensitivity (BRS) and power spectra of RRI, SBP, and RSP signals were calculated. During free-breathing, compared to CNT, HF patients showed a significantly greater modulation of respiratory volumes in the very-low-frequency (< 0.04 Hz) range and their BRS was not significantly different from that of CNT. During fast-paced breathing, when very-low-frequency modulations of respiration were reduced, BRS of HF patients was significantly lower than that of CNT and lower than during free breathing. During slow-paced breathing, BRS became again significantly higher than during fast breathing. In conclusion: (1) in free-breathing HF patients is present a greater modulation of respiratory volumes in the very-low-frequency range; (2) in HF patients modulation of respiration in the very-low and low frequency (around 0.1 Hz) ranges contributes to preserve baroreflex-mediated control of heart rate.
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Bonsignore MR, La Rovere MT. Sympathetic activation in patients with heart failure and central sleep apnoea: is it friend or foe? Eur Respir J 2023; 61:61/2/2202170. [PMID: 36758996 DOI: 10.1183/13993003.02170-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 11/12/2022] [Indexed: 02/11/2023]
Affiliation(s)
- Maria R Bonsignore
- PROMISE Department, University of Palermo, Palermo, Italy
- IRIB-CNR, Palermo, Italy
- Respiratory Division, V Cervello Hospital, Ospedali Riuniti Villa Sofia Cervello, Palermo, Italy
| | - Maria Teresa La Rovere
- Department of Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS, Istituto Scientifico di Montescano, Montescano, Italy
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Kaufmann DK, Raczak G, Szwoch M, Wabich E, Świątczak M, Daniłowicz-Szymanowicz L. Baroreflex sensitivity but not microvolt T-wave alternans can predict major adverse cardiac events in ischemic heart failure. Cardiol J 2022; 29:1004-1012. [PMID: 33001423 PMCID: PMC9788737 DOI: 10.5603/cj.a2020.0129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/23/2020] [Accepted: 08/28/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Major adverse cardiovascular events (MACE) constitutes the main cause of morbidity and mortality in ischemic heart failure (HF) patients. The prognostic value of the autonomic nervous system parameters and microvolt T-wave alternans (MTWA) in this issue has not been identified to date. The aim herein, was to assess the usefulness of the abovementioned parameters in the prediction of MACE in HF patients with left ventricular systolic dysfunction of ischemic origin. METHODS Baroreflex sensitivity (BRS), heart rate variability (HRV), MTWA and other well-known clinical parameters were analyzed in 188 ischemic HF outpatients with left ventricular ejection fraction (LVEF) ≤ 50%. During 34 (14-71) months of follow-up, 56 (30%) endpoints were noted. RESULTS Univariate Cox analyses revealed BRS (but not HRV), MTWA, age, New York Heart Association functional class III, LVEF, implantable cardioverter-defibrillator presence, use of diuretics and antiarrhythmic drugs, diabetes, and kidney insufficiency were defined as significant predictors of MACE. Pre-specified cut-off values for MACE occurrence for the aforementioned continuous parameters (age, LVEF, and BRS) were: ≥ 72 years, ≤ 33%, and ≤ 3 ms/mmHg, respectively. In a multivariate Cox analysis only BRS (HR 2.97, 95% CI 1.35-6.36, p < 0.006), and LVEF (HR 1.98, 95% CI 0.61-4.52, p < 0.038) maintained statistical significance in the prediction of MACE. CONCLUSIONS Baroreflex sensitivity and LVEF are independent of other well-known clinical parameters in the prediction of MACE in patients with HF of ischemic origin and LVEF up to 50%. BRS ≤ 3 ms/mmHg and LVEF ≤ 33% identified individuals with the highest probability of MACE during the follow-up period.
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A Methodological Perspective on the Function and Assessment of Peripheral Chemoreceptors in Heart Failure: A Review of Data from Clinical Trials. Biomolecules 2022; 12:biom12121758. [PMID: 36551186 PMCID: PMC9775522 DOI: 10.3390/biom12121758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
Augmented peripheral chemoreceptor sensitivity (PChS) is a common feature of many sympathetically mediated diseases, among others, and it is an important mechanism of the pathophysiology of heart failure (HF). It is related not only to the greater severity of symptoms, especially to dyspnea and lower exercise tolerance but also to a greater prevalence of complications and poor prognosis. The causes, mechanisms, and impact of the enhanced activity of peripheral chemoreceptors (PChR) in the HF population are subject to intense research. Several methodologies have been established and utilized to assess the PChR function. Each of them presents certain advantages and limitations. Furthermore, numerous factors could influence and modulate the response from PChR in studied subjects. Nevertheless, even with the impressive number of studies conducted in this field, there are still some gaps in knowledge that require further research. We performed a review of all clinical trials in HF human patients, in which the function of PChR was evaluated. This review provides an extensive synthesis of studies evaluating PChR function in the HF human population, including methods used, factors potentially influencing the results, and predictors of increased PChS.
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Charytan DM, Soomro QH, Caporotondi A, Guazzotti G, Maestri R, Pinna GD, La Rovere MT. Baroreceptor Sensitivity in Individuals with CKD and Heart Failure. KIDNEY360 2022; 3:2027-2035. [PMID: 36591344 PMCID: PMC9802545 DOI: 10.34067/kid.0004812022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 10/18/2022] [Indexed: 11/07/2022]
Abstract
Background Heart failure is the most common cardiovascular complication of chronic kidney disease (CKD) and foreshadows a high morbidity and mortality rate. Baroreflex impairment likely contributes to cardiovascular mortality. We aimed to study the associations between CKD, heart failure, and baroreflex sensitivity (BRS) and their association with cardiovascular outcomes. Methods We retrospectively analyzed data from a cohort of 247 individuals with moderate to severe HF. All subjects underwent BRS measurements after intravenous phenylephrine along with electrocardiography, echocardiography, and laboratory measurements. We used logistic regression models to assess the association of CKD (estimated glomerular filtration rate <60 ml/min per 1.73 m2) with BRS using iterative models. Cox proportional hazards models were used to assess associations of binary BRS and subgroups according to categorizations of CKD and BRS with cardiovascular mortality. Results Median eGFR among individuals with CKD was 52 (IQR 44-56) ml/min per 1.73 m2. eGFR was lower in those with depressed BRS (65 [IQR 54-76] ml/min per 1.73 m2) compared with those with preserved BRS (73 [IQR 64-87] ml/min per 1.73 m2; P≤0.001). The majority of individuals with CKD had depressed BRS compared with those without CKD (60% versus 29%; P=0.05). In regression models, CKD and BRS were independently associated. Cardiovascular mortality was significantly increased in individuals with or without CKD and depressed BRS compared with those with preserved BRS and CKD. Conclusions Cardiac BRS is depressed in patients with mild to moderate CKD and HF and associated with cardiovascular mortality. Additional study to confirm its contribution to cardiovascular mortality, particularly in advanced CKD, is warranted.
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Affiliation(s)
- David M. Charytan
- New York University Grossman School of Medicine, NYU Langone Health, New York, New York
| | - Qandeel H. Soomro
- New York University Grossman School of Medicine, NYU Langone Health, New York, New York
| | - Angelo Caporotondi
- Department of Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS, Istituto Scientifico di Montescano, Pavia, Italy
| | - Giampaolo Guazzotti
- Department of Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS, Istituto Scientifico di Montescano, Pavia, Italy
| | - Roberto Maestri
- Department of Biomedical Engineering, Istituti Clinici Scientifici Maugeri, IRCCS, Istituto Scientifico di Montescano, Pavia, Italy
| | - Gian Domenico Pinna
- Department of Biomedical Engineering, Istituti Clinici Scientifici Maugeri, IRCCS, Istituto Scientifico di Montescano, Pavia, Italy
| | - Maria Teresa La Rovere
- Department of Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS, Istituto Scientifico di Montescano, Pavia, Italy
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Giannoni A, Gentile F, Buoncristiani F, Borrelli C, Sciarrone P, Spiesshoefer J, Bramanti F, Iudice G, Javaheri S, Emdin M, Passino C. Chemoreflex and Baroreflex Sensitivity Hold a Strong Prognostic Value in Chronic Heart Failure. JACC: HEART FAILURE 2022; 10:662-676. [DOI: 10.1016/j.jchf.2022.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/07/2022] [Accepted: 02/11/2022] [Indexed: 02/07/2023]
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Kaze AD, Yuyun MF, Erqou S, Fonarow GC, Echouffo‐Tcheugui JB. Cardiac Autonomic Neuropathy and Risk of Incident Heart Failure Among Adults with Type 2 Diabetes. Eur J Heart Fail 2022; 24:634-641. [PMID: 35064959 PMCID: PMC10106110 DOI: 10.1002/ejhf.2432] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/29/2021] [Accepted: 01/13/2022] [Indexed: 11/07/2022] Open
Abstract
AIMS Community-based data on the association between cardiac autonomic neuropathy (CAN) and incident heart failure (HF) in type 2 diabetes are limited. We evaluated the association of CAN with incident HF in adults with type 2 diabetes. METHODS AND RESULTS This analysis included participants from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study without HF at baseline. CAN was assessed by electrocardiogram-based measures of heart rate variability (HRV) and QT interval index (QTI). HRV was measured using standard deviation of all normal-to-normal intervals (SDNN) and root mean square of successive differences between normal-to-normal intervals (rMSSD). CAN was defined using composite measures of the lowest quartile of SDNN and highest quartiles of QTI and heart rate. Multivariable Cox regression models were used to generate adjusted hazard ratios (aHR) for HF in relation to various CAN measures. A total of 7160 participants (mean age 62.3 [standard deviation 6.4] years, 40.8% women, 61.9% white) were included. Over a median follow-up of 4.9 years (interquartile range 4.0-5.7), 222 participants developed incident HF. After multivariable adjustment for relevant confounders, lower HRV as assessed by SDNN was associated with a higher risk of HF (aHR for the lowest vs highest quartile of SDNN: 1.70, 95% confidence interval [CI] 1.14-2.54). Participants with CAN (defined as lowest quartile of SDNN and highest quartiles of QTI and heart rate) had a 2.7-fold greater risk of HF (aHR 2.65, 95% CI 1.57-4.48). CONCLUSIONS In a large cohort of adults with type 2 diabetes, CAN was independently associated with higher risk of incident HF.
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Affiliation(s)
- Arnaud D. Kaze
- Department of Medicine University of Maryland Medical Center Baltimore MD USA
| | - Matthew F. Yuyun
- Department of Medicine, Division of Cardiology Harvard Medical School & Veteran Affairs Boston Healthcare System Boston Massachusetts USA
| | - Sebhat Erqou
- Department of Medicine, Division of Cardiology Providence VA Medical Center and Alpert Medical School of Brown University Providence RI USA
| | - Gregg C Fonarow
- Ahmanson‐UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center Los Angeles CA USA
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Angiotensin II and the Cardiac Parasympathetic Nervous System in Hypertension. Int J Mol Sci 2021; 22:ijms222212305. [PMID: 34830184 PMCID: PMC8624735 DOI: 10.3390/ijms222212305] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 01/08/2023] Open
Abstract
The renin-angiotensin-aldosterone system (RAAS) impacts cardiovascular homeostasis via direct actions on peripheral blood vessels and via modulation of the autonomic nervous system. To date, research has primarily focused on the actions of the RAAS on the sympathetic nervous system. Here, we review the critical role of the RAAS on parasympathetic nerve function during normal physiology and its role in cardiovascular disease, focusing on hypertension. Angiotensin (Ang) II receptors are present throughout the parasympathetic nerves and can modulate vagal activity via actions at the level of the nerve endings as well as via the circumventricular organs and as a neuromodulator acting within brain regions. There is tonic inhibition of cardiac vagal tone by endogenous Ang II. We review the actions of Ang II via peripheral nerve endings as well as via central actions on brain regions. We review the evidence that Ang II modulates arterial baroreflex function and examine the pathways via which Ang II can modulate baroreflex control of cardiac vagal drive. Although there is evidence that Ang II can modulate parasympathetic activity and has the potential to contribute to impaired baseline levels and impaired baroreflex control during hypertension, the exact central regions where Ang II acts need further investigation. The beneficial actions of angiotensin receptor blockers in hypertension may be mediated in part via actions on the parasympathetic nervous system. We highlight important unknown questions about the interaction between the RAAS and the parasympathetic nervous system and conclude that this remains an important area where future research is needed.
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Podsiadły A, Paleczny B, Olesińska-Mader M, Nowak K, Okupnik T, Wyciszkiewicz M, Łopusiewicz W, Ponikowski P, Ponikowska B. Valsalva-derived Measures and Phenylephrine Test in Patients With Heart Failure With Reduced Ejection Fraction Receiving Comprehensive Neurohormonal Blockade Drug Therapy: A 5-year Event-free Survival Analysis. J Card Fail 2021; 28:744-755. [PMID: 34758387 DOI: 10.1016/j.cardfail.2021.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/18/2021] [Accepted: 10/20/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND To assess the relationships between Valsalva- and phenylephrine test-derived measures and outcome in patients with heart failure with reduced ejection fraction (HFrEF) receiving comprehensive neurohormonal blockade pharmacotherapy. METHODS AND RESULTS Data from 56 patients with HFrEF (mean left ventricle ejection fraction of 32 ± 6%) subjected to Valsalva and phenylephrine tests were analyzed retrospectively. Baroreflex-related (Valsalva-ratio and blood pressure-RR interval slope from phase IV) and non-baroreflex-related measures (systolic blood pressure rise in phase IV [ΔSBPPHASE_IV], and pulse amplitude ratio [PAR]) were calculated from Valsalva. Short-term outcomes (HF-related hospitalization, implantable cardioverter-defibrillator shock or all-cause death within 24 months from examination) and long-term outcomes (implantable cardioverter-defibrillator shock or all-cause death within 60 months) were analyzed. The end point occurred in 16 and 18 patients, for the short- and long-term outcomes, respectively. A low ΔSBPPHASE_IV identified patients at risk in the long term, as evidenced by a low vs high ΔSBPPHASE_IV comparison (square-wave response patients assigned to low ΔSBPPHASE_IV group, P = .002), and Cox model (hazard ratio 0.91, 95% confidence interval 0.86-0.96, P < .001), and tended to identify patients at risk in the short term outcome (hazard ratio 0.95, 95% confidence interval 0.91-1.00, P = .055). There was a tendency toward a higher event-free survival in the low PAR group (low vs high PAR; hazard ratio 0.44, 95% CI 0.17-1.18, P = .104). CONCLUSIONS Non-baroreflex-related measures obtained from Valsalva-namely, ΔSBPPHASE_IV and PAR-might carry prognostic value in patients with HFrEF receiving neurohormonal blockade pharmacotherapy.
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Affiliation(s)
- Anna Podsiadły
- Department of Physiology and Pathophysiology, Wroclaw Medical Physiology, Wroclaw, Poland
| | - Bartłomiej Paleczny
- Department of Physiology and Pathophysiology, Wroclaw Medical Physiology, Wroclaw, Poland.
| | | | - Krzysztof Nowak
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland; Centre for Heart Diseases, University Hospital in Wroclaw, Wroclaw, Poland
| | - Tymoteusz Okupnik
- Department of Physiology and Pathophysiology, Wroclaw Medical Physiology, Wroclaw, Poland
| | | | - Wojciech Łopusiewicz
- Department of Physiology and Pathophysiology, Wroclaw Medical Physiology, Wroclaw, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland; Centre for Heart Diseases, University Hospital in Wroclaw, Wroclaw, Poland
| | - Beata Ponikowska
- Department of Physiology and Pathophysiology, Wroclaw Medical Physiology, Wroclaw, Poland
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14
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Abstract
Vagal nerve stimulation (VNS) has a strong pathophysiological rationale as a potentially beneficial treatment for heart failure with reduced ejection fraction. Despite several promising preclinical studies and pilot clinical studies, the two large, controlled trials—NECTAR-HF and INOVATE-HF—failed to demonstrate the expected benefit. It is likely that clinical application of VNS in phase III studies was performed before a sufficient degree of understanding of the complex pathophysiology of autonomic electrical modulation had been achieved, therefore leading to an underestimation of its potential benefit. More knowledge on the complex dose–response issue of VNS (i.e., pulse amplitude, frequency, duration and duty cycle) has been gathered since these trials and a new randomized study is currently underway with an adaptive design and a refined approach in an attempt to deliver the proper dose to a more selected group of patients.
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Affiliation(s)
- Veronica Dusi
- Division of Cardiology, Department of Medical Sciences, Citta della Salute e della Scienza Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy.
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Medical Sciences, Citta della Salute e della Scienza Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy
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15
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Biegus J, Niewinski P, Josiak K, Kulej K, Ponikowska B, Nowak K, Zymlinski R, Ponikowski P. Pathophysiology of Advanced Heart Failure: What Knowledge Is Needed for Clinical Management? Heart Fail Clin 2021; 17:519-531. [PMID: 34511202 DOI: 10.1016/j.hfc.2021.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Understanding of heart failure (HF) has evolved from a simple hemodynamic problem through a neurohormonally and proinflammatory-driven syndrome to a complex multiorgan dysfunction accompanied by inadequate energy handling. This article discusses the most important clinical aspects of advanced HF pathophysiology. It presents the concept of neurohormonal activation and its deleterious effect on cardiovascular system and reflex control. The current theories regarding the role of inflammation, cytokine activation, and myocardial remodeling in HF progression are presented. Advanced HF is a multiorgan syndrome with interplay between cardiovascular system and other organs. The role of iron deficiency is also discussed.
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Affiliation(s)
- Jan Biegus
- Department of Heart Diseases, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland; Centre for Heart Diseases, Wrocław University Hospital, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Piotr Niewinski
- Department of Heart Diseases, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland; Centre for Heart Diseases, Wrocław University Hospital, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Krystian Josiak
- Department of Heart Diseases, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland; Centre for Heart Diseases, Wrocław University Hospital, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Katarzyna Kulej
- Department of Heart Diseases, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland; Centre for Heart Diseases, Wrocław University Hospital, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Barbara Ponikowska
- Student Scientific Organization, Department of Heart Diseases, Wroclaw Medical University, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Krzysztof Nowak
- Department of Heart Diseases, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland; Centre for Heart Diseases, Wrocław University Hospital, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Robert Zymlinski
- Department of Heart Diseases, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland; Centre for Heart Diseases, Wrocław University Hospital, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Piotr Ponikowski
- Department of Heart Diseases, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland; Centre for Heart Diseases, Wrocław University Hospital, ul. Borowska 213, 50-556 Wrocław, Poland.
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16
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Komori T, Hoshide S, Kario K. Differential Effect of the Morning Blood Pressure Surge on Prognoses Between Heart Failure With Reduced and Preserved Ejection Fractions. Circ J 2021; 85:1535-1542. [PMID: 33853990 DOI: 10.1253/circj.cj-20-0972] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Rising blood pressure (BP) in the morning, known as the morning BP surge (MBPS), is known to pose a risk for cardiovascular events in hypertensive individuals. It was not known whether the MBPS was associated with a worse prognosis in patients with heart failure (HF) with a reduced (HFrEF) or preserved (HFpEF) ejection fraction.Methods and Results:We performed a prospective, observational cohort study of hospitalized HF patients who underwent ambulatory BP monitoring (ABPM). The MBPS was calculated by subtracting the mean systolic BP (SBP) during the 1 h that included the lowest sleep BP from the mean SBP during the 2 h after waking. The MBPS group was defined as the top decile of MBPS (>40 mmHg). In all, 456 hospitalized HF patients (mean [±SD] age 68±13 years, 63.9% male) were followed-up for a median of 1.67 years. There were 90 events (16.3 per 100 person-years) of the composite outcome (all-cause mortality and worsening HF) in the HFrEF group, compared with 53 events (19.6 per 100 person-years) in the HFpEF group. Multivariate Cox regression analysis showed that MBPS was a significant predictor of outcome (hazard ratio 2.84, 95% confidence interval 1.58-5.10, P<0.01) in the HFrEF but not HFpEF group. CONCLUSIONS MBPS was found to be a novel predictor of worsening HF in patients with HFrEF.
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Affiliation(s)
- Takahiro Komori
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | - Satoshi Hoshide
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
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17
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Salvatore T, Pafundi PC, Galiero R, Albanese G, Di Martino A, Caturano A, Vetrano E, Rinaldi L, Sasso FC. The Diabetic Cardiomyopathy: The Contributing Pathophysiological Mechanisms. Front Med (Lausanne) 2021; 8:695792. [PMID: 34277669 PMCID: PMC8279779 DOI: 10.3389/fmed.2021.695792] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/07/2021] [Indexed: 12/12/2022] Open
Abstract
Individuals with diabetes mellitus (DM) disclose a higher incidence and a poorer prognosis of heart failure (HF) than non-diabetic people, even in the absence of other HF risk factors. The adverse impact of diabetes on HF likely reflects an underlying “diabetic cardiomyopathy” (DM–CMP), which may by exacerbated by left ventricular hypertrophy and coronary artery disease (CAD). The pathogenesis of DM-CMP has been a hot topic of research since its first description and is still under active investigation, as a complex interplay among multiple mechanisms may play a role at systemic, myocardial, and cellular/molecular levels. Among these, metabolic abnormalities such as lipotoxicity and glucotoxicity, mitochondrial damage and dysfunction, oxidative stress, abnormal calcium signaling, inflammation, epigenetic factors, and others. These disturbances predispose the diabetic heart to extracellular remodeling and hypertrophy, thus leading to left ventricular diastolic and systolic dysfunction. This Review aims to outline the major pathophysiological changes and the underlying mechanisms leading to myocardial remodeling and cardiac functional derangement in DM-CMP.
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Affiliation(s)
- Teresa Salvatore
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Pia Clara Pafundi
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Raffaele Galiero
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Gaetana Albanese
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Anna Di Martino
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Alfredo Caturano
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Erica Vetrano
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Luca Rinaldi
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Ferdinando Carlo Sasso
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
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18
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Abstract
OBJECTIVES Although progress has been made in the regulation of hypertension over the past decades, the USA and some other countries have faced a significant rise in incidence of chronic pain management cases during the same period. Studies of the relationship between pain and blood pressure (BP) regulations propose that these two processes may be interconnected. Studies of effects of antihypertensive treatment on pain in general and its chronification have never been reviewed. METHODS A narrative review of respective studies with analysis of credibility of the findings was conducted. RESULTS Some studies have suggested that aggressive reduction of high BP may contribute to a return in pain symptoms and may require more aggressive, long-term pain management. Other studies propose that long-term antihypertensive medication could also increase the risk for new cases of chronic pain. Pain initiates a central neuroplastic resetting of the baroreceptor activation accounting for sustained increase of BP with an adaptive 'pain-killing' or maladaptive 'pain-complication' effect associated with pain chronification, and these mechanisms may be moderated by antihypertensive medications. However, different antihypertensive drugs and nondrug treatments may diversely affect pain mechanisms at different stages of treatments. CONCLUSION Uncontrollable reduction of high BP in some patients with hypertension could increase the risk for chronic pain incidence and its severity. Practical recommendations in BP control should be reconsidered to take into account patients' chronic pain. Further research is needed of moderation effects of different antihypertensive manipulations on pain to improve pain management in these patients.
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19
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Sailer C, Edelmann H, Buchanan C, Giro P, Babcock M, Swanson C, Spotts M, Schulte M, Pratt-Cordova A, Coe G, Beindorff M, Page RL, Ambardekar AV, Pal JD, Kohrt W, Wolfel E, Lawley JS, Tarumi T, Cornwell WK. Impairments in Blood Pressure Regulation and Cardiac Baroreceptor Sensitivity Among Patients With Heart Failure Supported With Continuous-Flow Left Ventricular Assist Devices. Circ Heart Fail 2021; 14:e007448. [PMID: 33464953 DOI: 10.1161/circheartfailure.120.007448] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Continuous-flow (CF) left ventricular assist devices (LVADs) improve outcomes for patients with advanced heart failure (HF). However, the lack of a physiological pulse predisposes to side-effects including uncontrolled blood pressure (BP), and there are little data regarding the impact of CF-LVADs on BP regulation. METHODS Twelve patients (10 males, 60±11 years) with advanced heart failure completed hemodynamic assessment 2.7±4.1 months before, and 4.3±1.3 months following CF-LVAD implantation. Heart rate and systolic BP via arterial catheterization were monitored during Valsalva maneuver, spontaneous breathing, and a 0.05 Hz repetitive squat-stand maneuver to characterize cardiac baroreceptor sensitivity. Plasma norepinephrine levels were assessed during head-up tilt at supine, 30o and 60o. Heart rate and BP were monitored during cardiopulmonary exercise testing. RESULTS Cardiac baroreceptor sensitivity, determined by Valsalva as well as Fourier transformation and transfer function gain of Heart rate and systolic BP during spontaneous breathing and squat-stand maneuver, was impaired before and following LVAD implantation. Norepinephrine levels were markedly elevated pre-LVAD and improved-but remained elevated post-LVAD (supine norepinephrine pre-LVAD versus post-LVAD: 654±437 versus 323±164 pg/mL). BP increased during cardiopulmonary exercise testing post-LVAD, but the magnitude of change was modest and comparable to the changes observed during the pre-LVAD cardiopulmonary exercise testing. CONCLUSIONS Among patients with advanced heart failure with reduced ejection fraction, CF-LVAD implantation is associated with modest improvements in autonomic tone, but persistent reductions in cardiac baroreceptor sensitivity. Exercise-induced increases in BP are blunted. These findings shed new light on mechanisms for adverse events such as stroke, and persistent reductions in functional capacity, among patients supported by CF-LVADs. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03078972.
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Affiliation(s)
- Christine Sailer
- Department of Medicine-Cardiology (C.S., G.C., M.B., A.V.A., E.W., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | | | - Cullen Buchanan
- Department of Medicine (C.B., P.G.), University of Colorado Anschutz Medical Campus, Aurora
| | - Pedro Giro
- Department of Medicine (C.B., P.G.), University of Colorado Anschutz Medical Campus, Aurora
| | - Matthew Babcock
- Division of Geriatric Medicine, Department of Medicine (M.B., W.K.), University of Colorado Anschutz Medical Campus, Aurora
| | - Christine Swanson
- Department of Medicine-Endocrinology, Metabolism and Diabetes (C.S.), University of Colorado Anschutz Medical Campus, Aurora
| | - Melanie Spotts
- Clinical and Translational Research Center (M. Spotts, M. Schulte, A.P.-C., W.K., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Margaret Schulte
- Clinical and Translational Research Center (M. Spotts, M. Schulte, A.P.-C., W.K., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Ashley Pratt-Cordova
- Clinical and Translational Research Center (M. Spotts, M. Schulte, A.P.-C., W.K., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Greg Coe
- Department of Medicine-Cardiology (C.S., G.C., M.B., A.V.A., E.W., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Mark Beindorff
- Department of Medicine-Cardiology (C.S., G.C., M.B., A.V.A., E.W., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Robert L Page
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Services, Aurora (R.L.P.)
| | - Amrut V Ambardekar
- Department of Medicine-Cardiology (C.S., G.C., M.B., A.V.A., E.W., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Jay D Pal
- Department of Cardiothoracic Surgery (J.D.P.), University of Colorado Anschutz Medical Campus, Aurora
| | - Wendy Kohrt
- Division of Geriatric Medicine, Department of Medicine (M.B., W.K.), University of Colorado Anschutz Medical Campus, Aurora.,Clinical and Translational Research Center (M. Spotts, M. Schulte, A.P.-C., W.K., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Eugene Wolfel
- Department of Medicine-Cardiology (C.S., G.C., M.B., A.V.A., E.W., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Justin S Lawley
- Department of Sport Science, University of Innsbruck, Austria (J.S.L.)
| | - Takashi Tarumi
- Human Informatics Interaction Research Institute, National Institute of Advanced Industrial Science and Technology, Ibaraki prefecture, Japan (T.T.)
| | - William K Cornwell
- Department of Medicine-Cardiology (C.S., G.C., M.B., A.V.A., E.W., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora.,Clinical and Translational Research Center (M. Spotts, M. Schulte, A.P.-C., W.K., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
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20
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Abstract
Heart failure with preserved ejection fraction (HFpEF) is a syndrome with an unfavorable prognosis, and the number of the patients continues to grow. Because there is no effective therapy established as a standard, including pharmacological treatments, a movement to develop and evaluate device-based therapies is an important emerging area in the treatment of HFpEF patients. Many devices have set their target to reduce the left atrial pressure or pulmonary capillary wedge pressure because they are strongly related to the symptoms and prognosis of HFpEF, but the methodology to achieve it varies based on the devices. In this review, we summarize and categorize these devices into the following: (1) interatrial shunt devices, (2) left ventricle expander, (3) electrical therapy, (4) left ventricular assist devices, and (5) mechanical circulatory support devices under development. Here, we describe the features and specifications of device-based therapies currently under development and those at more advanced stages of preclinical testing. Advantages and limitations of these technologies, with insights on their safety and feasibility for HFpEF patients, are described.
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21
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Badrov MB, Mak S, Floras JS. Cardiovascular Autonomic Disturbances in Heart Failure With Preserved Ejection Fraction. Can J Cardiol 2020; 37:609-620. [PMID: 33310140 DOI: 10.1016/j.cjca.2020.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 02/09/2023] Open
Abstract
In heart failure with reduced ejection fraction (HFrEF), diminished tonic and reflex vagal heart rate modulation and exaggerated sympathetic outflow and neural norepinephrine release are evident from disease inception. Each of these disturbances of autonomic regulation has been independently associated with shortened survival, and β-adrenoceptor antagonism and therapeutic autonomic modulation by other means have been demonstrated, in clinical trials, to lessen symptoms and prolong survival. In contrast, data concerning the autonomic status of patients with heart failure with preserved ejection fraction (HFpEF) are comparatively sparse. Little is known concerning the prognostic consequences of autonomic dysregulation in such individuals, and therapies applied with success in HFrEF have in most trials failed to improve symptoms or survival of those with HFpEF. A recent HFpEF Expert Scientific Panel report emphasised that without a deeper understanding of the pathophysiology of HFpEF, establishing effective treatment will be challenging. One aspect of such pathology may be cardiovascular autonomic disequilibrium, often worsened by acute exercise or routine daily activity. This review aims to summarise existing knowledge concerning parasympathetic and sympathetic function of patients with HFpEF, consider potential mechanisms and specific consequences of autonomic disturbances that have been identified, and propose hypotheses for future investigation.
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Affiliation(s)
- Mark B Badrov
- Division of Cardiology, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Susanna Mak
- Division of Cardiology, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - John S Floras
- Division of Cardiology, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto, Ontario, Canada.
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22
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Machhada A, Hosford PS, Dyson A, Ackland GL, Mastitskaya S, Gourine AV. Optogenetic Stimulation of Vagal Efferent Activity Preserves Left Ventricular Function in Experimental Heart Failure. JACC Basic Transl Sci 2020; 5:799-810. [PMID: 32875170 PMCID: PMC7452237 DOI: 10.1016/j.jacbts.2020.06.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 06/05/2020] [Accepted: 06/06/2020] [Indexed: 12/21/2022]
Abstract
This study was designed to determine the effect of selective optogenetic simulation of vagal efferent activity on left ventricular function in an animal (rat) model of MI-induced heart failure. Optogenetic stimulation of dorsal brainstem vagal pre-ganglionic neurons transduced to express light-sensitive channels preserved LV function and exercise capacity in animals with MI. The data suggest that activation of vagal efferents is critically important to deliver the therapeutic benefit of VNS in chronic heart failure.
Large clinical trials designed to test the efficacy of vagus nerve stimulation (VNS) in patients with heart failure did not demonstrate benefits with respect to the primary endpoints. The nonselective nature of VNS may account for the failure to translate promising results of preclinical and earlier clinical studies. This study showed that optogenetic stimulation of vagal pre-ganglionic neurons transduced to express light-sensitive channels preserved left ventricular function and exercise capacity in a rat model of myocardial infarction−induced heart failure. These data suggested that stimulation of vagal efferent activity is critically important to deliver the therapeutic benefit of VNS in heart failure.
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Key Words
- ABP, arterial blood pressure
- DVMN, dorsal motor nucleus of the vagus nerve
- GRK2, G-protein−coupled receptor kinase 2
- LAD, left anterior descending coronary artery
- LV dP/dtMAX, maximum rate of rise of left ventricular pressure
- LV, left ventricle
- LVEDP, left ventricular end-diastolic pressure
- LVESP, left ventricular end-systolic pressure
- LVP, left ventricular pressure
- LVV, lentiviral vector
- MI, myocardial infarction
- VNS, vagus nerve stimulation
- autonomic nervous system
- eGFP, enhanced green fluorescent protein
- heart failure
- myocardial infarction
- neuromodulation
- vagus nerve stimulation
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Affiliation(s)
- Asif Machhada
- Centre for Cardiovascular and Metabolic Neuroscience, Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Patrick S Hosford
- Centre for Cardiovascular and Metabolic Neuroscience, Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom.,Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Alex Dyson
- Clinical Physiology, Division of Medicine, University College London, London, United Kingdom
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Svetlana Mastitskaya
- Centre for Cardiovascular and Metabolic Neuroscience, Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Alexander V Gourine
- Centre for Cardiovascular and Metabolic Neuroscience, Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
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23
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Wessler I, Kirkpatrick CJ. Cholinergic signaling controls immune functions and promotes homeostasis. Int Immunopharmacol 2020; 83:106345. [PMID: 32203906 DOI: 10.1016/j.intimp.2020.106345] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/06/2020] [Accepted: 02/23/2020] [Indexed: 12/15/2022]
Abstract
Acetylcholine (ACh) was created by nature as one of the first signaling molecules, expressed already in procaryotes. Based on the positively charged nitrogen, ACh could initially mediate signaling in the absence of receptors. When evolution established more and more complex organisms the new emerging organs systems, like the smooth and skeletal muscle systems, energy-generating systems, sexual reproductive system, immune system and the nervous system have further optimized the cholinergic signaling machinery. Thus, it is not surprising that ACh and the cholinergic system are expressed in the vast majority of cells. Consequently, multiple common interfaces exist, for example, between the nervous and the immune system. Research of the last 20 years has unmasked these multiple regulating mechanisms mediated by cholinergic signaling and thus, the biological role of ACh has been revised. The present article summarizes new findings and describes the role of both non-neuronal and neuronal ACh in protecting the organism from external and internal health threats, in providing energy for the whole organism and for the individual cell, controling immune functions to prevent inflammatory dysbalance, and finally, the involvement in critical brain functions, such as learning and memory. All these capacities of ACh enable the organism to attain and maintain homeostasis under changing external conditions. However, the existence of identical interfaces between all these different organ systems complicates the research for new therapeutic interventions, making it essential that every effort should be undertaken to find out more specific targets to modulate cholinergic signaling in different diseases.
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Affiliation(s)
- Ignaz Wessler
- Institute of Pathology, University Medical Center, Johannes Gutenberg University, D-55101 Mainz, Germany.
| | - Charles James Kirkpatrick
- Institute of Pathology, University Medical Center, Johannes Gutenberg University, D-55101 Mainz, Germany
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24
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The Autonomic Regulation of Circulation and Adverse Events in Hypertensive Patients during Follow-Up Study. Cardiol Res Pract 2019; 2019:8391924. [PMID: 32082622 PMCID: PMC7012266 DOI: 10.1155/2019/8391924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 12/09/2019] [Indexed: 11/18/2022] Open
Abstract
Purpose Comprehensive study of autonomic regulation assessed during follow-up could provide new detailed information about the risks stratification for hypertensive patients. Therefore, we investigated the associations of these indices with death, stroke, and revascularization during the follow-up observation of 55 patients. Methods All patients were with target organ damage, and 27 of them had associated clinical conditions (ACC). Mean age of patients with and without ACC was 62.6 ± 4.2 and 51.9 ± 9.9 (mean ± SD) years, respectively. Follow-up was from 66 to 95 months. At entry, autonomic regulation was assessed by the tilt test, Valsalva maneuver, hand-grip test, and cold-stress vasoconstriction. Hemodynamic parameters were measured by continuous blood pressure monitoring, occlusion plethysmography, and electrocardiography. Re-examination of patients was carried out by questioning and physical and laboratory examination. Results We found that fatal outcomes were associated with a lower Valsalva index (1.34 ± 0.16 vs. 1.69 ± 0.37, P < 0.05) and depressed cold vasoconstriction (0.20 ± 0.02 vs. 0.39 ± 0.16%, P < 0.05) and depressed cold vasoconstriction (0.20 ± 0.02 vs. 0.39 ± 0.16%, P < 0.05) and depressed cold vasoconstriction (0.20 ± 0.02 vs. 0.39 ± 0.16%, P < 0.05) and depressed cold vasoconstriction (0.20 ± 0.02 vs. 0.39 ± 0.16%, P < 0.05) and depressed cold vasoconstriction (0.20 ± 0.02 vs. 0.39 ± 0.16%, P < 0.05) and depressed cold vasoconstriction (0.20 ± 0.02 vs. 0.39 ± 0.16%, P < 0.05) and depressed cold vasoconstriction (0.20 ± 0.02 vs. 0.39 ± 0.16%. Conclusions This study shows that such autonomic regulation indices as Valsalva index, blood pressure dynamics in the tilt test, cold-stress vasomotor reactivity, and BPV are important for prognosis of hypertension course.
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Kaufmann D, Raczak G, Szwoch M, Kozłowski D, Kwiatkowska J, Lewicka E, Daniłowicz-Szymanowicz L. Could autonomic nervous system parameters be still helpful in identifying patients with left ventricular systolic dysfunction at the highest risk of all-cause mortality? Cardiol J 2019; 28:914-922. [PMID: 31257569 PMCID: PMC8747825 DOI: 10.5603/cj.a2019.0065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 05/15/2019] [Accepted: 05/23/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Autonomic imbalance is associated with poor prognosis of patients with systolic dysfunction. Most of the previous data were written several years ago and constituted to cardiovascular or arrhythmic mortality. The current treatment of these patients has improved substantially over the last decades, and thus, the population at risk of death may have altered as well. Consequently, data on high-risk patients with systolic dysfunction in the modern era are sparse and those from previous trials may no longer be applicable. The aim herein, was to verify whether well-known autonomic indices - baroreflex sensitivity (BRS) and heart rate variability (HRV) - remain accurate predictors of mortality in patients with systolic dysfunction. METHODS Non-invasively obtained BRS and HRV were analyzed in 205 clinically stable patients with left ventricular ejection fraction (LVEF) ≤ 40%. 28 patients died within 28 ± 9 month follow-up. RESULTS Baroreflex sensitivity, low-frequency (LF) in normalized units, LF to high-frequency ratio and standard deviation of average R-R intervals were significantly associated with mortality; cut-off values of the highest discriminatory power for abovementioned parameters were ≤ 3.0 ms/mmHg, ≤ 41, ≤ 0.7 and ≤ 25 ms, respectively. In bivariate Cox analyses (adjusted for LVEF, New York Heart Association [NYHA] or absence of implantable cardioverter-defibrillator [ICD]) autonomic indices remain significant predictors of death. CONCLUSIONS Baroreflex sensitivity and HRV - may still be helpful in identifying patients with left ventricular systolic dysfunction at the highest risk of all-cause mortality, independently of LVEF, NYHA class, and ICD implantation.
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Affiliation(s)
- Damian Kaufmann
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Poland
| | - Grzegorz Raczak
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Poland
| | - Małgorzata Szwoch
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Poland
| | - Dariusz Kozłowski
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Poland
| | - Joanna Kwiatkowska
- Department of Pediatric Cardiology and Congenital Heart Defect, Medical University of Gdansk, Poland
| | - Ewa Lewicka
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Poland
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Trembach N, Zabolotskikh I. The pathophysiology of complications after laparoscopic colorectal surgery: Role of baroreflex and chemoreflex impairment. ACTA ACUST UNITED AC 2019; 26:115-120. [PMID: 31146925 DOI: 10.1016/j.pathophys.2019.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 04/14/2019] [Accepted: 05/21/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION The aim of this study was to assess the dynamics of baroreflex sensitivity (BRS) during laparoscopic colorectal surgery in patients with different chemoreflex sensitivity assessed with breath-holding test. METHODS The study included 80 patients (mean age, 68 ± 7 years) who underwent routine laparoscopic colorectal surgery under general/epidural anaesthesia. Patients were retrospectively divided into two groups: with normal (breath-holding duration ≥38 s, group N [n = 42]) or high (breath-holding duration <38 s, group H [n = 38]) chemoreflex sensitivity. BRS was initially evaluated after arterial catheter placement before induction, after induction, after pneumoperitoneum, after extubation, and 6 h and 24 h after extubation. RESULTS Average BRS was significantly lower in the group with high peripheral chemoreflex sensitivity at all time points. The use of pneumoperitoneum did not significantly influence BRS in either group. After the surgery and 6 h after extubation, no significant changes were observed. After 6 h of the surgery, 11.9% of patients in group N and 57.8% of those in group H (p < 0.05) had severe baroreflex dysfunction (BRS < 3 ms/mmHg). After 24 h, only two patients in group N (vs 13 [34.2%] in group H, p < 0.05) had this dysfunction. CONCLUSION Patients with high chemoreflex sensitivity have lower BRS, and it decreases further after anaesthesia induction. The recovery process can take up to 24 h, with an increased risk of perioperative complications in patients with high preoperative chemoreflex sensitivity. The use of pneumoperitoneum does not significantly affect BRS.
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Affiliation(s)
- Nikita Trembach
- Department of Anesthesiology, Intensive Care and Transfusiology, Kuban State Medical University, 350063, Krasnodar, Sedin str., 4, Russian Federation.
| | - Igor Zabolotskikh
- Department of Anesthesiology, Intensive Care and Transfusiology, Kuban State Medical University, 350063, Krasnodar, Sedin str., 4, Russian Federation.
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Ponte CMM, Fernandes VO, Liberato CBR, Montenegro APDR, Batista LA, Gurgel MHC, de Azevedo Karbage LB, Vasconcelos ITGF, d’Alva CB, Montenegro Júnior RM. Association between cardiovascular autonomic neuropathy and left ventricular hypertrophy in young patients with congenital generalized lipodystrophy. Diabetol Metab Syndr 2019; 11:53. [PMID: 31303898 PMCID: PMC6604128 DOI: 10.1186/s13098-019-0444-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 06/18/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Congenital generalized lipodystrophy (CGL) is a rare disorder characterized by the absence of subcutaneous adipose tissue, severe insulin resistance, diabetes mellitus, and cardiovascular complications, including cardiac autonomic neuropathy (CAN), left ventricular hypertrophy (LVH), and atherosclerosis. The present study aimed to access the association between CAN parameters and cardiovascular abnormalities in CGL patients. METHODS A cross-sectional study was conducted with 10 CGL patients and 20 healthy controls matched for age, sex, BMI, and pubertal stage. We evaluated clinical, laboratory, and cardiovascular parameters-left ventricular mass index (LVMI), interventricular septum thickness (IVS), systolic and diastolic function determined by two-dimensional transthoracic echocardiography; carotid intimal media thickness (cIMT); and cQT interval. Heart rate variability (HRV) was evaluated by spectral analysis components-high frequency (HF), low frequency (LF), very low frequency (VLF), LF/HF ratio, and total amplitude spectrum (TAS)-and cardiovascular reflexes tests (postural hypotension test, respiratory, orthostatic and Valsalva coefficients). RESULTS In CGL group, four patients (40%) had LVH and diastolic dysfunction. HF component (parasympathetic control) was lower in LVH patients. CGL patients presented higher values of cIMT and cQT interval than heathy subjects. Inverse association between LVMI and LF (p = 0.011), IVS and LF (p = 0.007), and cIMT and leptin (p < 0.001) were observed, even after adjustments by HOMA-IR, A1c, and blood pressure. In CGL group, there were associations between LMVI and HF component (IC95%: - 1.000; - 00.553), LVMI and TAS (IC95%: - 1.000; - 0.012), and IVS and HF component (IC95%: - 1.000; - 0.371). CONCLUSION The association between increased LV mass and parameters of HRV provides possible speculations about the involvement of CAN in the pathophysiology of the cardiac complications, including LVH, in patients with CGL.
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Affiliation(s)
- Clarisse Mourão Melo Ponte
- Brazilian Group for the Study of Inherited and Acquired Lipodystrophies, Faculdade de Medicina, Universidade Federal do Ceará, Rua Professor Costa Mendes 1608, Fortaleza, Ceará 60416-200 Brazil
| | - Virgínia Oliveira Fernandes
- Brazilian Group for the Study of Inherited and Acquired Lipodystrophies, Faculdade de Medicina, Universidade Federal do Ceará, Rua Professor Costa Mendes 1608, Fortaleza, Ceará 60416-200 Brazil
| | - Christiane Bezerra Rocha Liberato
- Brazilian Group for the Study of Inherited and Acquired Lipodystrophies, Faculdade de Medicina, Universidade Federal do Ceará, Rua Professor Costa Mendes 1608, Fortaleza, Ceará 60416-200 Brazil
| | - Ana Paula Dias Rangel Montenegro
- Brazilian Group for the Study of Inherited and Acquired Lipodystrophies, Faculdade de Medicina, Universidade Federal do Ceará, Rua Professor Costa Mendes 1608, Fortaleza, Ceará 60416-200 Brazil
| | - Lívia Aline Batista
- Brazilian Group for the Study of Inherited and Acquired Lipodystrophies, Faculdade de Medicina, Universidade Federal do Ceará, Rua Professor Costa Mendes 1608, Fortaleza, Ceará 60416-200 Brazil
| | - Maria Helane Costa Gurgel
- Brazilian Group for the Study of Inherited and Acquired Lipodystrophies, Faculdade de Medicina, Universidade Federal do Ceará, Rua Professor Costa Mendes 1608, Fortaleza, Ceará 60416-200 Brazil
| | - Lia Beatriz de Azevedo Karbage
- Brazilian Group for the Study of Inherited and Acquired Lipodystrophies, Faculdade de Medicina, Universidade Federal do Ceará, Rua Professor Costa Mendes 1608, Fortaleza, Ceará 60416-200 Brazil
| | - Izabella Tamira Galdino Farias Vasconcelos
- Brazilian Group for the Study of Inherited and Acquired Lipodystrophies, Faculdade de Medicina, Universidade Federal do Ceará, Rua Professor Costa Mendes 1608, Fortaleza, Ceará 60416-200 Brazil
| | - Catarina Brasil d’Alva
- Brazilian Group for the Study of Inherited and Acquired Lipodystrophies, Faculdade de Medicina, Universidade Federal do Ceará, Rua Professor Costa Mendes 1608, Fortaleza, Ceará 60416-200 Brazil
| | - Renan Magalhães Montenegro Júnior
- Brazilian Group for the Study of Inherited and Acquired Lipodystrophies, Faculdade de Medicina, Universidade Federal do Ceará, Rua Professor Costa Mendes 1608, Fortaleza, Ceará 60416-200 Brazil
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Parati G, Ochoa JE. Prognostic value of baroreflex sensitivity in heart failure. A 2018 reappraisal. Eur J Heart Fail 2018; 21:59-62. [PMID: 30468274 DOI: 10.1002/ejhf.1334] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 09/12/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- Gianfranco Parati
- Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Juan Eugenio Ochoa
- Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Milan, Italy
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Al-Zaiti SS, Pietrasik G, Carey MG, Alhamaydeh M, Canty JM, Fallavollita JA. The role of heart rate variability, heart rate turbulence, and deceleration capacity in predicting cause-specific mortality in chronic heart failure. J Electrocardiol 2018; 52:70-74. [PMID: 30476644 DOI: 10.1016/j.jelectrocard.2018.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 10/29/2018] [Accepted: 11/05/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND The volume of regional denervated myocardium (D-M) on positron emission tomography has been recently suggested as a strong independent predictor of cause-specific mortality from sudden cardiac arrest (SCA) in chronic heart failure. We sought to evaluate whether ECG indices of global autonomic function predict risk of SCA to a similar degree as regional D-M. METHODS Subjects enrolled in the Prediction of Arrhythmic Events using Positron Emission Tomography (PAREPET) study were included in this study. Patients completed a 24-hour Holter ECG at enrollment and were followed up at 3-month intervals. SCA events were adjudicated by two board-certified cardiologists. Other cardiovascular death events were classified as nonsudden cardiac death (NSCD). Eight measures of heart rate variability were analyzed: SDNN, RMSSD, low-frequency (LF) and high-frequency (HF) power, heart rate turbulence onset and slope, and acceleration and deceleration capacity. We used competing risk regression to delineate cause-specific mortality from SCA versus NSCD. RESULTS Our sample included 127 patients (age 67 ± 12, 92% male). After a median follow-up of 4.1 years, there were 22 (17%) adjudicated SCA and 18 (14%) adjudicated NSCD events. In multivariate Cox-regression, LF power was the only HRV parameter to predict time-to-SCA. However, in competing risk analysis, reduced LF power was preferentially associated with NSCD rather than SCA (HR = 0.92 [0.85-0.98], p = 0.019). CONCLUSION Depressed LF power might indicate impaired vagal reflex, which suggests that increasing vagal tone in these patients would have a protective effect against NSCD beyond that achieved by the mere slowing of heart rate using β-blockers.
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Affiliation(s)
- Salah S Al-Zaiti
- University of Pittsburgh, Pittsburgh, PA, United States of America.
| | | | - Mary G Carey
- Strong Memorial Hospital at University of Rochester Medical Center, Rochester, NY, United States of America
| | | | - John M Canty
- State University of New York, Buffalo, NY, United States of America; VA Western NY Health Care System, Buffalo, NY, United States of America
| | - James A Fallavollita
- State University of New York, Buffalo, NY, United States of America; VA Western NY Health Care System, Buffalo, NY, United States of America
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Paleczny B, Olesińska-Mader M, Siennicka A, Niewiński P, Nowak K, Buldańczyk A, Jankowska EA, Banasiak W, von Haehling S, Ponikowska B, Anker SD, Ponikowski P. Assessment of baroreflex sensitivity has no prognostic value in contemporary, optimally managed patients with mild-to-moderate heart failure with reduced ejection fraction: a retrospective analysis of 5-year survival. Eur J Heart Fail 2018; 21:50-58. [DOI: 10.1002/ejhf.1306] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 07/23/2018] [Accepted: 07/27/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- Bartłomiej Paleczny
- Department of Physiology; Wroclaw Medical University; Wroclaw Poland
- Department of Cardiology, Centre for Heart Diseases; 4th Military Hospital; Wroclaw Poland
| | | | - Agnieszka Siennicka
- Department of Physiology; Wroclaw Medical University; Wroclaw Poland
- Department of Cardiology, Centre for Heart Diseases; 4th Military Hospital; Wroclaw Poland
| | - Piotr Niewiński
- Department of Cardiology, Centre for Heart Diseases; 4th Military Hospital; Wroclaw Poland
- Department of Heart Diseases; Wroclaw Medical University; Wroclaw Poland
| | - Krzysztof Nowak
- Department of Cardiology, Centre for Heart Diseases; 4th Military Hospital; Wroclaw Poland
- Department of Heart Diseases; Wroclaw Medical University; Wroclaw Poland
| | | | - Ewa A. Jankowska
- Department of Cardiology, Centre for Heart Diseases; 4th Military Hospital; Wroclaw Poland
- Department of Heart Diseases; Wroclaw Medical University; Wroclaw Poland
| | - Waldemar Banasiak
- Department of Cardiology, Centre for Heart Diseases; 4th Military Hospital; Wroclaw Poland
| | - Stephan von Haehling
- Department of Cardiology and Pneumology; University of Göttingen Medical Center; Göttingen Germany
| | - Beata Ponikowska
- Department of Physiology; Wroclaw Medical University; Wroclaw Poland
| | - Stefan D. Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK; and Berlin-Brandenburg Centre for Regenerative Therapies (BCRT); Berlin Germany
- German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin; Germany
| | - Piotr Ponikowski
- Department of Cardiology, Centre for Heart Diseases; 4th Military Hospital; Wroclaw Poland
- Department of Heart Diseases; Wroclaw Medical University; Wroclaw Poland
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Sudden death risk markers for patients with left ventricular ejection fractions greater than 40. Trends Cardiovasc Med 2018; 28:516-521. [PMID: 29907466 DOI: 10.1016/j.tcm.2018.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 03/30/2018] [Accepted: 05/02/2018] [Indexed: 12/28/2022]
Abstract
The major burden of sudden cardiac death (SCD) in patients with heart disease occurs in those with a left ventricular ejection fraction > 40%. Although the annual risk of SCD may be lower in these patients compared to those with lower LVEF, their lifetime cumulative risk of SCD may be greater due to a better overall prognosis. It is plausible that those with LVEF > 40% who are at highest risk of life-threatening arrhythmia will benefit from implantable cardioverter defibrillators. Features that identify patients with a LVEF > 40% at high risk of SCD are urgently needed. We review existing studies examining SCD markers in this sub-group and discuss gaps in the current evidence base.
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Restoration of normal sympathetic neural function in heart failure following baroreflex activation therapy: final 43-month study report. J Hypertens 2018; 35:2532-2536. [PMID: 28816745 PMCID: PMC5673301 DOI: 10.1097/hjh.0000000000001498] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: Baroreflex activation therapy (BAT) exerts in severe heart failure sympathoinhibitory effects, improving clinical variables and reducing hospitalization rate. The current follow-up study was aimed at determining the long-term effects of BAT, assessing whether BAT in heart failure allows to restore physiological levels of sympathetic function. Methods: Seven patients out of the 11 heart failure patients aged 66.5 ± 3 years (mean ± SEM) in New York Heart Association Class III with left ventricular ejection fraction 40% or less and impaired functional capacity recruited in the study survived at the final follow-up (43.5 ± 2.1 months). Measurements included muscle sympathetic nerve activity (MSNA, microneurography) and spontaneous baroreflex-MSNA sensitivity together with hospitalization rate, echocardiography, Minnesota score, New York Heart Association class and standard clinical data. Measurements were collected before and at 6, 21 and 43 months following BAT. Data were compared with those collected in 17 age-matched healthy controls. All assessments were made with the heart failure patient on optimal active therapy. Results: In the seven patients, BAT maintained its beneficial effects over 43.5 ± 2.1 months of follow-up. MSNA values underwent a progressive significant reduction from baseline to 21 and 43 months follow-up following BAT (from 46.2 ± 2.4 to 31.3 ± 3.0 e 26.6 ± 2.0 bursts/min, P < 0.05 at least), becoming almost superimposable to the ones seen in healthy controls (25.5 ± 0.8 bursts/min). Baroreflex-MSNA sensitivity improved, without achieving, however, a full normalization. Blood pressure and heart rate did not change. Left ventricular ejection fraction improved significantly from 32.3 ± 2 to 36.7 ± 3% (P < 0.05). Hospitalization rate decreased substantially when measured as days/year/patients it decreased from 10.3 ± 2.5 preimplant to 1.01 ± 1.4 at the 43.5th month follow-up (P < 0.02). No side effects were reported in the long-term period. Conclusion: The current study provides evidence that BAT in heart failure with reduced ejection fraction allows not only to improve hemodynamic and clinical profile but also to exert profound sympathoinhibitory effects, allowing an almost complete restoration of physiological levels of the sympathetic neural function.
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Gronda E, Francis D, Zannad F, Hamm C, Brugada J, Vanoli E. Baroreflex activation therapy: a new approach to the management of advanced heart failure with reduced ejection fraction. J Cardiovasc Med (Hagerstown) 2018; 18:641-649. [PMID: 28737621 PMCID: PMC5555968 DOI: 10.2459/jcm.0000000000000544] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Chronic heart failure is a common clinical condition characterized by persistent excessive sympathetic nervous system activation. The derangement of the sympathetic activity has relevant implications for disease progression and patient survival. Aiming to positively impact patient outcome, autonomic nervous system modulatory therapies have been developed and tested in animal and clinical studies. As a general gross assumption, direct vagal stimulation and baroreflex activation are considered equivalent. This assumption does not take into account the fact that direct cervical vagal nerve stimulation involves activation of both afferent and efferent fibers innervating not only the heart, but the entire visceral system, leading to undesired responses to and from this compartment. The different action of baroreflex activation is based on generating a centrally mediated reduction of sympathetic outflow and increasing parasympathetic activity to the heart via a physiological reflex pathway. Thus, baroreflex activation rebalances the unbalanced autonomic nervous system via a specific path. Independent and complementary investigations have shown that sympathetic nerve activity can be rebalanced via control of the arterial baroreflex in heart failure patients. Results from recent pioneering research studies support the hypothesis that baroreflex activation can add significant therapeutic benefit on top of guideline-directed medical therapy in patients with advanced heart failure. In the present review, baroreflex activation therapy results are discussed, focusing on critical aspects like patient selection rationale to support clinician orientation in opting for baroreflex activation therapy when, on top of current guideline-directed medical treatment, other therapies are to be considered.
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Affiliation(s)
- Edoardo Gronda
- aCardiovascular Department, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy bNational Heart and Lung Institute, Imperial College London, London, UK cUnité 1116, Department of Cardiology, Centre d'Investigations Cliniques, INSERM, CHU de Nancy, Université de Lorraine, Nancy, France dKerckhoff Heart Center, Bad Nauheim Medical Clinic I, University of Giessen, Giessen, Germany eCardiovascular Institute, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain fDepartment of Molecular Medicine, University of Pavia, Pavia, Italy
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Different estimation methods of spontaneous baroreflex sensitivity have different predictive value in heart failure patients. J Hypertens 2018; 35:1666-1675. [PMID: 28399043 DOI: 10.1097/hjh.0000000000001377] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Several methods have been developed so far to estimate cardiac baroreflex sensitivity (BRS) through the analysis of spontaneous fluctuations of systolic arterial pressure (SAP) and R-R interval. Their relative performance in predicting cardiac mortality in heart failure patients is not known. The aim of this study was to compare the prognostic value of a set of representative indexes of spontaneous BRS in these patients. METHODS We studied 228 stable, moderate-to-severe heart failure patients with reduced ejection fraction, in sinus rhythm, who underwent an 8-min supine recording of ECG, arterial blood pressure and respiration during paced breathing (15 breaths/min). BRS was estimated according to the following methods: sequence (BRSSeq); nonparametric transfer function in the low-frequency band (BRSTF_NP-LF); parametric spectral computed in the low-frequency and high-frequency bands (BRSPS-LF and BRSPS-HF); parametric transfer function computed in the low-frequency and high-frequency bands (BRSTF_P-LF and BRSTF_P-HF); model-based closed loop (BRSCL); and bivariate phase-rectified signal averaging (BRSPRSA). RESULTS During a median follow-up of 36 months, 45 patients experienced a cardiac event. Only BRSTF_NP-LF, BRSPS-LF, BRSTF_P-LF and BRSPRSA were significantly associated with the outcome (P < 0.01), and statistical significance remained (P ≤ 0.03) after adjusting for clinical covariates. BRSTF_NP-LF and BRSPRSA also significantly improved the risk classification. CONCLUSION This study shows that different spontaneous BRS indexes have different predictive value in patients with heart failure. It also shows that the prognostic information of BRS estimates is linked to SAP and RR oscillations in the low-frequency band.
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Ayesta A, Martínez-Sellés H, Bayés de Luna A, Martínez-Sellés M. Prediction of sudden death in elderly patients with heart failure. J Geriatr Cardiol 2018; 15:185-192. [PMID: 29662512 PMCID: PMC5895958 DOI: 10.11909/j.issn.1671-5411.2018.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 02/25/2018] [Accepted: 02/27/2018] [Indexed: 02/06/2023] Open
Abstract
Most heart failure (HF) related mortality is due to sudden cardiac death (SCD) and worsening HF, particularly in the case of reduced ejection fraction. Predicting and preventing SCD is an important goal but most works include no or few patients with advanced age, and the prevention of SCD in elderly patients with HF is still controversial. A recent reduction in the annual rate of SCD has been recently described but it is not clear if this is also true in advanced age patients. Age is associated with SCD, although physicians frequently have the perception that elderly patients with HF die mainly of pump failure, underestimating the importance of SCD. Other clinical variables that have been associated to SCD are symptoms, New York Heart Association functional class, ischemic cause, and comorbidities (chronic obstructive pulmonary disease, renal dysfunction and diabetes). Some test results that should also be considered are left ventricular ejection fraction and diameters, natriuretic peptides, non-sustained ventricular tachycardias and autonomic abnormalities. The combination of all these markers is probably the best option to predict SCD. Different risk scores have been described and, although there are no specific ones for elderly populations, most include age as a risk predictor and some were developed in populations with mean age > 65 years. Finally, it is important to stress that these scores should be able to predict any type of SCD as, although most are due to tachyarrhythmias, bradyarrhythmias also play a role, particularly in the case of the elderly.
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Affiliation(s)
- Ana Ayesta
- Cardiology Department, Hospital Universitario del Sureste, Arganda del Rey, Madrid, Spain
| | | | | | - Manuel Martínez-Sellés
- Universidad Complutense, Madrid, Spain
- Cardiology Department, Hospital General Universitario Gregorio Marañón, CIVERCV, Universidad Europea, Madrid, Spain
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Expression and relevance of the G protein-gated K + channel in the mouse ventricle. Sci Rep 2018; 8:1192. [PMID: 29352184 PMCID: PMC5775354 DOI: 10.1038/s41598-018-19719-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/08/2018] [Indexed: 12/31/2022] Open
Abstract
The atrial G protein-gated inwardly rectifying K+ (GIRK) channel is a critical mediator of parasympathetic influence on cardiac physiology. Here, we probed the details and relevance of the GIRK channel in mouse ventricle. mRNAs for the atrial GIRK channel subunits (GIRK1, GIRK4), M2 muscarinic receptor (M2R), and RGS6, a negative regulator of atrial GIRK-dependent signaling, were detected in mouse ventricle at relatively low levels. The cholinergic agonist carbachol (CCh) activated small GIRK currents in adult wild-type ventricular myocytes that exhibited relatively slow kinetics and low CCh sensitivity; these currents were absent in ventricular myocytes from Girk1-/- or Girk4-/- mice. While loss of GIRK channels attenuated the CCh-induced shortening of action potential duration and suppression of ventricular myocyte excitability, selective ablation of GIRK channels in ventricle had no effect on heart rate, heart rate variability, or electrocardiogram parameters at baseline or after CCh injection. Additionally, loss of ventricular GIRK channels did not impact susceptibility to ventricular arrhythmias. These data suggest that the mouse ventricular GIRK channel is a GIRK1/GIRK4 heteromer, and show that while it contributes to the cholinergic suppression of ventricular myocyte excitability, this influence does not substantially impact cardiac physiology or ventricular arrhythmogenesis in the mouse.
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Zhang D, Tu H, Cao L, Zheng H, Muelleman RL, Wadman MC, Li YL. Reduced N-Type Ca 2+ Channels in Atrioventricular Ganglion Neurons Are Involved in Ventricular Arrhythmogenesis. J Am Heart Assoc 2018; 7:JAHA.117.007457. [PMID: 29335317 PMCID: PMC5850164 DOI: 10.1161/jaha.117.007457] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Attenuated cardiac vagal activity is associated with ventricular arrhythmogenesis and related mortality in patients with chronic heart failure. Our recent study has shown that expression of N‐type Ca2+ channel α‐subunits (Cav2.2‐α) and N‐type Ca2+ currents are reduced in intracardiac ganglion neurons from rats with chronic heart failure. Rat intracardiac ganglia are divided into the atrioventricular ganglion (AVG) and sinoatrial ganglion. Ventricular myocardium receives projection of neuronal terminals only from the AVG. In this study we tested whether a decrease in N‐type Ca2+ channels in AVG neurons contributes to ventricular arrhythmogenesis. Methods and Results Lentiviral Cav2.2‐α shRNA (2 μL, 2×107 pfu/mL) or scrambled shRNA was in vivo transfected into rat AVG neurons. Nontransfected sham rats served as controls. Using real‐time single‐cell polymerase chain reaction and reverse‐phase protein array, we found that in vivo transfection of Cav2.2‐α shRNA decreased expression of Cav2.2‐α mRNA and protein in rat AVG neurons. Whole‐cell patch‐clamp data showed that Cav2.2‐α shRNA reduced N‐type Ca2+ currents and cell excitability in AVG neurons. The data from telemetry electrocardiographic recording demonstrated that 83% (5 out of 6) of conscious rats with Cav2.2‐α shRNA transfection had premature ventricular contractions (P<0.05 versus 0% of nontransfected sham rats or scrambled shRNA‐transfected rats). Additionally, an index of susceptibility to ventricular arrhythmias, inducibility of ventricular arrhythmias evoked by programmed electrical stimulation, was higher in rats with Cav2.2‐α shRNA transfection compared with nontransfected sham rats and scrambled shRNA‐transfected rats. Conclusions A decrease in N‐type Ca2+ channels in AVG neurons attenuates vagal control of ventricular myocardium, thereby initiating ventricular arrhythmias.
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Affiliation(s)
- Dongze Zhang
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Huiyin Tu
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Liang Cao
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE.,Department of Cardiac surgery, Second Xiangya Hospital, Central South University, Changsha, China
| | - Hong Zheng
- Department of Cellular & Integrative Physiology, University of Nebraska Medical Center, Omaha, NE
| | - Robert L Muelleman
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Michael C Wadman
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Yu-Long Li
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE .,Department of Cellular & Integrative Physiology, University of Nebraska Medical Center, Omaha, NE
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Serhiyenko VA, Serhiyenko AA. Cardiac autonomic neuropathy: Risk factors, diagnosis and treatment. World J Diabetes 2018; 9:1-24. [PMID: 29359025 PMCID: PMC5763036 DOI: 10.4239/wjd.v9.i1.1] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 12/09/2017] [Accepted: 12/29/2017] [Indexed: 02/06/2023] Open
Abstract
Cardiac autonomic neuropathy (CAN) is a serious complication of diabetes mellitus (DM) that is strongly associated with approximately five-fold increased risk of cardiovascular mortality. CAN manifests in a spectrum of things, ranging from resting tachycardia and fixed heart rate (HR) to development of "silent" myocardial infarction. Clinical correlates or risk markers for CAN are age, DM duration, glycemic control, hypertension, and dyslipidemia (DLP), development of other microvascular complications. Established risk factors for CAN are poor glycemic control in type 1 DM and a combination of hypertension, DLP, obesity, and unsatisfactory glycemic control in type 2 DM. Symptomatic manifestations of CAN include sinus tachycardia, exercise intolerance, orthostatic hypotension (OH), abnormal blood pressure (BP) regulation, dizziness, presyncope and syncope, intraoperative cardiovascular instability, asymptomatic myocardial ischemia and infarction. Methods of CAN assessment in clinical practice include assessment of symptoms and signs, cardiovascular reflex tests based on HR and BP, short-term electrocardiography (ECG), QT interval prolongation, HR variability (24 h, classic 24 h Holter ECG), ambulatory BP monitoring, HR turbulence, baroreflex sensitivity, muscle sympathetic nerve activity, catecholamine assessment and cardiovascular sympathetic tests, heart sympathetic imaging. Although it is common complication, the significance of CAN has not been fully appreciated and there are no unified treatment algorithms for today. Treatment is based on early diagnosis, life style changes, optimization of glycemic control and management of cardiovascular risk factors. Pathogenetic treatment of CAN includes: Balanced diet and physical activity; optimization of glycemic control; treatment of DLP; antioxidants, first of all α-lipoic acid (ALA), aldose reductase inhibitors, acetyl-L-carnitine; vitamins, first of all fat-soluble vitamin B1; correction of vascular endothelial dysfunction; prevention and treatment of thrombosis; in severe cases-treatment of OH. The promising methods include prescription of prostacyclin analogues, thromboxane A2 blockers and drugs that contribute into strengthening and/or normalization of Na+, K+-ATPase (phosphodiesterase inhibitor), ALA, dihomo-γ-linolenic acid (DGLA), ω-3 polyunsaturated fatty acids (ω-3 PUFAs), and the simultaneous prescription of ALA, ω-3 PUFAs and DGLA, but the future investigations are needed. Development of OH is associated with severe or advanced CAN and prescription of nonpharmacological and pharmacological, in the foreground midodrine and fludrocortisone acetate, treatment methods are necessary.
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Affiliation(s)
- Victoria A Serhiyenko
- Department of Endocrinology, Lviv National Medical University Named by Danylo Halitsky, Lviv 79010, Ukraine
| | - Alexandr A Serhiyenko
- Department of Endocrinology, Lviv National Medical University Named by Danylo Halitsky, Lviv 79010, Ukraine
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Trembach N, Zabolotskikh I. Arterial baroreflex sensitivity: Relationship with peripheral chemoreflex in patients with chronic heart failure. Artery Res 2018. [DOI: 10.1016/j.artres.2018.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Jamali HK, Waqar F, Gerson MC. Cardiac autonomic innervation. J Nucl Cardiol 2017; 24:1558-1570. [PMID: 27844333 DOI: 10.1007/s12350-016-0725-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 10/25/2016] [Indexed: 10/20/2022]
Abstract
The autonomic nervous system plays a key role in regulating changes in the cardiovascular system and its adaptation to various human body functions. The sympathetic arm of the autonomic nervous system is associated with the fight and flight response, while the parasympathetic division is responsible for the restorative effects on heart rate, blood pressure, and contractility. Disorders involving these two divisions can lead to, and are seen as, a manifestation of most common cardiovascular disorders. Over the last few decades, extensive research has been performed establishing imaging techniques to quantify the autonomic dysfunction associated with various cardiovascular disorders. Additionally, several techniques have been tested with variable success in modulating the cardiac autonomic nervous system as treatment for these disorders. In this review, we summarize basic anatomy, physiology, and pathophysiology of the cardiac autonomic nervous system including adrenergic receptors. We have also discussed several imaging modalities available to aid in diagnosis of cardiac autonomic dysfunction and autonomic modulation techniques, including pharmacologic and device-based therapies, that have been or are being tested currently.
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Affiliation(s)
- Hina K Jamali
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, University of Cincinnati College of Medicine, P.O. Box 670542, Cincinnati, OH, USA
| | - Fahad Waqar
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, University of Cincinnati College of Medicine, P.O. Box 670542, Cincinnati, OH, USA
| | - Myron C Gerson
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, University of Cincinnati College of Medicine, P.O. Box 670542, Cincinnati, OH, USA.
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Maestri R, La Rovere MT, Raczak G, Danilowicz-Szymanowicz L, Pinna GD. Estimation of baroreflex sensitivity by the bivariate phase rectified signal averaging method: a comparison with the phenylephrine method. Physiol Meas 2017; 38:1874-1884. [PMID: 28885986 DOI: 10.1088/1361-6579/aa8b5a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES A novel technique to assess spontaneous baroreflex sensitivity (BRS) by bivariate phase-rectified signal averaging (PRSA-BRS) has been recently proposed and its independent prognostic power demonstrated. This method, however, has never been compared with the phenyleprine test (Phe-BRS), commonly regarded as the reference method in clinical and research applications. APPROACH In 192 heart failure (HF) and 41 post-myocardial infarction (post-MI) patients we compared PRSA-BRS with Phe-BRS, assessing both association and agreement. MAIN RESULTS Phe-BRS and PRSA-BRS were (mean ± SD) 4.8 ± 5.0 (range: -3.8,25.0) and 1.2 ± 1.5 (-2.1,6.9) ms mmHg-1 in HF (p < 0.0001), and 5.0 ± 3.8 (-1.2,12.5) and 0.8 ± 1.7 (-2.0,6.9) ms mmHg-1 in post-MI patients (p = 0.001). Moderate association was observed (r = 0.53, p < 0.0001 and r = 0.43, p = 0.004 in HF and post-MI, respectively). The vast majority (86% in HF and 90% in post-MI) of PRSA-BRS measurements were smaller than corresponding Phe-BRS values. The difference between PRSA-BRS and Phe-BRS was strongly dependent on the magnitude of BRS, with a trend towards more negative differences as BRS increased. Negative PRSA-BRS values were observed in 15% of HF and in 37% of post-MI patients, whereas negative Phe-BRS values were observed in 8% of HF and 5% of post-MI patients. SIGNIFICANCE Although the association with Phe-BRS suggests that PRSA-BRS contains relevant information about cardiac autonomic control and reflects the strength of the baroreceptor-heart rate reflex, the marked disagreement between the two measurements indicates that PRSA-BRS measurements cannot be taken as estimates of BRS. Many factors may account for the observed lack of agreement: the different physiological conditions under which Phe-BRS and PRSA-BRS are measured, the inclusion of non-baroreflex mediated components of RR-intervals in PRSA-BRS and some computational aspects related to the normalization of PRSA-BRS values.
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Affiliation(s)
- Roberto Maestri
- Department of Biomedical Engineering, Istituti Clinici Scientifici Maugeri, SpA, SB, IRCCS Montescano, Montescano (PV), Italy
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Sayegh ALC, Dos Santos MR, Sarmento AO, de Souza FR, Salemi VMC, Hotta VT, Marques ACDB, Krämer HH, Trombetta IC, Mady C, Alves MJDNN. Cardiac and peripheral autonomic control in restrictive cardiomyopathy. ESC Heart Fail 2017; 4:341-350. [PMID: 28772037 PMCID: PMC5542737 DOI: 10.1002/ehf2.12142] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/19/2017] [Accepted: 02/03/2017] [Indexed: 12/18/2022] Open
Abstract
AIMS Autonomic dysfunction determines the advance of dilated cardiomyopathy (DCM) and is related to poor outcomes. However, this autonomic imbalance is unknown in patients with restrictive cardiomyopathy (RCM) even though they have similar symptoms and poor quality of life as DCM patients have. The aim of this study was to evaluate if autonomic and neurovascular controls were altered in RCM patients. METHODS AND RESULTS Fifteen RCM patients, 10 DCM patients, and 10 healthy subjects were evaluated. Heart rate and blood pressure (BP) were recorded. Peripheral sympathetic activity [muscle sympathetic nerve activity (MSNA)] by microneurography and cardiac sympathetic activity by power spectrum analysis of heart rate variability. Spontaneous baroreflex sensitivity (BRS) was evaluated by the sequence method and forearm blood flow by venous occlusion plethysmography. Both cardiomyopathy groups had higher MSNA frequency (P < 0.001) and MSNA incidence (P < 0.001), higher cardiac sympathovagal balance (P < 0.02), reduced BRS for increase (P = 0.002) and for decrease in BP (P = 0.002), and lower forearm blood flow (P < 0.001) compared with healthy subjects. We found an inverse correlation between BRS for increase and decrease in BP and peripheral sympathetic activity (r = -0.609, P = 0.001 and r = -0.648, P < 0.001, respectively) and between BRS for increase and decrease in BP and cardiac sympathetic activity (r = -0.503, P = 0.03 and r = -0.487, P = 0.04, respectively). CONCLUSIONS The RCM patients had cardiac and peripheral autonomic dysfunctions associated with peripheral vasoconstriction. Nonetheless, the presence of normal ejection fraction underestimates the evolution of the disease and makes clinical treatment difficult. These alterations could lead to a similar cardiovascular risk as that observed in DCM patients.
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Affiliation(s)
- Ana Luiza C Sayegh
- Clinical Unit of Cardiomyopathy, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Marcelo R Dos Santos
- Cardiovascular Rehabilitation and Exercise Physiology Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Adriana O Sarmento
- Cardiovascular Rehabilitation and Exercise Physiology Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Francis R de Souza
- Cardiovascular Rehabilitation and Exercise Physiology Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Vera M C Salemi
- Clinical Unit of Heart Failure, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Viviane T Hotta
- Clinical Unit of Cardiomyopathy, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Akothirene Cristhina D B Marques
- Cardiovascular Rehabilitation and Exercise Physiology Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Heidrum H Krämer
- Departmente of Neurology, Justus-Liebig-University, Giessen, Germany
| | - Ivani C Trombetta
- Cardiovascular Rehabilitation and Exercise Physiology Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Charles Mady
- Clinical Unit of Cardiomyopathy, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
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Paleczny B, Olesińska M, Siennicka A, Niewiński P, Jankowska EA, Ponikowska B, Banasiak W, Von Haehling S, Anker SD, Ponikowski P. Central Chemoreceptor Sensitivity Is Not Enhanced in Contemporary Patients With Chronic Systolic Heart Failure Receiving Optimal Treatment. J Card Fail 2016; 23:83-87. [PMID: 27867115 DOI: 10.1016/j.cardfail.2016.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 11/07/2016] [Accepted: 11/15/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Clinical and prognostic consequences of enhanced central chemosensitivity in the contemporary optimally treated patients with chronic heart failure (CHF) are unknown. METHODS AND RESULTS We studied central chemosensitivity (defined as hypercapnic ventilatory response [HCVR; L/min/mmHg]) in 161 CHF patients (mean left ventricular ejection fraction [LVEF] 31 ± 6%, all receiving a combination of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and beta-blocker) and 55 sex- and age-matched healthy controls. HCVR did not differ between CHF patients and controls (median 0.63 vs 0.57 L/min-1/mmHg-1, P = .76). When the CHF patients were divided into tertiles according to their HCVR values, there were no significant differences in clinical characteristics (except for ischemic etiology, which was more frequent in those with the highest HCVR), results of the cardiopulmonary exercise testing, and indices of heart rate variability. During the follow-up (median 28 months, range 1-48 months, ≥15 months in all survivors), 21 patients died. HCVR was not related to survival in the Cox proportional hazards analysis. CONCLUSIONS Central chemosensitivity is not enhanced in contemporary, optimally treated CHF patients and its assessment does not provide significant clinical or prognostic information.
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Affiliation(s)
- Bartłomiej Paleczny
- Department of Physiology, Wroclaw Medical University, Wroclaw, Poland; Department of Cardiology, Centre for Heart Diseases, 4th Military Hospital, Wroclaw, Poland.
| | - Martyna Olesińska
- Department of Cardiology, Centre for Heart Diseases, 4th Military Hospital, Wroclaw, Poland
| | - Agnieszka Siennicka
- Department of Physiology, Wroclaw Medical University, Wroclaw, Poland; Department of Cardiology, Centre for Heart Diseases, 4th Military Hospital, Wroclaw, Poland
| | - Piotr Niewiński
- Department of Cardiology, Centre for Heart Diseases, 4th Military Hospital, Wroclaw, Poland
| | - Ewa A Jankowska
- Department of Cardiology, Centre for Heart Diseases, 4th Military Hospital, Wroclaw, Poland; Laboratory for Applied Research on Cardiovascular System, Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Beata Ponikowska
- Department of Physiology, Wroclaw Medical University, Wroclaw, Poland
| | - Waldemar Banasiak
- Department of Cardiology, Centre for Heart Diseases, 4th Military Hospital, Wroclaw, Poland
| | - Stephan Von Haehling
- Division of Innovative Clinical Trials, Department of Cardiology & Pulmonology, University Medicine Göttingen (UMG), Göttingen, Germany
| | - Stefan D Anker
- Division of Innovative Clinical Trials, Department of Cardiology & Pulmonology, University Medicine Göttingen (UMG), Göttingen, Germany
| | - Piotr Ponikowski
- Department of Cardiology, Centre for Heart Diseases, 4th Military Hospital, Wroclaw, Poland; Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
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Gronda E, Vanoli E. Autonomic Modulation With Baroreflex Activation Therapy in Heart Failure. Curr Heart Fail Rep 2016; 13:273-280. [DOI: 10.1007/s11897-016-0307-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Adlan AM, Paton JFR, Lip GYH, Kitas GD, Fisher JP. Increased sympathetic nerve activity and reduced cardiac baroreflex sensitivity in rheumatoid arthritis. J Physiol 2016; 595:967-981. [PMID: 27561790 PMCID: PMC5285627 DOI: 10.1113/jp272944] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 08/19/2016] [Indexed: 12/11/2022] Open
Abstract
KEY POINTS Rheumatoid arthritis (RA) is a chronic inflammatory condition associated with an increased risk of cardiovascular mortality. Increased sympathetic nerve activity and reduced cardiac baroreflex sensitivity heighten cardiovascular risk, althogh whether such autonomic dysfunction is present in RA is not known. In the present study, we observed an increased sympathetic nerve activity and reduced cardiac baroreflex sensitivity in patients with RA compared to matched controls. Pain was positively correlated with sympathetic nerve activity and negatively correlated with cardiac baroreflex sensitivity. The pattern of autonomic dysfunction that we describe may help to explain the increased cardiovascular risk in RA, and raises the possibility that optimizing pain management may resolve autonomic dysfunction in RA. ABSTRACT Rheumatoid arthritis (RA) is a chronic inflammatory condition associated with increased cardiovascular morbidity/mortality and an incompletely understood pathophysiology. In animal studies, central and blood borne inflammatory cytokines that can be elevated in RA evoke pathogenic increases in sympathetic activity and reductions in baroreflex sensitivity (BRS). We hypothesized that muscle sympathetic nerve activity (MSNA) was increased and BRS decreased in RA. MSNA, blood pressure and heart rate (HR) were recorded in age- and sex-matched RA-normotensive (n = 13), RA-hypertensive patients (RA-HTN; n = 17), normotensive (NC; n = 17) and hypertensive controls (HTN; n = 16). BRS was determined using the modified Oxford technique. Inflammation and pain were determined using serum high sensitivity C-reactive protein (hs-CRP) and a visual analogue scale (VAS), respectively. MSNA was elevated similarly in RA, RA-HTN and HTN patients (32 ± 9, 35 ± 14, 37 ± 8 bursts min-1 ) compared to NC (22 ± 9 bursts min-1 ; P = 0.004). Sympathetic BRS was similar between groups (P = 0.927), whereas cardiac BRS (cBRS) was reduced in RA, RA-HTN and HTN patients [5(3-8), 4 (2-7), 6 (4-9) ms mmHg-1 ] compared to NC [11 (8-15) ms mmHg-1 ; P = 0.002]. HR was independently associated with hs-CRP. Increased MSNA and reduced cBRS were associated with hs-CRP although confounded in multivariable analysis. VAS was independently associated with MSNA burst frequency, cBRS and HR. We provide the first evidence for heightened sympathetic outflow and reduced cBRS in RA that can be independent of hypertension. In RA patients, reported pain was positively correlated with MSNA and negatively correlated with cBRS. Future studies should assess whether therapies to ameliorate pain and inflammation in RA restores autonomic balance and reduces cardiovascular events.
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Affiliation(s)
- Ahmed M Adlan
- College of Life & Environmental Sciences, University of Birmingham, Birmingham, UK
| | - Julian F R Paton
- School of Physiology, Pharmacology & Neuroscience, Biomedical Sciences, University of Bristol, Bristol, UK
| | - Gregory Y H Lip
- University of Birmingham Centre of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - George D Kitas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands, UK
| | - James P Fisher
- College of Life & Environmental Sciences, University of Birmingham, Birmingham, UK
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Fiorino P, Américo A, Muller C, Evangelista F, Santos F, Leite A, Farah V. Exposure to high-fat diet since post-weaning induces cardiometabolic damage in adult rats. Life Sci 2016; 160:12-17. [DOI: 10.1016/j.lfs.2016.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 06/23/2016] [Accepted: 07/06/2016] [Indexed: 12/19/2022]
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Baroreflex deficiency aggravates atherosclerosis via α7 nicotinic acetylcholine receptor in mice. Vascul Pharmacol 2016; 87:92-99. [PMID: 27568460 DOI: 10.1016/j.vph.2016.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Revised: 07/12/2016] [Accepted: 08/23/2016] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Inflammation and oxidative stress play a key role in the initiation, propagation, and development of atherosclerosis. Arterial baroreflex (ABR) dysfunction induced by sinoaortic denervation (SAD) promoted the development of atherosclerosis in ApoE-/- mice. The present work was designed to examine whether ABR deficiency affected inflammation and oxidative stress via α7 nicotinic acetylcholine receptor (α7nAChR) leading to the aggravation of atherosclerosis in mice. METHODS AND RESULTS ApoE-/- mice were fed with a high-cholesterol diet for 6weeks and half of the mice received sinoaortic denervation that destroyed ABR. We studied the expression of vesicular acetylcholine transporter (VAChT), α7nAChR and levels of inflammatory response and oxidative stress. The results showed that baroreflex dysfunction could promote atherosclerosis, meanwhile, decrease the expression of VAChT and α7nAChR and significantly increase the levels of oxidative stress and inflammation in SAD mice. After treated with PNU-282987 (a selective α7nAChR agonist, 0.53mg/kg/day) for 6weeks in SAD and Sham mice, we found that PNU-282987 could attenuate atherosclerosis and significantly decreased oxidative stress and inflammation after SAD. In addition, α7nAChR+/+ and α7nAChR-/- mice fed with a high-cholesterol diet for 8weeks were co-treated with ketanserin (0.6mg/kg/day), a drug that can enhance baroreflex sensitivity (BRS). Ketanserin could alleviate atherosclerosis and markedly decrease oxidative stress and inflammation in α7nAChR+/+ mice. But there were no effects in α7nAChR knockout mice. CONCLUSIONS Our results demonstrate that ABR dysfunction aggravates atherosclerosis in mice via the vagus-ACh-α7nAChR-inflammation and oxidative stress pathway.
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Rousselet L, Le Rolle V, Ojeda D, Guiraud D, Hagége A, Bel A, Bonnet JL, Mabo P, Carrault G, Hernández AI. Influence of Vagus Nerve Stimulation parameters on chronotropism and inotropism in heart failure. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2016; 2014:526-9. [PMID: 25570012 DOI: 10.1109/embc.2014.6943644] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Vagus Nerve Stimulation (VNS) has been shown to be useful in heart failure patients, including antiarrhythmic effects, improvement of cardiac function and reduction of the mortality. However, the optimal configuration of VNS can be a difficult task, since there are several adjustable parameters, such as current amplitude (mA), pulse width (ms), burst frequency (Hz), number of pulses and, in the case of cardiac-triggered VNS, the delay (ms) between the R-wave and the beginning of the stimulation. The objective of this paper is to analyse the effect of these parameters, and their interaction, on the chronotropic and inotropic responses to vagal stimulation. 306 VNS sequences were tested on 12 sheep with induced heart failure. Autonomic markers of the chronotropic (changes in RR interval) and inotropic (changes in dP/dtmax) effects were extracted from the observed data. In order to analyse the influence of stimulation parameters on these markers, a sensitivity analysis method was applied. Results illustrate the strong interaction between the delay and the others parameters. The number of pulses, the current and the frequency seem to be particularly influent on chronotropism and inotropism although the effect of the frequency is highly non-linear or it depends on other parameters.
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Fernandes Serôdio J, Martins Oliveira M, Matoso Laranjo S, Tavares C, Silva Cunha P, Abreu A, Branco L, Alves S, Rocha I, Cruz Ferreira R. The arterial baroreflex effectiveness index in risk stratification of chronic heart failure patients who are candidates for cardiac resynchronization therapy. Rev Port Cardiol 2016; 35:343-50. [PMID: 27255174 DOI: 10.1016/j.repc.2015.11.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 11/22/2015] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Baroreflex function is an independent marker of prognosis in heart failure (HF). However, little is known about its relation to response to cardiac resynchronization therapy (CRT). The aim of this study is to assess arterial baroreflex function in HF patients who are candidates for CRT. METHODS The study population consisted of 25 patients with indication for CRT, aged 65±10 years, NYHA functional class ≥III in 52%, QRS width 159±15 ms, left ventricular ejection fraction (LVEF) 29±5%, left ventricular end-systolic volume (LVESV) 150±48 ml, B-type natriuretic peptide (BNP) 357±270 pg/ml, and peak oxygen consumption (peak VO2) 18.4±5.0 ml/kg/min. An orthostatic tilt test was performed to assess the baroreflex effectiveness index (BEI) by the sequence method. This group was compared with 15 age-matched healthy individuals. RESULTS HF patients showed a significantly depressed BEI during tilt (31±12% vs. 49±18%, p=0.001). A lower BEI was associated with higher BNP (p=0.038), lower peak VO2 (p=0.048), and higher LVESV (p=0.031). By applying a cut-off value of 25% for BEI, two clusters of patients were identified: lower risk cluster (BEI >25%) QRS 153 ms, LVESV 129 ml, BNP 146 pg/ml, peak VO2 19.0 ml/kg/min; and higher risk cluster (IEB ≤25%) QRS 167 ms, LVESV 189 ml, BNP 590 pg/ml, peak VO2 16.2 ml/kg/min. CONCLUSIONS Candidates for CRT show depressed arterial baroreflex function. Lower BEI was observed in high-risk HF patients. Baroreflex function correlated closely with other clinical HF parameters. Therefore, BEI may improve risk stratification in HF patients undergoing CRT.
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Affiliation(s)
| | - Mário Martins Oliveira
- Institute of Physiology, Faculty of Medicine, University of Lisbon, Lisbon, Portugal; Department of Cardiology, Santa Marta Hospital, Lisbon, Portugal
| | - Sérgio Matoso Laranjo
- Institute of Physiology, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Cristiano Tavares
- Institute of Physiology, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | | | - Ana Abreu
- Department of Cardiology, Santa Marta Hospital, Lisbon, Portugal
| | - Luísa Branco
- Department of Cardiology, Santa Marta Hospital, Lisbon, Portugal
| | - Sandra Alves
- Department of Cardiology, Santa Marta Hospital, Lisbon, Portugal
| | - Isabel Rocha
- Institute of Physiology, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
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Fernandes Serôdio J, Martins Oliveira M, Matoso Laranjo S, Tavares C, Silva Cunha P, Abreu A, Branco L, Alves S, Rocha I, Cruz Ferreira R. The arterial baroreflex effectiveness index in risk stratification of chronic heart failure patients who are candidates for cardiac resynchronization therapy. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.repce.2015.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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