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Chung WH, Lin YN, Wu MY, Chang KC. Sympathetic Modulation in Cardiac Arrhythmias: Where We Stand and Where We Go. J Pers Med 2023; 13:jpm13050786. [PMID: 37240956 DOI: 10.3390/jpm13050786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 04/27/2023] [Accepted: 04/29/2023] [Indexed: 05/28/2023] Open
Abstract
The nuance of autonomic cardiac control has been studied for more than 400 years, yet little is understood. This review aimed to provide a comprehensive overview of the current understanding, clinical implications, and ongoing studies of cardiac sympathetic modulation and its anti-ventricular arrhythmias' therapeutic potential. Molecular-level studies and clinical studies were reviewed to elucidate the gaps in knowledge and the possible future directions for these strategies to be translated into the clinical setting. Imbalanced sympathoexcitation and parasympathetic withdrawal destabilize cardiac electrophysiology and confer the development of ventricular arrhythmias. Therefore, the current strategy for rebalancing the autonomic system includes attenuating sympathoexcitation and increasing vagal tone. Multilevel targets of the cardiac neuraxis exist, and some have emerged as promising antiarrhythmic strategies. These interventions include pharmacological blockade, permanent cardiac sympathetic denervation, temporal cardiac sympathetic denervation, etc. The gold standard approach, however, has not been known. Although neuromodulatory strategies have been shown to be highly effective in several acute animal studies with very promising results, the individual and interspecies variation between human autonomic systems limits the progress in this young field. There is, however, still much room to refine the current neuromodulation therapy to meet the unmet need for life-threatening ventricular arrhythmias.
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Affiliation(s)
- Wei-Hsin Chung
- Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung 40447, Taiwan
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA 90024, USA
| | - Yen-Nien Lin
- Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung 40447, Taiwan
- School of Medicine, China Medical University, Taichung 404333, Taiwan
| | - Mei-Yao Wu
- School of Post-Baccalaureate Chinese Medicine, China Medical University, Taichung 404333, Taiwan
- Department of Chinese Medicine, China Medical University Hospital, Taichung 40447, Taiwan
| | - Kuan-Cheng Chang
- Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung 40447, Taiwan
- School of Medicine, China Medical University, Taichung 404333, Taiwan
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Keirns NG, Ouaddi S, Dunsiger S, Locatelli G, Gathright EC, Black E, Tripolone J, Breault C, Riegel B, Cohen R, Salmoirago-Blotcher E. Mind Your Heart-II: Protocol for a behavioral randomized controlled trial of mindfulness training to promote self-care in patients with comorbid heart failure and cognitive impairment. Contemp Clin Trials 2023; 126:107094. [PMID: 36682491 PMCID: PMC10026453 DOI: 10.1016/j.cct.2023.107094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Heart failure (HF) self-care is a robust predictor of prognosis in HF patients. Cognitive impairment is a common comorbidity in HF patients and constitutes a major challenge to HF self-care. Mindfulness training (MT) has been shown to improve cognitive function and interoception, two components essential to promoting effective HF self-care. OBJECTIVES The aims of the Mind Your Heart-II (MYH-II) study are to investigate the effects of MT on HF self-care via changes in cognitive function and interoception in patients with comorbid HF and cognitive impairment, and to study the process by which MT can improve cognitive function via vagal control. We hypothesize that MT will improve cognitive function, interoception, and vagal control, resulting in enhanced HF self-care, compared to control participants. METHODS MYH-II is a mechanistic parallel phase II behavioral randomized controlled trial. We will enroll 176 English or Spanish-speaking patients with comorbid chronic HF and mild cognitive impairment. Participants will be randomized to either: (1) 8-week phone-delivered MT + Enhanced Usual Care (EUC), or (2) EUC alone. Participants will complete baseline, end-of-treatment (3 months), and follow-up (9 months) assessments. The primary outcome is cognitive function (NIH Toolbox Fluid Cognition Composite Score). Additional key outcomes include: interoception (heartbeat tracking task, Multidimensional Assessment of Interoceptive Awareness), HF self-care (Self-Care of Heart Failure Index v7.2), and vagal control (high-frequency heart rate variability). IMPLICATIONS If study hypotheses are confirmed, phone-based MT may be a key tool for improving HF self-care, and possibly clinical outcomes, in HF patients with comorbid cognitive impairment.
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Affiliation(s)
- Natalie G Keirns
- Department of Psychiatry and Human Behavior, Warren Alpert School of Medicine, Brown University, Providence, RI, USA; Department of Psychology, Oklahoma State University, Stillwater, OK, USA.
| | - Sara Ouaddi
- Center for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI, USA
| | - Shira Dunsiger
- Center for Health Promotion and Health Equity, Department of Behavioral and Social Science, School of Public Health, Brown University, Providence, RI, USA
| | - Giulia Locatelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy; School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Australian Catholic University, Melbourne, Australia
| | - Emily C Gathright
- Department of Psychiatry and Human Behavior, Warren Alpert School of Medicine, Brown University, Providence, RI, USA; Center for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI, USA
| | - Emma Black
- Center for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI, USA
| | - Janice Tripolone
- Center for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI, USA
| | - Christopher Breault
- Center for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI, USA
| | - Barbara Riegel
- University of Pennsylvania, School of Nursing, Philadelphia, PA, USA; Australian Catholic University, Mary MacKillop Institute for Health Research, Melbourne, Australia; Center for Home Care Policy & Research at VNS Health, New York, NY, USA
| | - Ronald Cohen
- Cognitive Aging and Memory Program, McKnight Institute on Aging, University of Florida, Gainesville, FL, USA
| | - Elena Salmoirago-Blotcher
- Department of Psychiatry and Human Behavior, Warren Alpert School of Medicine, Brown University, Providence, RI, USA; Lifespan Cardiovascular Institute, The Miriam Hospital, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
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Limonova AS, Germanova KN, Gantman MV, Nazarova MA, Davtyan KV, Novikov PA, Sukmanova AA, Tarasov AV, Kharlap MS, Ershova AI, Drapkina OM. Neurovisceral interactions within the brain-heart axis as the basis of neurocardiology. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2022. [DOI: 10.15829/1728-8800-2022-3435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The use of a systematic approach to the study of the etiology of a certain pathology makes it possible to improve the understanding of its pathogenesis, as well as to develop more effective diagnostic and therapeutic approaches, including improving the prediction of its risk. Within this review, we will consider such an area of interdisciplinary research as neurocardiology, which studies the brain-heart axis. Examples of cardiovascular diseases associated with organic and functional disorders of this axis will be considered, as well as the prospects for research in this area and their translational significance for clinical medicine.
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Affiliation(s)
- A. S. Limonova
- National Medical Research Center for Therapy and Preventive Medicine
| | - K. N. Germanova
- National Medical Research Center for Therapy and Preventive Medicine; National Research University Higher School of Economics
| | - M. V. Gantman
- National Research University Higher School of Economics
| | - M. A. Nazarova
- National Research University Higher School of Economics; Harvard Medical School
| | - K. V. Davtyan
- National Medical Research Center for Therapy and Preventive Medicine
| | - P. A. Novikov
- National Research University Higher School of Economics
| | - A. A. Sukmanova
- National Medical Research Center for Therapy and Preventive Medicine; National Research University Higher School of Economics
| | - A. V. Tarasov
- National Medical Research Center for Therapy and Preventive Medicine
| | - M. S. Kharlap
- National Medical Research Center for Therapy and Preventive Medicine
| | - A. I. Ershova
- National Medical Research Center for Therapy and Preventive Medicine
| | - O. M. Drapkina
- National Medical Research Center for Therapy and Preventive Medicine
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Stavrakis S, Kulkarni K, Singh JP, Katritsis DG, Armoundas AA. Autonomic Modulation of Cardiac Arrhythmias: Methods to Assess Treatment and Outcomes. JACC Clin Electrophysiol 2021; 6:467-483. [PMID: 32439031 DOI: 10.1016/j.jacep.2020.02.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/06/2020] [Accepted: 02/14/2020] [Indexed: 02/08/2023]
Abstract
The autonomic nervous system plays a central role in the pathogenesis of multiple cardiac arrhythmias, including atrial fibrillation and ventricular tachycardia. As such, autonomic modulation represents an attractive therapeutic approach in these conditions. Notably, autonomic modulation exploits the plasticity of the neural tissue to induce neural remodeling and thus obtain therapeutic benefit. Different forms of autonomic modulation include vagus nerve stimulation, tragus stimulation, renal denervation, baroreceptor activation therapy, and cardiac sympathetic denervation. This review seeks to highlight these autonomic modulation therapeutic modalities, which have shown promise in early preclinical and clinical trials and represent exciting alternatives to standard arrhythmia treatment. We also present an overview of the various methods used to assess autonomic tone, including heart rate variability, skin sympathetic nerve activity, and alternans, which can be used as surrogate markers and predictors of the treatment effect. Although the use of autonomic modulation to treat cardiac arrhythmias is supported by strong preclinical data and preliminary studies in humans, in light of the disappointing results of a number of recent randomized clinical trials of autonomic modulation therapies in heart failure, the need for optimization of the stimulation parameters and rigorous patient selection based on appropriate biomarkers cannot be overemphasized.
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Affiliation(s)
- Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.
| | - Kanchan Kulkarni
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jagmeet P Singh
- Cardiology Division, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Antonis A Armoundas
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.
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Kulkarni K, Stavrakis S, Elkholey K, Singh JP, Parks KA, Armoundas AA. Microvolt T-Wave Alternans Is Modulated by Acute Low-Level Tragus Stimulation in Patients With Ischemic Cardiomyopathy and Heart Failure. Front Physiol 2021; 12:707724. [PMID: 34366894 PMCID: PMC8343129 DOI: 10.3389/fphys.2021.707724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/30/2021] [Indexed: 12/15/2022] Open
Abstract
Aims: Microvolt T-wave alternans (TWA), an oscillation in T-wave morphology of the electrocardiogram (ECG), has been associated with increased susceptibility to ventricular tachy-arrhythmias, while vagus nerve stimulation has shown promising anti-arrhythmic effects in in vivo and ex vivo animal studies. We aimed to examine the effect of non-invasive, acute low-level tragus stimulation (LLTS) on TWA in patients with ischemic cardiomyopathy and heart failure. Methods: 26 patients with ischemic cardiomyopathy (left ventricular ejection fraction <35%) and chronic stable heart failure, previously implanted with an automatic implantable cardioverter defibrillator (ICD) device with an atrial lead (dual chamber ICD or cardiac resynchronization therapy defibrillator), were enrolled in the study. Each patient sequentially received, (1) Sham LLTS (electrode on tragus, but no stimulation delivered) for 5 min; (2) Active LLTS at two different frequencies (5 and 20 Hz, 15 min each); and (3) Active LLTS, during concomitant atrial pacing at 100 bpm at two different frequencies (5 and 20 Hz, 15 min each). LLTS was delivered through a transcutaneous electrical nerve stimulation device (pulse width 200 μs, frequency 5/20 Hz, amplitude 1 mA lower than the discomfort threshold). TWA burden was assessed using continuous ECG monitoring during sham and active LLTS in sinus rhythm, as well as during atrial pacing. Results: Right atrial pacing at 100 bpm led to significantly heightened TWA burden compared to sinus rhythm, with or without LLTS. Acute LLTS at both 5 and 20 Hz, during sinus rhythm led to a significant rise in TWA burden in the precordial leads (p < 0.05). Conclusion: Acute LLTS results in a heart-rate dependent increase in TWA burden.
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Affiliation(s)
- Kanchan Kulkarni
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, United States
| | - Stavros Stavrakis
- Heart Rhythm Institute, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Khaled Elkholey
- Heart Rhythm Institute, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Jagmeet P Singh
- Cardiology Division, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA, United States
| | - Kimberly A Parks
- Cardiology Division, Brigham and Women's Hospital, Boston, MA, United States
| | - Antonis A Armoundas
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, United States.,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, United States
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Ghalwash M, Elmasry A, Omar NMAE. Possible cardioprotective role of NaHS on ECG and oxidative stress markers in an unpredictable chronic mild stress model in rats. Can J Physiol Pharmacol 2020; 99:321-327. [PMID: 33175584 DOI: 10.1139/cjpp-2019-0646] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The protective effect of H2S against various body organ injuries has been described. The aim of this work is to investigate the potential role of sodium hydrosulfide (NaHS) as an H2S donor in chronic mild stress induced changes in the rat heart. Forty adult male Sprague Dawley rats were assigned to four groups: control, stressed group, stressed rats treated with aminooxyacetic acid (AOAA), and stressed rats treated with NaHS. Arterial blood pressure (ABP) was recorded. Serum adrenaline, MDA, and GSH levels were measured. Chronic stress significantly increased HR and ABP. AOAA produced similar changes, while NaHS mitigated the rise in HR and ABP. Both stressed and AOAA-treated stressed groups showed a significant decrease in QRS amplitude and a shortening of the RR, QT, and QTc intervals with an elevation of the ST segment. NaHS produced a significant improvement in ECG recordings. Chronic stress produced a significant rise of adrenaline and MDA levels with a significant decline in GSH levels. The AOAA-treated stressed group showed similar elevations. NaHS treatment caused significant reduction in adrenaline and MDA levels but significantly improved GSH levels. In conclusion, H2S donor has a cardioprotective effect against stress-induced cardiovascular diseases through amelioration of the oxidative stress and raised adrenaline levels induced by chronic stress exposure.
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Affiliation(s)
- Mohammad Ghalwash
- Department of Medical Physiology, Faculty of Medicine, Mansoura University, Egypt, 35516
| | - Ahlam Elmasry
- Department of Clinical Pharmacology, Faculty of Medicine, Mansoura University, Egypt, 35516
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Silva CC, Correa AMB, Kushmerick C, Sharma NM, Patel KP, de Almeida JFQ, Moreira FA, Ferreira AJ, Fontes MAP. Angiotensin-converting enzyme 2 activator, DIZE in the basolateral amygdala attenuates the tachycardic response to acute stress by modulating glutamatergic tone. Neuropeptides 2020; 83:102076. [PMID: 32800589 DOI: 10.1016/j.npep.2020.102076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 07/03/2020] [Accepted: 08/02/2020] [Indexed: 02/07/2023]
Abstract
The basolateral amygdala (BLA) is critical in the control of the sympathetic output during stress. Studies demonstrated the involvement of the renin-angiotensin system components in the BLA. Angiotensin-(1-7) [Ang-(1-7)], acting through Mas receptors, reduces stress effects. Considering that angiotensin-converting enzyme 2 (ACE2) is the principal enzyme for the production of Ang-(1-7), here we evaluate the cardiovascular reactivity to acute stress after administration of the ACE2 activator, diminazene aceturate (DIZE) into the BLA. We also tested whether systemic treatment with DIZE could modify synaptic activity in the BLA and its effect directly on the expression of the N-methyl-d-aspartate receptors (NMDARs) in NG108 neurons in-vitro. Administration of DIZE into the BLA (200 pmol/100 nL) attenuated the tachycardia to stress (ΔHR, bpm: vehicle = 103 ± 17 vs DIZE = 49 ± 7 p = 0.018); this effect was inhibited by Ang-(1-7) antagonist, A-779 (ΔHR, bpm: DIZE = 49 ± 7 vs A-779 + DIZE = 100 ± 15 p = 0.04). Systemic treatment with DIZE attenuated the excitatory synaptic activity in the BLA (Frequency (Hz): vehicle = 2.9 ± 0.4 vs. DIZE =1.8 ± 0.3 p < 0.04). NG108 cells treated with DIZE demonstrated decreased expression of l subunit NMDAR-NR1 (NR1 expression (a.u): control = 0.534 ± 0.0593 vs. DIZE = 0.254 ± 0.0260) of NMDAR and increases of Mas receptors expression. These data demonstrate that DIZE attenuates the tachycardia evoked by acute stress. This effect results from a central action in the BLA involving activation of Mas receptors. The ACE2 activation via DIZE treatment attenuated the frequency of excitatory synaptic activity in the basolateral amygdala and this effect can be related with the decreases of the NMDAR-NR1 receptor expression.
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Affiliation(s)
- Carina Cunha Silva
- Departamento de Fisiologia e Biofísica, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Ana Maria Bernal Correa
- Departamento de Fisiologia e Biofísica, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Christopher Kushmerick
- Departamento de Fisiologia e Biofísica, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Neeru M Sharma
- Department of Cellular & Integrative Physiology, College of Medicine, University of Nebraska Medical Center, Omaha, United States
| | - Kaushik P Patel
- Department of Cellular & Integrative Physiology, College of Medicine, University of Nebraska Medical Center, Omaha, United States
| | | | - Fabrício A Moreira
- Departamento de Farmacologia, Instituto de Ciências Biológicas Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Anderson José Ferreira
- Departamento de Morfologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Marco Antônio Peliky Fontes
- Departamento de Fisiologia e Biofísica, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil..
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Bodén R, Lindström L, Rautaharju P, Sundström J. Electrocardiographic signs of autonomic imbalance in medicated patients with first-episode schizophrenia spectrum disorders – relations to first treatment discontinuation and five-year remission status. Eur Psychiatry 2020; 27:213-8. [DOI: 10.1016/j.eurpsy.2010.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Revised: 11/16/2010] [Accepted: 12/08/2010] [Indexed: 10/18/2022] Open
Abstract
AbstractPurposeTo explore measures in electrocardiograms (ECG) influenced by autonomic balance in early schizophrenia spectrum disorders and to examine their relation to subsequent first antipsychotic pharmacotherapy discontinuation and five-year remission status.Subjects and methodsTwelve-lead ECGs were recorded at baseline in 58 patients with first-episode schizophrenia spectrum disorders and in 47 healthy controls of similar age. Selected ECG variables included heart rate and measures of repolarization. Pharmacotherapy data were extracted from medical records. At a five-year follow-up the patients were interviewed and assessed with the Positive and Negative Syndrome Scale.ResultsPatients had higher heart rate and a different ST-T pattern than the controls. High T-wave amplitudes in the leads aVF and V5 and ST-elevations in V5 were associated both with higher risk of an earlier discontinuation of first antipsychotic pharmacotherapy and with non-remission five years later.Discussion and conclusionIn this longitudinal cohort study, simple ECG measures influenced by autonomic balance in the early phase of schizophrenia spectrum disorders contained prognostic information. As this is the first report of this association and is based on a relatively small sample, the results should be interpreted with caution.
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Orini M, Al-Amodi F, Koelsch S, Bailón R. The Effect of Emotional Valence on Ventricular Repolarization Dynamics Is Mediated by Heart Rate Variability: A Study of QT Variability and Music-Induced Emotions. Front Physiol 2019; 10:1465. [PMID: 31849711 PMCID: PMC6895139 DOI: 10.3389/fphys.2019.01465] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 11/14/2019] [Indexed: 12/20/2022] Open
Abstract
Background Emotions can affect cardiac activity, but their impact on ventricular repolarization variability, an important parameter providing information about cardiac risk and autonomic nervous system activity, is unknown. The beat-to-beat variability of the QT interval (QTV) from the body surface ECG is a non-invasive marker of repolarization variability, which can be decomposed into QTV related to RR variability (QTVrRRV) and QTV unrelated to RRV (QTVuRRV), with the latter thought to be a marker of intrinsic repolarization variability. Aim To determine the effect of emotional valence (pleasant and unpleasant) on repolarization variability in healthy volunteers by means of QTV analysis. Methods 75 individuals (24.5 ± 3.2 years, 36 females) without a history of cardiovascular disease listened to music-excerpts that were either felt as pleasant (n = 6) or unpleasant (n = 6). Excerpts lasted about 90 s and were presented in a random order along with silent intervals (n = 6). QTV and RRV were derived from the ECG and the time-frequency spectrum of RRV, QTV, QTVuRRV and QTVrRRV as well as time-frequency coherence between QTV and RRV were estimated. Analysis was performed in low-frequency (LF), high frequency (HF) and total spectral bands. Results The heart rate-corrected QTV showed a small but significant increase from silence (median 347/interquartile range 31 ms) to listening to music felt as unpleasant (351/30 ms) and pleasant (355/32 ms). The dynamic response of QTV to emotional valence showed a transient phase lasting about 20 s after the onset of each musical excerpt. QTV and RRV were highly correlated in both HF and LF (mean coherence ranging 0.76–0.85). QTV and QTVrRRV decreased during listening to music felt as pleasant and unpleasant with respect to silence and further decreased during listening to music felt as pleasant. QTVuRRV was small and not affected by emotional valence. Conclusion Emotional valence, as evoked by music, has a small but significant effect on QTV and QTVrRRV, but not on QTVuRRV. This suggests that the interaction between emotional valence and ventricular repolarization variability is mediated by cycle length dynamics and not due to intrinsic repolarization variability.
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Affiliation(s)
- Michele Orini
- Institute of Cardiovascular Sciences, University College London, London, United Kingdom.,The William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Faez Al-Amodi
- Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Stefan Koelsch
- Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway
| | - Raquel Bailón
- Aragon Institute for Engineering Research, University of Zaragoza, Zaragoza, Spain.,Center for Biomedical Research in the Network in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Madrid, Spain
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Kulkarni K, Merchant FM, Kassab MB, Sana F, Moazzami K, Sayadi O, Singh JP, Heist EK, Armoundas AA. Cardiac Alternans: Mechanisms and Clinical Utility in Arrhythmia Prevention. J Am Heart Assoc 2019; 8:e013750. [PMID: 31617437 PMCID: PMC6898836 DOI: 10.1161/jaha.119.013750] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Kanchan Kulkarni
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | | | - Mohamad B. Kassab
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | - Furrukh Sana
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | - Kasra Moazzami
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | - Omid Sayadi
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | - Jagmeet P. Singh
- Cardiology DivisionCardiac Arrhythmia ServiceMassachusetts General HospitalBostonMA
| | - E. Kevin Heist
- Cardiology DivisionCardiac Arrhythmia ServiceMassachusetts General HospitalBostonMA
| | - Antonis A. Armoundas
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
- Institute for Medical Engineering and ScienceMassachusetts Institute of TechnologyCambridgeMA
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Isakadze N, Soliman EZ, Vaccarino V, Whang W, Lampert R, Bremner JD, Shah AJ. Association of positive well-being with reduced cardiac repolarization abnormalities in the First National Health and Nutrition Examination Survey. Int J Cardiol 2018; 265:246-250. [PMID: 29735423 PMCID: PMC5994381 DOI: 10.1016/j.ijcard.2018.04.135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 02/02/2018] [Accepted: 04/30/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND The mechanisms by which psychological factors may influence possibly arrhythmia risk are not known. We hypothesized that psychological wellness, measured by the General Well-Being Schedule (GBWS), is associated with less repolarization heterogeneity as measured by T-axis. We also explored whether T-axis was a mediator in the relationship of GWBS with adverse cardiac outcomes. METHODS We studied 5533 adults aged 25-74 years without a history of CVD from NHANES I (National Health and Nutrition Examination Survey) (1971-75). Frontal T-axis was obtained through 12-lead ECG and characterized as normal (15° to 75°), borderline (-15° to 15° or 75° to 105°) or abnormal (>105° or <-15°). RESULTS The mean ± SD age was 43.1 ± 11.5 years and 55% were women. A 1-SD increase in GWBS score associated with a 23% reduced odds of abnormal T-axis (p < 0.001) and 11% lower hazard of composite CHD hospitalization and death (p = 0.02). When adjusting for sociodemographic factors, health behaviors, and CHD risk factors, the association was minimally changed and remained statistically significant. Additional adjustment for T-axis did not change the relationship with outcomes. CONCLUSION General well-being is independently associated with less abnormal frontal T-axis and CHD events in otherwise healthy individuals.
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Affiliation(s)
- Nino Isakadze
- Division of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Elsayed Z Soliman
- Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston Salem, NC, United States; Section on Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States; Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - William Whang
- Division of Cardiology, Mount Sinai Medical Center, NY, United States
| | - Rachel Lampert
- Department of Internal Medicine, Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - J Douglas Bremner
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Amit J Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States; Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States; Division of Cardiology, Department of Medicine, Atlanta Veterans Affairs Medical Center, Atlanta, GA, United States.
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Heine T, Lenis G, Reichensperger P, Beran T, Doessel O, Deml B. Electrocardiographic features for the measurement of drivers' mental workload. APPLIED ERGONOMICS 2017; 61:31-43. [PMID: 28237018 DOI: 10.1016/j.apergo.2016.12.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 11/26/2016] [Accepted: 12/21/2016] [Indexed: 06/06/2023]
Abstract
This study examines the effect of mental workload on the electrocardiogram (ECG) of participants driving the Lane Change Task (LCT). Different levels of mental workload were induced by a secondary task (n-back task) with three levels of difficulty. Subjective data showed a significant increase of the experienced workload over all three levels. An exploratory approach was chosen to extract a large number of rhythmical and morphological features from the ECG signal thereby identifying those which differentiated best between the levels of mental workload. No single rhythmical or morphological feature was able to differentiate between all three levels. A group of parameters were extracted which were at least able to discriminate between two levels. For future research, a combination of features is recommended to achieve best diagnosticity for different levels of mental workload.
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Affiliation(s)
- Tobias Heine
- Institute of Human and Industrial Engineering (ifab), Karlsruhe Institute of Technology (KIT), Kaiserstrasse 12, 76131 Karlsruhe, Germany.
| | - Gustavo Lenis
- Institute of Biomedical Engineering (IBT), Karlsruhe Institute of Technology (KIT), Fritz-Haber-Weg 1, 76131 Karlsruhe, Germany
| | - Patrick Reichensperger
- Institute of Biomedical Engineering (IBT), Karlsruhe Institute of Technology (KIT), Fritz-Haber-Weg 1, 76131 Karlsruhe, Germany
| | - Tobias Beran
- Institute of Human and Industrial Engineering (ifab), Karlsruhe Institute of Technology (KIT), Kaiserstrasse 12, 76131 Karlsruhe, Germany
| | - Olaf Doessel
- Institute of Biomedical Engineering (IBT), Karlsruhe Institute of Technology (KIT), Fritz-Haber-Weg 1, 76131 Karlsruhe, Germany
| | - Barbara Deml
- Institute of Human and Industrial Engineering (ifab), Karlsruhe Institute of Technology (KIT), Kaiserstrasse 12, 76131 Karlsruhe, Germany
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13
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Finlay M, Harmer SC, Tinker A. The control of cardiac ventricular excitability by autonomic pathways. Pharmacol Ther 2017; 174:97-111. [PMID: 28223225 DOI: 10.1016/j.pharmthera.2017.02.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Central to the genesis of ventricular cardiac arrhythmia are variations in determinants of excitability. These involve individual ionic channels and transporters in cardiac myocytes but also tissue factors such as variable conduction of the excitation wave, fibrosis and source-sink mismatch. It is also known that in certain diseases and particularly the channelopathies critical events occur with specific stressors. For example, in hereditary long QT syndrome due to mutations in KCNQ1 arrhythmic episodes are provoked by exercise and in particular swimming. Thus not only is the static substrate important but also how this is modified by dynamic signalling events associated with common physiological responses. In this review, we examine the regulation of ventricular excitability by signalling pathways from a cellular and tissue perspective in an effort to identify key processes, effectors and potential therapeutic approaches. We specifically focus on the autonomic nervous system and related signalling pathways.
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Affiliation(s)
- Malcolm Finlay
- The Heart Centre, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Charterhouse Square, London EC1M6BQ, UK
| | - Stephen C Harmer
- The Heart Centre, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Charterhouse Square, London EC1M6BQ, UK
| | - Andrew Tinker
- The Heart Centre, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Charterhouse Square, London EC1M6BQ, UK.
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14
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Lewek J, Ptaszynski P, Klingenheben T, Cygankiewicz I. The clinical value of T-wave alternans derived from Holter monitoring. Europace 2016; 19:529-534. [DOI: 10.1093/europace/euw292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 08/19/2016] [Indexed: 11/12/2022] Open
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15
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Oppenheimer S, Cechetto D. The Insular Cortex and the Regulation of Cardiac Function. Compr Physiol 2016; 6:1081-133. [DOI: 10.1002/cphy.c140076] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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16
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Brindle RC, Ginty AT, Phillips AC, Fisher JP, McIntyre D, Carroll D. Heart rate complexity: A novel approach to assessing cardiac stress reactivity. Psychophysiology 2015; 53:465-72. [PMID: 26585809 DOI: 10.1111/psyp.12576] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 10/08/2015] [Indexed: 02/04/2023]
Abstract
Correlation dimension (D2), a measure of heart rate (HR) complexity, has been shown to decrease in response to acute mental stress and relate to adverse cardiovascular health. However, the relationship between stress-induced changes in D2 and HR has yet to be established. The present studies aimed to assess this relationship systematically while controlling for changes in respiration and autonomic activity. In Study 1 (N = 25) D2 decreased during stress and predicted HR reactivity even after adjusting for changes in respiration rate, and cardiac vagal tone. This result was replicated in Study 2 (N = 162) and extended by including a measure of cardiac sympathetic activity; correlation dimension remained an independent predictor of HR reactivity in a hierarchical linear model containing measures of cardiac parasympathetic and sympathetic activity and their interaction. These results suggest that correlation dimension may provide additional information regarding cardiac stress reactivity above that provided by traditional measures of cardiac autonomic function.
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Affiliation(s)
- Ryan C Brindle
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Annie T Ginty
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anna C Phillips
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - James P Fisher
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - David McIntyre
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Douglas Carroll
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
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17
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Abstract
Psychological stress can lead to atrial and ventricular arrhythmias, but the physiological pathways have not been fully elucidated. Signal processing techniques can provide insight into electrophysiological mechanisms of stress-induced arrhythmia. T-wave alternans, as well as other ECG measures of heterogeneity of repolarization, increases with emotional and cognitive stress in the laboratory setting, and may also in "real life" settings. In the atrium, stress impacts components of the signal-averaged ECG. These changes suggest mechanisms by which everyday stressors can lead to arrhythmia.
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18
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Golbidi S, Frisbee JC, Laher I. Chronic stress impacts the cardiovascular system: animal models and clinical outcomes. Am J Physiol Heart Circ Physiol 2015; 308:H1476-98. [DOI: 10.1152/ajpheart.00859.2014] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 04/03/2015] [Indexed: 01/01/2023]
Abstract
Psychological stresses are associated with cardiovascular diseases to the extent that cardiovascular diseases are among the most important group of psychosomatic diseases. The longstanding association between stress and cardiovascular disease exists despite a large ambiguity about the underlying mechanisms. An array of possibilities have been proposed including overactivity of the autonomic nervous system and humoral changes, which then converge on endothelial dysfunction that initiates unwanted cardiovascular consequences. We review some of the features of the two most important stress-activated systems, i.e., the humoral and nervous systems, and focus on alterations in endothelial function that could ensue as a result of these changes. Cardiac and hematologic consequences of stress are also addressed briefly. It is likely that activation of the inflammatory cascade in association with oxidative imbalance represents key pathophysiological components of stress-induced cardiovascular changes. We also review some of the commonly used animal models of stress and discuss the cardiovascular outcomes reported in these models of stress. The unique ability of animals for adaptation under stressful conditions lessens the extrapolation of laboratory findings to conditions of human stress. An animal model of unpredictable chronic stress, which applies various stress modules in a random fashion, might be a useful solution to this predicament. The use of stress markers as indicators of stress intensity is also discussed in various models of animal stress and in clinical studies.
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Affiliation(s)
- Saeid Golbidi
- Department of Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada; and
| | - Jefferson C. Frisbee
- Center for Cardiovascular and Respiratory Sciences, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Ismail Laher
- Department of Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada; and
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19
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Yoshida K, Kaneshiro T, Ito Y, Kimata A, Koda N, Hiraya D, Baba M, Misaki M, Takeyasu N, Yamaguchi I, Aonuma K. Elevated plasma norepinephrine level and sick sinus syndrome in patients with lone atrial fibrillation. Heart 2015; 101:1133-8. [DOI: 10.1136/heartjnl-2014-307334] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 04/16/2015] [Indexed: 11/04/2022] Open
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20
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Imam MH, Karmakar CK, Khandoker AH, Palaniswami M. Effect of ECG-derived respiration (EDR) on modeling ventricular repolarization dynamics in different physiological and psychological conditions. Med Biol Eng Comput 2014; 52:851-60. [DOI: 10.1007/s11517-014-1188-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 08/13/2014] [Indexed: 11/29/2022]
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Sabharwal R. The link between stress disorders and autonomic dysfunction in muscular dystrophy. Front Physiol 2014; 5:25. [PMID: 24523698 PMCID: PMC3905207 DOI: 10.3389/fphys.2014.00025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 01/12/2014] [Indexed: 01/16/2023] Open
Abstract
Muscular dystrophy is a progressive disease of muscle weakness, muscle atrophy and cardiac dysfunction. Patients afflicted with muscular dystrophy exhibit autonomic dysfunction along with cognitive impairment, severe depression, sadness, and anxiety. Although the psychological aspects of cardiovascular disorders and stress disorders are well known, the physiological mechanism underlying this relationship is not well understood, particularly in muscular dystrophy. Therefore, the goal of this perspective is to highlight the importance of autonomic dysfunction and psychological stress disorders in the pathogenesis of muscular dystrophy. This article will for the first time—(i) outline autonomic mechanisms that are common to both psychological stress and cardiovascular disorders in muscular dystrophy; (ii) propose therapies that would improve behavioral and autonomic functions in muscular dystrophy.
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Affiliation(s)
- Rasna Sabharwal
- Department of Internal Medicine, University of Iowa Carver College of Medicine Iowa City, IA, USA
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22
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Peacock J, Whang W. Psychological distress and arrhythmia: risk prediction and potential modifiers. Prog Cardiovasc Dis 2013; 55:582-9. [PMID: 23621968 DOI: 10.1016/j.pcad.2013.03.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The connection between the heart and the brain has long been anecdotally recognized but has systematically been studied only relatively recently. Cardiac arrhythmias, especially ventricular arrhythmias that can lead to sudden cardiac death, remain a major public health concern and there is mounting evidence that psychological distress plays a critical role both as a predictor of high-risk cardiac substrate and as an inciting trigger. The transient, unpredictable nature of emotions and cardiac arrhythmias has made their study challenging, but evolving technologies in monitoring and imaging along with larger epidemiological data sets have encouraged more sophisticated studies examining this relationship. Here we review the research on psychological distress including anger, depression and anxiety on cardiac arrhythmias, insights into proposed mechanisms, and potential avenues for future research.
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Affiliation(s)
- James Peacock
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA
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23
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Burg MM, Edmondson D, Shimbo D, Shaffer J, Kronish IM, Whang W, Alcántara C, Schwartz JE, Muntner P, Davidson KW. The 'perfect storm' and acute coronary syndrome onset: do psychosocial factors play a role? Prog Cardiovasc Dis 2013; 55:601-10. [PMID: 23621970 DOI: 10.1016/j.pcad.2013.03.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The revolution in cardiac care over the past two decades, characterized by emergent revascularization, drug eluting stents, anti-platelet medications, and advanced imaging has had little impact on overall ACS recurrence, or ACS prevention. The "Perfect Storm" refers to a confluence of events and processes, including atherosclerotic plaque, coronary flow dynamics, hemostatic and fibrinolytic function, metabolic and inflammatory conditions, neurohormonal dysregulation, and environmental events that give rise to, and result in an ACS event. In this article we illustrate the limits of the traditional main effect research model, giving a brief description of the current state of knowledge regarding the development of atherosclerotic plaque and the rupturing of these plaques that defines an ACS event. We then apply the Perfect Storm conceptualization to describe a program of research concerning a psychosocial vulnerability factor that contributes to increased risk of recurrent ACS and early mortality, and that has defied our efforts to identify underlying pathophysiology and successfully mount efforts to fully mitigate this risk.
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Affiliation(s)
- Matthew M Burg
- Department of Medicine, Center for Cardiovascular Behavioral Health, Columbia University, New York, NY 10032, USA
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24
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Nozaki E, Nakamura A, Abe A, Kagaya Y, Kohzu K, Sato K, Nakajima S, Fukui S, Endo H, Takahashi T, Seki H, Tamaki K, Mochizuki I. Occurrence of Cardiovascular Events After the 2011 Great East Japan Earthquake and Tsunami Disaster. Int Heart J 2013; 54:247-53. [DOI: 10.1536/ihj.54.247] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Eiji Nozaki
- Department of Cardiology, Iwate Prefectural Central Hospital
| | | | - Akiyo Abe
- Department of Cardiology, Iwate Prefectural Central Hospital
| | - Yuta Kagaya
- Department of Cardiology, Iwate Prefectural Central Hospital
| | - Katsuya Kohzu
- Department of Cardiology, Iwate Prefectural Central Hospital
| | - Kenjiro Sato
- Department of Cardiology, Iwate Prefectural Central Hospital
| | - Souta Nakajima
- Department of Cardiology, Iwate Prefectural Central Hospital
| | - Sigefumi Fukui
- Department of Cardiology, Iwate Prefectural Central Hospital
| | - Hideaki Endo
- Department of Cardiology, Iwate Prefectural Central Hospital
| | - Tohru Takahashi
- Department of Cardiology, Iwate Prefectural Central Hospital
| | - Hirofumi Seki
- Department of Neurosurgery, Iwate Prefectural Central Hospital
| | - Kenji Tamaki
- Department of Cardiology, Iwate Prefectural Miyako Hospital
| | - Izumi Mochizuki
- Department of Gastroenterological Surgery, Iwate Prefectural Central Hospital
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25
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Kusha M, Masse S, Farid T, Urch B, Silverman F, Brook RD, Gold DR, Mangat I, Speck M, Nair K, Poku K, Meyer C, Mittleman MA, Wellenius GA, Nanthakumar K. Controlled exposure study of air pollution and T-wave alternans in volunteers without cardiovascular disease. ENVIRONMENTAL HEALTH PERSPECTIVES 2012; 120:1157-1161. [PMID: 22552907 PMCID: PMC3440072 DOI: 10.1289/ehp.1104171] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 05/02/2012] [Indexed: 05/31/2023]
Abstract
BACKGROUND Epidemiological studies have assessed T-wave alternans (TWA) as a possible mechanism of cardiac arrhythmias related to air pollution in high-risk subjects and have reported associations with increased TWA magnitude. OBJECTIVE In this controlled human exposure study, we assessed the impact of exposure to concentrated ambient particulate matter (CAP) and ozone (O3) on T-wave alternans in resting volunteers without preexisting cardiovascular disease. METHODS Seventeen participants without preexisting cardiovascular disease were randomized to filtered air (FA), CAP (150 μg/m3), O3 (120 ppb), or combined CAP + O3 exposures for 2 hr. Continuous electrocardiograms (ECGs) were recorded at rest and T-wave alternans (TWA) was computed by modified moving average analysis with QRS alignment for the artifact-free intervals of 20 beats along the V2 and V5 leads. Exposure-induced changes in the highest TWA magnitude (TWAMax) were estimated for the first and last 5 min of each exposure (TWAMax_Early and TWAMax_Late respectively). ΔTWAMax (Late-Early) were compared among exposure groups using analysis of variance. RESULTS Mean ± SD values for ΔTWAMax were -2.1 ± 0.4, -2.7 ± 1.1, -1.9 ± 1.5, and -1.2 ± 1.5 in FA, CAP, O3, and CAP + O3 exposure groups, respectively. No significant differences were observed between pollutant exposures and FA. CONCLUSION In our study of 17 volunteers who had no preexisting cardiovascular disease, we did not observe significant changes in T-wave alternans after 2-hr exposures to CAP, O3, or combined CAP + O3. This finding, however, does not preclude the possibility of pollution-related effects on TWA at elevated heart rates, such as during exercise, or the possibility of delayed responses.
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Affiliation(s)
- Marjan Kusha
- Division of Cardiology, Toronto General Hospital, Toronto, Ontario, Canada
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26
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Magrì D, Piccirillo G, Quaglione R, Dell'armi A, Mitra M, Velitti S, Di Barba D, Lizio A, Maisto D, Barillà F. Effect of Acute Mental Stress on Heart Rate and QT Variability in Postmyocardial Infarction Patients. ISRN CARDIOLOGY 2012; 2012:912672. [PMID: 22844616 PMCID: PMC3403409 DOI: 10.5402/2012/912672] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 05/16/2012] [Indexed: 01/08/2023]
Abstract
Emotionally charged events are associated with an increased risk of sudden cardiac death (SCD). In this study we assessed RR and QT variability index (QTVI) at baseline during anger recall test (AR). We calculated QTVI from a 5-min ECG recording and from a 10-beats segment around the presumed maximum sympathetic activation in thirty post-myocardial infarction patients under β-blocker therapy and 10 controls underwent. In all groups, the low-frequency component of RR and SBP increased during AR. In all recordings, the QTVI calculated on a 5-min ECG recording and the QTVI10 beats were higher in patients than in controls (P < 0.05). The QTVI during AR remained unchanged from baseline within each group. Conversely, during AR, the QTVI10 beats in controls diminished significantly (P < 0.05) from baseline whereas in patients remained unchanged. The inability to buffer an acute stress-induced increase in sympathetic activity could explain why events charged with acute stress are associated with an increased risk of ventricular arrhythmias in this setting of patients and support the role of cognitive behavior stress management strategies.
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Affiliation(s)
- Damiano Magrì
- Dipartimento di Medicina Clinica e Molecolare, Azienda Ospedaliera S. Andrea, "Sapienza" Università degli Studi di Roma, 00185 Rome, Italy
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27
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Koskela J, Kähönen M, Nieminen T, Lehtinen R, Viik J, Nikus K, Niemelä K, Kööbi T, Tobin MD, Samani NJ, Turjanmaa V, Pörsti I, Lehtimäki T. Allelic variant of NOS1AP effects on cardiac alternans of repolarization during exercise testing. Scandinavian Journal of Clinical and Laboratory Investigation 2011; 72:100-7. [PMID: 22133205 DOI: 10.3109/00365513.2011.638725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION A repolarization abnormality manifested as T-wave alternans (TWA) in electrocardiogram (ECG) predicts cardiovascular mortality. A common variant in the NOS1AP gene is associated with mortality and QT interval duration, possibly in a gender-specific manner, but data is lacking on potential association with TWA. This study tested association between rs10494366 in NOS1AP and both TWA and 4-year mortality. MATERIAL AND METHODS A total of 1963 Finnish Cardiovascular Study participants (36.6% female, 57.1 ± 13.0 years) were genotyped and their maximal TWA values were measured from continuous ECG recordings during clinical exercise test at rest, exercise and recovery. RESULTS We observed a significant gender-specific effect of NOS1AP genotype on TWA. In all subjects, there was no statistically significant difference between the three genotypes (TT, TG, GG) in the responses of TWA over the entire exercise test (time-by-genotype interaction p = 0.057). In women, after adjustment for age, coronary heart disease and β-blocker medication status, changes of TWA over different phases of exercise test were significantly associated with NOS1AP genotype (time-by-genotype interaction p = 0.001). In men, NOS1AP rs10494366 was not associated with TWA. During follow-up (mean 47 months), 113 patients died. NOS1AP rs10494366 was not a statistically significant predictor of mortality. CONCLUSION The NOSIAP variant rs10494366 influences TWA and TWA response during clinical exercise test in females. Gender-specific effects have also been previously reported for the influence of the variant on QT interval. If replicated, these findings should prompt studies to further elucidate the mechanisms underlying the gender differences in NOS1AP effects on repolarization.
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Affiliation(s)
- Jenni Koskela
- Department of Internal Medicine, Tampere University Hospital and School of Medicine at the University of Tampere, Finland.
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28
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Taggart P, Boyett MR, Logantha SJRJ, Lambiase PD. Anger, emotion, and arrhythmias: from brain to heart. Front Physiol 2011; 2:67. [PMID: 22022314 PMCID: PMC3196868 DOI: 10.3389/fphys.2011.00067] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 09/14/2011] [Indexed: 01/01/2023] Open
Abstract
Strong emotion and mental stress are now recognized as playing a significant role in severe and fatal ventricular arrhythmias. The mechanisms, although incompletely understood, include central processing at the cortical and brain stem level, the autonomic nerves and the electrophysiology of the myocardium. Each of these is usually studied separately by investigators from different disciplines. However, many are regulatory processes which incorporate interactive feedforward and feedback mechanisms. In this review we consider the whole as an integrated interactive brain-heart system.
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Affiliation(s)
- Peter Taggart
- Neurocardiology Research Unit, Department of Medicine, University College LondonLondon, UK
| | - Mark R. Boyett
- Cardiovascular Medicine, University of ManchesterManchester, UK
| | | | - Pier D. Lambiase
- Department of Cardiology, University College London HospitalsLondon, UK
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29
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Abisse SS, Lampert R, Burg M, Soufer R, Shusterman V. Cardiac repolarization instability during psychological stress in patients with ventricular arrhythmias. J Electrocardiol 2011; 44:678-83. [PMID: 21920534 DOI: 10.1016/j.jelectrocard.2011.07.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2011] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Changes in the autonomic nervous system activity are a major trigger of life-threatening ventricular tachyarrhythmias (VTAs). Mental arithmetic, a condition administered in a laboratory setting, can provide insight into the autonomic nervous system activity effects on cardiac physiology. We examined the responses of cardiac repolarization to laboratory-induced psychological stressors in patients with implantable cardioverter-defibrillators (ICDs) with the objective of identifying the indices that differentiate patients with and without subsequent VTA in follow-up. METHODS Continuous electrocardiographic signals were recorded using 3 standard bipolar (Holter) leads in 56 patients (age, 63.6 ± 11.9; female, 12%; left ventricular ejection fraction, 32.3 ± 11) with ICDs during mental arithmetic. The patients were separated into those with subsequent VTA during 3 to 4 years of follow-up (group 1: n = 9) and those without VTA (group 2: n = 47). Changes in repolarization (QT interval, mean T wave amplitude [Tamp], and T wave area) were analyzed during 5 minutes at baseline, stress, and recovery. The temporal instability of Tamp and T wave area was examined using the range (Δ) and variance (σ(2)) of beat-to-beat variations of the corresponding parameters. RESULTS There were no significant differences in heart rate between the 2 groups at baseline (61 vs 63 beats per minute, P = .97), stress (64 vs 65 beats per minute, P = .40), and recovery (62 vs 61 beats per minute, P = .88). However, during mental stress and poststress recovery, ΔTamp was almost 2-fold greater in group 1 compared with group 2 (111 [57-203] vs 68 [44-94] μV, P = .04, respectively). Changes in QT intervals were also greater in group 1 compared with group 2 (P = .02). CONCLUSION Among patients with ICDs, changes of Tamp after psychological stress were greater in those with subsequent arrhythmic events. This might signal proarrhythmic repolarization response and help identify patients who would benefit the most from ICD implantation and proactive management.
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Affiliation(s)
- Saddam S Abisse
- Cardiovascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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30
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Pedersen SS, den Broek KCV, Theuns DA, Erdman RA, Alings M, Meijer A, Jordaens L, Denollet J. Risk of chronic anxiety in implantable defibrillator patients: A multi-center study. Int J Cardiol 2011; 147:420-3. [DOI: 10.1016/j.ijcard.2009.09.549] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Revised: 08/21/2009] [Accepted: 09/01/2009] [Indexed: 11/16/2022]
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Lampert R, Salberg L, Burg M. Emotional stress triggers symptoms in hypertrophic cardiomyopathy: a survey of the Hypertrophic Cardiomyopathy Association. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 33:1047-53. [PMID: 20487360 DOI: 10.1111/j.1540-8159.2010.02770.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Symptoms are among the most important factors impacting quality of life (QOL) in hypertrophic cardiomyopathy (HCM) patients, and reflect a poor prognosis. Whether emotional stress can trigger symptoms of chest pain, dyspnea, palpitations, and lightheadedness has not been described. METHODS Members of the Hypertrophic Cardiomyopathy Association (HCMA) received an electronic link via e-mail to an ongoing online survey, also accessed via links on the HCMA message-board and homepage. Between May 2007 and November 2008, there were 1,297 respondents. The survey queried demographic and self-reported clinical information, and types and triggers of symptoms. Respondents reported physical and emotional QOL on a 1-10 Likert scale. RESULTS Symptoms reported included chest pain (49%), dyspnea (70%), palpitations (61%), and syncope/lightheadedness (59%). The most common symptom trigger was exertion, 64% describing symptoms while climbing stairs or hills. Forty-nine percent described experiencing symptoms during emotional stress. Those reporting chest pain were more likely to report emotion triggering (60%) than those reporting palpitations, syncope/lightheadedness, or dyspnea (50-54% each). Both physical and emotional QOL were significantly decreased in those describing emotion-triggered symptoms. Women were more likely than men to report symptoms overall, as well as emotion-triggered symptoms (50% vs 35%, P < 0.001) and exertion-triggered symptoms (79% vs 58%, P < 0.001). After controlling for presence of symptoms, both emotion- and exertion-triggered symptoms remained significantly more common in women. CONCLUSIONS Triggering of symptoms by emotion is common in individuals with HCM. Further studies will determine pathways linking emotional stressors with chest pain, dyspnea, palpitations, and lightheadedness in these patients.
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Affiliation(s)
- Rachel Lampert
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT, USA.
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Takasugi N, Kubota T, Nishigaki K, Verrier RL, Kawasaki M, Takasugi M, Ushikoshi H, Hattori A, Ojio S, Aoyama T, Takemura G, Minatoguchi S. Continuous T-wave alternans monitoring to predict impending life-threatening cardiac arrhythmias during emergent coronary reperfusion therapy in patients with acute coronary syndrome. Europace 2011; 13:708-15. [DOI: 10.1093/europace/euq512] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Burg MM, Soufer A, Lampert R, Collins D, Soufer R. Autonomic contribution to endothelin-1 increase during laboratory anger-recall stress in patients with coronary artery disease. Mol Med 2011; 17:495-501. [PMID: 21267513 DOI: 10.2119/molmed.2010.00083] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Accepted: 01/14/2011] [Indexed: 01/08/2023] Open
Abstract
In coronary artery disease (CAD), endothelin-1 (ET-1) is released by activated macrophages and thereby contributes to coronary plaque rupture and triggered cardiac events. The multifactorial regulation of ET-1 includes stimulated release by cytokines and autonomic factors. Laboratory stress provokes alteration in autonomic tone and prolonged ET-1 mediated endothelial dysfunction. The objective of the study is to determine the autonomic contribution to an increase in ET-1 in response to laboratory stress in patients with CAD. Patients (n = 88) with chronic stable CAD instrumented with hemodynamic monitor, digital electrocardiogram (ECG) monitor and indwelling catheter for blood sampling completed a laboratory protocol that included initial rest (30 min), baseline (BL: 10 min), and anger recall stress (AR: 8 min). Change from BL to AR was determined for (a) parasympathetic activity (by spectral analysis of ECG); (b) sympathetic activity (by circulating catecholamines); and (c) ET-1. AR provoked increases from BL in catecholamines, and a decrease in parasympathetic activity. Multivariate analysis with change in parasympathetic activity and catecholamines, while controlling for age and use of β-blockers, revealed a significant odds ratio (OR = 3.27, 95% CI 1.03, 10.41 P = 0.04) for an increase in ET-1 associated with parasympathetic withdrawal; no other variables were significant. The predominant influence of parasympathetic activity on anger/stress-provoked increase in ET-1 is consistent with the cholinergic antiinflammatory pathway. Future examination of autonomic influences on atherosclerotic leukocytes, endothelial cell function and the dynamics of ET-1 are warranted.
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Affiliation(s)
- Matthew M Burg
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.
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Lampert R. Air Pollution and Repolarization Heterogeneity. J Am Coll Cardiol 2011; 57:207-9. [DOI: 10.1016/j.jacc.2010.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Accepted: 07/27/2010] [Indexed: 11/24/2022]
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Min SS, Turner JR, Nada A, DiMino TL, Hynie I, Kleiman R, Kowey P, Krucoff MW, Mason JW, Phipps A, Newton-Cheh C, Pordy R, Strnadova C, Targum S, Uhl K, Finkle J. Evaluation of ventricular arrhythmias in early clinical pharmacology trials and potential consequences for later development. Am Heart J 2010; 159:716-29. [PMID: 20435178 DOI: 10.1016/j.ahj.2010.02.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Accepted: 02/03/2010] [Indexed: 11/15/2022]
Abstract
This white paper, prepared by members of the Cardiac Safety Research Consortium, discusses several important issues regarding the evaluation of ventricular arrhythmias in early clinical pharmacology trials and their potential consequences for later clinical drug development. Ventricular arrhythmias are infrequent but potentially important medical events whose occurrence in early clinical pharmacology trials can dramatically increase safety concerns. Given the increasing concern with all potential safety signals and the resultant more extensive electrocardiographic monitoring of subjects participating in early phase trials, an important question must be addressed: Are relatively more frequent observations of ventricular arrhythmias related simply to more extensive monitoring, or are they genuinely related to the drug under development? The discussions in this paper provide current thinking and suggestions for addressing this question.
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Takasugi N, Nishigaki K, Kubota T, Tsuchiya K, Natsuyama K, Takasugi M, Nawa T, Ojio S, Aoyama T, Kawasaki M, Takemura G, Minatoguchi S. Sleep apnoea induces cardiac electrical instability assessed by T-wave alternans in patients with congestive heart failure. Eur J Heart Fail 2010; 11:1063-70. [PMID: 19875406 DOI: 10.1093/eurjhf/hfp138] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS To assess the involvement of sleep apnoea in nocturnal sudden cardiac death (SCD) by evaluating cardiac electrical instability using T-wave alternans (TWA), a risk marker for lethal cardiac arrhythmias, and severity of sleep apnoea in congestive heart failure (CHF) patients. METHODS AND RESULTS A total of 40 CHF patients simultaneously underwent overnight simplified respiratory polygraphy and 24 h continuous electrocardiography. Peak TWA during both daytime and nighttime were calculated by the modified moving average method. The patients were divided into two groups; 30 patients with daytime predominant TWA (whose peak TWA was higher during daytime than during nighttime) and 10 with nighttime predominant. Apnoea-hypopnoea index (AHI) was significantly higher in patients with nighttime predominant TWA than in those with daytime predominant (35.9 +/- 8.1 vs. 23.9 +/- 14.4 events/h, P = 0.02), and was an independent predictor of nighttime predominant TWA (odds ratio, 1.08; 95% confidence interval, 1.01-1.16; P = 0.03). Moreover, peak TWA during the night was correlated positively with AHI (P < 0.001), and AHI was an independent determinant of nocturnal TWA value (r(2) = 0.27, P = 0.009). CONCLUSION In CHF patients, sleep apnoea induces cardiac electrical instability manifested as TWA, reflecting increased risk of nocturnal SCD. Moreover, some CHF patients with sleep apnoea exhibit nighttime predominant TWA. Therefore, TWA should also be evaluated during the night.
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Affiliation(s)
- Nobuhiro Takasugi
- Regeneration and Advanced Medical Science, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu 501-1194, Japan.
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Feng Y, Caiping M, Li C, Can R, Feichao X, Li Z, Zhice X. Fetal and offspring arrhythmia following exposure to nicotine during pregnancy. J Appl Toxicol 2010; 30:53-8. [PMID: 19728315 DOI: 10.1002/jat.1471] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Although recent studies have demonstrated prenatal nicotine can increase cardiovascular risk in the offspring, it is unknown whether exposure to nicotine during pregnancy also may be a risk for development of arrhythmia in the offspring. In addition, in previous studies of fetal arrhythmia affected by smoking, only two patterns, bradycardia and tachycardia, were observed. The present study examined acute effects of maternal nicotine on the fetal arrhythmia in utero, and chronic influence on offspring arrhythmia at adult stage following prenatal exposure to nicotine. Nicotine was administered to pregnant ewes and rats. In the fetal sheep, intravenous nicotine not only induced changes of fetal heart rate, but also caused cardiac cycle irregularity, single and multiple dropped cardiac cycles. Although maternal nicotine had no influence on fetal blood pH, lactic acid, hemocrit, Na(+), K(+) levels and plasma osmolality, fetal blood PO(2) levels were significantly decreased following maternal nicotine in ewes. In offspring rats at 4-5 months after birth, prenatal exposure to nicotine significantly increased heart rate and premature ventricular contraction in restraint stress. In addition, arrhythmias induced by injection of nicotine were higher in the offspring prenatal exposure to nicotine in utero. The results provide new evidence that exposure to nicotine in pregnancy can cause fetal arrhythmia in various patterns besides tachycardia and bradycardia, the possible mechanisms for nicotine-induced fetal arrhythmia included in utero hypoxia. Importantly, following exposure to nicotine significantly increased risk of arrhythmia in the adult offspring. The finding offers new insight for development of cardiac rhythm problems in fetal origins.
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Affiliation(s)
- Yu Feng
- Perinatal Biology Center, Soochow University, Suzhou 213325, China
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Abstract
PURPOSE OF REVIEW Although anecdotal evidence has long suggested links between emotion and ventricular arrhythmia, more recent studies have prospectively demonstrated the arrhythmogenic effects of anger, as well as mechanisms underlying these effects. RECENT FINDINGS Epidemiological studies reveal that psychological stress increases sudden death, as well as arrhythmias, in patients with implantable cardioverter-defibrillators, in populations during emotionally devastating disasters such as earthquake or war. Diary-based studies confirm that anger and other negative emotions can trigger potentially lethal ventricular arrhythmias. Anger alters electrophysiological properties of the myocardium, including T-wave alternans, a measure of heterogeneity of repolarization, suggesting one mechanistic link between emotion and arrhythmia. Pilot studies of behavioral interventions have shown promise in decreasing arrhythmias in patients with implantable cardioverter-defibrillators. SUMMARY Anger and other strong emotions can trigger polymorphic, potentially life-threatening ventricular arrhythmias in vulnerable patients. Through autonomic changes including increased sympathetic activity and vagal withdrawal, anger leads to increases in heterogeneity of repolarization as measured by T-wave alternans, known to be associated with arrhythmogenesis, as well as increasing inducibility of arrhythmia. Further delineation of mechanisms linking anger and arrhythmia, and of approaches to decrease the detrimental effects of anger and other negative emotions on arrhythmogenesis, are important areas of future investigation.
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Rationale and design of a randomized clinical trial comparing stress reduction treatment to usual cardiac care: the Reducing Vulnerability to Implantable Cardioverter Defibrillator Shock-Treated Ventricular Arrhythmias (RISTA) trial. Psychosom Med 2010; 72:172-7. [PMID: 20028832 PMCID: PMC2826193 DOI: 10.1097/psy.0b013e3181c932d4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To present the design of a multicenter, randomized trial testing the effects of stress reduction treatment (SRT) on the prevalence of shock-treated ventricular arrhythmias among patients with an implantable cardioverter defibrillator (ICD). Significant adjustment problems secondary to ICD shock can increase the likelihood of arrhythmias requiring shock for termination. Whether SRT can reduce arrhythmias requiring shock for termination in patients with ICDs has not been tested in clinical trials. METHODS New ICD recipients and previous recipients who have received an appropriate therapeutic shock in the last 6 months (n = 304) will be enrolled and randomized to either SRT or usual cardiac care. Participants complete a psychosocial questionnaire and undergo laboratory mental stress testing and 24-hour Holter monitoring with diary at study entry and approximately 4 months later. Follow-ups are completed at 6, 12, and 24 months post randomization to assess occurrence of ICD shock for ventricular arrhythmias (primary outcome), antitachycardia pacing events, medication changes, hospitalizations, deaths, and quality of life. RESULTS Log-rank test and Cox proportional hazards model will be used to test the effects of SRT on time to first shock-treated ventricular arrhythmia, with exploratory analyses testing the effects on overall frequency of ventricular arrhythmia. Secondary analyses will test the effects of SRT on laboratory stress-induced and 24-hour arrhythmogenic electrophysiological indices from pre to post treatment, and both quality of life and measures of anger across the 2 years of the study. CONCLUSIONS The Reducing Vulnerability to ICD Shock-Treated Ventricular Arrhythmias (RISTA) Trial is the first large-scale, randomized, clinical trial designed to evaluate the effect of SRT on the prevalence of shock-treated arrhythmias among patients with an ICD. Results may demonstrate a treatment that can reduce vulnerability to arrhythmia-provoked shock and improve quality of life.
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Shusterman V, McTiernan CF, Goldberg A, Saba S, Salama G, London B. Adrenergic stimulation promotes T-wave alternans and arrhythmia inducibility in a TNF-alpha genetic mouse model of congestive heart failure. Am J Physiol Heart Circ Physiol 2009; 298:H440-50. [PMID: 19940073 DOI: 10.1152/ajpheart.01024.2008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
T-wave alternans (TWA) is a proarrhythmic repolarization instability that is common in congestive heart failure (CHF). Although transgenic mice are commonly used to study the mechanisms of arrhythmogenesis in CHF, little is known about the dynamics of TWA in these species. We hypothesized that TWA is present in a TNF-alpha model of CHF and can be further promoted by adrenergic stimulation. We studied 16 TNF-alpha mice and 12 FVB controls using 1) in vivo intracardiac electrophysiological testing and 2) ambulatory telemetry during 30 min before and after an intraperitoneal injection of isoproterenol. TWA was examined using both linear and nonlinear filtering applied in the time domain. In addition, changes in the mean amplitude of the T wave and area under the T wave were computed. During intracardiac electrophysiological testing, none of the animals had TWA or inducible arrhythmias before the injection of isoproterenol. After the injection, sustained TWA and inducible ventricular tachyarrhythmias were observed in TNF-alpha mice but not in FVB mice. In ambulatory telemetry, before the isoproterenol injection, the cardiac cycle length (CL) was longer in TNF-alpha mice than in FVB mice (98 +/- 9 and 88 +/- 3 ms, P = 0.04). After the injection of isoproterenol, the CL became 8% and 6% shorter in TNF-alpha and FVB mice (P < 10(-4)); however, the 2% difference between the groups in the magnitude of CL changes was not significant. In TNF-alpha mice, the magnitude of TWA was 1.5-2 times greater than in FVB mice both before and after the isoproterenol injection. The magnitude of TWA increased significantly after the isoproterenol injection compared with the baseline in TNF-alpha mice (P = 0.003) but not in FVB mice. The mean amplitude of the T wave and area under the T wave increased 60% and 80% in FVB mice (P = 0.006 and 0.009) but not in TNF-alpha mice. In conclusion, TWA is present in a TNF-alpha model of CHF and can be further promoted by adrenergic stimulation, along with the enhanced susceptibility for ventricular arrhythmias.
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Affiliation(s)
- Vladimir Shusterman
- Cardiovascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Shusterman V, Lampert R, London B. The many faces of repolarization instability: which one is prognostic? J Electrocardiol 2009; 42:511-6. [PMID: 19717165 DOI: 10.1016/j.jelectrocard.2009.06.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Indexed: 11/27/2022]
Abstract
Instabilities of the STT segment's magnitude, and particularly the 0.5 beat/cycle oscillations (T-wave alternans, or TWA), have been linked to the heightened risk of ventricular tachyarrhythmias (VTA) and sudden cardiac death (SCD). During the last decade theoretical, experimental and clinical research efforts have focused primarily on TWA, examining its mechanisms and predictive value using time-invariant cutoff values. However, recent evidence suggests that such a single-snapshot test of a single-frequency (TWA) oscillation using a constant cutoff value might be suboptimal for risk stratification because of several reasons. First, it is well known that the risk of VTA/SCD evolves over time with changes in electrophysiologic substrate, environmental and physiologic triggers, and the impact of other physiologic (eg, circadian) rhythmicity. Hence, the outcome of TWA testing might depend on the time of day, as Holter-based TWA studies have demonstrated. Furthermore, currently used single-snapshot testing with a binary cutoff value may not coincide with the periods of heightened risk for VTA/SCD and may not yield prognostic information, as a recent TWA substudy of the sudden cardiac death in heart failure trial has showed. Second, the analysis focused on TWA alone ignores the existence of multiple (alternating and nonalternating) forms of repolarization instability that have been shown to arise or increase before the onset of VTA/SCD. Summarizing, recent studies have identified multiple forms of repolarization instabilities modulated by distinct mechanisms, which might have different prognostic values. Therefore, the assessment of TWA needs to be dynamic and personalized to take into account the time evolution of risk and individual history.
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MINKKINEN MIKKO, KÄHÖNEN MIKA, VIIK JARI, NIKUS KJELL, LEHTIMÄKI TERHO, LEHTINEN RAMI, KÖÖBI TIIT, TURJANMAA VÄINÖ, KAISER WILLI, VERRIER RICHARDL, NIEMINEN TUOMO. Enhanced Predictive Power of Quantitative TWA during Routine Exercise Testing in the Finnish Cardiovascular Study. J Cardiovasc Electrophysiol 2009; 20:408-15. [DOI: 10.1111/j.1540-8167.2008.01325.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lampert R, Shusterman V, Burg M, McPherson C, Batsford W, Goldberg A, Soufer R. Anger-induced T-wave alternans predicts future ventricular arrhythmias in patients with implantable cardioverter-defibrillators. J Am Coll Cardiol 2009; 53:774-8. [PMID: 19245968 DOI: 10.1016/j.jacc.2008.10.053] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2008] [Revised: 10/14/2008] [Accepted: 10/19/2008] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study sought to determine whether T-wave alternans (TWA) induced by anger in a laboratory setting predicts future ventricular arrhythmias in patients with implantable cardioverter-defibrillators (ICDs). BACKGROUND Anger can precipitate spontaneous ventricular tachycardia/ventricular fibrillation and induce TWA. Whether anger-induced TWA predicts future arrhythmias is unknown. METHODS Sixty-two patients with ICDs underwent ambulatory electrocardiography during a mental stress protocol, 3 months after the ICD was implanted. T-wave alternans was analyzed using time-domain methods. After a > or =1 year follow-up, ICD stored data was reviewed to determine incidence of ICD-terminated ventricular tachycardia/ventricular fibrillation. RESULTS Patients with ICD-terminated arrhythmias during follow-up (n = 10) had higher TWA induced by anger, 13.2 microV (interquartile range [IQR] 9.3 to 16 microV), compared with those patients without future ventricular arrhythmias, 9.3 microV (IQR 7.5 to 11.5 microV, p < 0.01). Patients in the highest quartile of anger-induced TWA (>11.9 microV, n = 15) were more likely to experience arrhythmias by 1 year than those in the lower quartiles (33% vs. 4%) and during extended follow-up (40% vs. 9%, p < 0.01 for both). In multivariable regression controlling for ejection fraction, prior clinical arrhythmia, and wide QRS, anger-induced TWA remained a significant predictor of arrhythmia, with likelihood in the top quartile 10.8 times that of other patients (95% confidence interval: 1.6 to 113, p < 0.05). CONCLUSIONS Anger-induced TWA predicts future ventricular arrhythmias in patients with ICDs, suggesting that emotion-induced repolarization instability may be 1 mechanism linking stress and sudden death. Whether there is a clinical role for anger-induced TWA testing requires further study.
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Affiliation(s)
- Rachel Lampert
- Yale University School of Medicine, New Haven, Connecticut, USA
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Rashba EJ. Anger Management May Save Your Life. J Am Coll Cardiol 2009; 53:779-81. [DOI: 10.1016/j.jacc.2008.11.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2008] [Accepted: 11/25/2008] [Indexed: 11/28/2022]
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Garcia EDV. T-wave alternans: reviewing the clinical performance, understanding limitations, characterizing methodologies. Ann Noninvasive Electrocardiol 2009; 13:401-20. [PMID: 18973498 DOI: 10.1111/j.1542-474x.2008.00254.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Accurate recognition of individuals at higher immediate risk of sudden cardiac death (SCD) is still an open question. The fortuitous nature of acute cardiovascular events just does not seem to fit the well-known model of ventricular tachycardia/fibrillation induction in a static arrhythmogenic substrate by a synchronous trigger. On the mechanism of SCD, a dynamical electrical instability would better explain the rarity of the simultaneous association of a correct trigger and an appropriate cardiac substrate. Several studies have been conducted trying to measure this cardiac electrical instability (or any valid surrogate) in an ECG beat stream. Among the current possible candidates we can number QT prolongation, QT dispersion, late potentials, T-wave alternans (TWA), and heart rate turbulence. This article reviews the particular role of TWA in the current cardiac risk stratification scenario. TWA findings are still heterogeneous, ranging from very good to nearly null prognostic performance depending on the clinical population observed and clinical protocol in use. To fill the current gaps in the TWA base of knowledge, practitioners, and researchers should better explore the technical features of the several technologies available for TWA evaluation and pay greater attention to the fact that TWA values are responsive to several factors other than medications. Information about the cellular and subcellular mechanisms of TWA is outside the scope of this article, but the reader is referred to some of the good papers available on this topic whenever this extra information could help the understanding of the concepts and facts covered herein.
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Affiliation(s)
- Euler de Vilhena Garcia
- The Heart Institute (InCor), University of São Paulo Medical School - Electrocardiology Service, São Paulo, Brazil.
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Dawes D, Ho J, Miner J. The neuroendocrine effects of the TASER X26®: A brief report. Forensic Sci Int 2009; 183:14-9. [DOI: 10.1016/j.forsciint.2008.09.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2008] [Revised: 07/24/2008] [Accepted: 09/23/2008] [Indexed: 11/26/2022]
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Repolarization changes induced by mental stress in normal subjects and patients with coronary artery disease: effect of nitroglycerine. Psychosom Med 2009; 71:23-9. [PMID: 19124615 DOI: 10.1097/psy.0b013e31818a1d56] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Mental stress can significantly affect ventricular repolarization, which could potentially trigger arrhythmias. We compared the effect of mental stress on repolarization indexed by the amplitude and area of the T wave in patients with coronary artery disease (CAD) and healthy subjects. METHODS Fourteen healthy controls (11 M, mean age 42 years) and 14 patients with stable CAD (12 M, mean age 64) underwent a mental stress protocol consisting of mental arithmetic followed by a speech (5 minutes each), which was performed on two occasions following either nitroglycerine (NTG) or placebo. Multiple 12-lead electrocardiograms were acquired and repolarization was analyzed using automatically measured T wave amplitude (T(amp)) and area (T(area)). RESULTS When preceded by placebo the overall effect of mental stress, whether induced by arithmetic or speech, was significantly different in CAD patients compared with controls, with a decrease in T(amp) and T(area) in controls and an increase in patients; e.g., change in T(amp) during arithmetic -20 +/- 3 microV in controls versus 4 +/- 2 microV in patients, p < .001, and during speech -9 +/- 3 microV in controls versus 7 +/- 1 microV in patients, p < .001. Following NTG, the effect of stress on repolarization was similar in the 2 groups, with a reversed effect, i.e., decrease instead of increase in T(amp) and T(area) in CAD patients. CONCLUSIONS The effect of mental stress on ventricular repolarization is significantly different in CAD patients compared with healthy controls. These differences are considerably reduced by NTG.
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Das S, O’Keefe JH. Behavioral cardiology: Recognizing and addressing the profound impact of psychosocial stress on cardiovascular health. Curr Hypertens Rep 2008; 10:374-81. [DOI: 10.1007/s11906-008-0070-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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STEIN PHYLLISK, SANGHAVI DEVANG, DOMITROVICH PETERP, MACKEY ROBERTA, DEEDWANIA PRAKASH. Ambulatory ECG-Based T-Wave Alternans Predicts Sudden Cardiac Death in High-Risk Post-MI Patients with Left Ventricular Dysfunction in the EPHESUS Study. J Cardiovasc Electrophysiol 2008; 19:1037-42. [DOI: 10.1111/j.1540-8167.2008.01225.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Madias JE. T-wave Alternans Assessed by Atropine-Induced Sinus Tachycardia. Pacing Clin Electrophysiol 2008; 31:520-1; author reply 521. [DOI: 10.1111/j.1540-8159.2008.01026_4.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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