AT1 antagonism by eprosartan lowers heart rate variability and baroreflex gain

A framework for the interpretation of heart rate variability applied to transcutaneous auricular vagus nerve stimulation and osteopathic manipulation

Reports on autonomic responses to transcutaneous auricular vagus nerve stimulation (taVNS) and osteopathic manipulative techniques have been equivocal, partly due to inconsistent interpretation of heart rate variability (HRV). We developed a mechanistic framework for the interpretation of HRV based on a model of sinus node automaticity that considers autonomic effects on Phase 3 repolarization and Phase 4 depolarization of the sinoatrial action potential. The model was applied to HRV parameters calculated from ECG recordings (healthy adult humans, both genders) before (30 min), during (15 min), and after (30 min) a time control intervention (rest, n = 23), taVNS (10 Hz, 300 μs, 1-2 mA, cymba concha, left ear, n = 12), or occipitoatlantal decompression (OA-D, n = 14). The experimental protocol was repeated on 3 consecutive days. The model simulation revealed that low frequency (LF) HRV best predicts sympathetic tone when calculated from heart rate time series, while high frequency (HF) HRV best predicts parasympathetic tone when calculated from heart period time series. Applying our model to the HRV responses to taVNS and OA-D, revealed that taVNS increases cardiac parasympathetic tone, while OA-D elicits a mild decrease in cardiac sympathetic tone.

The Role of Angiotensin Receptor Blockers in the Personalized Management of Diabetic Neuropathy

Neuropathy is a frequent complication of diabetes mellitus (DM) and is associated with the increased risk ofamputation and vascular events. Tight glycemic control is an important component inthe prevention of diabetic neuropathy. However, accumulating data suggest that angiotensin receptor blockers (ARBs) might also be useful in this setting. We discuss the findings of both experimental and clinical studies that evaluated the effects of ARBs on indices of diabetic neuropathy. We also review the implicated mechanisms of the neuroprotective actions of these agents. Overall, it appears that ARBs might be a helpful tool for preventing and delaying the progression of diabetic neuropathy, but more data are needed to clarify their role in the management of this overlooked complication of DM.

Intranasal Angiotensin II in Humans Reduces Blood Pressure When Angiotensin II Type 1 Receptors Are Blocked

Intranasal administration of angiotensin II (ANGII) affects blood pressure in a mode different from intravenously administered ANGII via a direct access to the brain bypassing the blood–brain barrier. This clinical study investigated blood pressure regulation after intranasal ANGII administration in healthy humans, whereas systemic, blood-mediated effects of ANGII were specifically blocked. In a balanced crossover design, men (n=8) and women (n=8) were intranasally administered ANGII (400 μg) or placebo after ANGII type 1 receptors had been blocked by pretreatment with valsartan (80 mg; 12 and 6 hours before intranasal administration). Plasma levels of ANGII, aldosterone, renin, vasopressin, and norepinephrine were measured; blood pressure and heart rate were recorded continuously. Intranasal ANGII acutely decreased blood pressure without altering the heart rate. Plasma levels of vasopressin and norepinephrine remained unaffected. Plasma ANGII levels were increased throughout the recording period. Aldosterone levels increased despite the peripheral ANGII type 1 receptor blockade, indicating an aldosterone escape phenomenon. In conclusion, intranasal ANGII reduces blood pressure in the presence of selective ANGII type 1 receptor blockade. Intranasal ANGII administration represents a useful approach for unraveling the role of this peptide in blood pressure regulation in humans.

Cardiac autonomic balance in rats submitted to protein restriction after weaning

1. In the present study, we evaluated the autonomic balance of the heart in protein/energy-undernourished rats. 2. Rats were divided into two groups according to the diet they received after weaning: (i) the control group (n=16), given a 15% protein diet, and (ii) the malnourished group (n=14), fed a 6% protein diet. Cardiovascular recordings were made and, through selective autonomic blockade, the tonic autonomic balance, cardiac autonomic index and the power spectrum of heart rate (HR) variability were determined. 3. Muscarinic receptor blockade with methylatropine (5.0 mg/kg, i.v.) increased HR in the control group (371 ± 6 vs 427 ± 15 b.p.m. before and after drug administration, respectively), but not the malnourished group (438 ± 24 vs 472 ± 38 b.p.m. before and after drug administration, respectively). Inhibition of β(1)-adrenoceptors with metoprolol (2.0 mg/kg, i.v.) reduced HR in malnourished rats (428 ± 24 vs 355 ± 16 b.p.m. before and after drug administration, respectively), but had no effect on the HR of the control group (363 ± 8 vs 362 ± 7 b.p.m. before and after drug administration, respectively). Double autonomic blockade by inhibiting both muscarinic cholinoceptors and β(1)-adrenoceptors reduced HR in the malnourished group (428 ± 24 vs 342 ± 14 b.p.m.) but had no effect on HR in the control group (371 ± 6 vs 382 ± 6 b.p.m.). 4. Sympathetic tone was augmented in malnourished compared with control rats (131 ± 17 vs 41 ± 11 b.p.m., respectively), whereas parasympathetic tone was reduced in malnourished compared with control rats (-4 ± 4 vs 22 ± 9 b.p.m., respectively). 5. The ratio of oscillations in HR induced by sympathetic and parasympathetic activity was higher in malnourished compared with control rats (0.43 ± 0.03 vs 0.34 ± 0.02, respectively). 6. The results of the present study indicate that protein malnutrition after weaning increases sympathetic activity and reduces vagal activity to the heart in rats. These data provide a new perspective on the pathophysiology of metabolic and cardiovascular diseases associated with protein malnutrition, especially with regard to autonomic modulation.

Increased baroreflex sensitivity and heart rate variability in migraine patients

OBJECTIVES

We investigated whether spontaneous baroreflex sensitivity and heart rate variability (HRV) are different in migraine patients compared to healthy controls.

MATERIAL AND METHODS

Sixteen female migraine patients without aura aged 18-30 years and 14 age-matched healthy female controls were included. Continuous finger blood pressure and ECG were measured supine during paced breathing in the laboratory. Continuous finger blood pressure was measured the following 24-h period. Spontaneous baroreflex sensitivity (time-domain cross correlation baroreflex sensitivity) as well as HRV parameters were calculated.

RESULTS

Spontaneous baroreflex sensitivity measured in the 24-h period was increased in patients (20.6 ms/mmHg) compared to controls (15.7 ms/mmHg, P = 0.031). HRV parameters were increased during paced breathing in patients (P < 0.045).

CONCLUSIONS

The results suggest that central hypersensitivity in migraine also includes cardiovascular reactivity and may be important for the understanding of the mechanisms for the effect of antihypertensive drugs for migraine prophylaxis.

Stress responses and baroreflex function in coronary disease

Exaggerated pressor responses to mental stress in patients with coronary artery disease (CAD) are associated with increased risk for subsequent cardiovascular events. The integrated baroreflex gain and its mechanical and neural component were estimated and then related to the blood pressure and heart rate responses to simulated real-life stressors: mental arithmetic and public speaking. Eighteen healthy individuals (aged 61 +/- 8 yr) and 29 individuals with documented CAD but no other comorbidities (aged 59 +/- 8 yr) were studied. Heart rate and blood pressures were continuously assessed before, during preparation for, and during performance of a math task and a speech task. The assessment of beat-to-beat carotid diameters during baroreflex engagement was used to estimate the integrated baroreflex gain and its mechanical and neural component. The CAD subjects demonstrated significantly greater increases in heart rate and blood pressures for the performance of the speech task. However, there were no group differences in integrated cardiovagal baroreflex gain or either mechanical or neural baroreflex component. These findings indicate that the augmented pressor responses in CAD do not result from a generalized arterial baroreflex deficit.

IDENTIFICATION OF BLOOD PRESSURE CONTROL MECHANISMS BY POWER SPECTRAL ANALYSIS

1. Blood pressure and organ perfusion are controlled by a variety of cardiovascular control systems, such as the baroreceptor reflex and the renin-angiotensin system (RAS), and by local vascular mechanisms, such as shear stress-induced release of nitric oxide (NO) from the endothelium and the myogenic vascular response. Deviations in arterial blood pressure from its set point activate these mechanisms in an attempt to restore blood pressure and/or secure organ perfusion. However, the response times at which different cardiovascular mechanisms operate differ considerably (e.g. blood pressure control by the RAS is slower than blood pressure control via the baroreceptor reflex). 2. Owing to these different response times, some cardiovascular control systems affect blood pressure more rapidly and others more slowly. Thus, identifying the frequency components of blood pressure variability (BPV) by power spectral analysis can potentially provide important information on individual blood pressure control mechanisms. 3. Evidence is presented that the RAS, catecholamines, endothelial-derived NO and myogenic vascular function affect BPV at very low frequencies (0.02-0.2 Hz) and that low-frequency (LF) BPV (0.2-0.6 Hz) is affected by sympathetic modulation of vascular tone and endothelial-derived NO in rats. In humans, LF BPV (0.075-0.15 Hz) is affected by sympathetic modulation of vascular tone and myogenic vascular function. The impact of the RAS and endothelial-derived NO on BPV in humans requires further investigation. 4. In conclusion, power spectral analysis is a powerful diagnostic tool that allows identification of pathophysiological mechanisms contributing to cardiovascular diseases, such as hypertension, heart failure and stroke, because it can separate slow from fast cardiovascular control mechanisms. The limitation that some cardiovascular control mechanisms affect the same frequency components of BPV requires the combination of blood pressure spectral analysis with other techniques.

Effects of Atenolol and Losartan on Baroreflex Sensitivity and Heart Rate Variability in Uncomplicated Essential Hypertension

Baroreflex sensitivity (BRS) and heart rate variability (HRV) are potential therapeutic targets. The present study was conducted to assess changes in BRS and HRV after monotherapy with losartan versus that of atenolol in uncomplicated essential hypertension. Thirty subjects with uncomplicated essential hypertension were randomized to receive atenolol 50 mg to 100 mg (n = 15) or losartan 50 mg to 100 mg (N = 15) daily for 6 months. Instantaneous systolic blood pressure (SBP) and heart rate were assessed using servo-controlled infrared finger plethysmography before treatment and at the end of 3 months and 6 months after treatment. The fluctuation in SBP and interpulse interval (IPI) was divided into three specific frequency ranges by fast Fourier transform as high frequency (HF; 0.15 Hz-0.4 Hz), low frequency (LF; 0.04 Hz-0.15 Hz), and very low frequency (VLF; 0.004 Hz-0.04 Hz). The BRS was expressed as (1) SBP-IPI transfer function with its magnitude in the HF and LF ranges and (2) BRS index alpha. The HRV was expressed as total power and power in the LF and HF ranges of interpulse interval. Blood pressure was reduced to a similar extent in both groups. Compared with the baseline, BRS did not improve in both groups at month 3. However, BRS was significantly improved in the losartan group (P < 0.05) but not in the atenolol group at month 6. In addition, BRS was significantly higher in the losartan group than the atenolol group at month 3 and month 6 (P < 0.05). Moreover, heart rate variability was significantly reduced in the atenolol group at month 6 (P < 0.05), but not in the losartan group. The HRV in the losartan group was significantly higher than that in the atenolol group at month 6 (P < 0.05). These findings suggest superior effects of losartan on BRS and HRV than atenolol in uncomplicated essential hypertension, which may be beyond blood pressure reduction/resetting.

Eprosartan

The angiotensin II receptor antagonist eprosartan is approved for the treatment of essential hypertension and may be administered using a convenient once-daily regimen. The drug is a well tolerated and effective antihypertensive agent with benefit in the secondary prevention of cerebrovascular events, independent of blood pressure (BP)-lowering effects. Eprosartan has a low potential for serious adverse events and has not been associated with clinically significant drug interactions, establishing it as a promising agent for combination antihypertensive strategies. Unlike ACE inhibitors such as enalapril, eprosartan does not have a tendency to cause persistent nonproductive cough. Accordingly, eprosartan represents a useful therapeutic option in the management of patients with hypertension, including those who have had a stroke and those with co-morbid type 2 diabetes mellitus.

Cardiovascular autonomic control in mice lacking angiotensin AT1a receptors

Studies examined the role of angiotensin (ANG) AT1a receptors in cardiovascular autonomic control by measuring arterial pressure (AP) and heart rate (HR) variability and the effect of autonomic blockade in mice lacking AT1a receptors (AT1a -/-). Using radiotelemetry in conscious AT1a +/+ and AT1a -/- mice, we determined 1) AP and pulse interval (PI) variability in time and frequency (spectral analysis) domains, 2) AP response to alpha(1)-adrenergic and ganglionic blockade, and 3) intrinsic HR after ganglionic blockade. Pulsatile AP was recorded (5 kHz) for measurement of AP and PI and respective variability. Steady-state AP responses to prazosin (1 microg/g ip) and hexamethonium (30 microg/g ip) were also measured. AP was lower in AT1a -/- vs. AT1a +/+, whereas HR was not changed. Prazosin and hexamethonium produced greater decreases in mean AP in AT1a -/- than in AT1a +/+. The blood pressure difference was marked after ganglionic blockade (change in mean AP of -44 +/- 10 vs. -18 +/- 2 mmHg, AT1a -/- vs. AT1a +/+ mice). Intrinsic HR was also lower in AT1a -/- mice (431 +/- 32 vs. 524 +/- 22 beats/min, AT1a -/- vs. AT1a +/+). Beat-by-beat series of systolic AP and PI were submitted to autoregressive spectral estimation with variability quantified in low-frequency (LF: 0.1-1 Hz) and high-frequency (HF: 1-5 Hz) ranges. AT1a -/- mice showed a reduction in systolic AP LF variability (4.3 +/- 0.8 vs. 9.8 +/- 1.3 mmHg(2)), with no change in HF (2.7 +/- 0.3 vs. 3.3 +/- 0.6 mmHg(2)). There was a reduction in PI variability of AT1a -/- in both LF (18.7 +/- 3.7 vs. 32.1 +/- 4.2 ms(2)) and HF (17.7 +/- 1.9 vs. 40.3 +/- 7.3 ms(2)) ranges. The association of lower AP and PI variability in AT1a -/- mice with enhanced AP response to alpha(1)-adrenergic and ganglionic blockade suggests that removal of the ANG AT1a receptor produces autonomic imbalance. This is seen as enhanced sympathetic drive to compensate for the lack of ANG signaling.