Muscle afferent inputs to cardiovascular control during isometric exercise vary with muscle group in patients with chronic heart failure

Sympathetic neural responses in heart failure during exercise and after exercise training

The sympathetic nervous system coordinates the cardiovascular response to exercise. This regulation is impaired in both experimental and human heart failure with reduced ejection fraction (HFrEF), resulting in a state of sympathoexcitation which limits exercise capacity and contributes to adverse outcome. Exercise training can moderate sympathetic excess at rest. Recording sympathetic nerve firing during exercise is more challenging. Hence, data acquired during exercise are scant and results vary according to exercise modality. In this review we will: (1) describe sympathetic activity during various exercise modes in both experimental and human HFrEF and consider factors which influence these responses; and (2) summarise the effect of exercise training on sympathetic outflow both at rest and during exercise in both animal models and human HFrEF. We will particularly highlight studies in humans which report direct measurements of efferent sympathetic nerve traffic using intraneural recordings. Future research is required to clarify the neural afferent mechanisms which contribute to efferent sympathetic activation during exercise in HFrEF, how this may be altered by exercise training, and the impact of such attenuation on cardiac and renal function.

Blood pressure-lowering efficacy of a 6-week multi-modal isometric exercise intervention

Isometric exercise training (IET) is an effective method for reducing resting blood pressure (BP). To date, no research studies have been conducted using multiple exercises within an IET intervention. Previous research has suggested that varied exercise programmes may have a positive effect on adherence. Therefore, this randomized controlled study aimed to investigate the BP-lowering efficacy of a multi-modal IET (MIET) intervention in healthy young adults. Twenty healthy participants were randomized to an MIET [n = 10; four women; SBP 117.9 ± 6.9 mmHg; DBP 66.3 ± 5.1 mmHg] or control (CON) group (n = 10; five women; SBP, 123.3 ± 10.4 mmHg; DBP, 77.3 ± 6.7 mmHg). The MIET group completed three sessions per week of 4, 2-min isometric contractions, with a 1-min rest between each contraction, for 6 weeks. Resting BP and heart rate (HR) were measured at baseline and post-intervention. Pre-to-post intervention within-group reductions in resting BP were observed (SBP: 5.3 ± 6.1 mmHg, DBP: 3.4 ± 3.7 mmHg, MAP: 4.0 ± 3.9 mmHg, HR: 4.8 ±6 .6 bpm), although clinically relevant (≥2 mmHg), these changes were not statistically significant. Significant (p < 0.05) between-group differences were found between the intervention and control groups, indicating that the MIET intervention has a greater BP-lowering effect compared to control. The clinically relevant post-training reductions in resting BP suggest that MIET may be a promising additional IET method for hypertension prevention. These findings; however, must be interpreted with caution due to the small sample size and the non-clinical cohort.

Training heart failure patients with reduced ejection fraction attenuates muscle sympathetic nerve activation during mild dynamic exercise

Muscle sympathetic nerve activity (MSNA) decreases during low-intensity dynamic one-leg exercise in healthy subjects but increases in patients with heart failure with reduced ejection fraction (HFrEF). We hypothesized that increased peak oxygen uptake (V̇o_2peak) after aerobic training would be accompanied by less sympathoexcitation during both mild and moderate one-leg dynamic cycling, an attenuated muscle metaboreflex, and greater skin vasodilation. We studied 27 stable, treated HFrEF patients (6 women; mean age: 65 ± 2 SE yr; mean left ventricular ejection fraction: 30 ± 1%) and 18 healthy age-matched volunteers (6 women; mean age: 57 ± 2 yr). We assessed V̇o_2peak (open-circuit spirometry) and the skin microcirculatory response to reactive hyperemia (laser flowmetry). Fibular MSNA (microneurography) was recorded before and during one-leg cycling (2 min unloaded and 2 min at 50% of V̇o_2peak) and, to assess the muscle metaboreflex, during posthandgrip ischemia (PHGI). HFrEF patients were evaluated before and after 6 mo of exercise-based cardiac rehabilitation. Pretraining V̇o_2peak and skin vasodilatation were lower (P < 0.001) and resting MSNA higher (P = 0.01) in HFrEF than control subjects. Training improved V̇o_2peak (+3.0 ± 1.0 mL·kg^-1·min^-1; P < 0.001) and cutaneous vasodilation and diminished resting MSNA (-6.0 ± 2.0, P = 0.01) plus exercise MSNA during unloaded (-4.0 ± 2.5, P = 0.04) but not loaded cycling (-1.0 ± 4.0 bursts/min, P = 0.34) and MSNA during PHGI (P < 0.05). In HFrEF patients, exercise training lowers MSNA at rest, desensitizes the sympathoexcitatory metaboreflex, and diminishes MSNA elicited by mild but not moderate cycling. Training-induced downregulation of resting MSNA and attenuated reflex sympathetic excitation may improve exercise capacity and survival.

The Mechanoreflex and Hemodynamic Response to Passive Leg Movement in Heart Failure

BACKGROUND

Sensitization of mechanosensitive afferents, which contribute to the exercise pressor reflex, has been recognized as a characteristic of patients with heart failure (HF); however, the hemodynamic implications of this hypersensitivity are unclear.

OBJECTIVES

The present study used passive leg movement (PLM) and intrathecal injection of fentanyl to blunt the afferent portion of this reflex arc to better understand the role of the mechanoreflex on central and peripheral hemodynamics in HF.

METHODS

Femoral blood flow (FBF), mean arterial pressure, femoral vascular conductance, HR, stroke volume, cardiac output, ventilation, and muscle oxygenation of the vastus lateralis were assessed in 10 patients with New York Heart Association class II HF at baseline and during 3 min of PLM both with fentanyl and without (control).

RESULTS

Fentanyl had no effect on baseline measures but increased (control vs fentanyl, P < 0.05) the peak PLM-induced change in FBF (493 ± 155 vs 804 ± 198 ΔmL·min(-1)) and femoral vascular conductance (4.7 ± 2 vs 8.5 ± 3 ΔmL·min(-1)·mm Hg)(-1) while norepinephrine spillover (103% ± 19% vs 58% ± 17%Δ) and retrograde FBF (371 ± 115 vs 260 ± 68 ΔmL·min(-1)) tended to be reduced (P < 0.10). In addition, fentanyl administration resulted in greater PLM-induced increases in muscle oxygenation, suggestive of increased microvascular perfusion. Fentanyl had no effect on the ventilation, mean arterial pressure, HR, stroke volume, or cardiac output response to PLM.

CONCLUSIONS

Although movement-induced central hemodynamics were unchanged by afferent blockade, peripheral hemodynamic responses were significantly enhanced. Thus, in patients with HF, a heightened mechanoreflex seems to augment peripheral sympathetic vasoconstriction in response to movement, a phenomenon that may contribute to exercise intolerance in this population.

Influence of the metaboreflex on arterial blood pressure in heart failure patients

BACKGROUND

Feedback from active locomotor muscles contributes to the exercise pressor response in healthy humans, and is thought to be more prominent in heart failure (HF). The purpose of this study was to examine the influence of metaboreflex stimulation on arterial pressure in HF.

METHODS

Eleven HF patients (51 ± 5 years, New York Heart Association Class I/II, left ventricular ejection fraction 32 ± 3%) and 11 controls (42 ± 3 years) were recruited. Participants completed two exercise sessions on separate days: (1) symptom limited graded exercise test; and (2) constant work rate cycling (60% peak oxygen consumption,V˙O2) for 4 minutes with 2 minutes passive recovery. Recovery was randomized to normal or locomotor muscle regional circulatory occlusion (RCO). Mean arterial pressure (MAP), systolic pressure (SBP), diastolic pressure, heart rate (HR) and V˙O2 were measured at rest, end-exercise and recovery. O2 pulse (V˙O2/HR) and the rate pressure product (RPP = HR × SBP) were calculated.

RESULTS

In response to RCO, mean arterial pressure and SBP increased in HF compared with CTLs (6.8 ± 5.8% vs -3.0 ± 7.8%, P < .01 and 3.4 ± 6.4% vs -12.7 ± 10.4%, P < .01, respectively), with no difference in diastolic pressure (P = .61). HF patients had a smaller reduction in HR and RPP, but also displayed a larger decrease in O2 pulse consequent to locomotor metaboreflex stimulation (P < .05, for all).

CONCLUSION

RCO resulted in a markedly increased pressor response in HF relative to controls, due primarily to an increase of SBP and attenuated cardiac recovery as noted by the persistent elevation in HR.

Muscle afferents and cardiorespiratory control: the Birmingham connection

NEW FINDINGS

What is the topic of this review? This brief review describes the work of Professor John Coote and colleagues at the University of Birmingham, which has contributed to understanding of the role of muscle afferent involvement in cardiorespiratory control in exercise. What advances does it highlight? The seminal findings of John Coote's early work are highlighted, as well as more recent developments in the field, especially the role of muscle afferents in the control of human ventilation during exercise. Through the work of John Coote, research into the role of muscle afferent involvement in cardiorespiratory control has had strong links with Birmingham since the late 1960s. This brief review gives an historical background to John's early work and how his research and mentorship of colleagues continues to have a profound influence on the field today.

Mechanism of augmented exercise hyperpnea in chronic heart failure and dead space loading

Patients with chronic heart failure (CHF) suffer increased alveolar VD/VT (dead-space-to-tidal-volume ratio), yet they demonstrate augmented pulmonary ventilation such that arterial [Formula: see text] ( [Formula: see text] ) remains remarkably normal from rest to moderate exercise. This paradoxical effect suggests that the control law governing exercise hyperpnea is not merely determined by metabolic CO2 production ( [Formula: see text] ) per se but is responsive to an apparent (real-feel) metabolic CO2 load ( [Formula: see text] ) that also incorporates the adverse effect of physiological VD/VT on pulmonary CO2 elimination. By contrast, healthy individuals subjected to dead space loading also experience augmented ventilation at rest and during exercise as with increased alveolar VD/VT in CHF, but the resultant response is hypercapnic instead of eucapnic, as with CO2 breathing. The ventilatory effects of dead space loading are therefore similar to those of increased alveolar VD/VT and CO2 breathing combined. These observations are consistent with the hypothesis that the increased series VD/VT in dead space loading adds to [Formula: see text] as with increased alveolar VD/VT in CHF, but this is through rebreathing of CO2 in dead space gas thus creating a virtual (illusory) airway CO2 load within each inspiration, as opposed to a true airway CO2 load during CO2 breathing that clogs the mechanism for CO2 elimination through pulmonary ventilation. Thus, the chemosensing mechanism at the respiratory controller may be responsive to putative drive signals mediated by within-breath [Formula: see text] oscillations independent of breath-to-breath fluctuations of the mean [Formula: see text] level. Skeletal muscle afferents feedback, while important for early-phase exercise cardioventilatory dynamics, appears inconsequential for late-phase exercise hyperpnea.

The pulmonary vascular response to combined activation of the muscle metaboreflex and mechanoreflex

Muscle metabo- and mechanoreflexes are known to influence systemic cardiovascular responses to exercise. Whether interplay between these reflexes is operant in the control of the pulmonary vascular response to exercise is unknown. The aim of this study was to assess the pulmonary vascular response to the combined activation of the two muscle reflexes. Nine healthy subjects performed a bout of isometric calf plantarflexion exercise during local circulatory occlusion, which was continued for 9 min postexercise (PECO). At 5 min into PECO the calf muscle was passively stretched for 180 s. A control (no exercise) protocol was also undertaken. Heart rate, blood pressure measurements and echocardiographically determined estimates of systolic pulmonary artery pressure (SPAP) and cardiac output ( ) were obtained at intervals throughout the two protocols. Elevations in SPAP (by 22.51 ± 2.61%), (by 26.92 ± 2.99%) and mean arterial pressure (by 15.38 ± 2.29%) were noted during isometric exercise in comparison to baseline (all P < 0.05). Increases in SPAP and mean arterial pressure persisted during PECO (All P < 0.05), whereas returned to resting levels. These increases in mean arterial pressure and SPAP were sustained during stretch which significantly elevated (All P < 0.05). These data suggest that activation of the muscle mechanoreflex attenuated the increases in pulmonary vascular resistance caused by metaboreflex activation. This finding has important implications for the regulation of pulmonary haemodynamics during human exercise.

Cardiovascular regulation by skeletal muscle reflexes in health and disease

Heart rate and blood pressure are elevated at the onset and throughout the duration of dynamic or static exercise. These neurally mediated cardiovascular adjustments to physical activity are regulated, in part, by a peripheral reflex originating in contracting skeletal muscle termed the exercise pressor reflex. Mechanically sensitive and metabolically sensitive receptors activating the exercise pressor reflex are located on the unencapsulated nerve terminals of group III and group IV afferent sensory neurons, respectively. Mechanoreceptors are stimulated by the physical distortion of their receptive fields during muscle contraction and can be sensitized by the production of metabolites generated by working skeletal myocytes. The chemical by-products of muscle contraction also stimulate metaboreceptors. Once activated, group III and IV sensory impulses are transmitted to cardiovascular control centers within the brain stem where they are integrated and processed. Activation of the reflex results in an increase in efferent sympathetic nerve activity and a withdrawal of parasympathetic nerve activity. These actions result in the precise alterations in cardiovascular hemodynamics requisite to meet the metabolic demands of working skeletal muscle. Coordinated activity by this reflex is altered after the development of cardiovascular disease, generating exaggerated increases in sympathetic nerve activity, blood pressure, heart rate, and vascular resistance. The basic components and operational characteristics of the reflex, the techniques used in human and animals to study the reflex, and the emerging evidence describing the dysfunction of the reflex with the advent of cardiovascular disease are highlighted in this review.

Differential contribution of central command to the cardiovascular responses during static exercise of ankle dorsal and plantar flexion in humans

To examine whether central command contributes differently to the cardiovascular responses during voluntary static exercise engaged by different muscle groups, we encouraged healthy subjects to perform voluntary and electrically evoked involuntary static exercise of ankle dorsal and plantar flexion. Each exercise was conducted with 25% of the maximum voluntary force of the right ankle dorsal and plantar flexion, respectively, for 2 min. Heart rate (HR) and mean arterial blood pressure (MAP) were recorded, and stroke volume, cardiac output (CO), and total peripheral resistance were calculated. With voluntary exercise, HR, MAP, and CO significantly increased during dorsal flexion (the maximum increase, HR: 12 ± 2.3 beats/min; MAP: 14 ± 2.0 mmHg; CO: 1 ± 0.2 l/min), whereas only MAP increased during plantar flexion (the maximum increase, 6 ± 2.0 mmHg). Stroke volume and total peripheral resistance were unchanged throughout the two kinds of voluntary static exercise. With involuntary exercise, there were no significant changes in all cardiovascular variables, irrespective of dorsal or plantar flexion. Furthermore, before the force onset of voluntary static exercise, HR and MAP started to increase without muscle contraction, whereas they had no significant changes with involuntary exercise at the moment. The present findings indicate that differential contribution of central command is responsible for the different cardiovascular responses to static exercise, depending on the strength of central control of the contracting muscle.

Muscle afferent contributions to the cardiovascular response to isometric exercise

The cardiovascular response to isometric exercise is governed by both central and peripheral mechanisms. Both metabolic and mechanical stresses on the exercising skeletal muscle produce cardiovascular change, yet it is often overlooked that the afferent signal arising from the muscle can be modified by factors other than exercise intensity. This review discusses research revealing that muscle fibre type, muscle mass and training status are important factors in modifying this peripheral feedback from the active muscles. Studies in both animals and humans have shown that the pressor response resulting from exercise of muscle with a faster contractile character and isomyosin content is greater than that from a muscle of slower contractile character. Athletic groups participating in training programmes that place a high anaerobic load on skeletal muscle groups show attenuated muscle afferent feedback. Similarly, longitudinal studies have shown that specific local muscle training also blunts the pressor response to isometric exercise. Thus it appears that training may decrease the metabolic stimulation of muscle afferents and in some instances chronic exposure to the products of anaerobic metabolism may blunt the sensitivity of the muscle metaboreflex. There may be surprising parallels between the local muscle conditions induced in athletes training for longer sprint events (e.g. 400 m) and by the low-flow conditions in, for example, the muscles of chronic heart failure patients. Whether their similar attenuations in muscle afferent feedback during exercise are due to decreased metabolite accumulation or to a desensitization of the muscle afferents is not yet known.