Baroreflex sensitivity in secondary hypertension

An Outline of Renal Artery Stenosis Pathophysiology-A Narrative Review

Renal artery stenosis (RAS) is conditioned mainly by two disturbances: fibromuscular dysplasia or atherosclerosis of the renal artery. RAS is an example of renovascular disease, with complex pathophysiology and consequences. There are multiple pathophysiological mechanisms triggered in response to significant renal artery stenosis, including disturbances within endothelin, kinin-kallikrein and sympathetic nervous systems, with angiotensin II and the renin-angiotensin-aldosterone system (RAAS) playing a central and key role in the pathogenesis of RAS. The increased oxidative stress and the release of pro-inflammatory mediators contributing to pathological tissue remodelling and renal fibrosis are also important pathogenetic elements of RAS. This review briefly summarises these pathophysiological issues, focusing on renovascular hypertension and ischemic nephropathy as major clinical manifestations of RAS. The activation of RAAS and its haemodynamic consequences is the primary and key element in the pathophysiological cascade triggered in response to renal artery stenosis. However, the pathomechanism of RAS is more complex and also includes other disturbances that ultimately contribute to the development of the diseases mentioned above. To sum up, RAS is characterised by different clinical pictures, including asymptomatic disorders diagnosed in kidney imaging, renovascular hypertension, usually characterised by severe course, and chronic ischemic nephropathy, described by pathological remodelling of kidney tissue, ultimately leading to kidney injury and chronic kidney disease.

Hemodynamic and Electrocardiographic Aspects of Uncomplicated Singleton Pregnancy

Pregnancy is associated with significant changes in maternal hemodynamics, which are triggered by profound systemic vasodilation and mediated through the autonomic nervous system as well as the renin-angiotensin-aldosterone system. Vascular function changes to help accommodate an increase in intravascular volume due to blood volume expansion associated with pregnancy while maintaining the efficiency of ventricular-arterial coupling and diastolic perfusion pressure. The heart undergoes physiological (eccentric) hypertrophy due to increased volume load and cardiac stroke work, whereas the functional change of the left ventricle remains controversial. There are changes in cardiac electrical activity during pregnancy which can be detected in the electrocardiogram that are not related to disease. Sympathetic activation is a common phenomenon during uncomplicated pregnancy and may be a compensatory mechanism induced by profound systemic vasodilation and a decrease in mean arterial pressure. Despite marked sympathetic activation, vasoconstrictor responsiveness is blunted during uncomplicated pregnancy. There are race and ethnic differences in maternal hemodynamic adaptations to uncomplicated pregnancy, which may be attributed to differences in socioeconomic status or in prevalence rates of cardiovascular risk factors.

Low Plasma Volume Coincides With Sympathetic Hyperactivity and Reduced Baroreflex Sensitivity In Formerly Preeclamptic Patients

BACKGROUND

Preeclampsia is associated with enhanced sympathetic activity as well as subnormal plasma volume. Meanwhile, in over 50% of these complicated pregnancies, the subnormal plasma volume has been found to persist for a prolonged period after pregnancy. The objective of this study is to test the hypothesis that in normotensive formerly-preeclamptic women, persistence of a subnormal plasma volume coincides with enhanced sympathetic activity and with it, an altered autonomic control of blood pressure.

METHODS

Forty-eight formerly-preeclamptic women participated in this study. After measurement of their plasma volume by iodine 125-albumin indicator dilution, they were subdivided into a group with a normal plasma volume (plasma volume > 48 ml/kg lean body mass) and a group with a subnormal plasma volume (< or = 48 ml/kg lean body mass). We performed spectral analysis on their beat-to-beat blood pressure and heart rate recordings and compared both groups using non-parametric tests.

RESULTS

Formerly-preeclamptic women with a subnormal plasma volume had a higher sympathetic activity (P = .001) and a lower baroreflex sensitivity (P = .04) than their counterparts with a normal plasma volume.

CONCLUSION

In normotensive formerly-preeclamptic women, a subnormal plasma volume coincides with a higher sympathetic activity in the blood pressure regulation and lower baroreflex sensitivity. Whether these alterations in the autonomic control mechanisms are a cause or effect of the subnormal plasma volume remains to be elucidated.

Influence of different breathing patterns on heart rate variability indices and reproducibility during experimental endotoxaemia in human subjects

HRV (heart rate variability) analysis is a widely employed method to assess cardiac autonomic nervous system activity. Accurate HRV measurement is critical to its value as a diagnostic and prognostic tool. Different breathing patterns may affect HRV, but results obtained under static conditions are conflicting. HRV indices decrease considerably during systemic inflammation evoked by experimental endotoxaemia, enabling the determination of the effects of different breathing patterns on HRV in a dynamic setting. We investigated the impact of different breathing patterns on short-term HRV measurements during experimental endotoxaemia. Furthermore, we assessed whether paced breathing improved HRV reproducibility. Twelve healthy male volunteers received an intravenous bolus (2 ng/kg of body weight) of endotoxin [LPS (lipopolysaccharide), derived from Escherichia coli O:113] on two occasions with an interval of 2 weeks. Five-minute HRV recordings were performed just prior to LPS administration and hourly thereafter until 8 h post-LPS. Three breathing protocols were employed every hour: (i) spontaneous breathing, (ii) metronome-guided breathing at the subject's normal respiratory rate ('paced') and (iii) metronome-guided breathing at 150% of the subject's normal respiratory rate ('mild hyperventilation'). LPS administration resulted in a sharp decrease in all of the HRV indices measured, which was similar during both LPS administrations. Neither paced breathing nor mild hyperventilation influenced HRV indices compared with spontaneous breathing. Paced breathing did not improve reproducibility as it did not exert a significant effect on intra-subject coefficients of variation and intra-class correlation coefficients (calculated between both visits). In conclusion, over a wide range of HRV magnitudes during experimental endotoxaemia, neither paced breathing nor mild hyperventilation affected HRV indices. Moreover, paced breathing did not result in a significant improvement in reproducibility. Therefore employing a paced breathing protocol is not required to obtain valid HRV data during endotoxaemia.

Angiotensin-(1-7) antagonist, A-779, microinjection into the caudal ventrolateral medulla of renovascular hypertensive rats restores baroreflex bradycardia

In the present study we evaluated the effect of caudal ventrolateral medulla (CVLM) microinjection of the main angiotensin (Ang) peptides, Ang II and Ang-(1-7), and their selective antagonists on baseline arterial pressure (AP) and on baroreceptor-mediated bradycardia in renovascular hypertensive rats (2K1C). Microinjection of Ang II and Ang-(1-7) into the CVLM of 2K1C rats produced similar decrease in AP as observed in Sham rats. In both Sham and 2K1C, the hypotensive effect of Ang II and Ang-(1-7) at the CVLM was blocked, for up to 30 min, by previous CVLM microinjection of the Ang II AT1 receptor antagonist, Losartan, and Ang-(1-7) Mas antagonist, A-779, respectively. As expected, the baroreflex bradycardia was lower in 2K1C in comparison to Sham rats. CVLM microinjection of A-779 improved the sensitivity of baroreflex bradycardia in 2K1C hypertensive rats. In contrast, Losartan had no effect on the baroreflex bradycardia in either 2K1C or Sham rats. These results suggest that Ang-(1-7) at the CVLM may contribute to the low sensitivity of the baroreflex control of heart rate in renovascular hypertensive rats.

Autonomic circulatory control during pregnancy in humans

Pregnancy is associated with dramatic alterations in maternal hemodynamics, which begin as early as 4 to 5 weeks of gestation. It has been proposed that these changes occur through autonomic control mechanisms, but the actual role of the autonomic nervous system in pregnancy is poorly understood. Here, we review what is known about the hemodynamic adaptation, changes in vascular endothelial function, sympathetic neural control and vascular responsiveness in pregnancy, and baroreflex function during pregnancy in humans. However, whether and how the sympathetic nervous system plays a role in hemodynamic homeostasis during EARLY human pregnancy remains completely unknown. Understanding the pathophysiology underlying autonomic control of maternal hemodynamics may be particularly important for prevention of cardiovascular complications during pregnancy and may improve risk stratification and prevention of cardiovascular disease for women well beyond the postpartum period.

Theoretical and electrophysiological evidence for axial loading about aortic baroreceptor nerve terminals in rats

Arterial baroreceptors are essential for neurocirculatory control, providing rapid hemodynamic feedback to the central nervous system. The pressure-dependent discharge of carotid and aortic baroreceptor afferents has been extensively studied. A common assumption has been that circumferential deformation of the arterial wall is the predominant mechanical force affecting baroreceptor discharge. However, in vivo the arterial tree is under significant longitudinal tension, leading to the hypothesis that axially directed forces may contribute to baroreceptor function. To test this hypothesis, we utilized a combination of finite element modeling methods and an in vitro rat aortic arch preparation. Model formulation utilized traditional analytic constructs available in the literature followed by refinement of model material parameters through direct comparison of computationally and experimentally generated pressure-diameter curves. The numerical simulations strongly indicated a functional role for axial loading within the region of the baroreceptive nerve terminal. This prediction was confirmed through single-fiber recording of baroreceptor nerve discharge under conditions with and without longitudinal tension in the vessel preparation. The recordings (n = 5) demonstrated that longitudinal tension significantly (P < 0.02) lowered both the pressure threshold (P(th), mmHg) for baroreceptor discharge and sensitivity (S(th), Hz/mmHg). The effect was nearly instantaneous and sustained; i.e., under longitudinal tension average P(th) was 84 +/- 3 mmHg and S(th) was 0.71 +/- 0.15 Hz/mmHg, which immediately increased to a P(th) of 94 +/- 4 mmHg and a S(th) of 1.20 +/- 0.32 Hz/mmHg with loss of axial tension. Possible explanations of how an abrupt change in axial loading could result in a synchronized increase in afferent drive of the baroreceptor reflex, and the potentiating effect this could have on neurogenically mediated orthostatic intolerance are discussed.

Nitric oxide impairs baroreflex gain during acute psychological stress

Psychological stress can suppress baroreflex function, but the mechanism has not been fully elucidated. Nitric oxide in the brain and in the adrenal cortex, as well as plasma glucocorticoids, increases during stress and has been shown to suppress reflex gain in unstressed animals. Therefore, the purpose of this study was to test the hypothesis that stress, caused by exposure to a novel environment, decreases baroreflex gain in rabbits through the actions of nitric oxide to increase corticosterone release. Baroreflex control of heart rate and plasma corticosterone levels was quantified before and after blockade of nitric oxide synthase (NOS) with N(omega)-nitro-L-arginine (L-NNA; 20 mg/kg iv) in conscious rabbits exposed to a novel environment and in the same rabbits once they had been conditioned to the environment. Stress significantly reduced baroreflex gain from -23.4 +/- 2 to -12.2 +/- 1.6 beats x min(-1) x mmHg(-1) (P < 0.05) and increased plasma corticosterone levels from 5.4 +/- 0.7 to 15.5 +/- 5.0 ng/ml (P < 0.05). NOS blockade increased gain in stressed animals (to -27.2 +/- 5.4 beats x min(-1) x mmHg(-1), P < 0.05) but did not alter gain in unstressed rabbits (-26.8 +/- 4.9 beats x min(-1) x mmHg(-1)) such that gain was equalized between the two states. NOS blockade increased plasma corticosterone levels in unstressed animals (to 14.3 +/- 2.1 ng/ml, P < 0.05) but failed to significantly alter levels in stressed rabbits (14.0 +/- 3.9 ng/ml). In conclusion, psychological stress may act via nitric oxide, independently of increases in corticosterone, to decrease baroreflex gain.

Characteristics of Blood Pressure in Pheochromocytoma

Pheochromocytomas are catecholamine-producing tumors arising from chromaffin cells. One of the most typical symptoms of the catecholamine-excess state is hypertension either in the sustained or paroxysmal form, and its severity does not depend on the level of circulating catecholamines. On the other hand, hypertension in pheochromocytoma is very often characterized by the amelioration or even inversion of the circadian blood pressure rhythm. In some subjects, high circulating levels of catecholamines lead to the enhanced blood pressure variability. One possible explanation for such blood pressure variability is the desensitization of the catecholamine receptors due to high levels of circulating catecholamines.