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Farhat K, Po SS, Stavrakis S. Non-invasive Neuromodulation of Arrhythmias. Card Electrophysiol Clin 2024; 16:307-314. [PMID: 39084723 PMCID: PMC11292161 DOI: 10.1016/j.ccep.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
The autonomic nervous system plays a central role in the pathogenesis of arrhythmias. Preclinical and clinical studies have demonstrated the therapeutic effect of neuromodulation at multiple anatomic targets across the neurocardiac axis for the treatment of arrhythmias. In this review, we discuss the rationale and clinical application of noninvasive neuromodulation techniques in treating arrhythmias and explore associated barriers and future directions, including optimization of stimulation parameters and patient selection.
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Affiliation(s)
| | - Sunny S Po
- University of Oklahoma Health Sciences Center
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2
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Sarkar A, Ajijola OA. Pathophysiologic Mechanisms in Cardiac Autonomic Nervous System and Arrhythmias. Card Electrophysiol Clin 2024; 16:261-269. [PMID: 39084719 DOI: 10.1016/j.ccep.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
The autonomic nervous system, including the central nervous system and the cardiac plexus, maintains cardiac physiology. In diseased states, autonomic changes through neuronal remodeling generate electrical mechanisms of arrhythmia such as triggered activity or increased automaticity. This article will focus on the pathophysiological mechanisms of arrhythmia to highlight the role of the autonomic nervous system in disease and the related therapeutic interventions.
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Affiliation(s)
- Abdullah Sarkar
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research program of Excellence, Los Angeles, CA, USA
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research program of Excellence, Los Angeles, CA, USA.
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3
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Hanna P, Ardell JL. Cardiac Neuroanatomy and Fundamentals of Neurocardiology. Card Electrophysiol Clin 2024; 16:229-237. [PMID: 39084716 DOI: 10.1016/j.ccep.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Cardiac control is mediated via nested-feedback reflex control networks involving the intrinsic cardiac ganglia, intra-thoracic extra-cardiac ganglia, spinal cord, brainstem, and higher centers. This control system is optimized to respond to normal physiologic stressors; however, it can be catastrophically disrupted by pathologic events such as myocardial ischemia. In fact, it is now recognized that cardiac disease progression reflects the dynamic interplay between adverse remodeling of the cardiac substrate coupled with autonomic dysregulation. With advances in understanding of this network dynamic in normal and pathologic states, neuroscience-based neuromodulation therapies can be devised for the management of acute and chronic cardiac pathologies.
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Affiliation(s)
- Peter Hanna
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, Los Angeles, CA 90095, USA; UCLA Neurocardiology Research Program of Excellence, UCLA, Los Angeles, CA 90095, USA
| | - Jeffrey L Ardell
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, Los Angeles, CA 90095, USA; UCLA Neurocardiology Research Program of Excellence, UCLA, Los Angeles, CA 90095, USA.
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4
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Zuhair M, Keene D, Kanagaratnam P, Lim PB. Percutaneous Neuromodulation for Atrial Fibrillation. Card Electrophysiol Clin 2024; 16:281-296. [PMID: 39084721 DOI: 10.1016/j.ccep.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Percutaneous neuromodulation is emerging as a promising therapeutic approach for atrial fibrillation (AF). This article explores techniques such as ganglionated plexi (GP) ablation, and vagus nerve stimulation, pinpointing their potential in modulating AF triggers and maintenance. Noninvasive methods, such as transcutaneous low-level tragus stimulation, offer innovative treatment pathways, with early trials indicating a significant reduction in AF burden. GP ablation may address autonomic triggers, and the potential for GP ablation in neuromodulation is discussed. The article stresses the necessity for more rigorous clinical trials to validate the safety, reproducibility, and efficacy of these neuromodulation techniques in AF treatment.
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Affiliation(s)
- Mohamed Zuhair
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12, UK.
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12, UK
| | - Prapa Kanagaratnam
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12, UK
| | - Phang Boon Lim
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12, UK
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Wang C, Zhou L, Liu C, Qiao J, Han X, Wang L, Liu Y, Xu B, Qiu Q, Zhang Z, Wang J, Zhou X, Zeng M, Yu L, Fu L. Pt nanoshells with a high NIR-II photothermal conversion efficiency mediates multimodal neuromodulation against ventricular arrhythmias. Nat Commun 2024; 15:6362. [PMID: 39069566 DOI: 10.1038/s41467-024-50557-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 07/16/2024] [Indexed: 07/30/2024] Open
Abstract
Autonomic nervous system disorders play a pivotal role in the pathophysiology of cardiovascular diseases. Regulating it is essential for preventing and treating acute ventricular arrhythmias (VAs). Photothermal neuromodulation is a nonimplanted technique, but the response temperature ranges of transient receptor potential vanilloid 1 (TRPV1) and TWIK-related K+ Channel 1 (TREK1) exhibit differences while being closely aligned, and the acute nature of VAs require that it must be rapid and precise. However, the low photothermal conversion efficiency (PCE) still poses limitations in achieving rapid and precise treatment. Here, we achieve a nearly perfect blackbody absorption and a high PCE in the second near infrared (NIR-II) window (73.7% at 1064 nm) via a Pt nanoparticle shell (PtNP-shell). By precisely manipulating the photothermal effect, we successfully achieve rapid and precise multimodal neuromodulation encompassing neural activation (41.0-42.9 °C) and inhibition (45.0-46.9 °C) in a male canine model. The NIR-II photothermal modulation additionally achieves multimodal reversible autonomic modulation and confers protection against acute VAs associated with myocardial ischemia and reperfusion injury in interventional therapy.
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Affiliation(s)
- Chenlu Wang
- College of Chemistry and Molecular Sciences, Wuhan University, Wuhan, China
| | - Liping Zhou
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Key Laboratory of Autonomic Nervous System Modulation, Wuhan, China
- Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Taikang Center for Life and Medical Sciences, Wuhan University, Wuhan, China
- Institute of Molecular Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Chengzhe Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Key Laboratory of Autonomic Nervous System Modulation, Wuhan, China
- Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Taikang Center for Life and Medical Sciences, Wuhan University, Wuhan, China
- Institute of Molecular Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jiaming Qiao
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Key Laboratory of Autonomic Nervous System Modulation, Wuhan, China
- Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Taikang Center for Life and Medical Sciences, Wuhan University, Wuhan, China
- Institute of Molecular Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xinrui Han
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Key Laboratory of Autonomic Nervous System Modulation, Wuhan, China
- Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Taikang Center for Life and Medical Sciences, Wuhan University, Wuhan, China
- Institute of Molecular Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Luyang Wang
- College of Chemistry and Molecular Sciences, Wuhan University, Wuhan, China
| | - Yaxi Liu
- College of Chemistry and Molecular Sciences, Wuhan University, Wuhan, China
| | - Bi Xu
- College of Chemistry and Molecular Sciences, Wuhan University, Wuhan, China
| | - Qinfang Qiu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Key Laboratory of Autonomic Nervous System Modulation, Wuhan, China
- Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Taikang Center for Life and Medical Sciences, Wuhan University, Wuhan, China
- Institute of Molecular Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zizhuo Zhang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Key Laboratory of Autonomic Nervous System Modulation, Wuhan, China
- Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Taikang Center for Life and Medical Sciences, Wuhan University, Wuhan, China
- Institute of Molecular Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jiale Wang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Key Laboratory of Autonomic Nervous System Modulation, Wuhan, China
- Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Taikang Center for Life and Medical Sciences, Wuhan University, Wuhan, China
- Institute of Molecular Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiaoya Zhou
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.
- Hubei Key Laboratory of Autonomic Nervous System Modulation, Wuhan, China.
- Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, China.
- Hubei Key Laboratory of Cardiology, Wuhan, China.
- Cardiovascular Research Institute, Wuhan University, Wuhan, China.
- Taikang Center for Life and Medical Sciences, Wuhan University, Wuhan, China.
- Institute of Molecular Medicine, Renmin Hospital of Wuhan University, Wuhan, China.
| | - Mengqi Zeng
- College of Chemistry and Molecular Sciences, Wuhan University, Wuhan, China
| | - Lilei Yu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.
- Hubei Key Laboratory of Autonomic Nervous System Modulation, Wuhan, China.
- Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, China.
- Hubei Key Laboratory of Cardiology, Wuhan, China.
- Cardiovascular Research Institute, Wuhan University, Wuhan, China.
- Taikang Center for Life and Medical Sciences, Wuhan University, Wuhan, China.
- Institute of Molecular Medicine, Renmin Hospital of Wuhan University, Wuhan, China.
| | - Lei Fu
- College of Chemistry and Molecular Sciences, Wuhan University, Wuhan, China.
- Taikang Center for Life and Medical Sciences, Wuhan University, Wuhan, China.
- Institute of Molecular Medicine, Renmin Hospital of Wuhan University, Wuhan, China.
- The Institute for Advanced Studies, Wuhan University, Wuhan, China.
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6
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Cao LL, Liu HR, Ji YJ, Zhang YT, Wang BQ, Xue XH, Wang P, Luo ZH, Wu HG. Research Progress of Vagal Nerve Regulation Mechanism in Acupuncture Treatment of Atrial Fibrillation. Chin J Integr Med 2024:10.1007/s11655-024-3660-5. [PMID: 38990478 DOI: 10.1007/s11655-024-3660-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 07/12/2024]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in clinical practice. It has a high prevalence and poor prognosis. The application of antiarrhythmic drugs and even surgery cannot completely treat the disease, and there are many sequelae. AF can be classified into the category of "palpitation" in Chinese medicine according to its symptoms. Acupuncture has a significant effect on AF. The authors find that an important mechanism of acupuncture in AF treatment is to regulate the cardiac vagus nerve. Therefore, this article intends to review the distribution and function of vagus nerve in the heart, the application and the regulatroy effect for the treatment of AF.
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Affiliation(s)
- Lu-Lu Cao
- Immunology Laboratory, Shanghai Research Institute of Acupuncture and Meridian, Shanghai, 200232, China
| | - Hui-Rong Liu
- Immunology Laboratory, Shanghai Research Institute of Acupuncture and Meridian, Shanghai, 200232, China
| | - Ya-Jie Ji
- Breast Disease Department, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 200437, China
| | - Yin-Tao Zhang
- Graduate College, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Bing-Quan Wang
- Department of Acupuncture and Moxibusion Tuina Traumatology, Shanghai Sixth People's Hospital, Shanghai, 200233, China
| | - Xiao-Hong Xue
- Breast Disease Department, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 200437, China
| | - Pei Wang
- Graduate College, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Zhi-Hui Luo
- Graduate College, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Huan-Gan Wu
- Immunology Laboratory, Shanghai Research Institute of Acupuncture and Meridian, Shanghai, 200232, China.
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Zafeiropoulos S, Ahmed U, Bikou A, Mughrabi IT, Stavrakis S, Zanos S. Vagus nerve stimulation for cardiovascular diseases: Is there light at the end of the tunnel? Trends Cardiovasc Med 2024; 34:327-337. [PMID: 37506989 DOI: 10.1016/j.tcm.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/12/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023]
Abstract
Autonomic dysfunction and chronic inflammation contribute to the pathogenesis and progression of several cardiovascular diseases (CVD), such as heart failure with preserved ejection fraction, atherosclerotic CVD, pulmonary arterial hypertension, and atrial fibrillation. The vagus nerve provides parasympathetic innervation to the heart, vessels, and lungs, and is also implicated in the neural control of inflammation through a neuroimmune pathway involving the spleen. Stimulation of the vagus nerve (VNS) can in principle restore autonomic balance and suppress inflammation, with potential therapeutic benefits in these diseases. Although VNS ameliorated CVD in several animal models, early human studies have demonstrated variable efficacy. The purpose of this review is to discuss the rationale behind the use of VNS in the treatment of CVD, to critically review animal and human studies of VNS in CVD, and to propose possible means to overcome the challenges in the clinical translation of VNS in CVD.
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Affiliation(s)
- Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine at Northwell Health, Manhasset, NY, USA; Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Umair Ahmed
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Alexia Bikou
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Ibrahim T Mughrabi
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Stavros Zanos
- Elmezzi Graduate School of Molecular Medicine at Northwell Health, Manhasset, NY, USA; Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, USA.
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Zhang J, He Y, Yin Z, Li R, Zhang X, Wang Y, Wang H. Circulating neuropeptide Y as a biomarker in postoperative atrial fibrillation cases administered off-pump coronary bypass Graft surgery. Heliyon 2024; 10:e31251. [PMID: 38803941 PMCID: PMC11129009 DOI: 10.1016/j.heliyon.2024.e31251] [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: 01/31/2024] [Revised: 05/13/2024] [Accepted: 05/13/2024] [Indexed: 05/29/2024] Open
Abstract
Background and aims Postoperative atrial fibrillation (POAF) is considered the most prevalent irregular heart rhythm after heart surgery. The cardiac autonomic nervous system significantly affects POAF, and neuropeptide Y (NPY), an abundant neuropeptide in the cardiovascular system, is involved in this autonomic regulation. The current work aimed to examine the potential association of NPY with POAF in individuals administered isolated off-pump coronary artery bypass grafting. Methods From January 1 to May 31, 2020, we examined consecutive cases administered successful isolated off-pump coronary artery bypass grafting with no previously diagnosed atrial fibrillation (AF). Clinical characteristics and plasma samples were collected before surgery. NPY was quantified by enzyme-linked immunosorbent assay (ELISA) in peripheral blood, and POAF cases were identified through a 7-day Holter monitoring. Results Among 120 cases with no previously diagnosed AF, 33 (27.5 %) developed POAF during hospitalization. Median NPY levels were markedly elevated in the POAF group in comparison with the sinus rhythm group (31.72 vs. 27.95, P = 0.014). Multivariable logistic regression analysis revealed age (OR = 1.135, 95%CI 1.054-1.223; P = 0.001), left atrial size (OR = 1.136, 95%CI 1.004-1.285; P = 0.043), and NPY levels in peripheral blood (OR = 1.055, 95%CI 1.002-1.111; p = 0.041) independently predicted POAF. Additionally, NPY levels were positively correlated with high-frequency (HF) (r = 0.2774, P = 0.0022) and low-frequency (LF) (r = 0.2095, P = 0.0217) components of heart rate variability. Conclusion In summary, this study demonstrates an association between elevated NPY levels in peripheral blood before surgery and POAF occurrence.
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Affiliation(s)
- Jian Zhang
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, No.83, Wenhua Road, Shenhe District, Shenyang, Liaoning,110016 China
| | - Yuanchen He
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, No.83, Wenhua Road, Shenhe District, Shenyang, Liaoning,110016 China
- Postgraduate Training Base of Northern Theater Command General Hospital,Dalian Medical University, No. 9, Lvshun western south Road, LvShunKou District, Dalian, Liaoning 116044, China
| | - Zongtao Yin
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, No.83, Wenhua Road, Shenhe District, Shenyang, Liaoning,110016 China
| | - Rui Li
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, No.83, Wenhua Road, Shenhe District, Shenyang, Liaoning,110016 China
- Postgraduate Training Base of Northern Theater Command General Hospital,China Medical University, No.83, Wenhua Road, Shenhe District, Shenyang, Liaoning,110016 China
| | - Xiaohui Zhang
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, No.83, Wenhua Road, Shenhe District, Shenyang, Liaoning,110016 China
- Postgraduate Training Base of Northern Theater Command General Hospital,China Medical University, No.83, Wenhua Road, Shenhe District, Shenyang, Liaoning,110016 China
| | - Yang Wang
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, No.83, Wenhua Road, Shenhe District, Shenyang, Liaoning,110016 China
| | - Huishan Wang
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, No.83, Wenhua Road, Shenhe District, Shenyang, Liaoning,110016 China
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de Melo PS, Gianlorenco AC, Marduy A, Kim CK, Choi H, Song JJ, Fregni F. A Mechanistic Analysis of the Neural Modulation of the Inflammatory System Through Vagus Nerve Stimulation: A Systematic Review and Meta-analysis. Neuromodulation 2024:S1094-7159(24)00065-5. [PMID: 38795094 DOI: 10.1016/j.neurom.2024.03.002] [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: 10/22/2023] [Revised: 03/03/2024] [Accepted: 03/04/2024] [Indexed: 05/27/2024]
Abstract
OBJECTIVE We aimed to conduct a systematic review and meta-analysis assessing the antiinflammatory effects of various VNS methods while exploring multiple antiinflammatory pathways. MATERIALS AND METHODS We included clinical trials that used electrical stimulation of the vagus nerve and assessed inflammatory markers up to October 2022. We excluded studies lacking control groups, those with combined interventions, or abstracts without full text. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Handbook for Systematic Reviews. For each inflammatory marker, a random-effects meta-analysis using the inverse variance method was performed. Methods used include transcutaneous auricular VNS (taVNS), transcutaneous cervical VNS (tcVNS), invasive cervical VNS (iVNS), and electroacupuncture VNS (eaVNS). Main reported outcomes included tumor necrosis factor (TNF)-α, interleukin (IL)-6, IL-1ß, C-reactive protein (CRP), and IL-10. Risk of bias was evaluated using the Cochrane Collaboration Tool (RoB 2.0). RESULTS This review included 15 studies, involving 597 patients. No statistically significant general VNS effect was observed on TNF-α, IL-6, and IL-1ß. However, CRP, IL-10, and interferon (IFN)-γ were significantly modulated by VNS across all methods. Subgroup analysis revealed specific stimulation techniques producing significant results, such as taVNS effects in IL-1ß and IL-10, and iVNS in IL-6, whereas tcVNS and eaVNS did not convey significant pooled results individually. Cumulative exposure to VNS, higher risk of bias, study design, and pulse width were identified as effect size predictors in our meta-regression models. CONCLUSIONS Pooling all VNS techniques indicated the ability of VNS to modulate inflammatory markers such as CRP, IL-10, and IFN-γ. Individually, methods such as taVNS were effective in modulating IL-1ß and IL-10, whereas iVNS modulated IL-6. However, different VNS techniques should be separately analyzed in larger, homogeneous, and powerful studies to achieve a clearer and more consistent understanding of the effect of each VNS method on the inflammatory system.
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Affiliation(s)
- Paulo S de Melo
- Medicine, Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil; Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anna C Gianlorenco
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Physical Therapy, Federal University of São Carlos, Brazil
| | - Anna Marduy
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Medicine, União Metropolitana de Ensino e Cultura (UNIME), Salvador, Bahia, Brazil
| | - Chi K Kim
- Department of Neurology, Korea University Guro Hospital, Seoul, South Korea
| | - Hyuk Choi
- Department of Medical Sciences, Graduate School of Medicine, Korea University, Seoul, South Korea; Neurive Co, Ltd, Gimhae, South Korea
| | - Jae-Jun Song
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University Medical Center, Seoul, South Korea; Neurive Co, Ltd, Gimhae, South Korea
| | - Felipe Fregni
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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10
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Oh S. Neuromodulation for Atrial Fibrillation Control. Korean Circ J 2024; 54:223-232. [PMID: 38654454 PMCID: PMC11109834 DOI: 10.4070/kcj.2024.0050] [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: 02/01/2024] [Accepted: 02/13/2024] [Indexed: 04/26/2024] Open
Abstract
Trigger and functional substrate are related to the tone of autonomic nervous system, and the role of the autonomic nerve is more significant in paroxysmal atrial fibrillation (AF) compared to non-paroxysmal AF. We have several options for neuromodulation to help to manage patients with AF. Neuromodulation targets can be divided into efferent and afferent pathways. On the efferent side, block would be an intuitive approach. However, permanent block is hard to achieve due to completeness of the procedure and reinnervation issues. Temporary block such as botulinum toxin injection into ganglionated plexi would be a possible option for post-cardiac surgery AF. Low-level subthreshold stimulation could also prevent AF, but the invasiveness of the procedure is the barrier for the general use. On the afferent side, block is also an option. Various renal denervation approaches are currently under investigation. Auditory vagus nerve stimulation is one of the representative low-level afferent stimulation methods. This technique is noninvasive and easy to apply, so it has the potential to be widely utilized if its efficacy is confirmed.
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Affiliation(s)
- Seil Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
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11
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Ye T, Yang J, Liu Z, Yu Y, Zhang C, Guo Y, Yu F, Zhou Y, Song Z, Shi J, Wang L, Yang B, Wang X. Inhibition of the P2X7 receptor prevents atrial proarrhythmic remodeling in experimental post-operative atrial fibrillation. Int Immunopharmacol 2024; 129:111536. [PMID: 38320354 DOI: 10.1016/j.intimp.2024.111536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/10/2024] [Accepted: 01/10/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Post-operative atrial fibrillation (POAF) is a common complication in patients undergoing cardiac surgery. The purinergic receptor P2X7 (P2X7R) is involved in some cardiovascular diseases, whereas its effects on atrial fibrillation (AF) are unclear. OBJECTIVE This study was to assess the effect of P2X7R on atrial arrhythmogenic remodeling in the rat model of sterile pericarditis (SP). METHODS Male Sprague-Dawley (SD) rats were used to induce the SP model. Electrocardiogram, atrial electrophysiological protocol, histology, mRNA sequencing, real-time quantitative PCR, western blot, and Elisa assay were performed. RESULTS SP significantly up-regulated P2X7R expression; increased AF susceptibility; reduced the protein expression of ion channels including Nav1.5, Cav1.2, Kv4.2, Kv4.3, and Kv1.5; caused atrial fibrosis; increased norepinephrine (NE) level in plasma; promoted the production of inflammatory cytokines such as TNF-α, IL-1β, and IL-6; increased the accumulation of immune cells (CD68- and MPO- positive cells); and activated NLRP3 inflammasome signaling pathway. P2X7R antagonist Brilliant Blue G (BBG) mitigated SP-induced alterations. The mRNA sequencing demonstrated that BBG prevented POAF mainly by regulating the immune system. In addition, another selective P2X7R antagonist A740003, and IL-1R antagonist anakinra also reduced AF inducibility in the SP model. CONCLUSIONS P2X7R inhibition prevents SP-induced atrial proarrhythmic remodeling, which is closely associated with the improvement of inflammatory changes, ion channel expression, atrial fibrosis, and sympathetic activation. The findings point to P2X7R inhibition as a promising target for AF (particularly POAF) and perhaps other conditions.
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Affiliation(s)
- Tianxin Ye
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Jinxiu Yang
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Zhangchi Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, PR China; Hubei Key Laboratory of Cardiology, Wuhan 430060, PR China
| | - Yi Yu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, PR China; Hubei Key Laboratory of Cardiology, Wuhan 430060, PR China
| | - Cui Zhang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, PR China; Hubei Key Laboratory of Cardiology, Wuhan 430060, PR China
| | - Yan Guo
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Fangcong Yu
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Yunping Zhou
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Zhuonan Song
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Jiaran Shi
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Longbo Wang
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Bo Yang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, PR China; Hubei Key Laboratory of Cardiology, Wuhan 430060, PR China.
| | - Xingxiang Wang
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China.
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12
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Zhang Z, Xiao Y, Dai Y, Lin Q, Liu Q. Device therapy for patients with atrial fibrillation and heart failure with preserved ejection fraction. Heart Fail Rev 2024; 29:417-430. [PMID: 37940727 PMCID: PMC10943171 DOI: 10.1007/s10741-023-10366-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/29/2023] [Indexed: 11/10/2023]
Abstract
Device therapy is a nonpharmacological approach that presents a crucial advancement for managing patients with atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF). This review investigated the impact of device-based interventions and emphasized their potential for optimizing treatment for this complex patient demographic. Cardiac resynchronization therapy, augmented by atrioventricular node ablation with His-bundle pacing or left bundle-branch pacing, is effective for enhancing cardiac function and establishing atrioventricular synchrony. Cardiac contractility modulation and vagus nerve stimulation represent novel strategies for increasing myocardial contractility and adjusting the autonomic balance. Left ventricular expanders have demonstrated short-term benefits in HFpEF patients but require more investigation for long-term effectiveness and safety, especially in patients with AF. Research gaps regarding complications arising from left ventricular expander implantation need to be addressed. Device-based therapies for heart valve diseases, such as transcatheter aortic valve replacement and transcatheter edge-to-edge repair, show promise for patients with AF and HFpEF, particularly those with mitral or tricuspid regurgitation. Clinical evaluations show that these device therapies lessen AF occurrence, improve exercise tolerance, and boost left ventricular diastolic function. However, additional studies are required to perfect patient selection criteria and ascertain the long-term effectiveness and safety of these interventions. Our review underscores the significant potential of device therapy for improving the outcomes and quality of life for patients with AF and HFpEF.
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Affiliation(s)
- Zixi Zhang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, People's Republic of China
| | - Yichao Xiao
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, People's Republic of China.
| | - Yongguo Dai
- Department of Pharmacology, Wuhan University TaiKang Medical School (School of Basic Medical Sciences), Wuhan, 430071, Hubei Province, People's Republic of China
| | - Qiuzhen Lin
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, People's Republic of China
| | - Qiming Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, People's Republic of China.
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13
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Giannino G, Braia V, Griffith Brookles C, Giacobbe F, D'Ascenzo F, Angelini F, Saglietto A, De Ferrari GM, Dusi V. The Intrinsic Cardiac Nervous System: From Pathophysiology to Therapeutic Implications. BIOLOGY 2024; 13:105. [PMID: 38392323 PMCID: PMC10887082 DOI: 10.3390/biology13020105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 02/24/2024]
Abstract
The cardiac autonomic nervous system (CANS) plays a pivotal role in cardiac homeostasis as well as in cardiac pathology. The first level of cardiac autonomic control, the intrinsic cardiac nervous system (ICNS), is located within the epicardial fat pads and is physically organized in ganglionated plexi (GPs). The ICNS system does not only contain parasympathetic cardiac efferent neurons, as long believed, but also afferent neurons and local circuit neurons. Thanks to its high degree of connectivity, combined with neuronal plasticity and memory capacity, the ICNS allows for a beat-to-beat control of all cardiac functions and responses as well as integration with extracardiac and higher centers for longer-term cardiovascular reflexes. The present review provides a detailed overview of the current knowledge of the bidirectional connection between the ICNS and the most studied cardiac pathologies/conditions (myocardial infarction, heart failure, arrhythmias and heart transplant) and the potential therapeutic implications. Indeed, GP modulation with efferent activity inhibition, differently achieved, has been studied for atrial fibrillation and functional bradyarrhythmias, while GP modulation with efferent activity stimulation has been evaluated for myocardial infarction, heart failure and ventricular arrhythmias. Electrical therapy has the unique potential to allow for both kinds of ICNS modulation while preserving the anatomical integrity of the system.
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Affiliation(s)
- Giuseppe Giannino
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Valentina Braia
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Carola Griffith Brookles
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Federico Giacobbe
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Fabrizio D'Ascenzo
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Filippo Angelini
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Andrea Saglietto
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Gaetano Maria De Ferrari
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Veronica Dusi
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
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Schiweck C, Sausmekat S, Zhao T, Jacobsen L, Reif A, Edwin Thanarajah S. No consistent evidence for the anti-inflammatory effect of vagus nerve stimulation in humans: A systematic review and meta-analysis. Brain Behav Immun 2024; 116:237-258. [PMID: 38070618 DOI: 10.1016/j.bbi.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/17/2023] [Accepted: 12/04/2023] [Indexed: 12/21/2023] Open
Abstract
Vagus nerve stimulation (VNS) has been identified as an innovative immunosuppressive treatment strategy in rodent studies. However, its' clinical potential is still unclear. Therefore, we aimed to assess whether VNS can reduce inflammatory proteins and/or immune cells in humans, through a pre-registered systematic review and meta-analysis according to PRISMA guidelines. The databases Cochrane, Pubmed and World of Knowledge were searched in duplicate up to the 3rd of March 2022 and publications from identified clinical trial registrations were identified until 20th of August 2023. Studies were included if they provided peer-reviewed data for humans who received VNS as short-term (<=1 day) or long-term (>=2 days-365 days) stimulation and reported at least one cytokine or immune cell after treatment.Screening of title, abstract, full text, and data extraction was performed in duplicate by two independent reviewers. Data were pooled using a random-effects model and meta-regression was performed for moderating factors. Reporting bias was assessed. The standardized mean difference (Hedge's g) was used to indicate overall differences of cytokine data (mean and standard deviation or median and interquartile range at the study level) to test our a-priori hypothesis. The systematic review of 36 studies with 1135 participants (355 receiving a control/sham condition and 780 receiving VNS) revealed anti-inflammatory effects of VNS for cytokines in several reports, albeit often in subgroup analyses, but our meta-analyses of 26 studies did not confirm these findings. Although most cytokines were numerically reduced, the reduction did not reach statistical significance after VNS: not in the between-group comparisons (short-term: TNF-α: g = -0.21, p = 0.359; IL-6: g = -0.94, p = 0.112; long-term: TNF-α: g = -0.13, p = 0.196; IL-6: g = -0.67, p = 0.306); nor in the within-study designs (short-term: TNF-α: g = -0.45, p = 0.630; IL-6: g = 0.28, p = 0.840; TNF-α: g = -0.53, p = 0.297; IL-6:g = -0.02, p = 0.954). Only the subgroup analysis of 4 long-term studies with acute inflammation was significant: VNS decreased CRP significantly more than sham stimulation. Additional subgroup analyses including stimulation duration, stimulation method (invasive/non-invasive), immune stimulation, and study quality did not alter results. However, heterogeneity was high, and most studies had poor to fair quality. Given the low number of studies for each disease, a disease-specific analysis was not possible. In conclusion, while numeric effects were reported in individual studies, the current evidence does not substantiate the claim that VNS impacts inflammatory cytokines in humans. However, it may be beneficial during acute inflammatory events. To assess its full potential, high-quality studies and technological advances are required.
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Affiliation(s)
- Carmen Schiweck
- Department of Psychiatry, Psychotherapy and Psychosomatics, Goethe University Frankfurt, Germany
| | - Sonja Sausmekat
- Department of Psychiatry, Psychotherapy and Psychosomatics, Goethe University Frankfurt, Germany
| | - Tong Zhao
- Department of Psychiatry, Psychotherapy and Psychosomatics, Goethe University Frankfurt, Germany
| | - Leona Jacobsen
- Department of Psychiatry, Psychotherapy and Psychosomatics, Goethe University Frankfurt, Germany
| | - Andreas Reif
- Department of Psychiatry, Psychotherapy and Psychosomatics, Goethe University Frankfurt, Germany
| | - Sharmili Edwin Thanarajah
- Department of Psychiatry, Psychotherapy and Psychosomatics, Goethe University Frankfurt, Germany; Max Planck Institute for Metabolism Research, Cologne, Germany.
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15
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Heckbert SR, Jensen PN, Erus G, Nasrallah IM, Rashid T, Habes M, Austin TR, Floyd JS, Schaich CL, Redline S, Bryan RN, Costa MD. Heart rate fragmentation and brain MRI markers of small vessel disease in MESA. Alzheimers Dement 2024; 20:1397-1405. [PMID: 38009395 PMCID: PMC10917025 DOI: 10.1002/alz.13554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 10/12/2023] [Accepted: 10/23/2023] [Indexed: 11/28/2023]
Abstract
INTRODUCTION Heart rate (HR) fragmentation indices quantify breakdown of HR regulation and are associated with atrial fibrillation and cognitive impairment. Their association with brain magnetic resonance imaging (MRI) markers of small vessel disease is unexplored. METHODS In 606 stroke-free participants of the Multi-Ethnic Study of Atherosclerosis (mean age 67), HR fragmentation indices including percentage of inflection points (PIP) were derived from sleep study recordings. We examined PIP in relation to white matter hyperintensity (WMH) volume, total white matter fractional anisotropy (FA), and microbleeds from 3-Tesla brain MRI completed 7 years later. RESULTS In adjusted analyses, higher PIP was associated with greater WMH volume (14% per standard deviation [SD], 95% confidence interval [CI]: 2, 27%, P = 0.02) and lower WM FA (-0.09 SD per SD, 95% CI: -0.16, -0.01, P = 0.03). DISCUSSION HR fragmentation was associated with small vessel disease. HR fragmentation can be measured automatically from ambulatory electrocardiogram devices and may be useful as a biomarker of vascular brain injury.
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Affiliation(s)
- Susan R. Heckbert
- Cardiovascular Health Research UnitUniversity of WashingtonSeattleWashingtonUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Paul N. Jensen
- Cardiovascular Health Research UnitUniversity of WashingtonSeattleWashingtonUSA
- Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Guray Erus
- Center for AI and Data Science for Integrated Diagnostics and Center for Biomedical Image Computing and AnalyticsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Ilya M. Nasrallah
- Center for AI and Data Science for Integrated Diagnostics and Center for Biomedical Image Computing and AnalyticsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of RadiologyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Tanweer Rashid
- Neuroimage Analytics Laboratory and Biggs Institute Neuroimaging CoreGlenn Biggs Institute for Alzheimer's and Neurodegenerative DiseasesUniversity of Texas Health Science Center San AntonioSan AntonioTexasUSA
| | - Mohamad Habes
- Center for AI and Data Science for Integrated Diagnostics and Center for Biomedical Image Computing and AnalyticsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Neuroimage Analytics Laboratory and Biggs Institute Neuroimaging CoreGlenn Biggs Institute for Alzheimer's and Neurodegenerative DiseasesUniversity of Texas Health Science Center San AntonioSan AntonioTexasUSA
| | - Thomas R. Austin
- Cardiovascular Health Research UnitUniversity of WashingtonSeattleWashingtonUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - James S. Floyd
- Cardiovascular Health Research UnitUniversity of WashingtonSeattleWashingtonUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
- Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Christopher L. Schaich
- Department of SurgeryHypertension and Vascular Research CenterWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Susan Redline
- Brigham and Women's HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - R. Nick Bryan
- Department of RadiologyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Madalena D. Costa
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
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Huang J, Wu B, Qin P, Cheng Y, Zhang Z, Chen Y. Research on atrial fibrillation mechanisms and prediction of therapeutic prospects: focus on the autonomic nervous system upstream pathways. Front Cardiovasc Med 2023; 10:1270452. [PMID: 38028487 PMCID: PMC10663310 DOI: 10.3389/fcvm.2023.1270452] [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: 07/31/2023] [Accepted: 10/25/2023] [Indexed: 12/01/2023] Open
Abstract
Atrial fibrillation (AF) is the most common clinical arrhythmia disorder. It can easily lead to complications such as thromboembolism, palpitations, dizziness, angina, heart failure, and stroke. The disability and mortality rates associated with AF are extremely high, significantly affecting the quality of life and work of patients. With the deepening of research into the brain-heart connection, the link between AF and stroke has become increasingly evident. AF is now categorized as either Known Atrial Fibrillation (KAF) or Atrial Fibrillation Detected After Stroke (AFDAS), with stroke as the baseline. This article, through a literature review, briefly summarizes the current pathogenesis of KAF and AFDAS, as well as the status of their clinical pharmacological and non-pharmacological treatments. It has been found that the existing treatments for KAF and AFDAS have limited efficacy and are often associated with significant adverse reactions and a risk of recurrence. Moreover, most drugs and treatment methods tend to focus on a single mechanism pathway. For example, drugs targeting ion channels primarily modulate ion channels and have relatively limited impact on other pathways. This limitation underscores the need to break away from the "one disease, one target, one drug/measurement" dogma for the development of innovative treatments, promoting both drug and non-drug therapies and significantly improving the quality of clinical treatment. With the increasing refinement of the overall mechanisms of KAF and AFDAS, a deeper exploration of physiological pathology, and comprehensive research on the brain-heart relationship, it is imperative to shift from long-term symptom management to more precise and optimized treatment methods that are effective for almost all patients. We anticipate that drugs or non-drug therapies targeting the central nervous system and upstream pathways can guide the simultaneous treatment of multiple downstream pathways in AF, thereby becoming a new breakthrough in AF treatment research.
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Affiliation(s)
- Jingjie Huang
- Postgraduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Bangqi Wu
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Peng Qin
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yupei Cheng
- Postgraduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Ziyi Zhang
- Postgraduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yameng Chen
- Postgraduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
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17
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Bazoukis G, Stavrakis S, Armoundas AA. Vagus Nerve Stimulation and Inflammation in Cardiovascular Disease: A State-of-the-Art Review. J Am Heart Assoc 2023; 12:e030539. [PMID: 37721168 PMCID: PMC10727239 DOI: 10.1161/jaha.123.030539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Vagus nerve stimulation (VNS) has been found to exert anti-inflammatory effects in different clinical settings and has been associated with improvement of clinical outcomes. However, evidence on the mechanistic link between the potential association of inflammatory status with clinical outcomes following VNS is scarce. This review aims to summarize the existing knowledge linking VNS with inflammation and its potential link with major outcomes in cardiovascular diseases, in both preclinical and clinical studies. Existing data show that in the setting of myocardial ischemia and reperfusion, VNS seems to reduce inflammation resulting in reduced infarct size and reduced incidence of ventricular arrhythmias during reperfusion. Furthermore, VNS has a protective role in vascular function following myocardial ischemia and reperfusion. Atrial fibrillation burden has also been reduced by VNS, whereas suppression of inflammation may be a potential mechanism for this effect. In the setting of heart failure, VNS was found to improve systolic function and reverse cardiac remodeling. In summary, existing experimental data show a reduction in inflammatory markers by VNS, which may cause improved clinical outcomes in cardiovascular diseases. However, more data are needed to evaluate the association between the inflammatory status with the clinical outcomes following VNS.
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Affiliation(s)
- George Bazoukis
- Department of CardiologyLarnaca General HospitalLarnacaCyprus
- Department of Basic and Clinical SciencesUniversity of Nicosia Medical SchoolNicosiaCyprus
| | - Stavros Stavrakis
- Heart Rhythm InstituteUniversity of Oklahoma Health Sciences CenterOklahoma CityOKUSA
| | - Antonis A. Armoundas
- Cardiovascular Research CenterMassachusetts General HospitalBostonMAUSA
- Broad Institute, Massachusetts Institute of TechnologyCambridgeMAUSA
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18
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Soltani D, Stavrakis S. Neuromodulation for the Management of Atrial Fibrillation—How to Optimize Patient Selection and the Procedural Approach. CURRENT CARDIOVASCULAR RISK REPORTS 2023. [DOI: 10.1007/s12170-023-00718-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
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19
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Pinto TP, Inácio JC, de Aguiar Ferreira E, de Sá Ferreira A, Sudo FK, Tovar-Moll F, Rodrigues E. Prefrontal tDCS modulates autonomic responses in COVID-19 inpatients. Brain Stimul 2023; 16:657-666. [PMID: 36940750 PMCID: PMC10027235 DOI: 10.1016/j.brs.2023.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/22/2023] [Accepted: 03/02/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND maladaptive changes in the autonomic nervous system (ANS) have been observed in short and long-term phases of COVID-19 infection. Identifying effective treatments to modulate autonomic imbalance could be a strategy for preventing and reducing disease severity and induced complications. OBJECTIVE to investigate the efficacy, safety, and feasibility of a single session of bihemispheric prefrontal tDCS on indicators of cardiac autonomic regulation and mood of COVID-19 inpatients. METHODS patients were randomized to receive a single 30-minute session of bihemispheric active tDCS over the dorsolateral prefrontal cortex (2mA; n = 20) or sham (n = 20). Changes in time [post-pre intervention] in heart rate variability (HRV), mood, heart rate, respiratory rate, and oxygen saturation were compared between groups. Additionally, clinical worsening indicators and the occurrence of falls and skin injuries were evaluated. The Brunoni Adverse Effects Questionary was employed after the intervention. RESULTS there was a large effect size (Hedges' g = 0.7) of intervention on HRV frequency parameters, suggesting alterations in cardiac autonomic regulation. An increment in oxygen saturation was observed in the active group but not in the sham after the intervention (P = 0.045). There were no group differences regarding mood, incidence and intensity of adverse effects, no occurrence of skin lesions, falls, or clinical worsening. CONCLUSIONS a single prefrontal tDCS session is safe and feasible to modulate indicators of cardiac autonomic regulation in acute COVID-19 inpatients. Further research comprising a thorough assessment of autonomic function and inflammatory biomarkers is required to verify its potential to manage autonomic dysfunctions, mitigate inflammatory responses and enhance clinical outcomes.
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Affiliation(s)
- Talita P Pinto
- Instituto D'Or de Pesquisa e Ensino (IDOR), Rua Diniz Cordeiro 30, Botafogo, 22281-100, Rio de Janeiro, Brazil.
| | - Jacqueline Cunha Inácio
- Programa de Pós-Graduação Em Ciências da Reabilitação, Centro Universitário Augusto Motta - UNISUAM, Rio de Janeiro, Brazil.
| | - Erivelton de Aguiar Ferreira
- Programa de Pós-Graduação Em Ciências da Reabilitação, Centro Universitário Augusto Motta - UNISUAM, Rio de Janeiro, Brazil.
| | - Arthur de Sá Ferreira
- Programa de Pós-Graduação Em Ciências da Reabilitação, Centro Universitário Augusto Motta - UNISUAM, Rio de Janeiro, Brazil.
| | - Felipe Kenji Sudo
- Instituto D'Or de Pesquisa e Ensino (IDOR), Rua Diniz Cordeiro 30, Botafogo, 22281-100, Rio de Janeiro, Brazil.
| | - Fernanda Tovar-Moll
- Instituto D'Or de Pesquisa e Ensino (IDOR), Rua Diniz Cordeiro 30, Botafogo, 22281-100, Rio de Janeiro, Brazil.
| | - Erika Rodrigues
- Instituto D'Or de Pesquisa e Ensino (IDOR), Rua Diniz Cordeiro 30, Botafogo, 22281-100, Rio de Janeiro, Brazil; Programa de Pós-Graduação Em Ciências da Reabilitação, Centro Universitário Augusto Motta - UNISUAM, Rio de Janeiro, Brazil.
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20
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Elamin ABA, Forsat K, Senok SS, Goswami N. Vagus Nerve Stimulation and Its Cardioprotective Abilities: A Systematic Review. J Clin Med 2023; 12:jcm12051717. [PMID: 36902505 PMCID: PMC10003006 DOI: 10.3390/jcm12051717] [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: 12/29/2022] [Revised: 02/10/2023] [Accepted: 02/18/2023] [Indexed: 02/24/2023] Open
Abstract
Despite the vagus nerve stimulator (VNS) being used in neuroscience, it has recently been highlighted that it has cardioprotective functions. However, many studies related to VNS are not mechanistic in nature. This systematic review aims to focus on the role of VNS in cardioprotective therapy, selective vagus nerve stimulators (sVNS), and their functional capabilities. A systemic review of the current literature was conducted on VNS, sVNS, and their ability to induce positive effects on arrhythmias, cardiac arrest, myocardial ischemia/reperfusion injury, and heart failure. Both experimental and clinical studies were reviewed and assessed separately. Of 522 research articles retrieved from literature archives, 35 met the inclusion criteria and were included in the review. Literature analysis proves that combining fiber-type selectivity with spatially-targeted vagus nerve stimulation is feasible. The role of VNS as a tool for modulating heart dynamics, inflammatory response, and structural cellular components was prominently seen across the literature. The application of transcutaneous VNS, as opposed to implanted electrodes, provides the best clinical outcome with minimal side effects. VNS presents a method for future cardiovascular treatment that can modulate human cardiac physiology. However, continued research is needed for further insight.
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Affiliation(s)
| | - Kowthar Forsat
- College of Medicine, Ajman University, Ajman P.O. Box 346, United Arab Emirates
| | - Solomon Silas Senok
- College of Medicine, Ajman University, Ajman P.O. Box 346, United Arab Emirates
| | - Nandu Goswami
- Institute of Physiology (Gravitational Physiology and Medicine), Medical University of Graz, 8036 Graz, Austria
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai P.O. Box 505055, United Arab Emirates
- Correspondence:
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21
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Karatela MF, Fudim M, Mathew JP, Piccini JP. Neuromodulation therapy for atrial fibrillation. Heart Rhythm 2023; 20:100-111. [PMID: 35988908 DOI: 10.1016/j.hrthm.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/07/2022] [Accepted: 08/12/2022] [Indexed: 02/08/2023]
Abstract
Atrial fibrillation has a multifactorial pathophysiology influenced by cardiac autonomic innervation. Both sympathetic and parasympathetic influences are profibrillatory. Innovative therapies targeting the neurocardiac axis include catheter ablation or pharmacologic suppression of ganglionated plexi, renal sympathetic denervation, low-level vagal stimulation, and stellate ganglion blockade. To date, these therapies have variable efficacy. As our understanding of atrial fibrillation and the cardiac nervous system expands, our approach to therapeutic neuromodulation will continue evolving for the benefit of those with AF.
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Affiliation(s)
- Maham F Karatela
- Cardiac Electrophysiology Section, Duke Heart Center and Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Marat Fudim
- Cardiac Electrophysiology Section, Duke Heart Center and Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Jonathan P Piccini
- Cardiac Electrophysiology Section, Duke Heart Center and Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
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22
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Sridharan A, Bradfield JS, Shivkumar K, Ajijola OA. Autonomic nervous system and arrhythmias in structural heart disease. Auton Neurosci 2022; 243:103037. [DOI: 10.1016/j.autneu.2022.103037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/21/2022] [Accepted: 09/21/2022] [Indexed: 11/28/2022]
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Ge P, Fu Y, Su Q, Jin M, Guo L, Miao C, Zhu S, Zhuang J, Zhang Z, Hong J. Colchicine for prevention of post-operative atrial fibrillation: Meta-analysis of randomized controlled trials. Front Cardiovasc Med 2022; 9:1032116. [PMID: 36531704 PMCID: PMC9752015 DOI: 10.3389/fcvm.2022.1032116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/16/2022] [Indexed: 11/03/2023] Open
Abstract
Objective This study intended to assess the efficacy of colchicine for prevention of post-operative atrial fibrillation (AF). Background Post-operative AF is a common complication of surgery operations. Inflammation plays a crucial role in the pathogenesis of post-operative AF. Colchicine, a potent anti-inflammatory drug, may have a role in mitigating the incidence of post-operative AF. Methods We searched Cochrane Library, Web of Science, PubMed, China National Knowledge Infrastructure (CNKI), Database of Chinese sci-tech periodicals (COVIP), and Wanfang Database for randomized controlled trials (RCTs) comparing colchicine versus placebo, or usual care for prevention of post-operative AF. The main outcome was the occurrence of AF post operation, which includes cardiac surgery, lung surgery, or pulmonary vein isolation. The estimated risk ratio (RR) for the occurrence of post-operative AF was evaluated using a random-effects model. The safety end point was the development of any side effects. Results A total of 12 RCTs with 2274 patients were eventually included in this meta-analysis, where 1141 patients received colchicine and 1133 patients received placebo or usual care. Perioperative colchicine treatment was related to a decreased incidence of post-operative AF (RR: 0.65; 95% confidence interval [CI]: 0.56 to 0.75, p<0.001). Although the incidence of gastrointestinal side effects was increased with colchicine therapy when compared to placebo (RR = 2.49, 95% CI 1.85 to 3.34, p < 0.001), the incidence of major adverse events was not increased (RR = 0.86, 95% CI 0.46 to 1.60, p = 0.64). Conclusion In conclusion, the results of our meta-analysis suggest that colchicine treatment could lower the incidence of post-operative AF. Further studies are needed to determine the optimal colchicine treatment regime to minimize the incidence of adverse events.
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Affiliation(s)
- Peibing Ge
- Shanghai General Hospital of Nanjing Medical University, Shanghai, China
- Department of Cardiology, The Affiliated Huaian No.1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu, China
| | - Yu Fu
- Department of Emergency and Critical Care, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qi Su
- Department of Emergency and Critical Care, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mengdi Jin
- Department of Emergency and Critical Care, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Guo
- Shanghai General Hospital of Nanjing Medical University, Shanghai, China
| | - Congliang Miao
- Department of Internal and Emergency Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shun Zhu
- Department of Emergency and Critical Care, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinqiang Zhuang
- Department of Internal and Emergency Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhi Zhang
- Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiang Hong
- Shanghai General Hospital of Nanjing Medical University, Shanghai, China
- Department of Emergency and Critical Care, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Limonova AS, Germanova KN, Gantman MV, Nazarova MA, Davtyan KV, Novikov PA, Sukmanova AA, Tarasov AV, Kharlap MS, Ershova AI, Drapkina OM. Neurovisceral interactions within the brain-heart axis as the basis of neurocardiology. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2022. [DOI: 10.15829/1728-8800-2022-3435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The use of a systematic approach to the study of the etiology of a certain pathology makes it possible to improve the understanding of its pathogenesis, as well as to develop more effective diagnostic and therapeutic approaches, including improving the prediction of its risk. Within this review, we will consider such an area of interdisciplinary research as neurocardiology, which studies the brain-heart axis. Examples of cardiovascular diseases associated with organic and functional disorders of this axis will be considered, as well as the prospects for research in this area and their translational significance for clinical medicine.
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Affiliation(s)
- A. S. Limonova
- National Medical Research Center for Therapy and Preventive Medicine
| | - K. N. Germanova
- National Medical Research Center for Therapy and Preventive Medicine; National Research University Higher School of Economics
| | - M. V. Gantman
- National Research University Higher School of Economics
| | - M. A. Nazarova
- National Research University Higher School of Economics; Harvard Medical School
| | - K. V. Davtyan
- National Medical Research Center for Therapy and Preventive Medicine
| | - P. A. Novikov
- National Research University Higher School of Economics
| | - A. A. Sukmanova
- National Medical Research Center for Therapy and Preventive Medicine; National Research University Higher School of Economics
| | - A. V. Tarasov
- National Medical Research Center for Therapy and Preventive Medicine
| | - M. S. Kharlap
- National Medical Research Center for Therapy and Preventive Medicine
| | - A. I. Ershova
- National Medical Research Center for Therapy and Preventive Medicine
| | - O. M. Drapkina
- National Medical Research Center for Therapy and Preventive Medicine
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25
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Yang Y, Xie L, Peng Y, Yan H, Huang J, Xiao Z, Lu X. Single-Cell Transcriptional Profiling Reveals Low-Level Tragus Stimulation Improves Sepsis-Induced Myocardial Dysfunction by Promoting M2 Macrophage Polarization. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:3327583. [PMID: 36285297 PMCID: PMC9588360 DOI: 10.1155/2022/3327583] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/22/2022] [Indexed: 11/17/2022]
Abstract
Background Sepsis can lead to multiple organ damage, of which the heart is one of the most vulnerable organs. Vagal nerve stimulation can reduce myocardial injury in sepsis and improve survival rates. However, the potential impact of low-level tragus stimulation and disparate cell populations on sepsis-induced myocardial dysfunction remains undetermined. Methods A cardiac single-cell transcriptomic approach was used for characterizing cardiac cell populations that form the heart. Single-cell mRNA sequencing data were used for selecting all cardiac macrophages from CD45+ cells. Then, echocardiography, western blot, flow cytometry, immunofluorescence, and immunohistochemistry were performed to verify the single-cell mRNA sequencing results. Results Using single-cell mRNA sequencing data, we uncovered the multiple cell populations contributing to myocardial injury in sepsis under low-level tragus stimulation, thereby illustrating a comprehensive map of the cardiac cellular landscape. Pseudotiming analysis in single-cell sequencing showed that low-level vagal nerve stimulation played an anti-inflammatory role by promoting cardiac monocytes into M2 macrophages, which significantly increased α7nAChR expression in heart tissues. Echocardiography assessment indicated that low-level vagal nerve stimulation could also improve cardiac functions in mice with sepsis-induced myocardial dysfunction. In addition, the heart tissues of mice from the sepsis group with low-level tragus stimulation had significantly lower interleukin-1β expression levels than those from the sepsis group. Flow cytometry analysis showed that different acetylcholine concentrations promoted cardiac monocytes into M2 macrophages in in vitro experiments. Conclusion Low-level tragus stimulation could improve sepsis-induced myocardial dysfunction by promoting cardiac monocytes to M2 macrophages.
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Affiliation(s)
- Yufan Yang
- Department of Pediatric Intensive Care Unit of Hunan Children's Hospital, No. 86 Ziyuan Road, Changsha, Hunan 410007, China
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, No. 86 Ziyuan Road, Changsha, Hunan 410007, China
| | - Longlong Xie
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, No. 86 Ziyuan Road, Changsha, Hunan 410007, China
| | - Yinghui Peng
- Department of Pediatric Intensive Care Unit of Hunan Children's Hospital, No. 86 Ziyuan Road, Changsha, Hunan 410007, China
- Department of Ultrasound of Hunan Children's Hospital, No. 86 Ziyuan Road, Changsha, Hunan 410007, China
| | - Haipeng Yan
- Department of Pediatric Intensive Care Unit of Hunan Children's Hospital, No. 86 Ziyuan Road, Changsha, Hunan 410007, China
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, No. 86 Ziyuan Road, Changsha, Hunan 410007, China
| | - Jiaotian Huang
- Department of Pediatric Intensive Care Unit of Hunan Children's Hospital, No. 86 Ziyuan Road, Changsha, Hunan 410007, China
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, No. 86 Ziyuan Road, Changsha, Hunan 410007, China
| | - Zhenghui Xiao
- Department of Pediatric Intensive Care Unit of Hunan Children's Hospital, No. 86 Ziyuan Road, Changsha, Hunan 410007, China
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, No. 86 Ziyuan Road, Changsha, Hunan 410007, China
| | - Xiulan Lu
- Department of Pediatric Intensive Care Unit of Hunan Children's Hospital, No. 86 Ziyuan Road, Changsha, Hunan 410007, China
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, No. 86 Ziyuan Road, Changsha, Hunan 410007, China
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Barthelemy JC, Pichot V, Hupin D, Berger M, Celle S, Mouhli L, Bäck M, Lacour JR, Roche F. Targeting autonomic nervous system as a biomarker of well-ageing in the prevention of stroke. Front Aging Neurosci 2022; 14:969352. [PMID: 36185479 PMCID: PMC9521604 DOI: 10.3389/fnagi.2022.969352] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
Stroke prediction is a key health issue for preventive medicine. Atrial fibrillation (AF) detection is well established and the importance of obstructive sleep apneas (OSA) has emerged in recent years. Although autonomic nervous system (ANS) appears strongly implicated in stroke occurrence, this factor is more rarely considered. However, the consequences of decreased parasympathetic activity explored in large cohort studies through measurement of ANS activity indicate that an ability to improve its activity level and equilibrium may prevent stroke. In support of these observations, a compensatory neurostimulation has already proved beneficial on endothelium function. The available data on stroke predictions from ANS is based on many long-term stroke cohorts. These data underline the need of repeated ANS evaluation for the general population, in a medical environment, and remotely by emerging telemedicine digital tools. This would help uncovering the reasons behind the ANS imbalance that would need to be medically adjusted to decrease the risk of stroke. This ANS unbalance help to draw attention on clinical or non-clinical evidence, disclosing the vascular risk, as ANS activity integrates the cumulated risk from many factors of which most are modifiable, such as metabolic inadaptation in diabetes and obesity, sleep ventilatory disorders, hypertension, inflammation, and lack of physical activity. Treating these factors may determine ANS recovery through the appropriate management of these conditions. Natural aging also decreases ANS activity. ANS recovery will decrease global circulating inflammation, which will reinforce endothelial function and thus protect the vessels and the associated organs. ANS is the whistle-blower of vascular risk and the actor of vascular health. Such as, ANS should be regularly checked to help draw attention on vascular risk and help follow the improvements in response to our interventions. While today prediction of stroke relies on classical cardiovascular risk factors, adding autonomic biomarkers as HRV parameters may significantly increase the prediction of stroke.
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Affiliation(s)
- Jean-Claude Barthelemy
- Physical Exercise and Clinical Physiology Department, CHU Nord, Saint-Étienne, France
- INSERM U1059 Santé Ingénierie Biologie, Université Jean Monnet, Saint-Étienne, France
- *Correspondence: Jean-Claude Barthelemy,
| | - Vincent Pichot
- Physical Exercise and Clinical Physiology Department, CHU Nord, Saint-Étienne, France
- INSERM U1059 Santé Ingénierie Biologie, Université Jean Monnet, Saint-Étienne, France
| | - David Hupin
- Physical Exercise and Clinical Physiology Department, CHU Nord, Saint-Étienne, France
- INSERM U1059 Santé Ingénierie Biologie, Université Jean Monnet, Saint-Étienne, France
- Section of Translational Cardiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Mathieu Berger
- Physical Exercise and Clinical Physiology Department, CHU Nord, Saint-Étienne, France
- INSERM U1059 Santé Ingénierie Biologie, Université Jean Monnet, Saint-Étienne, France
- Centre d’Investigation et de Recherche sur le Sommeil, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Sébastien Celle
- Physical Exercise and Clinical Physiology Department, CHU Nord, Saint-Étienne, France
- INSERM U1059 Santé Ingénierie Biologie, Université Jean Monnet, Saint-Étienne, France
| | - Lytissia Mouhli
- Physical Exercise and Clinical Physiology Department, CHU Nord, Saint-Étienne, France
- Département de Neurologie, Hôpital Universitaire Nord, Saint-Étienne, France
| | - Magnus Bäck
- Section of Translational Cardiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Jean-René Lacour
- Laboratoire de Physiologie, Faculté de Médecine Lyon-Sud, Oullins, France
| | - Frederic Roche
- Physical Exercise and Clinical Physiology Department, CHU Nord, Saint-Étienne, France
- INSERM U1059 Santé Ingénierie Biologie, Université Jean Monnet, Saint-Étienne, France
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27
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Elkholey K, Niewiadomska M, Morris L, Whyte S, Houser J, Humphrey MB, Stavrakis S. Transcutaneous Vagus Nerve Stimulation Ameliorates the Phenotype of Heart Failure With Preserved Ejection Fraction Through Its Anti-Inflammatory Effects. Circ Heart Fail 2022; 15:e009288. [PMID: 35862007 PMCID: PMC9388556 DOI: 10.1161/circheartfailure.122.009288] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A systemic proinflammatory state plays a central role in the development of heart failure with preserved ejection fraction (HFpEF). Low-level transcutaneous vagus nerve stimulation (LLTS) suppresses inflammation in animals and humans, mediated by an α7nAchR (alpha7 nicotinic acetylcholine receptor)-dependent pathway. We examined the effects of LLTS on cardiac function, inflammation, and fibrosis in the presence of α7nAchR pharmacological blockade in a rat model of HFpEF. METHODS Dahl salt-sensitive rats at 7 weeks of age were treated with high-salt diet for 6 weeks to induce HFpEF, followed by 4 weeks of (1) LLTS, (2) LLTS with the α7nAchR blocker methyllycaconitine, (3) sham, and (4) olmesartan. Blood pressure, cardiac function by echocardiography, heart rate variability, and serum cytokines were measured at 13 and 17 weeks of age. Cardiac fibrosis, inflammatory cell infiltration, and gene expression were determined at 17 weeks. RESULTS LLTS attenuated the increase in blood pressure; improved cardiac function; decreased inflammatory cytokines, macrophage infiltration, and fibrosis; and improved survival compared with other groups. Methyllycaconitine attenuated these effects, whereas olmesartan did not improve cardiac function or fibrosis despite maintaining similar blood pressure as LLTS. Heart rate variability was similarly improved in the LLTS and LLTS plus methyllycaconitine groups but remained low in the other groups. LLTS reversed the dysregulated inflammatory signaling pathways in HFpEF hearts. CONCLUSIONS Neuromodulation with LLTS improved cardiac function in a rat model of HFpEF through its anti-inflammatory and antifibrotic effects. These results provide the basis for further clinical trials in humans.
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Affiliation(s)
- Khaled Elkholey
- Cardiovascular Section, Department of Medicine (K.E., M.N., L.M., S.W., S.S.), University of Oklahoma Health Science Center, Oklahoma City
| | - Monika Niewiadomska
- Cardiovascular Section, Department of Medicine (K.E., M.N., L.M., S.W., S.S.), University of Oklahoma Health Science Center, Oklahoma City
| | - Lynsie Morris
- Cardiovascular Section, Department of Medicine (K.E., M.N., L.M., S.W., S.S.), University of Oklahoma Health Science Center, Oklahoma City
| | - Seabrook Whyte
- Cardiovascular Section, Department of Medicine (K.E., M.N., L.M., S.W., S.S.), University of Oklahoma Health Science Center, Oklahoma City
| | - Jeremy Houser
- Rheumatology Section, Department of Medicine (J.H., M.B.H.), University of Oklahoma Health Science Center, Oklahoma City
| | - Mary Beth Humphrey
- Rheumatology Section, Department of Medicine (J.H., M.B.H.), University of Oklahoma Health Science Center, Oklahoma City
| | - Stavros Stavrakis
- Cardiovascular Section, Department of Medicine (K.E., M.N., L.M., S.W., S.S.), University of Oklahoma Health Science Center, Oklahoma City
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28
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Tornero C, Pastor E, Garzando MDM, Orduña J, Forner MJ, Bocigas I, Cedeño DL, Vallejo R, McClure CK, Czura CJ, Liebler EJ, Staats P. Non-invasive Vagus Nerve Stimulation for COVID-19: Results From a Randomized Controlled Trial (SAVIOR I). Front Neurol 2022; 13:820864. [PMID: 35463130 PMCID: PMC9028764 DOI: 10.3389/fneur.2022.820864] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/14/2022] [Indexed: 01/08/2023] Open
Abstract
Background Severe coronavirus disease 2019 (COVID-19) is characterized, in part, by an excessive inflammatory response. Evidence from animal and human studies suggests that vagus nerve stimulation can lead to reduced levels of various biomarkers of inflammation. We conducted a prospective randomized controlled study (SAVIOR-I) to assess the feasibility, efficacy, and safety of non-invasive vagus nerve stimulation (nVNS) for the treatment of respiratory symptoms and inflammatory markers among patients who were hospitalized for COVID-19 (ClinicalTrials.gov identifier: NCT04368156). Methods Participants were randomly assigned in a 1:1 allocation to receive either the standard of care (SoC) alone or nVNS therapy plus the SoC. The nVNS group received 2 consecutive 2-min doses of nVNS 3 times daily as prophylaxis. Efficacy and safety were evaluated via the incidence of specific clinical events, inflammatory biomarker levels, and the occurrence of adverse events. Results Of the 110 participants who were enrolled and randomly assigned, 97 (nVNS, n = 47; SoC, n = 50) had sufficient available data and comprised the evaluable population. C-reactive protein (CRP) levels decreased from baseline to a significantly greater degree in the nVNS group than in the SoC group at day 5 and overall (i.e., all postbaseline data points collected through day 5, combined). Procalcitonin level also showed significantly greater decreases from baseline to day 5 in the nVNS group than in the SoC group. D-dimer levels were decreased from baseline for the nVNS group and increased from baseline for the SoC group at day 5 and overall, although the difference between the treatment groups did not reach statistical significance. No significant treatment differences were seen for clinical respiratory outcomes or any of the other biochemical markers evaluated. No serious nVNS-related adverse events occurred during the study. Conclusions nVNS therapy led to significant reductions in levels of inflammatory markers, specifically CRP and procalcitonin. Because nVNS has multiple mechanisms of action that may be relevant to COVID-19, additional research into its potential use earlier in the course of COVID-19 and its potential to mitigate some of the symptoms associated with post-acute sequelae of COVID-19 is warranted.
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Affiliation(s)
- Carlos Tornero
- Hospital Clínico Universitario de Valencia, Anesthesia, Critical Care and Pain Management Unit, Valencia, Spain
- Cátedra Dolor, UFV-Fundación Vithas, Madrid, Spain
| | - Ernesto Pastor
- Hospital Clínico Universitario de Valencia, Anesthesia, Critical Care and Pain Management Unit, Valencia, Spain
| | - María del Mar Garzando
- Hospital Clínico Universitario de Valencia, Anesthesia, Critical Care and Pain Management Unit, Valencia, Spain
| | - Jorge Orduña
- Hospital Clínico Universitario de Valencia, Anesthesia, Critical Care and Pain Management Unit, Valencia, Spain
| | - Maria J. Forner
- Hospital Clínico Universitario de Valencia, Internal Medicine Department, Valencia, Spain
| | - Irene Bocigas
- Hospital Clínico Universitario de Valencia, Pulmonary Department, Valencia, Spain
| | - David L. Cedeño
- Department of Basic Science, Millennium Pain Center, Bloomington, IL, United States
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL, United States
| | - Ricardo Vallejo
- Department of Basic Science, Millennium Pain Center, Bloomington, IL, United States
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL, United States
| | | | | | | | - Peter Staats
- electroCore, Inc., Rockaway, NJ, United States
- *Correspondence: Peter Staats
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Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia despite substantial efforts to understand the pathophysiology of the condition and develop improved treatments. Identifying the underlying causative mechanisms of AF in individual patients is difficult and the efficacy of current therapies is suboptimal. Consequently, the incidence of AF is steadily rising and there is a pressing need for novel therapies. Research has revealed that defects in specific molecular pathways underlie AF pathogenesis, resulting in electrical conduction disorders that drive AF. The severity of this so-called electropathology correlates with the stage of AF disease progression and determines the response to AF treatment. Therefore, unravelling the molecular mechanisms underlying electropathology is expected to fuel the development of innovative personalized diagnostic tools and mechanism-based therapies. Moreover, the co-creation of AF studies with patients to implement novel diagnostic tools and therapies is a prerequisite for successful personalized AF management. Currently, various treatment modalities targeting AF-related electropathology, including lifestyle changes, pharmaceutical and nutraceutical therapy, substrate-based ablative therapy, and neuromodulation, are available to maintain sinus rhythm and might offer a novel holistic strategy to treat AF.
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Affiliation(s)
- Bianca J J M Brundel
- Department of Physiology, Amsterdam University Medical Centers, VU Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands.
| | - Xun Ai
- Department of Physiology and Cell Biology, College of Medicine/Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | | | - Myrthe F Kuipers
- AFIPonline.org, Atrial Fibrillation Innovation Platform, Amsterdam, Netherlands
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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30
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Kharbanda RK, van der Does WFB, van Staveren LN, Taverne YJHJ, Bogers AJJC, de Groot NMS. Vagus Nerve Stimulation and Atrial Fibrillation: Revealing the Paradox. Neuromodulation 2022; 25:356-365. [PMID: 35190246 DOI: 10.1016/j.neurom.2022.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 12/28/2021] [Accepted: 01/04/2022] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVE The cardiac autonomic nervous system (CANS) plays an important role in the pathophysiology of atrial fibrillation (AF). Cardiovascular disease can cause an imbalance within the CANS, which may contribute to the initiation and maintenance of AF. Increased understanding of neuromodulation of the CANS has resulted in novel emerging therapies to treat cardiac arrhythmias by targeting different circuits of the CANS. Regarding AF, neuromodulation therapies targeting the vagus nerve have yielded promising outcomes. However, targeting the vagus nerve can be both pro-arrhythmogenic and anti-arrhythmogenic. Currently, these opposing effects of vagus nerve stimulation (VNS) have not been clearly described. The aim of this review is therefore to discuss both pro-arrhythmogenic and anti-arrhythmogenic effects of VNS and recent advances in clinical practice and to provide future perspectives for VNS to treat AF. MATERIALS AND METHODS A comprehensive review of current literature on VNS and its pro-arrhythmogenic and anti-arrhythmogenic effects on atrial tissue was performed. Both experimental and clinical studies are reviewed and discussed separately. RESULTS VNS exhibits both pro-arrhythmogenic and anti-arrhythmogenic effects. The anatomical site and stimulation settings during VNS play a crucial role in determining its effect on cardiac electrophysiology. Since the last decade, there is accumulating evidence from experimental studies and randomized clinical studies that low-level VNS (LLVNS), below the bradycardia threshold, is an effective treatment for AF. CONCLUSION LLVNS is a promising novel therapeutic modality to treat AF and further research will further elucidate the underlying anti-arrhythmogenic mechanisms, optimal stimulation settings, and site to apply LLVNS.
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Affiliation(s)
- Rohit K Kharbanda
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
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Mehra R, Tjurmina OA, Ajijola OA, Arora R, Bolser DC, Chapleau MW, Chen PS, Clancy CE, Delisle BP, Gold MR, Goldberger JJ, Goldstein DS, Habecker BA, Handoko ML, Harvey R, Hummel JP, Hund T, Meyer C, Redline S, Ripplinger CM, Simon MA, Somers VK, Stavrakis S, Taylor-Clark T, Undem BJ, Verrier RL, Zucker IH, Sopko G, Shivkumar K. Research Opportunities in Autonomic Neural Mechanisms of Cardiopulmonary Regulation: A Report From the National Heart, Lung, and Blood Institute and the National Institutes of Health Office of the Director Workshop. JACC Basic Transl Sci 2022; 7:265-293. [PMID: 35411324 PMCID: PMC8993767 DOI: 10.1016/j.jacbts.2021.11.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 12/22/2022]
Abstract
This virtual workshop was convened by the National Heart, Lung, and Blood Institute, in partnership with the Office of Strategic Coordination of the Office of the National Institutes of Health Director, and held September 2 to 3, 2020. The intent was to assemble a multidisciplinary group of experts in basic, translational, and clinical research in neuroscience and cardiopulmonary disorders to identify knowledge gaps, guide future research efforts, and foster multidisciplinary collaborations pertaining to autonomic neural mechanisms of cardiopulmonary regulation. The group critically evaluated the current state of knowledge of the roles that the autonomic nervous system plays in regulation of cardiopulmonary function in health and in pathophysiology of arrhythmias, heart failure, sleep and circadian dysfunction, and breathing disorders. Opportunities to leverage the Common Fund's SPARC (Stimulating Peripheral Activity to Relieve Conditions) program were characterized as related to nonpharmacologic neuromodulation and device-based therapies. Common themes discussed include knowledge gaps, research priorities, and approaches to develop novel predictive markers of autonomic dysfunction. Approaches to precisely target neural pathophysiological mechanisms to herald new therapies for arrhythmias, heart failure, sleep and circadian rhythm physiology, and breathing disorders were also detailed.
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Key Words
- ACE, angiotensin-converting enzyme
- AD, autonomic dysregulation
- AF, atrial fibrillation
- ANS, autonomic nervous system
- Ach, acetylcholine
- CNS, central nervous system
- COPD, chronic obstructive pulmonary disease
- CSA, central sleep apnea
- CVD, cardiovascular disease
- ECG, electrocardiogram
- EV, extracellular vesicle
- GP, ganglionated plexi
- HF, heart failure
- HFpEF, heart failure with preserved ejection fraction
- HFrEF, heart failure with reduced ejection fraction
- HRV, heart rate variability
- LQT, long QT
- MI, myocardial infarction
- NE, norepinephrine
- NHLBI, National Heart, Lung, and Blood Institute
- NPY, neuropeptide Y
- NREM, non-rapid eye movement
- OSA, obstructive sleep apnea
- PAH, pulmonary arterial hypertension
- PV, pulmonary vein
- REM, rapid eye movement
- RV, right ventricular
- SCD, sudden cardiac death
- SDB, sleep disordered breathing
- SNA, sympathetic nerve activity
- SNSA, sympathetic nervous system activity
- TLD, targeted lung denervation
- asthma
- atrial fibrillation
- autonomic nervous system
- cardiopulmonary
- chronic obstructive pulmonary disease
- circadian
- heart failure
- pulmonary arterial hypertension
- sleep apnea
- ventricular arrhythmia
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Affiliation(s)
- Reena Mehra
- Cleveland Clinic, Cleveland, Ohio, USA
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Olga A. Tjurmina
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | | | - Rishi Arora
- Feinberg School of Medicine at Northwestern University, Chicago, Illinois, USA
| | | | - Mark W. Chapleau
- University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | | | | | | | - Michael R. Gold
- Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - David S. Goldstein
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
| | - Beth A. Habecker
- Oregon Health and Science University School of Medicine, Portland, Oregon, USA
| | - M. Louis Handoko
- Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | | | - James P. Hummel
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | | | | | | | - Marc A. Simon
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- University of California-San Francisco, San Francisco, California, USA
| | | | - Stavros Stavrakis
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | | | | | - Richard L. Verrier
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - George Sopko
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
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Structural and function organization of intrathoracic extracardiac autonomic projections to the porcine heart: implications for targeted neuromodulation therapy. Heart Rhythm 2022; 19:975-983. [DOI: 10.1016/j.hrthm.2022.01.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 01/20/2022] [Accepted: 01/28/2022] [Indexed: 12/30/2022]
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Tynan A, Brines M, Chavan SS. Control of inflammation using non-invasive neuromodulation: past, present and promise. Int Immunol 2022; 34:119-128. [PMID: 34558623 PMCID: PMC8783606 DOI: 10.1093/intimm/dxab073] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/20/2021] [Indexed: 12/14/2022] Open
Abstract
The nervous system has been increasingly recognized as a novel and accessible target in the regulation of inflammation. The use of implantable and invasive devices targeting neural circuits has yielded successful results in clinical settings but does have some risk or adverse effects. Recent advances in technology and understanding of mechanistic pathways have opened new avenues of non-invasive neuromodulation. Through this review we discuss the novel research and outcomes of major modalities of non-invasive neuromodulation in the context of inflammation including transcutaneous electrical, magnetic and ultrasound neuromodulation. In addition to highlighting the scientific observations and breakthroughs, we discuss the underlying mechanisms and pathways for neural regulation of inflammation.
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Affiliation(s)
- Aisling Tynan
- Laboratory of Biomedical Science, Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY, USA
| | - Michael Brines
- Laboratory of Biomedical Science, Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY, USA
| | - Sangeeta S Chavan
- Laboratory of Biomedical Science, Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY, USA
- Elmezzi Graduate School of Molecular Medicine, 350 Community Drive, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra University, Hempstead, NY, USA
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Stavrakis S, Elkholey K, Morris L, Niewiadomska M, Asad ZUA, Humphrey MB. Neuromodulation of Inflammation to Treat Heart Failure With Preserved Ejection Fraction: A Pilot Randomized Clinical Trial. J Am Heart Assoc 2022; 11:e023582. [PMID: 35023349 PMCID: PMC9238491 DOI: 10.1161/jaha.121.023582] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background A systemic proinflammatory state plays a central role in the development of heart failure with preserved ejection fraction. Low‐level transcutaneous vagus nerve stimulation suppresses inflammation in humans. We conducted a sham‐controlled, double‐blind, randomized clinical trial to examine the effect of chronic low‐level transcutaneous vagus nerve stimulation on cardiac function, exercise capacity, and inflammation in patients with heart failure with preserved ejection fraction. Methods and Results Patients with heart failure with preserved ejection fraction and at least 2 additional comorbidities (obesity, diabetes, hypertension, or age ≥65 years) were randomized to either active (tragus) or sham (earlobe) low‐level transcutaneous vagus nerve stimulation (20 Hz, 1 mA below discomfort threshold), for 1 hour daily for 3 months. Echocardiography, 6‐minute walk test, quality of life, and serum cytokines were assessed at baseline and 3 months. Fifty‐two patients (mean age 70.4±9.2 years; 70% female) were included (active, n=26; sham, n=26). Baseline characteristics were balanced between the 2 arms. Adherence to the protocol of daily stimulation was >90% in both arms (P>0.05). While the early mitral inflow Doppler velocity to the early diastolic mitral annulus velocity ratio did not differ between groups, global longitudinal strain and tumor necrosis factor‐α levels at 3 months were significantly improved in the active compared with the sham arm (−18.6%±2.5% versus −16.0%±2.4%, P=0.002; 8.9±2.8 pg/mL versus 11.3±2.9 pg/mL, P=0.007, respectively). The reduction in tumor necrosis factor‐α levels correlated with global longitudinal strain improvement (r=−0.73, P=0.001). Quality of life was better in the active arm. No device‐related side effects were observed. Conclusions Neuromodulation with low‐level transcutaneous vagus nerve stimulation over 3 months resulted in a significant improvement in global longitudinal strain, inflammatory cytokines, and quality of life in patients with heart failure with preserved ejection fraction. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03327649.
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Affiliation(s)
| | - Khaled Elkholey
- University of Oklahoma Health Science Center Oklahoma City OK
| | - Lynsie Morris
- University of Oklahoma Health Science Center Oklahoma City OK
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Patel ABU, Weber V, Gourine AV, Ackland GL. The potential for autonomic neuromodulation to reduce perioperative complications and pain: a systematic review and meta-analysis. Br J Anaesth 2022; 128:135-149. [PMID: 34801224 PMCID: PMC8787777 DOI: 10.1016/j.bja.2021.08.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/09/2021] [Accepted: 08/25/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Autonomic dysfunction promotes organ injury after major surgery through numerous pathological mechanisms. Vagal withdrawal is a key feature of autonomic dysfunction, and it may increase the severity of pain. We systematically evaluated studies that examined whether vagal neuromodulation can reduce perioperative complications and pain. METHODS Two independent reviewers searched PubMed, EMBASE, and the Cochrane Register of Controlled Clinical Trials for studies of vagal neuromodulation in humans. Risk of bias was assessed; I2 index quantified heterogeneity. Primary outcomes were organ dysfunction (assessed by measures of cognition, cardiovascular function, and inflammation) and pain. Secondary outcomes were autonomic measures. Standardised mean difference (SMD) using the inverse variance random-effects model with 95% confidence interval (CI) summarised effect sizes for continuous outcomes. RESULTS From 1258 records, 166 full-text articles were retrieved, of which 31 studies involving patients (n=721) or volunteers (n=679) met the inclusion criteria. Six studies involved interventional cardiology or surgical patients. Indirect stimulation modalities (auricular [n=23] or cervical transcutaneous [n=5]) were most common. Vagal neuromodulation reduced pain (n=10 studies; SMD=2.29 [95% CI, 1.08-3.50]; P=0.0002; I2=97%) and inflammation (n=6 studies; SMD=1.31 [0.45-2.18]; P=0.003; I2=91%), and improved cognition (n=11 studies; SMD=1.74 [0.96-2.52]; P<0.0001; I2=94%) and cardiovascular function (n=6 studies; SMD=3.28 [1.96-4.59]; P<0.00001; I2=96%). Five of six studies demonstrated autonomic changes after vagal neuromodulation by measuring heart rate variability, muscle sympathetic nerve activity, or both. CONCLUSIONS Indirect vagal neuromodulation improves physiological measures associated with limiting organ dysfunction, although studies are of low quality, are susceptible to bias and lack specific focus on perioperative patients.
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Affiliation(s)
- Amour B U Patel
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| | - Valentin Weber
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| | - Alexander V Gourine
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology and Pharmacology, University College London, London, UK
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK.
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36
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Stavrakis S, Kulkarni K, Singh JP, Katritsis DG, Armoundas AA. Autonomic Modulation of Cardiac Arrhythmias: Methods to Assess Treatment and Outcomes. JACC Clin Electrophysiol 2021; 6:467-483. [PMID: 32439031 DOI: 10.1016/j.jacep.2020.02.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/06/2020] [Accepted: 02/14/2020] [Indexed: 02/08/2023]
Abstract
The autonomic nervous system plays a central role in the pathogenesis of multiple cardiac arrhythmias, including atrial fibrillation and ventricular tachycardia. As such, autonomic modulation represents an attractive therapeutic approach in these conditions. Notably, autonomic modulation exploits the plasticity of the neural tissue to induce neural remodeling and thus obtain therapeutic benefit. Different forms of autonomic modulation include vagus nerve stimulation, tragus stimulation, renal denervation, baroreceptor activation therapy, and cardiac sympathetic denervation. This review seeks to highlight these autonomic modulation therapeutic modalities, which have shown promise in early preclinical and clinical trials and represent exciting alternatives to standard arrhythmia treatment. We also present an overview of the various methods used to assess autonomic tone, including heart rate variability, skin sympathetic nerve activity, and alternans, which can be used as surrogate markers and predictors of the treatment effect. Although the use of autonomic modulation to treat cardiac arrhythmias is supported by strong preclinical data and preliminary studies in humans, in light of the disappointing results of a number of recent randomized clinical trials of autonomic modulation therapies in heart failure, the need for optimization of the stimulation parameters and rigorous patient selection based on appropriate biomarkers cannot be overemphasized.
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Affiliation(s)
- Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.
| | - Kanchan Kulkarni
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jagmeet P Singh
- Cardiology Division, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Antonis A Armoundas
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.
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37
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Hanna P, Buch E, Stavrakis S, Meyer C, Tompkins JD, Ardell JL, Shivkumar K. Neuroscientific therapies for atrial fibrillation. Cardiovasc Res 2021; 117:1732-1745. [PMID: 33989382 PMCID: PMC8208752 DOI: 10.1093/cvr/cvab172] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/13/2021] [Indexed: 02/06/2023] Open
Abstract
The cardiac autonomic nervous system (ANS) plays an integral role in normal cardiac physiology as well as in disease states that cause cardiac arrhythmias. The cardiac ANS, comprised of a complex neural hierarchy in a nested series of interacting feedback loops, regulates atrial electrophysiology and is itself susceptible to remodelling by atrial rhythm. In light of the challenges of treating atrial fibrillation (AF) with conventional pharmacologic and myoablative techniques, increasingly interest has begun to focus on targeting the cardiac neuraxis for AF. Strong evidence from animal models and clinical patients demonstrates that parasympathetic and sympathetic activity within this neuraxis may trigger AF, and the ANS may either induce atrial remodelling or undergo remodelling itself to serve as a substrate for AF. Multiple nexus points within the cardiac neuraxis are therapeutic targets, and neuroablative and neuromodulatory therapies for AF include ganglionated plexus ablation, epicardial botulinum toxin injection, vagal nerve (tragus) stimulation, renal denervation, stellate ganglion block/resection, baroreceptor activation therapy, and spinal cord stimulation. Pre-clinical and clinical studies on these modalities have had promising results and are reviewed here.
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Affiliation(s)
- Peter Hanna
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Neurocardiology Research Program of Excellence, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Molecular, Cellular & Integrative Physiology Program, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
| | - Eric Buch
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
| | - Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, 1100 N Lindsay Ave, Oklahoma City, OK 73104, USA
| | - Christian Meyer
- Division of Cardiology, cardiac Neuro- and Electrophysiology Research Consortium (cNEP), EVK Düsseldorf, Teaching Hospital University of Düsseldorf, Kirchfeldstraße 40, 40217 Düsseldorf, Germany
- Institute of Neural and Sensory Physiology, cardiac Neuro- and Electrophysiology Research Consortium (cNEP), University of Düsseldorf, Universitätsstraße 1, 40225 Düsseldorf, Germany
| | - John D Tompkins
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Neurocardiology Research Program of Excellence, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
| | - Jeffrey L Ardell
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Neurocardiology Research Program of Excellence, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Molecular, Cellular & Integrative Physiology Program, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
| | - Kalyanam Shivkumar
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Neurocardiology Research Program of Excellence, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Molecular, Cellular & Integrative Physiology Program, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
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Steven D, van den Bruck JH, Wörmann J, Filipovic K, Dittrich S, Lüker J, Sultan A. Nicht invasive Vagusstimulation zur Behandlung von paroxysmalem Vorhofflimmern: eine vielversprechende Alternative? AKTUELLE KARDIOLOGIE 2021. [DOI: 10.1055/a-1478-3091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungAutonome Dysbalance kann die Wahrscheinlichkeit für das Auftreten von paroxysmalem Vorhofflimmern beeinflussen. Frühere Studien haben gezeigt, dass die Ablation autonomer Ganglien im linken Vorhof Rezidive von Vorhofflimmern reduzieren kann. Die bisherige Therapie von Vorhofflimmern besteht aus wenig effektiven medikamentösen Ansätzen und potenziell mit Risiken behafteten invasiven Verfahren, wie der katheterbasierten Isolation der Pulmonalvenen. Eine einfach durchzuführende nicht invasive Stimulation des N. vagus könnte eine mögliche Therapieoption sein. Die Effektivität dieses Verfahrens ist in einer kürzlich erschienenen randomisierten Arbeit mit einer relativ geringen Anzahl von Patienten untersucht worden. Der vorliegende Artikel gibt einen Überblick über die Therapie und ordnet den Stellenwert perspektivisch ein.
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Affiliation(s)
- Daniel Steven
- Herzzentrum, Abteilung für Elektrophysiologie, Uniklinik Köln, Köln, Deutschland
| | | | - Jonas Wörmann
- Herzzentrum, Abteilung für Elektrophysiologie, Uniklinik Köln, Köln, Deutschland
| | - Karlo Filipovic
- Herzzentrum, Abteilung für Elektrophysiologie, Uniklinik Köln, Köln, Deutschland
| | - Sebastian Dittrich
- Herzzentrum, Abteilung für Elektrophysiologie, Uniklinik Köln, Köln, Deutschland
| | - Jakob Lüker
- Herzzentrum, Abteilung für Elektrophysiologie, Uniklinik Köln, Köln, Deutschland
| | - Arian Sultan
- Herzzentrum, Abteilung für Elektrophysiologie, Uniklinik Köln, Köln, Deutschland
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39
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Chatterjee NA, Singh JP. Autonomic modulation and cardiac arrhythmias: old insights and novel strategies. Europace 2021; 23:1708-1721. [PMID: 34050642 DOI: 10.1093/europace/euab118] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 04/13/2021] [Indexed: 11/13/2022] Open
Abstract
The autonomic nervous system (ANS) plays a critical role in both health and states of cardiovascular disease. There has been a long-recognized role of the ANS in the pathogenesis of both atrial and ventricular arrhythmias (VAs). This historical understanding has been expanded in the context of evolving insights into the anatomy and physiology of the ANS, including dysfunction of the ANS in cardiovascular disease such as heart failure and myocardial infarction. An expanding armamentarium of therapeutic strategies-both invasive and non-invasive-have brought the potential of ANS modulation to contemporary clinical practice. Here, we summarize the integrative neuro-cardiac anatomy underlying the ANS, review the physiological rationale for autonomic modulation in atrial and VAs, highlight strategies for autonomic modulation, and finally frame future challenges and opportunities for ANS therapeutics.
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Affiliation(s)
- Neal A Chatterjee
- Electrophysiology Section, Cardiology Division, Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Jagmeet P Singh
- Cardiac Arrhythmia Service, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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40
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Dasari TW, Csipo T, Amil F, Lipecz A, Fulop GA, Jiang Y, Samannan R, Johnston S, Zhao YD, Silva-Palacios F, Stavrakis S, Yabluchanskiy A, Po SS. Effects of Low-Level Tragus Stimulation on Endothelial Function in Heart Failure With Reduced Ejection Fraction. J Card Fail 2021; 27:568-576. [PMID: 33387632 PMCID: PMC9473302 DOI: 10.1016/j.cardfail.2020.12.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Autonomic dysregulation in heart failure with reduced ejection fraction plays a major role in endothelial dysfunction. Low-level tragus stimulation (LLTS) is a novel, noninvasive method of autonomic modulation. METHODS AND RESULTS We enrolled 50 patients with heart failure with reduced ejection fraction (left ventricular ejection fraction of ≤40%) in a randomized, double-blinded, crossover study. On day 1, patients underwent 60 minutes of LLTS with a transcutaneous stimulator (20 Hz, 200 μs pulse width) or sham (ear lobule) stimulation. Macrovascular function was assessed using flow-mediated dilatation in the brachial artery and cutaneous microcirculation with laser speckle contrast imaging in the hand and nail bed. On day 2, patients were crossed over to the other study arm and underwent sham or LLTS; vascular tests were repeated before and after stimulation. Compared with the sham, LLTS improved flow-mediated dilatation by increasing the percent change in the brachial artery diameter (from 5.0 to 7.5, LLTS on day 1, P = .02; and from 4.9 to 7.1, LLTS on day 2, P = .003), compared with no significant change in the sham group (from 4.6 to 4.7, P = .84 on day 1; and from 5.6 to 5.9 on day 2, P = .65). Cutaneous microcirculation in the hand showed no improvement and perfusion of the nail bed showed a trend toward improvement. CONCLUSIONS Our study demonstrated the beneficial effects of acute neuromodulation on macrovascular function. Larger studies to validate these findings and understand mechanistic links are warranted.
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Affiliation(s)
- Tarun W Dasari
- Cardiovascular Section, Department of Internal Medicine; Heart Rhythm Institute.
| | - Tamas Csipo
- Department of Biochemistry and Molecular Biology; Section of Geriatrics, Department of Internal Medicine
| | - Faris Amil
- Cardiovascular Section, Department of Internal Medicine
| | - Agnes Lipecz
- Department of Biochemistry and Molecular Biology; Section of Geriatrics, Department of Internal Medicine
| | - Gabor A Fulop
- Department of Biochemistry and Molecular Biology; Section of Geriatrics, Department of Internal Medicine
| | | | | | - Sarah Johnston
- Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Yan D Zhao
- Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | | | - Stavros Stavrakis
- Cardiovascular Section, Department of Internal Medicine; Heart Rhythm Institute
| | - Andriy Yabluchanskiy
- Department of Biochemistry and Molecular Biology; Section of Geriatrics, Department of Internal Medicine
| | - Sunny S Po
- Cardiovascular Section, Department of Internal Medicine; Heart Rhythm Institute
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41
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Kusayama T, Wan J, Yuan Y, Chen PS. Neural Mechanisms and Therapeutic Opportunities for Atrial Fibrillation. Methodist Debakey Cardiovasc J 2021; 17:43-47. [PMID: 34104319 DOI: 10.14797/fvdn2224] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with an increased risk of all-cause mortality and complications. The autonomic nervous system (ANS) plays a central role in AF, with the heart regulated by both extrinsic and intrinsic properties. In the extrinsic ANS, the sympathetic fibers are derived from the major paravertebral ganglia, especially the stellate ganglion (SG), which is a source of cardiac sympathetic innervation since it connects with multiple intrathoracic nerves and structures. The major intrinsic ANS is a network of axons and ganglionated plexi that contains a variety of sympathetic and parasympathetic neurons, which communicate with the extrinsic ANS. Simultaneous sympathovagal activation contributes to the development of AF because it increases calcium entry and shortens the atrial action potential duration. In animal and human studies, neuromodulation methods such as electrical stimulation and renal denervation have indicated potential benefits in controlling AF in patients as they cause SG remodeling and reduce sympathetic outflow. This review focuses on the neural mechanisms relevant to AF and the recent developments of neuromodulation methods for AF control.
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Affiliation(s)
- Takashi Kusayama
- Indiana University School of Medicine, Indianapolis, Indiana.,Kanazawa University Graduate School of Medical Sciences, Ishikawa, Japan
| | - Juyi Wan
- Indiana University School of Medicine, Indianapolis, Indiana.,The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Yuan Yuan
- Indiana University School of Medicine, Indianapolis, Indiana.,Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Peng-Sheng Chen
- Indiana University School of Medicine, Indianapolis, Indiana.,Cedars-Sinai Medical Center, Los Angeles, California
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42
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Fontaine AK, Futia GL, Rajendran PS, Littich SF, Mizoguchi N, Shivkumar K, Ardell JL, Restrepo D, Caldwell JH, Gibson EA, Weir RFF. Optical vagus nerve modulation of heart and respiration via heart-injected retrograde AAV. Sci Rep 2021; 11:3664. [PMID: 33574459 PMCID: PMC7878800 DOI: 10.1038/s41598-021-83280-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 01/18/2021] [Indexed: 12/16/2022] Open
Abstract
Vagus nerve stimulation has shown many benefits for disease therapies but current approaches involve imprecise electrical stimulation that gives rise to off-target effects, while the functionally relevant pathways remain poorly understood. One method to overcome these limitations is the use of optogenetic techniques, which facilitate targeted neural communication with light-sensitive actuators (opsins) and can be targeted to organs of interest based on the location of viral delivery. Here, we tested whether retrograde adeno-associated virus (rAAV2-retro) injected in the heart can be used to selectively express opsins in vagus nerve fibers controlling cardiac function. Furthermore, we investigated whether perturbations in cardiac function could be achieved with photostimulation at the cervical vagus nerve. Viral injection in the heart resulted in robust, primarily afferent, opsin reporter expression in the vagus nerve, nodose ganglion, and brainstem. Photostimulation using both one-photon stimulation and two-photon holography with a GRIN-lens incorporated nerve cuff, was tested on the pilot-cohort of injected mice. Changes in heart rate, surface electrocardiogram, and respiratory responses were observed in response to both one- and two-photon photostimulation. The results demonstrate feasibility of retrograde labeling for organ targeted optical neuromodulation.
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Affiliation(s)
- Arjun K Fontaine
- Departments of Bioengineering, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA.
- Biomechatronics Development Laboratory, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA.
| | - Gregory L Futia
- Departments of Bioengineering, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - Pradeep S Rajendran
- UCLA Cardiac Arrhythmia Center, University of California Los Angeles, Los Angeles, CA, USA
- UCLA Neurocardiology Research Program of Excellence, University of California Los Angeles, Los Angeles, CA, USA
| | - Samuel F Littich
- Departments of Bioengineering, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
- Biomechatronics Development Laboratory, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - Naoko Mizoguchi
- Departments of Cell and Developmental Biology, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
- Division of Pharmacology, Department of Diagnostic and Therapeutic Sciences, Meikai University School of Dentistry, Saitama, Japan
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, University of California Los Angeles, Los Angeles, CA, USA
- UCLA Neurocardiology Research Program of Excellence, University of California Los Angeles, Los Angeles, CA, USA
| | - Jeffrey L Ardell
- UCLA Cardiac Arrhythmia Center, University of California Los Angeles, Los Angeles, CA, USA
- UCLA Neurocardiology Research Program of Excellence, University of California Los Angeles, Los Angeles, CA, USA
| | - Diego Restrepo
- Departments of Cell and Developmental Biology, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - John H Caldwell
- Departments of Cell and Developmental Biology, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - Emily A Gibson
- Departments of Bioengineering, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - Richard F Ff Weir
- Departments of Bioengineering, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
- Biomechatronics Development Laboratory, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
- Rocky Mountain Veterans Affairs Medical Center (VAMC), Aurora, CO, USA
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43
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Son AY, Karim AS, Fiehler M, Andrei AC, Vassallo P, Churyla A, Pham DT, McCarthy PM, Chris Malaisrie S. Outcomes of 3-day discharge after elective cardiac surgery. J Card Surg 2021; 36:1441-1447. [PMID: 33567130 DOI: 10.1111/jocs.15404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/06/2020] [Accepted: 12/14/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Shorter length of stay (LOS) is a welcome consequence of optimized perioperative care. However, accelerated hospital discharge may have unintended consequences. Before implementing an institutional enhanced recovery after surgery protocol, we evaluated the safety of shorter LOS and compared outcomes of patients with shorter LOS (LOS ≤ 3 days) to those with longer LOS (LOS > 3 days). METHODS We identified all patients undergoing elective cardiac surgery with cardiopulmonary bypass between July 2004 and June 2017. Transcatheter approaches, ventricular assist devices, transplants, and traumas were excluded. Patients were divided into two cohorts, one with shorter hospitalizations (LOS ≤ 3 days) and one with longer hospitalizations (LOS > 3 days). Propensity score matching (PSM) was performed and differences between the two groups were compared. RESULTS A total of 5,987 patients (63.0 ± 13.8 years old, 34% female) were identified and 131 (2.2%) patients were LOS ≤ 3 days; median STS Risk score was 1.2 (0.6-2.4). PSM resulted in a total of 478 patients (357 LOS > 3 and 121 LOS ≤ 3 days); median STS Risk score was 0.4 (0.3-0.9). LOS ≤ 3 days had lower rates of postoperative atrial fibrillation (2% vs. 19%; p < .001) and major in-hospital complications (0% vs. 9%; p = .001); however, 30-day readmissions (8% LOS ≤ 3 vs. 6% LOS > 3 days; p = .66) and mortality rates (0% vs. 0%) were comparable between the two groups. CONCLUSION LOS ≤ 3 days was associated with less postoperative atrial fibrillation and fewer major in-hospital complications. LOS ≤ 3 days was not associated with rehospitalization or mortality. Shorter LOS after elective cardiac surgery appears to be a safe practice with favorable outcomes, especially in low operative risk patients.
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Affiliation(s)
- Andre Y Son
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
| | - Azad S Karim
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
| | - Monica Fiehler
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
| | - Adin-Cristian Andrei
- Division of Biostatistics, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
| | - Patricia Vassallo
- Division of Cardiology, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
| | - Andrei Churyla
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
| | - Duc Thinh Pham
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
| | - Patrick M McCarthy
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
| | - S Chris Malaisrie
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
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44
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Pfenniger A, Geist GE, Arora R. Autonomic Dysfunction and Neurohormonal Disorders in Atrial Fibrillation. Card Electrophysiol Clin 2021; 13:183-190. [PMID: 33516396 DOI: 10.1016/j.ccep.2020.11.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Atrial fibrillation (AF) is the most commonly diagnosed arrhythmia and eludes an efficacious cure despite an increasing prevalence and a significant association with morbidity and mortality. In addition to an array of clinical sequelae, the origins and propagation of AF are multifactorial. In recent years, the contribution from the autonomic nervous system has been an area of particular interest. This review highlights the relevant physiology of autonomic and neurohormonal contributions to AF origin and maintenance, the current state of the literature on targeted therapies, and the path forward for clinical interventions.
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Affiliation(s)
- Anna Pfenniger
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, 251 East Huron, Feinberg 8-503, Chicago, IL 60611, USA
| | - Gail Elizabeth Geist
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, 251 East Huron, Feinberg 8-503, Chicago, IL 60611, USA
| | - Rishi Arora
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, 251 East Huron, Feinberg 8-503, Chicago, IL 60611, USA.
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45
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Chen M, Wang S, Li X, Yu L, Yang H, Liu Q, Tang J, Zhou S. Non-invasive Autonomic Neuromodulation Is Opening New Landscapes for Cardiovascular Diseases. Front Physiol 2021; 11:550578. [PMID: 33384606 PMCID: PMC7769808 DOI: 10.3389/fphys.2020.550578] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 10/27/2020] [Indexed: 01/09/2023] Open
Abstract
Autonomic imbalance plays a crucial role in the genesis and maintenance of cardiac disorders. Approaches to maintain sympatho-vagal balance in heart diseases have gained great interest in recent years. Emerging therapies However, certain types of emerging therapies including direct electrical stimulation and nerve denervation require invasive implantation of a generator and a bipolar electrode subcutaneously or result in autonomic nervous system (ANS) damage, inevitably increasing the risk of complications. More recently, non-invasive neuromodulation approaches have received great interest in ANS modulation. Non-invasive approaches have opened new fields in the treatment of cardiovascular diseases. Herein, we will review the protective roles of non-invasive neuromodulation techniques in heart diseases, including transcutaneous auricular vagus nerve stimulation, electromagnetic field stimulation, ultrasound stimulation, autonomic modulation in optogenetics, and light-emitting diode and transcutaneous cervical vagus nerve stimulation (gammaCore).
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Affiliation(s)
- Mingxian Chen
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Songyun Wang
- Department of Cardiology, Renmin Hospital, Wuhan University, Wuhan, China
| | - Xuping Li
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Lilei Yu
- Department of Cardiology, Renmin Hospital, Wuhan University, Wuhan, China
| | - Hui Yang
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Qiming Liu
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jianjun Tang
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Shenghua Zhou
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China
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46
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Fudim M, Qadri YJ, Ghadimi K, MacLeod DB, Molinger J, Piccini JP, Whittle J, Wischmeyer PE, Patel MR, Ulloa L. Implications for Neuromodulation Therapy to Control Inflammation and Related Organ Dysfunction in COVID-19. J Cardiovasc Transl Res 2020; 13:894-899. [PMID: 32458400 PMCID: PMC7250255 DOI: 10.1007/s12265-020-10031-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/12/2020] [Indexed: 12/31/2022]
Abstract
COVID-19 is a syndrome that includes more than just isolated respiratory disease, as severe acute respiratory syndrome-coronavirus 2 (SARS-CoV2) also interacts with the cardiovascular, nervous, renal, and immune system at multiple levels, increasing morbidity in patients with underlying cardiometabolic conditions and inducing myocardial injury or dysfunction. Emerging evidence suggests that patients with the highest rate of morbidity and mortality following SARS-CoV2 infection have also developed a hyperinflammatory syndrome (also termed cytokine release syndrome). We lay out the potential contribution of a dysfunction in autonomic tone to the cytokine release syndrome and related multiorgan damage in COVID-19. We hypothesize that a cholinergic anti-inflammatory pathway could be targeted as a therapeutic avenue. Graphical Abstract .
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Affiliation(s)
- Marat Fudim
- Department of Medicine, Division of Cardiology, Duke University, 2301 Erwin Road, Durham, NC, 27710, USA.
| | - Yawar J Qadri
- Department of Anesthesiology & Critical Care, Duke University, Durham, NC, USA
| | - Kamrouz Ghadimi
- Department of Anesthesiology & Critical Care, Duke University, Durham, NC, USA
| | - David B MacLeod
- Department of Anesthesiology & Critical Care, Duke University, Durham, NC, USA
| | - Jeroen Molinger
- Department of Anesthesiology & Critical Care, Duke University, Durham, NC, USA
| | - Jonathan P Piccini
- Department of Medicine, Division of Cardiology, Duke University, 2301 Erwin Road, Durham, NC, 27710, USA
- Duke Center for Atrial Fibrillation, Duke University Medical Center, Duke University, Durham, NC, USA
| | - John Whittle
- Department of Anesthesiology & Critical Care, Duke University, Durham, NC, USA
| | - Paul E Wischmeyer
- Department of Anesthesiology & Critical Care, Duke University, Durham, NC, USA
| | - Manesh R Patel
- Department of Medicine, Division of Cardiology, Duke University, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Luis Ulloa
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University, Durham, NC, USA
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47
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Geng M, Lin A, Nguyen TP. Revisiting Antiarrhythmic Drug Therapy for Atrial Fibrillation: Reviewing Lessons Learned and Redefining Therapeutic Paradigms. Front Pharmacol 2020; 11:581837. [PMID: 33240090 PMCID: PMC7680856 DOI: 10.3389/fphar.2020.581837] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/17/2020] [Indexed: 12/12/2022] Open
Abstract
Since the clinical use of digitalis as the first pharmacological therapy for atrial fibrillation (AF) 235 years ago in 1785, antiarrhythmic drug therapy has advanced considerably and become a cornerstone of AF clinical management. Yet, a preventive or curative panacea for sustained AF does not exist despite the rise of AF global prevalence to epidemiological proportions. While multiple elevated risk factors for AF have been established, the natural history and etiology of AF remain incompletely understood. In the present article, the first section selectively highlights some disappointing shortcomings and current efforts in antiarrhythmic drug therapy to uncover reasons why AF is such a clinical challenge. The second section discusses some modern takes on the natural history of AF as a relentless, progressive fibro-inflammatory "atriomyopathy." The final section emphasizes the need to redefine therapeutic strategies on par with new insights of AF pathophysiology.
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Affiliation(s)
| | | | - Thao P. Nguyen
- Division of Cardiology, Department of Medicine, The Cardiovascular Research Laboratory, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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48
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Subramanian M, Edwards L, Melton A, Branen L, Herron A, Sivasubramanian MK, Monteiro R, Stansbury S, Balasubramanian P, Morris L, Elkholey K, Niewiadomska M, Stavrakis S. Non-invasive vagus nerve stimulation attenuates proinflammatory cytokines and augments antioxidant levels in the brainstem and forebrain regions of Dahl salt sensitive rats. Sci Rep 2020; 10:17576. [PMID: 33067477 PMCID: PMC7567801 DOI: 10.1038/s41598-020-74257-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/21/2020] [Indexed: 12/16/2022] Open
Abstract
The anti-inflammatory effects of vagus nerve stimulation are well known. It has recently been shown that low-level, transcutaneous stimulation of vagus nerve at the tragus (LLTS) reduces cardiac inflammation in a rat model of heart failure with preserved ejection fraction (HFpEF). The mechanisms by which LLTS affect the central neural circuits within the brain regions that are important for the regulation of cardiac vagal tone are not clear. Female Dahl salt-sensitive rats were initially fed with either low salt (LS) or high salt (HS) diet for a period of 6 weeks, followed by sham or active stimulation (LLTS) for 30 min daily for 4 weeks. To study the central effects of LLTS, four brainstem (SP5, NAb, NTS, and RVLM) and two forebrain sites (PVN and SFO) were examined. HS diet significantly increased the gene expression of proinflammatory cytokines in the SP5 and SFO. LLTS reversed HS diet-induced changes at both these sites. Furthermore, LLTS augmented the levels of antioxidant Nrf2 in the SP5 and SFO. Taken together, these findings suggest that LLTS has central anti-inflammatory and antioxidant properties that could mediate the neuromodulation of cardiac vagal tone in the rat model of HFpEF.
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Affiliation(s)
- Madhan Subramanian
- Department of Physiological Sciences, College of Veterinary Medicine, Oklahoma State University, 277 McElroy Hall, Stillwater, OK, 74078, USA.
| | - Laura Edwards
- Department of Physiological Sciences, College of Veterinary Medicine, Oklahoma State University, 277 McElroy Hall, Stillwater, OK, 74078, USA
| | - Avery Melton
- Department of Physiological Sciences, College of Veterinary Medicine, Oklahoma State University, 277 McElroy Hall, Stillwater, OK, 74078, USA
| | - Lyndee Branen
- Department of Physiological Sciences, College of Veterinary Medicine, Oklahoma State University, 277 McElroy Hall, Stillwater, OK, 74078, USA
| | - Angela Herron
- Department of Physiological Sciences, College of Veterinary Medicine, Oklahoma State University, 277 McElroy Hall, Stillwater, OK, 74078, USA
| | - Mahesh Kumar Sivasubramanian
- Department of Physiological Sciences, College of Veterinary Medicine, Oklahoma State University, 277 McElroy Hall, Stillwater, OK, 74078, USA
| | - Raisa Monteiro
- Department of Physiological Sciences, College of Veterinary Medicine, Oklahoma State University, 277 McElroy Hall, Stillwater, OK, 74078, USA
| | - Samantha Stansbury
- Department of Physiological Sciences, College of Veterinary Medicine, Oklahoma State University, 277 McElroy Hall, Stillwater, OK, 74078, USA
| | - Priya Balasubramanian
- Reynolds Oklahoma Center On Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Lynsie Morris
- Department of Medicine, Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Department of Medicine, Heart Rhythm Institute, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, Suite 5400, Oklahoma City, OK, 73104, USA
| | - Khaled Elkholey
- Department of Medicine, Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Monika Niewiadomska
- Department of Medicine, Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Stavros Stavrakis
- Department of Medicine, Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
- Department of Medicine, Heart Rhythm Institute, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, Suite 5400, Oklahoma City, OK, 73104, USA.
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49
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Sergeevichev D, Fomenko V, Strelnikov A, Dokuchaeva A, Vasilieva M, Chepeleva E, Rusakova Y, Artemenko S, Romanov A, Salakhutdinov N, Chernyavskiy A. Botulinum Toxin-Chitosan Nanoparticles Prevent Arrhythmia in Experimental Rat Models. Mar Drugs 2020; 18:md18080410. [PMID: 32748868 PMCID: PMC7460516 DOI: 10.3390/md18080410] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/22/2020] [Accepted: 07/27/2020] [Indexed: 11/16/2022] Open
Abstract
Several experimental studies have recently demonstrated that temporary autonomic block using botulinum toxin (BoNT/A1) might be a novel option for the treatment of atrial fibrillation. However, the assessment of antiarrhythmic properties of BoNT has so far been limited, relying exclusively on vagal stimulation and rapid atrial pacing models. The present study examined the antiarrhythmic effect of specially formulated BoNT/A1-chitosan nanoparticles (BTN) in calcium chloride-, barium chloride- and electrically induced arrhythmia rat models. BTN enhanced the effect of BoNT/A1. Subepicardial injection of BTN resulted in a significant antiarrhythmic effect in investigated rat models. BTN formulation antagonizes arrhythmia induced by the activation of Ca, K and Na channels.
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50
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Liu C, Jiang H, Yu L, S Po S. Vagal Stimulation and Arrhythmias. J Atr Fibrillation 2020; 13:2398. [PMID: 33024499 DOI: 10.4022/jafib.2398] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 02/14/2020] [Accepted: 03/17/2020] [Indexed: 12/14/2022]
Abstract
I mbalance of the sympathetic and parasympathetic nervous systems is probably the most prevalent autonomic mechanism underlying many a rrhythmias . Recently, vagus nerve stimulation ( VNS has emerged as a novel therapeutic modality to treat arrhythmias through its anti adrenergic and anti inflammatory actions . C linical trials applying VNS to the cervical vagus nerve in heart failure pati en ts yielded conflicting results, possibly due to limited understanding of the optimal stimulation parameters for the targeted cardiovascular diseases. Transcutaneous VNS by stimulating the auricular branch of the vagus nerve, has attracted great attention d ue to its noninvasiveness. In this r eview, we summarize current knowledge about the complex relationship between VNS and cardiac arrhythmias and discuss recent advances in using VNS , particularly transcutaneous VNS , to treat arrhythmias.
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Affiliation(s)
- Chengzhe Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiac Autonomic Nervous System Research Center of Wuhan Univer s ity, Wuhan, China.,Cardiovascular Research Institute, Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiac Autonomic Nervous System Research Center of Wuhan Univer s ity, Wuhan, China.,Cardiovascular Research Institute, Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Lilei Yu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiac Autonomic Nervous System Research Center of Wuhan Univer s ity, Wuhan, China.,Cardiovascular Research Institute, Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Sunny S Po
- Heart Rhythm Institute and Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, O K USA
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