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Li J, Sun W, Yang X, Tu B, Cai S, Hu F, Weng Z, Liu S, Lai Z, Zheng L, Yao Y. Characteristics of deceleration capacity and deceleration runs in vasovagal syncope. Clin Auton Res 2024; 34:143-151. [PMID: 37776375 DOI: 10.1007/s10286-023-00989-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 09/19/2023] [Indexed: 10/02/2023]
Abstract
PURPOSE Increased vagal activity plays a prominent role in vasovagal syncope (VVS). The aim of this study was to characterize vagal function in VVS by evaluating the heart rate (HR) deceleration capacity (DC) and the HR deceleration runs (DRs) in patients with VVS between attacks. METHODS A total of 188 consecutive VVS patients were enrolled in the study, of whom 129 had positive head-up tilt test (HUTT); 132 healthy participants were enrolled as controls. DC, DRs (DR2, i.e., episodes of 2 consecutive beat-to-beat HR decelerations), and the sum of DR8-10 (very long DR [VLDR]) were calculated using 24-h electrograms. Clinical characteristics, DC, and DRs were compared among syncope groups and controls. RESULTS Patients with VVS had higher DC (10.63 ± 2.1 vs. 6.58 ± 1.7 ms; P < 0.001) and lower minimum HR and DR6-10 than controls. No significant differences in DC or DR6-10 were found between the patients with positive and those with negative HUTT results. In multivariate logistic regression analysis, minimum HR ≥ 40 bpm (odds ratio [OR] 0.408, 95% confidence interval [CI] 0.167-0.989; P = 0.048), daytime DC ≥ 7.37 ms (OR 3.040, 95% CI 1.220-7.576; P = 0.013), and VLDR ≥ 0.046% (OR 0.306, 95% CI 0.138-0.679; P = 0.004) were demonstrated to be risk factors significantly associated with VVS. CONCLUSION Compared to healthy controls, patients with VVS demonstrated distinct HR deceleration profiles between attacks, including overall higher DC and lower DR6-10.
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Affiliation(s)
- Jiakun Li
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Sun
- Cardiology department, Eastern Health-Box Hill Hospital, Melbourne, Australia
| | - Xu Yang
- Premium Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Tu
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Simin Cai
- Cardiac Arrhythmia Center, Huazhong Fuwai Hospital, Heart Center, Henan Provincial People's Hospital, The People's Hospital of Zhengzhou University, Henan, China
| | - Feng Hu
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Zhiyuan Weng
- Cardiovascular Department, Fujian Institute of Hypertension, The First Affiliated Hospital, Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, China
| | - Shangyu Liu
- Department of Cardiovasology, The First Hospital of Hebei Medical University, No. 89 Donggang Road, Yuhua District, Shijiazhuang, 050031, Hebei, China
| | - Zihao Lai
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lihui Zheng
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Yan Yao
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Meglič B, Danieli A. Glyceryl trinitrate-induced blood pressure variability decrease during head-up tilt test predicts vasovagal response. Blood Press Monit 2023; 28:236-243. [PMID: 37334541 DOI: 10.1097/mbp.0000000000000653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
PURPOSE Glyceryl trinitrate (GTN) provoked cardioinhibitory syncope during the head-up tilt test is preceded by a period of disrupted blood pressure variability (BPV). Endogenous nitric oxide (NO) attenuates BPV independently of blood pressure (BP). We hypothesized that exogenous NO donor GTN might decrease BPV during the presyncope period. A decrease in BPV may predict the tilt outcome. METHODS We analyzed 29 tilt test recordings of subjects with GTN-induced cardioinhibitory syncope and 30 recordings of negative subjects. A recursive autoregressive model of BPV after GTN was performed; powers of the respiratory (0.15-0.45 Hz) and nonrespiratory frequency (0.01-0.15 Hz) bands were calculated for each of the 20 normalized time periods. The post-GTN relative changes in heart rate, BP, and BPV were calculated. RESULTS In the syncope group, spectral power of nonrespiratory frequency systolic and diastolic BPV progressively felt for 30% after GTN application and stabilized after 180 s. BP started to fall 240 s after the GTN application. Decrease in nonrespiratory frequency power of diastolic BPV 20 s after GTN administration predicted cardioinhibitory syncope (area under the curve 0.811; 77% sensitivity; 70% specificity; cutoff value > 7%). CONCLUSION GTN application during the tilt test attenuates systolic and diastolic nonrespiratory frequency BPV during the presyncope period, independent of BP. A decrease in nonrespiratory frequency diastolic BPV 20 s after GTN application predicts cardioinhibitory syncope with good sensitivity and moderate specificity.
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Affiliation(s)
- Bernard Meglič
- Department of Neurology, University Medical Center Ljubljana, Ljubljana, Slovenia
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Akbarzadeh A, Akbarzadeh F, Kazemi B. Simultaneous beat-to-beat heart rate and systolic blood pressure variability in patients with and without neurally mediated syncope. J Cardiovasc Thorac Res 2022; 14:108-115. [PMID: 35935387 PMCID: PMC9339730 DOI: 10.34172/jcvtr.2022.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 04/29/2022] [Indexed: 11/09/2022] Open
Abstract
Introduction: Autonomic changes play an essential role in the genesis of neurally mediated syncope (NMS). The aim of this study was to compare the changes of the autonomic nervous system (ANS) by measuring spectral indices of beat-to-beat systolic blood pressure and heart rate variability (SBPV and HRV) in ranges of low frequency (LF), high frequency (HF), and the LF/HF ratio during head-up tilt test (HUTT) in patients with and without a syncope response.
Methods: In this case-control study of 46 patients with a suspected history of unexplained syncope, data were recorded separately during the typical three phases of HUTT. Patients who developed syncope were designated as the case group and the rest as the control group. Results: Thirty one patients experienced syncope during HUTT. Resting HRV and SBPV indices were significantly lower in cases than controls. After tilting in the syncope group, both HF and LF powers of SBPV showed a significant and gradual decrease. LF/HF in HRV increased in both groups similarly during the test but in SBPV, mainly driven by oscilations in its LF power, it increased significantly more during the first two phases of the test in syncope patients only to paradoxically decrease during active tilt (P< 0.001). Conclusion: Our findings show an abnormal autonomic function in patients with syncope, both at rest and tilting. Fluctuations of spectral indices of beat-to-beat SBPV, a potential noval index of pure sympathetic activity, show an exaggerated response during tilt and its withdrawal before syncope.
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Affiliation(s)
| | - Fariborz Akbarzadeh
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Babak Kazemi
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Gelpi F, Bari V, Cairo B, De Maria B, Tonon D, Rossato G, Faes L, Porta A. Dynamic cerebrovascular autoregulation in patients prone to postural syncope: Comparison of techniques assessing the autoregulation index from spontaneous variability series. Auton Neurosci 2021; 237:102920. [PMID: 34808528 DOI: 10.1016/j.autneu.2021.102920] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 10/20/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
Three approaches to the assessment of cerebrovascular autoregulation (CA) via the computation of the autoregulation index (ARI) from spontaneous variability of mean arterial pressure (MAP) and mean cerebral blood flow velocity (MCBFV) were applied: 1) a time domain method (TDM); 2) a nonparametric method (nonPM); 3) a parametric method (PM). Performances were tested over matched and surrogate unmatched pairs. Data were analyzed at supine resting (REST) and during the early phase of 60° head-up tilt (TILT) in 13 subjects with previous history of postural syncope (SYNC, age: 28 ± 9 yrs.; 5 males) and 13 control individuals (noSYNC, age: 27 ± 8 yrs.; 5 males). Analysis was completed by computing autonomic markers from heart period (HP) and systolic arterial pressure (SAP) variability series via spectral approach. HP and SAP spectral indexes suggested that noSYNC and SYNC groups exhibited different autonomic responses to TILT. ARI analysis indicated that: i) all methods have a sufficient statistical power to separate matched from unmatched pairs with the exception of nonPM applied to impulse response; ii) ARI estimates derived from different methods might be uncorrelated and, even when correlated, might exhibit a significant bias; iii) orthostatic stressor did not induce any evident ARI change in either noSYNC or SYNC individuals; iv) this conclusion held regardless of the method. Methods for the ARI estimation from spontaneous variability provide different ARIs but none indicate that noSYNC and SYNC subjects have different dynamic component of CA.
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Affiliation(s)
- Francesca Gelpi
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy; Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Vlasta Bari
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Beatrice Cairo
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | | | - Davide Tonon
- Department of Neurology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - Gianluca Rossato
- Department of Neurology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - Luca Faes
- Department of Engineering, University of Palermo, Palermo, Italy
| | - Alberto Porta
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy; Department of Biomedical Sciences for Health, University of Milan, Milan, Italy.
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He Z, Du L, Du S, Wu B, Fan Z, Xin B, Chen X, Fang Z, Liu J. Machine learning for the early prediction of head-up tilt testing outcome. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2021.102904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Alboni P, Messop AC, Lauri A, Furlan R. Are women really more affected by vasovagal syncope than men? J Cardiovasc Med (Hagerstown) 2021; 22:69-78. [PMID: 32925389 DOI: 10.2459/jcm.0000000000001009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
It is commonly reported that vasovagal syncope (VVS) is more frequent in women. Presently, this issue has never been investigated. The purpose of this review was to evaluate, through an extensive review of the literature, whether women are really more affected by VVS than men. The gender distribution was investigated in individuals with classical and nonclassical VVS. The database PubMed was searched using the terms 'syncope', 'vasovagal syncope', 'neurally mediated syncope' and 'tilt testing'. Twelve studies dealing with classical and 75 with nonclassical VVS were eligible. In the individuals with classical (N = 1861) and nonclassical VVS (N = 9696), a trend towards a greater percentage of women emerged (P = 0.14 and 0.07, respectively). In the total population with VVS (N = 11 557), the percentage of women was significantly higher than that of men (58 versus 42%, P = 0.03). Most of the individuals were young or middle-aged. In 84% of the studies, the percentage of women was greater than that of men. A separate analysis was carried out in older VVS patients (≥60 years) and only two studies were eligible to be evaluated. Considering that almost all the studies were carried out in the western nations, where the number of men and women is almost superimposable until the age of 65 years and a bias by gender has never been reported in the management of VVS, these data strongly suggest that young and middle-aged women are more affected by VVS than their male counterparts. At present, data are too scant to draw a definitive conclusion in older VVS patients.
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Affiliation(s)
| | | | - Alessandro Lauri
- Section of Economics and Statistics, Ospedale Privato Quisisana, Ferrara
| | - Raffaello Furlan
- Internal Medicine, Humanitas Clinical and Research Center, IRCCS, Humanitas University, Rozzano, Italy
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Cardiac and Vascular Sympathetic Baroreflex Control during Orthostatic Pre-Syncope. J Clin Med 2019; 8:jcm8091434. [PMID: 31510103 PMCID: PMC6781174 DOI: 10.3390/jcm8091434] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 11/17/2022] Open
Abstract
We hypothesized that sympathetic baroreflex mediated uncoupling between neural sympathetic discharge pattern and arterial pressure (AP) fluctuations at 0.1 Hz during baroreceptor unloading might promote orthostatic pre-syncope. Ten volunteers (32 ± 6 years) underwent electrocardiogram, beat-to-beat AP, respiratory activity and muscle sympathetic nerve activity (MSNA) recordings while supine (REST) and during 80° head-up tilt (HUT) followed by -10 mmHg stepwise increase of lower body negative pressure until pre-syncope. Cardiac and sympathetic baroreflex sensitivity were quantified. Spectrum analysis of systolic and diastolic AP (SAP and DAP) and calibrated MSNA (cMSNA) variability assessed the low frequency fluctuations (LF, ~0.1 Hz) of SAP, DAP and cMSNA variability. The squared coherence function (K2) quantified the coupling between cMSNA and DAP in the LF band. Analyses were performed while supine, during asymptomatic HUT (T1) and at pre-syncope onset (T2). During T2 we found that: (1) sympathetic baroreceptor modulation was virtually abolished compared to T1; (2) a progressive decrease in AP was accompanied by a persistent but chaotic sympathetic firing; (3) coupling between cMSNA and AP series at 0.1 Hz was reduced compared to T1. A negligible sympathetic baroreceptor modulation during pre-syncope might disrupt sympathetic discharge pattern impairing the capability of vessels to constrict and promote pre-syncope.
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Piccirillo G, Moscucci F, Fabietti M, Parrotta I, Mastropietri F, Di Iorio C, Sabatino T, Crapanzano D, Vespignani G, Mariani MV, Salvi N, Magrì D. Arrhythmic Risk in Elderly Patients Candidates to Transcatheter Aortic Valve Replacement: Predictive Role of Repolarization Temporal Dispersion. Front Physiol 2019; 10:991. [PMID: 31447689 PMCID: PMC6691061 DOI: 10.3389/fphys.2019.00991] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/18/2019] [Indexed: 12/30/2022] Open
Abstract
Background/Aim Degenerative aortic valve stenosis (AS) is associated to ventricular arrhythmias and sudden cardiac death, as well as mental stress in specific patients. In such a context, substrate, autonomic imbalance as well as repolarization dispersion abnormalities play an undoubted role. Aim of the study was to evaluate the increase of premature ventricular contractions (PVC) and complex ventricular arrhythmias during mental stress in elderly patients candidate to the transcatheter aortic valve replacement (TAVR). Methods In eighty-one elderly patients with AS we calculated several short-period RR- and QT-derived variables at rest, during controlled breathing and during mild mental stress, the latter being represented by a mini-mental state evaluation (MMSE). Results All the myocardial repolarization dispersion markers worsened during mental stress (p < 0.05). Furthermore, during MMSE, low frequency component of the RR variability increased significantly both as absolute power (LFRR) and normalized units (LFRRN U) (p < 0.05) as well as the low-high frequency ratio (LFRR/HFRR) (p < 0.05). Eventually, twenty-four (30%) and twelve (15%) patients increased significantly PVC and, respectively, complex ventricular arrhythmias during the MMSE administration. At multivariate logistic regression analysis, the standard deviation of QTend (QTesd), obtained at rest, was predictive of increased PVC (odd ratio: 1.54, 95% CI 1.14-2.08; p = 0.005) and complex ventricular arrhythmias (odd ratio: 2.31, 95% CI 1.40-3.83; p = 0.001) during MMSE. The QTesd showed the widest sensitive-specificity area under the curve for the increase of PVC (AUC: 0.699, 95% CI: 0.576-0.822, p < 0.05) and complex ventricular arrhythmias (AUC: 0.801, 95% CI: 0.648-0.954, p < 0.05). Conclusion In elderly with AS ventricular arrhythmias worsened during a simple cognitive assessment, this events being a possible further burden on the outcome of TAVR. QTesd might be useful to identify those patients with the highest risk of ventricular arrhythmias. Whether the TAVR could led to a QTesd reduction and, hence, to a reduction of the arrhythmic burden in this setting of patients is worthy to be investigated.
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Affiliation(s)
- Gianfranco Piccirillo
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Geriatriche, Anestesiologiche e Nefrologiche, Policlinico Umberto I, "La Sapienza" University of Rome, Rome, Italy
| | - Federica Moscucci
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Geriatriche, Anestesiologiche e Nefrologiche, Policlinico Umberto I, "La Sapienza" University of Rome, Rome, Italy
| | - Marcella Fabietti
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Geriatriche, Anestesiologiche e Nefrologiche, Policlinico Umberto I, "La Sapienza" University of Rome, Rome, Italy
| | - Ilaria Parrotta
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Geriatriche, Anestesiologiche e Nefrologiche, Policlinico Umberto I, "La Sapienza" University of Rome, Rome, Italy
| | - Fabiola Mastropietri
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Geriatriche, Anestesiologiche e Nefrologiche, Policlinico Umberto I, "La Sapienza" University of Rome, Rome, Italy
| | - Claudia Di Iorio
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Geriatriche, Anestesiologiche e Nefrologiche, Policlinico Umberto I, "La Sapienza" University of Rome, Rome, Italy
| | - Teresa Sabatino
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Geriatriche, Anestesiologiche e Nefrologiche, Policlinico Umberto I, "La Sapienza" University of Rome, Rome, Italy
| | - Davide Crapanzano
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Geriatriche, Anestesiologiche e Nefrologiche, Policlinico Umberto I, "La Sapienza" University of Rome, Rome, Italy
| | - Giulia Vespignani
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Geriatriche, Anestesiologiche e Nefrologiche, Policlinico Umberto I, "La Sapienza" University of Rome, Rome, Italy
| | - Marco Valerio Mariani
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Geriatriche, Anestesiologiche e Nefrologiche, Policlinico Umberto I, "La Sapienza" University of Rome, Rome, Italy
| | - Nicolò Salvi
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Geriatriche, Anestesiologiche e Nefrologiche, Policlinico Umberto I, "La Sapienza" University of Rome, Rome, Italy
| | - Damiano Magrì
- Dipartimento di Medicina Clinica e Molecolare, S. Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
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Kim E, Choi DL, Jung JY, Byun SH, Kim JD, Jwa EK, Kim TY, Kim DH, Kim JH. Shift in Sympathovagal Balance Toward Parasympathetic Predominance Is Associated With Attenuation of Portal Hyperperfusion in Cirrhotic Recipients Undergoing Living Donor Liver Transplant. Transplant Proc 2019; 51:1511-1515. [PMID: 31155184 DOI: 10.1016/j.transproceed.2019.01.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 01/28/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND The autonomic innervation to a liver graft remains lost up to 1 year after liver transplant. Therefore, we investigated the effects of recipients' autonomic nervous activity on the extent of portal hyperperfusion of a partial liver graft in the absence of the autonomic innervation. METHODS A total of 31 cirrhotic recipients undergoing right lobe living donor liver transplant were analyzed. Following a 10-minute absence of surgical stimulation after hepatic artery and bile duct reconstruction, the electrocardiogram and blood pressure waveforms were recorded for 5 minutes. Low-frequency (LF) and high-frequency (HF) powers and their ratio (LF/HF) were calculated using fast Fourier transform from the electrocardiogram waveform. A decrease in LF/HF represents a shift in sympathovagal balance toward parasympathetic predominance. Then, portal venous (PVF) and hepatic arterial (HAF) blood flows were measured in mL/min per 100 g of liver weight using spectral Doppler ultrasonography. A decrease in their ratio (PVF/HAF) represents attenuation of portal hyperperfusion. RESULTS The medians of the PVF and HAF were 349 and 27 mL/min/100 g liver weight with interquartile ranges of 272 to 617 mL/min/100 g liver weight and 22 to 41 mL/min/100 g liver weight, respectively, yielding a median of the PVF/HAF of 13.7 (interquartile range, 8.5-21.3). The median of LF/HF was 0.67 (interquartile range, 0.16-1.45). With a reduction in LF/HF, PVF/HAF decreased according to an S-curve regression model between them (PVF/HAF=e2.743+-0.031LF/HF,adjustedR2=0.129,P=0.027). CONCLUSION A shift in sympathovagal balance toward parasympathetic predominance is associated with attenuation of portal hyperperfusion in a partial liver graft.
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Affiliation(s)
- E Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Medical Center, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - D L Choi
- Division of Hepatobiliary Pancreas Surgery and Abdominal Organ Transplantation, Department of Surgery, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - J Y Jung
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - S H Byun
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - J D Kim
- Division of Hepatobiliary Pancreas Surgery and Abdominal Organ Transplantation, Department of Surgery, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - E K Jwa
- Division of Hepatobiliary Pancreas Surgery and Abdominal Organ Transplantation, Department of Surgery, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - T Y Kim
- Division of Acute Care Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - D H Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - J H Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea.
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Sardu C, Paolisso P, Santamaria M, Sacra C, Pieretti G, Rizzo MR, Barbieri M, Scisciola L, Nicoletti G, Paolisso G, Marfella R. Cardiac syncope recurrence in type 2 diabetes mellitus patients vs. normoglycemics patients: The CARVAS study. Diabetes Res Clin Pract 2019; 151:152-162. [PMID: 31004672 DOI: 10.1016/j.diabres.2019.04.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/01/2019] [Accepted: 04/12/2019] [Indexed: 01/18/2023]
Abstract
STUDY HYPOTHESIS Cardiac autonomic dysfunction might lead to higher vaso vagal syncope (VVS) recurrence rate in type 2 diabetes mellitus (T2DM) patients vs. non diabetics patients. BACKGROUND VVS recurrence might be due to alterations of autonomic system function, as assessed by heart rate variability (HRV). To date, in this study we investigated the correlation between HRV alterations and VVS recurrence at 12 months of follow up in T2DM vs. non T2DM patients. MATERIALS AND METHODS In a prospective multicenter study we studied a propensity score matching (PSM) analysis of 121 T2DM vs. 121 non T2DM patients affected by VVS. RESULTS T2DM vs. non T2DM patients had at baseline a higher rate of HRV dysfunction, and this was linked to higher rate of VVS recurrence at 12 months of follow up (p < 0.05). Blood pressure alterations and lower LF/HF ratio were linked to higher rate of all cause syncope recurrence, and of vasodepressor, cardio inhibitory, and mixed syncope recurrence (p < 0.05). Anti hypertensive drug therapies increased the number of vasodepressor and mixed syncope events (p < 0.05); alterations of heart rate increased syncope recurrence and mixed syncope recurrence events (p < 0.05). Finally, T2DM was linked to higher rate of VVS recurrence, and specifically of vasodepressor and mixed VVS recurrence (p < 0.05). CONCLUSIONS T2DM patients have alterations of the autonomic nervous system, as result of cardiac autonomic neuropathy. However, T2DM diagnosis and autonomic dysfunction assessed by HRV alterations predicted VVS recurrence.
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Affiliation(s)
- Celestino Sardu
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Pasquale Paolisso
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Matteo Santamaria
- Cardiovascular and Arrhythmias Department, Juan Paul II Research and Care Foundation, Campobasso, Italy.
| | - Cosimo Sacra
- Cardiovascular and Arrhythmias Department, Juan Paul II Research and Care Foundation, Campobasso, Italy.
| | - Gorizio Pieretti
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Maria Rosaria Rizzo
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Michelangela Barbieri
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Lucia Scisciola
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Gianfranco Nicoletti
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Giuseppe Paolisso
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy.
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Mezue K, Goyal A, Pressman GS, Matthew R, Horrow JC, Rangaswami J. Blood pressure variability predicts adverse events and cardiovascular outcomes in SPRINT. J Clin Hypertens (Greenwich) 2018; 20:1247-1252. [PMID: 29984884 DOI: 10.1111/jch.13346] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/01/2018] [Accepted: 06/07/2018] [Indexed: 01/13/2023]
Abstract
SPRINT (Systolic Blood Pressure Intervention Trial) highlighted the benefits of intensive targeted antihypertensive therapy but resulted in higher rates of treatment-related adverse events. Blood pressure (BP) variability has emerged as a significant predictor of outcomes over and above levels of BP. Using the SPRINT data set, we aimed to determine the relationship of BP variability with cardiovascular outcomes and side effects of antihypertensive therapy. The analyses included all participants randomized in SPRINT who reached the target systolic BP (SBP) for their respective groups (intensive < 120 mm Hg; standard < 140 mm Hg). Coefficients of variation (CV) for SBP, diastolic BP (DBP), and PP for each patient characterized variability. Student t test was used to compare treatment arms for each CV metric. Cox proportional hazards regression was used to identify independent predictors of the SPRINT primary outcome and adverse events. P < .15 on univariate analysis was required to enter the model and P < .05 to remain in it. A total of 8884 patients (4561 standard group; 4323 intensive group) met inclusion criteria. DBP CV differed between the groups (9.12 ± 3.20 standard group; 9.47 ± 3.49 intensive group [P < .0001]). DBP CV predicted a greater hazard for the primary outcome (hazard ratio [HR], 1.14) in the overall model as well as separate analyses by treatment arms (standard group HR, 1.15; intensive group HR, 1.19), each P < .0001. DBP CV also independently predicted a greater hazard for acute kidney injury (HR, 1.12) and hypotensive events (HR, 1.12). Visit-to-visit DBP variability independently predicted worse cardiovascular outcomes and hypoperfusion-related adverse events in SPRINT.
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Affiliation(s)
- Kenechukwu Mezue
- Division of Hospital Medicine, Altru Health System, Grand Forks, ND, USA.,Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Abhinav Goyal
- Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Gregg S Pressman
- Heart and Vascular Institute, Division of Cardiology, Einstein Medical Center, Philadelphia, PA, USA
| | - Roy Matthew
- Department of Nephrology, Albany Medical College, Albany, NY, USA
| | - Jay C Horrow
- Department of Anesthesiology & Perioperative Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Janani Rangaswami
- Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA.,Sidney Kimmel College of Thomas Jefferson University, Philadelphia, PA, USA
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Watano C, Shiota Y, Onoda K, Sheikh AM, Mishima S, Nitta E, Yano S, Yamaguchi S, Nagai A. Evaluation of autonomic functions of patients with multiple system atrophy and Parkinson's disease by head-up tilt test. J Neural Transm (Vienna) 2017; 125:153-162. [PMID: 29185078 DOI: 10.1007/s00702-017-1816-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 11/16/2017] [Indexed: 01/08/2023]
Abstract
The aim of this study was to evaluate the autonomic neural function in Parkinson's disease (PD) and multiple system atrophy (MSA) with head-up tilt test and spectral analysis of cardiovascular parameters. This study included 15 patients with MSA, 15 patients with PD, and 29 healthy control (HC) subjects. High frequency power of the RR interval (RR-HF), the ratio of low frequency power of RR interval to RR-HF (RR-LF/HF) and LF power of systolic BP were used to evaluate parasympathetic, cardiac sympathetic and vasomotor sympathetic functions, respectively. Both patients with PD and MSA showed orthostatic hypotension and lower parasympathetic function (RR-HF) at tilt position as compared to HC subjects. Cardiac sympathetic function (RR-LF/HF) was significantly high in patients with PD than MSA at supine position. RR-LF/HF tended to increase in MSA and HC, but decreased in PD by tilting. Consequently, the change of the ratio due to tilting (ΔRR-LF/HF) was significantly lower in patients with PD than in HC subjects. Further analysis showed that compared to mild stage of PD, RR-LF/HF at the supine position was significantly higher in advanced stage. By tilting, it was increased in mild stage and decreased in the advanced stage of PD, causing ΔRR-LF/HF to decrease significantly in the advanced stage. Thus, we demonstrated that spectral analysis of cardiovascular parameters is useful to identify sympathetic and parasympathetic disorders in MSA and PD. High cardiac sympathetic function at the supine position, and its reduction by tilting might be a characteristic feature of PD, especially in the advanced stage.
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Affiliation(s)
- Chikako Watano
- Clinical Laboratory Division, Shimane University Hospital, Izumo, Japan
| | - Yuri Shiota
- Clinical Laboratory Division, Shimane University Hospital, Izumo, Japan
| | - Keiichi Onoda
- Department of Internal Medicine III, Shimane University Faculty of Medicine, Izumo, Japan
| | - Abdullah Md Sheikh
- Department of Laboratory Medicine, Shimane University School of Medicine, 89-1 Enya Cho, Izumo, 693-8501, Japan
| | - Seiji Mishima
- Clinical Laboratory Division, Shimane University Hospital, Izumo, Japan
| | - Eri Nitta
- Clinical Laboratory Division, Shimane University Hospital, Izumo, Japan
| | - Shozo Yano
- Department of Laboratory Medicine, Shimane University School of Medicine, 89-1 Enya Cho, Izumo, 693-8501, Japan
| | - Shuhei Yamaguchi
- Department of Internal Medicine III, Shimane University Faculty of Medicine, Izumo, Japan
| | - Atsushi Nagai
- Clinical Laboratory Division, Shimane University Hospital, Izumo, Japan. .,Department of Laboratory Medicine, Shimane University School of Medicine, 89-1 Enya Cho, Izumo, 693-8501, Japan.
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Piccirillo G, Moscucci F, Fiorucci C, Di Iorio C, Mastropietri F, Magrì D. Time- and frequency-domain analysis of beat to beat P-wave duration, PR interval and RR interval can predict asystole as form of syncope during head-up tilt. Physiol Meas 2016; 37:1910-1924. [PMID: 27681167 DOI: 10.1088/0967-3334/37/11/1910] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
To seek possible differences in short-period temporal RR interval, P-wave and PR interval dispersion and spectral coherence in patients with a head-up tilt test positive for vasovagal syncope with or without prolonged asystole, severe symptoms and at high risk of trauma. We retrospectively reviewed 5 min ECG and blood pressure recordings obtained at baseline, at rest and during head-up tilt in 40 patients diagnosed as having recurrent vasovagal syncope confirmed at a head-up tilt test. We analysed autoregressive spectral power for all the ECG-derived variables, focusing on temporal P-wave and PR interval dispersion indexes as well as their spectral coherence calculated on the same 5 min recordings at rest and during tilt. ECG recordings obtained during tilt before syncope showed significantly lower P → PR spectral coherence and higher RR standard deviations in patients with tilt-induced asystole than in those without (0.567 ± 0.097 versus 0.670 ± 0.127, p: 0.010 and 84 ± 36 versus 46 ± 22 ms2, p < 0.0001). Differences in the RR standard deviations persisted also on the last hundred beats (-100) (113 ± 54 versus 34 ± 17 ms2, p < 0.0001). Multiple regression analysis identified a significantly negative association between the maximum RR intervals and P → PR coherence at rest (β: -0.3, p < 0.05) and positive association with RR-100 standard deviation during tilt-induced syncope (β: 0.621, p < 0.001). P → PR spectral coherence could be used to assess the risk of prolonged asystole in patients with tilt-induced vasovagal syncope as well as as a possible surrogate for tilt-testing during these patients' follow-up.
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Affiliation(s)
- Gianfranco Piccirillo
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, Policlinico Umberto I, 'Sapienza' University of Rome, Rome, Italy
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14
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Recurrence plot of heart rate variability signal in patients with vasovagal syncopes. Biomed Signal Process Control 2016. [DOI: 10.1016/j.bspc.2015.10.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Podd S, Hunt J, Sulke N. Home Orthostatic Training in Elderly Patients with Vasovagal Syncope - A Prospective Randomised Controlled Trial. Eur Cardiol 2015; 10:123-127. [PMID: 30310437 DOI: 10.15420/ecr.2015.10.2.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Aim: The aim of this study was to assess the effect of home orthostatic training (HOT) on autonomic reflexes in elderly patients with vasovagal syncope (VVS). Methods: Design and Setting: A single-blind randomised control trial was conducted at Eastbourne District General Hospital, East Sussex NHS Trust. Patients: Individuals with recurrent syncope underwent tilt-table testing between August 2007 and October 2009.Those with at least two syncopal episodes and tilt-test proven VVS were recruited. Participants were divided into those aged >65 years (O65) and those aged <65 years (U65). Interventions: Patients in the O65 group were randomised 1:1 to receive active HOT (O65+) or sham HOT (O65-). The U65 group received active HOT. Participants performed HOT/sham HOT and recorded their training and symptoms. Patients had a repeat tilt test at 3 months. Outcome Measures: Time to syncope at repeat tilt-table testing, low-frequency heart rate variability (LF-HRV), high-frequency heart rate variability (HF-HRV), mean upslope baroreflex sensitivity (BRS) and mean downslope BRS were assessed. Results: A total of 106 patients with recurrent syncope underwent tilt-table testing. Of these, 45 consecutive patients (30 in the O65 group and 15 in the U65 group) were recruited. Two, one and three patients withdrew or were lost-to-follow-up in the O65+, O65-, and U65 groups, respectively. Symptomatic benefit occurred in four (31 %) of the O65+, four (29 %) of the O65-, and six (50 %) of the U65. None of the autonomic measures changed significantly in any group. No difference was seen with HF-HRV, LF-HRV mean upslope BRS and mean downslope BRS. Fifty per-cent of the O65+ group stopped training because of back pain. Time constraint (25 %) was the most common reason for cessation in the U65 group. Conclusions: Despite good tilt training compliance, no improvement in autonomic measures in any group was shown. The most common reason for cessation of training was back pain in the elderly groups. This study does not support the use of HOT in elderly patients.
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Affiliation(s)
- Steven Podd
- Eastbourne District General Hospital, East Sussex, United Kingdom
| | - Jacqueline Hunt
- Eastbourne District General Hospital, East Sussex, United Kingdom
| | - Neil Sulke
- Eastbourne District General Hospital, East Sussex, United Kingdom
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Kim JH, Song SY, Ryu T, Choi CH, Sung SY, Roh WS. Changes in heart rate variability after sitting following interscalene block. Clin Auton Res 2015; 25:327-33. [DOI: 10.1007/s10286-015-0312-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 07/07/2015] [Indexed: 10/23/2022]
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Entropy Measures in the Assessment of Heart Rate Variability in Patients with Cardiodepressive Vasovagal Syncope. ENTROPY 2015. [DOI: 10.3390/e17031007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Piccirillo G, Moscucci F, Pascucci M, Di Barba D, Montesanti D, Magrì D. Effects of weather on neurally mediated syncope tests. Int J Cardiol 2014; 176:1411-3. [PMID: 25129308 DOI: 10.1016/j.ijcard.2014.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 08/02/2014] [Indexed: 12/31/2022]
Affiliation(s)
- Gianfranco Piccirillo
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy.
| | - Federica Moscucci
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Matteo Pascucci
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Daniele Di Barba
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Dalma Montesanti
- Dipartimento di Medicina Clinica e Molecolare - Azienda Ospedaliera Sant' Andrea, University of Rome, Rome, Italy
| | - Damiano Magrì
- Dipartimento di Medicina Clinica e Molecolare - Azienda Ospedaliera Sant' Andrea, University of Rome, Rome, Italy
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Blood pressure variability in patients with atrial fibrillation. Auton Neurosci 2014; 185:129-33. [DOI: 10.1016/j.autneu.2014.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 07/25/2014] [Accepted: 08/12/2014] [Indexed: 11/24/2022]
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Kramarz E, Makowski K. Clinical significance of second degree Wenckebach type sinoatrial block identified during Holter monitoring in patients with symptoms suggestive of arrhythmia. Europace 2014; 17:123-30. [DOI: 10.1093/europace/euu158] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Shim SH, Park SY, Moon SN, Oh JH, Lee JY, Kim HH, Han JW, Lee SJ. Baseline heart rate variability in children and adolescents with vasovagal syncope. KOREAN JOURNAL OF PEDIATRICS 2014; 57:193-8. [PMID: 24868217 PMCID: PMC4030121 DOI: 10.3345/kjp.2014.57.4.193] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Purpose This study aimed to evaluate the autonomic imbalance in syncope by comparing the baseline heart rate variability (HRV) between healthy children and those with vasovagal syncope. Methods To characterize the autonomic profile in children experiencing vasovagal syncope, we evaluated the HRV of 23 patients aged 7-18 years and 20 healthy children. These children were divided into preadolescent (<12 years) and adolescent groups. The following time-domain indices were calculated: root mean square of the successive differences (RMSSD); standard deviation of all average R-R intervals (SDNN); and frequency domain indices including high frequency (HF), low frequency (LF), normalized high frequency, normalized low frequency, and low frequency to high frequency ratio (LF/HF). Results HRV values were significantly different between healthy children and those with syncope. Student t test indicated significantly higher SNDD values (60.46 ms vs. 37.42 ms, P=0.003) and RMSSD (57.90 ms vs. 26.92 ms, P=0.000) in the patient group than in the control group. In the patient group, RMSSD (80.41 ms vs. 45.89 ms, P=0.015) and normalized HF (61.18 ms vs. 43.19 ms, P=0.022) were significantly higher in adolescents, whereas normalized LF (38.81 ms vs. 56.76 ms, P=0.022) and LF/HF ratio (0.76 vs. 1.89, P=0.041) were significantly lower in adolescents. In contrast, the control group did not have significant differences in HRV values between adolescents and preadolescents. Conclusion The results of this study indicated that children with syncope had a decreased sympathetic tone and increased vagal tone compared to healthy children. Additionally, more severe autonomic imbalances possibly occur in adolescents than in preadolescents.
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Affiliation(s)
- Sun Hee Shim
- Department of Pediatrics, The Catholic University of Korea, Bucheon St. Mary's Hospital, Bucheon, Korea
| | - Sun-Young Park
- Department of Pediatrics, The Catholic University of Korea, Yeouido St. Mary's Hospital, Seoul, Korea
| | - Se Na Moon
- Department of Pediatrics, The Catholic University of Korea, St. Paul's Hospital, Seoul, Korea
| | - Jin Hee Oh
- Department of Pediatrics, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | - Jae Young Lee
- Department of Pediatrics, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Hyun Hee Kim
- Department of Pediatrics, The Catholic University of Korea, Yeouido St. Mary's Hospital, Seoul, Korea
| | - Ji Whan Han
- Department of Pediatrics, The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Uijeongbu, Korea
| | - Soon Ju Lee
- Department of Pediatrics, The Catholic University of Korea, Yeouido St. Mary's Hospital, Seoul, Korea
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Payne P, Crane-Godreau MA. Meditative movement for depression and anxiety. Front Psychiatry 2013; 4:71. [PMID: 23898306 PMCID: PMC3721087 DOI: 10.3389/fpsyt.2013.00071] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 07/05/2013] [Indexed: 01/29/2023] Open
Abstract
This review focuses on Meditative Movement (MM) and its effects on anxiety, depression, and other affective states. MM is a term identifying forms of exercise that use movement in conjunction with meditative attention to body sensations, including proprioception, interoception, and kinesthesis. MM includes the traditional Chinese methods of Qigong (Chi Kung) and Taijiquan (Tai Chi), some forms of Yoga, and other Asian practices, as well as Western Somatic practices; however this review focuses primarily on Qigong and Taijiquan. We clarify the differences between MM and conventional exercise, present descriptions of several of the key methodologies of MM, and suggest how research into these practices may be approached in a systematic way. We also present evidence for possible mechanisms of the effects of MM on affective states, including the roles of posture, rhythm, coherent breathing, and the involvement of specific cortical and subcortical structures. We survey research outcomes summarized in reviews published since 2007. Results suggest that MM may be at least as effective as conventional exercise or other interventions in ameliorating anxiety and depression; however, study quality is generally poor and there are many confounding factors. This makes it difficult to draw definitive conclusions at this time. We suggest, however, that more research is warranted, and we offer specific suggestions for ensuring high-quality and productive future studies.
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Affiliation(s)
- Peter Payne
- Microbiology and Immunology, Geisel School of Medicine at Dartmouth , Lebanon, NH , USA
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Graff B, Graff G, Koźluk E, Tokarczyk M, Piątkowska A, Budrejko S, Kozłowski D, Dąbrowska-Kugacka A, Lewicka E, Świątecka G, Raczak G. Electrophysiological features in patients with sinus node dysfunction and vasovagal syncope. Arch Med Sci 2011; 7:963-70. [PMID: 22328878 PMCID: PMC3264987 DOI: 10.5114/aoms.2011.26607] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Revised: 03/20/2011] [Accepted: 04/11/2011] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Syncope is a common presentation of sinus node dysfunction (SND). Some patients who receive a permanent pacemaker due to SND do not benefit from it and further diagnostic workup leads to the diagnosis of vasovagal syncope (VVS). The aim of the study was to identify electrophysiological criteria that can be used for identification of patients with SND and concurrent VVS. MATERIAL AND METHODS Transoesophageal atrial pacing (TAP) was performed in 100 patients divided into four groups depending on symptoms and TAP results. Standard electrophysiological parameters of sinus node function and their variability were obtained in the basal state and after pharmacological autonomic blockade (AB). RESULTS Patients with concurrent SND and VVS had a greater variability of sinoatrial conduction time assessed by Strauss' method than patients without incidents of syncope (83.2 ±53.9 vs. 34.1 ±19.6, 47.8 ±33.6 and 32.1 ±22.99). Apart from abnormal sinus node recovery time and second pause, patients with SND had bigger basal state variability of these parameters. In patients with SND and concurrent vasovagal syncope the variability of sinus node recovery time (SNRT), corrected SNRT (cSNRT) and second pause (IIP) decreased after autonomic blockade. CONCLUSIONS Patients with concurrent SND and VVS have distinct electrophysiological features - greater sinoatrial conduction time (SACT) variability and the decrease of SNRT, cSNRT and IIP variability after AB. However, further studies in larger study groups are needed to validate our findings. Transoesophageal atrial pacing is a useful procedure in patients with syncope, especially when the coexistence of more than one cardiac cause is suspected.
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Affiliation(s)
- Beata Graff
- Hypertension Unit, Department of Hypertension and Diabetology, Medical University of Gdansk, Poland
| | - Grzegorz Graff
- Faculty of Applied Physics and Mathematics, Gdansk University of Technology, Poland
| | - Edward Koźluk
- 1 Chair and Department of Cardiology, Medical University of Warsaw, Poland
| | - Monika Tokarczyk
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Poland
| | | | - Szymon Budrejko
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Poland
| | - Dariusz Kozłowski
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Poland
| | | | - Ewa Lewicka
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Poland
| | - Grażyna Świątecka
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Poland
| | - Grzegorz Raczak
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Poland
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Constitutive overexpression of muscarinic receptors leads to vagal hyperreactivity. PLoS One 2010; 5:e15618. [PMID: 21203511 PMCID: PMC3008725 DOI: 10.1371/journal.pone.0015618] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Accepted: 11/15/2010] [Indexed: 01/10/2023] Open
Abstract
Background Alterations in muscarinic receptor expression and acetylcholinesterase (AchE) activity have been observed in tissues from Sudden Infant Death Syndrome (SIDS). Vagal overactivity has been proposed as a possible cause of SIDS as well as of vasovagal syncopes. The aim of the present study was to seek whether muscarinic receptor overexpression may be the underlying mechanism of vagal hyperreactivity. Rabbits with marked vagal pauses following injection of phenylephrine were selected and crossed to obtain a vagal hyperreactive strain. The density of cardiac muscarinic receptors and acetylcholinesterase (AchE) gene expression were assessed. Blood markers of the observed cardiac abnormalities were also sought. Methodology/Principal Findings Cardiac muscarinic M2 and M3 receptors were overexpressed in hyperreactive rabbits compared to control animals (2.3-fold and 2.5-fold, respectively) and the severity of the phenylephrine-induced bradycardia was correlated with their densities. A similar overexpression of M2 receptors was observed in peripheral mononuclear white blood cells, suggesting that cardiac M2 receptor expression can be inferred with high confidence from measurements in blood cells. Sequencing of the coding fragment of the M2 receptor gene revealed a single nucleotide mutation in 83% of hyperreactive animals, possibly contributing for the transcript overexpression. Significant increases in AchE expression and activity were also assessed (AchE mRNA amplification ratio of 3.6 versus normal rabbits). This phenomenon might represent a compensatory consequence of muscarinic receptors overexpression. Alterations in M2 receptor and AchE expression occurred between the 5th and the 7th week of age, a critical period also characterized by a higher mortality rate of hyperreactive rabbits (52% in H rabbits versus 13% in normal rabbits) and preceeded the appearance of functional disorders. Conclusions/Significance The results suggest that cardiac muscarinic receptor overexpression plays a critical role in the development of vagal hyperreactivity, whereas AchE hyperactivity appears as a compensatory consequence of it. Since similar vagal disorders were observed recently by us in SIDS, muscarinic receptor overexpression could become a marker of risk of vasovagal syncopes and SIDS.
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Schroeder C, Tank J, Heusser K, Busjahn A, Diedrich A, Luft FC, Jordan J. Orthostatic tolerance is difficult to predict in recurrent syncope patients. Clin Auton Res 2010; 21:37-45. [PMID: 20924773 DOI: 10.1007/s10286-010-0090-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2010] [Accepted: 09/16/2010] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We tested the hypothesis that detailed anthropometric and hemodynamic measurements predict orthostatic tolerance in neurally mediated syncope patients. In addition, we tested whether orthostatic tolerance is related to syncope frequency in real life. BACKGROUND Earlier studies in patients with neurally mediated syncope suggested that orthostatic heart rate and blood pressure responses predict the tilt table responses with high sensitivity and specificity. METHODS We analyzed data from 157 consecutive patients (n = 100 exploratory cohort, n = 57 confirmatory cohort) with recurrent syncope in whom orthostatic tolerance was quantified as the time to (pre)syncope during head-up tilt testing combined with lower body negative pressure. We measured heart rate, brachial blood pressure, cardiac stroke volume, heart rate and blood pressure variability, and spontaneous baroreflex sensitivity supine and early during head-up tilt. RESULTS The orthostatic heart rate increase showed the strongest correlation with orthostatic tolerance. The best multivariate model including age, supine diastolic blood pressure, supine blood pressure variability, as well as tilt-induced changes in diastolic blood pressure and heart rate explained no more that 40% of the variability in orthostatic tolerance. The model failed to predict orthostatic tolerance in the confirmatory cohort. Frequency or number of free-living syncopal episodes were only weakly related to orthostatic tolerance. CONCLUSIONS In patients with neurally mediated syncope, orthostatic tolerance in the clinical laboratory is difficult to predict with a wide range of anthropometric and cardiovascular measurements and correlates poorly with syncope occurrence in real life.
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Affiliation(s)
- Christoph Schroeder
- Experimental Clinical Research Center, Max-Delbrueck-Centrum for Molecular Medicine, Medical University Charité, Lindenberger Weg 80, Berlin, Germany.
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Tan MP, Newton JL, Chadwick TJ, Gray JC, Nath S, Parry SW. Home orthostatic training in vasovagal syncope modifies autonomic tone: results of a randomized, placebo-controlled pilot study. Europace 2009; 12:240-6. [DOI: 10.1093/europace/eup368] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Beacher FDCC, Gray MA, Mathias CJ, Critchley HD. Vulnerability to simple faints is predicted by regional differences in brain anatomy. Neuroimage 2009; 47:937-45. [PMID: 19464376 PMCID: PMC2726440 DOI: 10.1016/j.neuroimage.2009.05.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Revised: 05/01/2009] [Accepted: 05/12/2009] [Indexed: 01/21/2023] Open
Abstract
Neurocardiogenic syncope (NCS, simple fainting) is a common and typically benign familial condition, which rarely may result in traumatic injury or hypoxic convulsions. NCS is associated with emotional triggers, anxiety states and stress. However, the etiology of NCS, as a psychophysiological process, is poorly understood. We therefore investigated the relationship between NCS and brain anatomy. We studied a non-clinical sample of eighteen individuals with histories characteristic of NCS, and nineteen matched controls who had never fainted. We recorded fainting frequency, resting heart rate variability measures and anxiety levels. Structural T1-weighted magnetic resonance images (MRI) were acquired at 1.5 T. Associations between brain morphometry (regional gray and white matter volumes) and NCS, resting physiology and anxiety were tested using voxel-based morphometry (VBM). Compared to controls, NCS participants had lower regional brain volume within medulla and midbrain (a priori regions of interest). Moreover, across NCS individuals, lower gray matter volume in contiguous regions of left caudate nucleus predicted enhanced parasympathetic cardiac tone, fainting frequency and anxiety levels. Our findings provide preliminary evidence for a hierarchical anatomical basis to NCS. First, differences in the volume of brainstem centers supporting cardiovascular homeostasis may relate to constitutional predisposition to NCS. Second, differences in the structural organization of the caudate nucleus in NCS individuals may relate to fainting frequency via interactions between emotional state and parasympathetic control of the heart. These observations highlight the application of VBM to the identification of neurovisceral mechanisms relevant to psychosomatic medicine and the neuroscience of emotion.
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Affiliation(s)
- Felix D C C Beacher
- Clinical Imaging Sciences Centre, Brighton and Sussex Medical School, Brighton, BN1 9RY, UK.
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Salameh E, Kadri Z, Neemtallah R, Azar R, Badaoui G, Jaoude SA, Kassab R. [Heart rate variability and vasovagal syncope]. Ann Cardiol Angeiol (Paris) 2007; 56:88-91. [PMID: 17484093 DOI: 10.1016/j.ancard.2007.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Tilt Table testing is widely used for the diagnosis and evaluation of vasovagal syncope. By evaluating the fluctuations of the autonomic nervous system that play an important role in syncope genesis, heart rate variability (HRV) can be considered as a tool of added value. METHODS We evaluated prospectively 123 patients admitted for recurrent syncope with a positive tilt Table testing. A time domain analysis of a 24 hours ambulatory electrocardiography was used in all patients to asses the particularities of their autonomic function. We compared their results with those obtained from a group of 82 healthy volunteers. RESULTS Statistical analysis of the results showed a significant increase of all HRV parameters in the group of vasovagal syncope compared to the healthy volunteers. SDNNidx (58 vs 42; p < 0.001), rMSSD (40 vs 27; p < 0.001), SDNN (102 vs 83; p < 0.001), SDANN (79 vs 67; p< 0.001), pNN50 (11 vs 4.9; p <0.001). CONCLUSION Time domain analysis of heart rate variability reveals increased values in patients with vasovagal syncope. It seems to be an interesting, easy and complementary test in the evaluation of syncope of unknown etiology.
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Affiliation(s)
- E Salameh
- Service de cardiologie, Hôpital Hôtel-Dieu de France, rue Alfred-Naccache, Beyrouth, Liban.
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Suzuki M, Hori S, Tomita Y, Aikawa N. Orthostatic decrease in cardiac chaos during the head-up tilt test in patients with vasovagal syncope. Circ J 2006; 70:902-8. [PMID: 16799246 DOI: 10.1253/circj.70.902] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Autonomic dysfunction contributes to orthostatic intolerance in vasovagal syncope (VVS), but as it has not been identified by spectral analysis of heart rate variability (HRV) in previous studies, the present hypothesis was that nonlinear analysis of HRV would identify the orthostatic intolerance in VVS. METHODS AND RESULTS Twenty-six patients with VVS and 14 matched controls were subjected to 80-degree head-up tilt test (positive: 13 patients; negative: 13 patients and 14 controls). There were no differences in the orthostatic changes in the indices of spectral analyses of HRV among the 3 groups. The Lyapunov exponent (LE) was calculated from 200 consecutive RR-intervals to investigate chaotic behavior, and cardiac chaos was defined as the incidence of the presence of a positive finite LE. Orthostatic decreases in cardiac chaos were observed in the VVS patients (both the positive and negative groups), although there was no orthostatic decrease in the control group (ANOVA: p = 0.008). The receiver-operator characteristic curve indicated that cardiac chaos during the tilt identified VVS regardless of the results of the tilt (p < 0.001, sensitivity: 85.7%, specificity: 96.2%). CONCLUSIONS The decrease in cardiac chaos during the tilt test was specific to patients with VVS, even if their response to the test was negative.
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Affiliation(s)
- Masaru Suzuki
- Department of Emergency Medicine, School of Medicine, Keio University, Tokyo, Japan.
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Piccirillo G, Magrì D, Di Carlo S, Matera S, Magnanti M, De Laurentis T, Torrini A, Marchitto N, Lionetti M, Moisè A. Power spectral analysis of heart rate variability as a predictive test in choosing the most effective length for tilt-training. Int J Cardiol 2006; 111:59-66. [PMID: 16081172 DOI: 10.1016/j.ijcard.2005.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2005] [Revised: 06/25/2005] [Accepted: 07/04/2005] [Indexed: 11/29/2022]
Abstract
BACKGROUND In patients with refractory neurally mediated syncope, tilt training--standing motionless against a wall for increased periods of time per day over one month--can often eliminate recurrent episodes and reduce presyncopal symptoms. We designed dual retrospective and prospective studies to assess cardiovascular autonomic function in subjects with recurrent syncope and identify the most effective length of tilt training between one and three months. METHODS AND RESULTS In the retrospective study, before tilt training, and in the prospective study, before and after training, all subjects underwent a recording for short-term spectral analysis of heart rate and systolic blood pressure variability. Before tilt-training, autonomic nervous system function differs in patients with recurrent neurally mediated syncope who respond to tilt training for one month and those who do not. "Responders", patients experiencing no episodes of syncope during the 12-month follow-up, had higher low-frequency power of RR (LF(RR)) (p < 0.05) and LF(RR) in normalized units (NU) (p < 0.001) and lower high-frequency power (HF(RR)) (p < 0.05) and HF(RR)NU (p < 0.001) than "non-responders", patients reporting at least one syncopal episode during the 12-month follow-up. In the retrospective study, no difference was found between spectral data for "non-responders" with positive responses to tilt test with and without nitro derivatives. Prolonging tilt-training to three months increased the number of responders (late-responders) by 80% (p < 0.001) and power spectral analysis of heart rate variability (HRV) before tilt training can identify late-responders by their low LF(RR)NUs (<40) and high HF(RR)Nus (>60). Furthermore in late-responders, tilt training brings about a change in cardiovascular autonomic function: at 3 months, LF(RR)NUs increase and HF(RR)NU diminish. CONCLUSION Power spectral analysis of HRV seems to be a useful tool to preselect patients who are most likely to benefit from prolonged therapy, thus increasing compliance.
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Affiliation(s)
- Gianfranco Piccirillo
- Dipartimento di Scienze dell'Invecchiamento, I Clinica Medica, Policlinico Umberto I, 00161 Rome, Italy.
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Piccirillo G, Germanò G, Vitarelli A, Ragazzo M, di Carlo S, De Laurentis T, Torrini A, Matera S, Magnanti M, Marchitto N, Bonanni L, Magrì D. Autonomic cardiovascular control and diastolic dysfunction in hypertensive subjects. Int J Cardiol 2006; 110:160-6. [PMID: 16051387 DOI: 10.1016/j.ijcard.2005.06.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2005] [Revised: 06/17/2005] [Accepted: 06/18/2005] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early hypertension is associated with left ventricular diastolic dysfunction due to increased end-diastolic pressure. This increase, through the cardiopulmonary reflexes, can influence autonomic cardiovascular control. METHODS We assessed autonomic nervous system modulation of cardiovascular signals by power spectral analysis of RR interval and systolic arterial pressure variabilities in subjects with recently diagnosed hypertension with or without diastolic dysfunction and in normotensive control subjects. RESULTS Both hypertensive groups had higher low-frequency (LF) power expressed in normalized units (NUs) than normotensive controls (p < 0.05; p < 0.001) during controlled breathing at rest. The LF spectral index measured after tilt was greater in hypertensive subjects with diastolic dysfunction than in those without (p < 0.05). LF NUs measured at rest correlated significantly with the E/A wave ratio and after tilt with the E-wave deceleration time. CONCLUSIONS These results seem to indicate that in subjects with recently diagnosed hypertension sympathetic modulation of the sinus node prevails. During tilt, a maneuver designed to stimulate systemic arterial and cardiopulmonary baroreceptor reflexes, hypertensive subjects with diastolic dysfunction, who presumably also have higher end-diastolic pressures, seem to have greater sympathetic modulation of the sinus node than hypertensive subjects without diastolic dysfunction.
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Affiliation(s)
- Gianfranco Piccirillo
- Dipartimento di Scienze dell'Invecchiamento, Policlinico Umberto I, Università La Sapienza, Rome, Italy.
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Ma HT, Zhang YT. Spectral analysis of pulse transit time variability and its coherence with other cardiovascular variabilities. CONFERENCE PROCEEDINGS : ... ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL CONFERENCE 2006; 2006:6442-6445. [PMID: 17946768 DOI: 10.1109/iembs.2006.259365] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Pulse transit time (PTT) has been reported correlated with heart rate (HR) and blood pressure (BP), however, the results are not consistent in different investigations. Towards a better understanding of the underlying mechanisms of the PTT changes, this study compares the power spectrum density of the variability in PTT with that in HR and BP under rest and post-exercise physiological conditions. Coherence function is also examined to quantify the strength of coupling between paired variabilities. The results show that the pulse transit time variability (PTTV) has significant coherence (>0.5) with heart rate variability (HRV) and blood pressure variability (BPV) under all physiological conditions at high frequency (HF). However, at the low frequency (LF) band, the coherence reduced to insignificance immediately after the exercise (< or =5 minutes after exercise) and then return back to significant level 9 minutes after the exercise. The results show that PTTV is strongly coupled with HRV and BPV at the HF, indicating that the parasympathetic modulation could be the main cause of PTTV. The unstable coupling relationship of PTTV with BPV at LF should raise caution in the beat-to-beat BP estimation by PTT in the dynamic situation.
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Affiliation(s)
- Heather T Ma
- Dept. of Electron. Eng., Chinese Univ. of Hong Kong, Shatin Hong Kong, China
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Resmini E, Casu M, Patrone V, Murialdo G, Bianchi F, Giusti M, Ferone D, Minuto F. Sympathovagal imbalance in acromegalic patients. J Clin Endocrinol Metab 2006; 91:115-20. [PMID: 16263819 DOI: 10.1210/jc.2005-1506] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
CONTEXT Sympathovagal imbalance is a common finding in diabetes and is considered to be a cardiovascular risk factor. No data are available on sympathovagal balance (SB) in acromegalic patients. OBJECTIVE The objective of this study was to evaluate SB in acromegalic patients. PATIENTS Twenty nondiabetic, nonhypopituitary, acromegalic patients (13 women and seven men; mean age +/- sem, 51.30 +/- 3.09 yr) were compared with age-matched subjects (21 normal subjects, 20 patients with type 1 diabetes mellitus, and 15 patients with type 2 diabetes mellitus). INTERVENTIONS Autonomic tests, used to evaluate SB, were performed by power spectral analysis of heart rate variability in clinostatism (c) and orthostatism (o), using a frequency domain method. Power spectral analysis identifies peaks of power: high frequency (HF), which expresses vagal activity, and low frequency (LF), which expresses sympathetic activity. RESULTS Acromegalic patients displayed significantly lower LFc/HFc (P = 0.002) and LFo/HFo (P < 0.001) ratios than normal subjects. HFo was significantly higher in acromegalic patients than in normal subjects (P < 0.001) and patients with type 1 diabetes mellitus (P = 0.004), but no different from that in type 2 diabetes mellitus patients (P = 0.069). In untreated acromegalic patients, the alterations found in the whole group were confirmed; no statistically significant differences were found between untreated acromegalic patients and those treated with somatostatin analogs. Similarly, the same alterations found in the whole group were evident in the controlled acromegalic patients, and no significant differences were found between controlled and uncontrolled patients. CONCLUSION Our study evidenced that sympathovagal imbalance in acromegalic patients, due to vagal hypertone, is difficult to reverse and is not influenced by medical therapy. This could be a new cardiovascular risk factor.
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Affiliation(s)
- Eugenia Resmini
- Department of Endocrinology and Metabolism, Center of Excellence for Biomedical Research, University of Genova, Genova, Italy
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