Cardiac and autonomic responses to change in posture or vitamin C supplementation in sickle cell anemia subjects

Mechanisms linking red blood cell disorders and cardiovascular diseases

The present paper aims to review the main pathophysiological links between red blood cell disorders and cardiovascular diseases, provides a brief description of the latest studies in this area, and considers implications for clinical practice and therapy. Anemia is associated with a special risk in proatherosclerotic conditions and heart disease and became a new therapeutic target. Guidelines must be updated for the management of patients with red blood cell disorders and cardiovascular diseases, and targets for hemoglobin level should be established. Risk scores in several cardiovascular diseases should include red blood cell count and RDW. Complete blood count and hemorheological parameters represent useful, inexpensive, widely available tools for the management and prognosis of patients with coronary heart disease, heart failure, hypertension, arrhythmias, and stroke. Hypoxia and iron accumulation cause the most important cardiovascular effects of sickle cell disease and thalassemia. Patients with congenital chronic hemolytic anemia undergoing splenectomy should be monitored, considering thromboembolic and cardiovascular risk.

Peripheral vasoconstriction and abnormal parasympathetic response to sighs and transient hypoxia in sickle cell disease

RATIONALE

Sickle cell disease is an inherited blood disorder characterized by vasoocclusive crises. Although hypoxia and pulmonary disease are known risk factors for these crises, the mechanisms that initiate vasoocclusive events are not well known.

OBJECTIVES

To study the relationship between transient hypoxia, respiration, and microvascular blood flow in patients with sickle cell.

METHODS

We established a protocol that mimics nighttime hypoxic episodes and measured microvascular blood flow to determine if transient hypoxia causes a decrease in microvascular blood flow. Significant desaturations were induced safely by five breaths of 100% nitrogen.

MEASUREMENTS AND MAIN RESULTS

Desaturation did not induce change in microvascular perfusion; however, it induced substantial transient parasympathetic activity withdrawal in patients with sickle cell disease, but not controls subjects. Marked periodic drops in peripheral microvascular perfusion, unrelated to hypoxia, were triggered by sighs in 11 of 11 patients with sickle cell and 8 of 11 control subjects. Although the sigh frequency was the same in both groups, the probability of a sigh inducing a perfusion drop was 78% in patients with sickle cell and 17% in control subjects (P < 0.001). Evidence for sigh-induced sympathetic nervous system dominance was seen in patients with sickle cell (P < 0.05), but was not significant in control subjects.

CONCLUSIONS

These data demonstrate significant disruption of autonomic nervous system balance, with marked parasympathetic withdrawal in response to transient hypoxia. They draw attention to an enhanced autonomic nervous system–mediated sigh–vasoconstrictor response in patients with sickle cell that could increase red cell retention in the microvasculature, promoting vasoocclusion.

Sickle cell disease: selected aspects of pathophysiology

Sickle cell disease (SCD), a genetically-determined pathology due to an amino acid substitution (i.e., valine for glutamic acid) on the beta-chain of hemoglobin, is characterized by abnormal blood rheology and periods of painful vascular occlusive crises. Sickle cell trait (SCT) is a typically benign variant in which only one beta chain is affected by the mutation. Although both SCD and SCT have been the subject of numerous studies, information related to neurological function and transfusion therapy is still incomplete: an overview of these areas is presented. An initial section provides pertinent background information on the pathology and clinical significance of these diseases. The roles of three factors in the clinical manifestations of the diseases are then discussed: hypoxia, autonomic nervous system regulation and blood rheology. The possibility of a causal relationship between these three factors and sudden death is also examined. It is concluded that further studies in these specific areas are warranted. It is anticipated that the outcome of such research is likely to provide valuable insights into the pathophysiology of SCD and SCT and will lead to improved clinical management and enhanced quality of life.

The Role of Nutrition in Sickle Cell Disease

Finding a widely available cure for sickle cell anemia (HbSS) still remains a challenge one hundred years after its discovery as a genetically inherited disease. However, growing interest in the nutritional problems of the disease has created a body of literature from researchers seeking nutritional alternatives as a means of decreasing morbidity and improving quality of life among HbSS patients. This review demonstrates that over the past 30 years the role of protein/energy deficiency in HbSS has been more clearly defined via direct measurements, leading to the concept of a relative shortage of nutrients for growth and development, despite apparently adequate dietary intakes. Although there is still a paucity of data supporting the efficacy of macronutrient supplementation, it is becoming clearer that recommended dietary allowances (RDAs) for the general population are insufficient for the sickle cell patient. A similar shortage is likely to be true for micronutrient deficiencies, including recent findings of vitamin D deficiency that may be associated with incomplete ossification and bone disease, which are well known complications of HbSS disease. We conclude that there is need for more effort and resources to be dedicated to research (including supplementation studies of larger sample size) aimed at establishing specific RDAs for HbSS patients, much like the specific RDAs developed for pregnancy and growth within the general population.

Poor vitamin C status is associated with increased carotid intima-media thickness, decreased microvascular function, and delayed myocardial repolarization in young patients with type 1 diabetes

BACKGROUND

Vascular endothelial dysfunction, accelerated thickening of arterial intima, and changes in ventricular repolarization contribute to increased cardiovascular morbidity in type 1 diabetes (T1D). Although vitamin C has important antioxidant functions and increased oxidative stress is a central mechanism of cardiovascular dysfunction in T1D, the relation between vitamin C and the cardiovascular system in young diabetic patients has not been investigated.

OBJECTIVE

In a cohort of young patients with T1D, we investigated the relation of plasma concentrations of vitamin C with indexes of vascular function and structure and duration of the QT interval corrected for heart rate (QT(c)).

DESIGN

Carotid artery intima-media thickness, cutaneous microvascular function, and duration of the QT(c) interval were measured in 59 patients (mean age: 17 y; range: 10-22 y) with T1D (diabetes duration: 3-20 y). Plasma vitamin C was analyzed by HPLC with coulometric detection.

RESULTS

Carotid artery intima-media thickness and duration of the QT(c) interval were higher in patients in the lowest tertile of vitamin C than in those in the highest tertile (P < 0.05 for both). The cutaneous microvascular response to acetylcholine was lower (P = 0.003) in the lowest tertile group than in the highest tertile group, but the response to sodium nitroprusside was not significantly different between these 2 groups. All differences remained significant after adjustment for age, sex, diabetes duration, body mass index, and glycated hemoglobin.

CONCLUSIONS

In this relatively small-scale cross-sectional study of young patients with T1D, lower plasma concentrations of vitamin C seem to be associated with adverse changes in the microcirculation, peripheral arteries, and ventricular repolarization. Large-scale prospective studies are needed to confirm these results and to clarify the underlying mechanisms.