Effects of cardiac denervation on blood pressure and heart rate during natural sleep in the cat

Distinction between epileptic and non-epileptic arousal by heart rate change

OBJECTIVE

We investigated the difference in heart rate (HR) change between epileptic and non-epileptic arousals in adult patients with epilepsy (PWE).

METHODS

This is a case-control study conducted at the University Hospitals of Cleveland Medical Center. Inclusion criteria are (1) adult (≥18 years old) PWE who had arousal related to a focal aware or impaired awareness automatism seizure with or without focal to bilateral tonic-clonic seizure during an Epilepsy Monitoring Unit (EMU) admission between January 2009 and January 2021 or (2) adult PWE who had a non-epileptic arousal during an EMU admission between July 2020 and January 2021. Outcomes are (1) a percent change in baseline HR within 60 s after arousal and (2) the highest percent change in baseline HR within a 10-s sliding time window within 60 s after arousal.

RESULTS

We included 20 non-epileptic arousals from 20 adult PWE and 29 epileptic arousals with seizures from 29 adult PWE. Within 60 s after arousal, HR increased by a median of 86.7% (interquartile range (IQR), 52.7%-121.3%) in the epileptic arousal group compared to a median of 26.1% (12.9%-43.3%) in the non-epileptic arousal group (p < 0.001). The cut-off value was 48.7%. The area under the curve (AUC), sensitivity, and specificity were 0.85, 0.79, and 0.80, respectively. More than 70.1% was only in the epileptic arousals, with 100% specificity. Within 10 s of the greatest change, HR increased by 36.5 (18.7%-48.4%) in the epileptic arousal group compared to 17.7 (10.9%-23.7%) in the non-epileptic arousal group (p < 0.001). The cut-off value was 36.5%. The AUC, sensitivity, and specificity were 0.79, 0.52, and 0.95, respectively. More than 48.1% was only in the epileptic arousals, with 100% specificity.

SIGNIFICANCE

Tachycardia during epileptic arousals was significantly higher and more robust compared to tachycardia during non-epileptic arousals.

Systemic and pulmonary hemodynamic responses to normal and obstructed breathing during sleep

We examined the hemodynamic responses to normal breathing and induced upper airway obstructions during sleep in a canine model of obstructive sleep apnea. During normal breathing, cardiac output decreased (12.9 +/- 3.5%, P < 0.025) from wakefulness to non-rapid-eye-movement sleep (NREM) but did not change from NREM to rapid-eye-movement (REM) sleep. There was a decrease (P < 0.05) in systemic (7.2 +/- 2.1 mmHg) and pulmonary (2.0 +/- 0.6 mmHg) arterial pressures from wakefulness to NREM sleep. In contrast, systemic (8.1 +/- 1.0 mmHg, P < 0.025), but not pulmonary, arterial pressures decreased from NREM to REM sleep. During repetitive airway obstructions (56.0 +/- 4.7 events/h) in NREM sleep, cardiac output (17.9 +/- 3.1%) and heart rate (16.2 +/- 2.5%) increased (P < 0.05), without a change in stroke volume, compared with normal breathing during NREM sleep. During single obstructive events, left (7.8 +/- 3.0%, P < 0.05) and right (7.1 +/- 0.7%, P < 0.01) ventricular outputs decreased during the apneic period. However, left (20.7 +/- 1.6%, P < 0.01) and right (24.0 +/- 4.2%, P < 0.05) ventricular outputs increased in the post-apneic period because of an increase in heart rate. Thus 1) the systemic, but not the pulmonary, circulation vasodilates during REM sleep with normal breathing; 2) heart rate, rather than stroke volume, is the dominant factor modulating ventricular output in response to apnea; and 3) left and right ventricular outputs oscillate markedly and in phase throughout the apnea cycle.

Twenty-four-hour ambulatory blood pressure and vasoactive hormones in valvular aortic disease

The aim of this study was to assess the blood pressure profile and vasoactive hormones in valvular aortic disease. Thirteen aortic stenosis and/or aortic regurgitation patients were matched with 13 control subjects. Ambulatory blood pressure monitoring was performed for 24 h. Arterial and venous plasma concentrations of renin, angiotensin II, aldosterone, arginine vasopressin, atrial natriuretic peptide, immunoreactive endothelin and cyclic-GMP were measured. The mean 24-h blood pressure was higher in the patient group (94.9 mmHg) compared with control subjects (88.2 mmHg) (p < 0.0001), despite no differences in daytime blood pressures. The nocturnal blood pressure fall was attenuated in the patients (systolic/diastolic blood pressure -8.5/-3.5; -20.3/-14.3 mmHg (p < 0.001/p < 0.01)); in heart rate too the nightly fall was blunted in the patients (-4.8/ -13.4/min (p < 0.0013)). PRA, Ang II, AVP, ANP, ir-ET and cGMP were significantly increased in the patients compared to the controls. Nightly systolic blood pressure fall was inversely related to arterial (r = -0.75, p < 0.003) and venous (r = -0.65, p < 0.04) plasma renin activity and arterial aldosterone (r = -0.64, p < 0.05) in valvular aortic disease patients. In conclusion, valvular aortic disease patients have attenuated falls in blood pressure and heart rate during the night. Increased activity in the renin aldosterone system may be involved in this abnormal blood pressure regulation.

Serial changes in blood pressure and neurohormone levels after the onset of lacunar stroke

To assess serial changes in blood pressure and its circadian variation following a lacunar stroke, the authors studied 7 patients who developed a single lacunar infarction in either the internal capsule or the corona radiata. Blood pressure and pulse rate were monitored noninvasively for twenty-four hours by an ambulatory blood pressure monitoring device in the acute, subacute, and chronic phases of the strokes. In the acute and chronic phases, the authors also measured urinary excretion of catecholamines every 6 hr, and serum cortisol concentration at 9:00, 17:00, and 21:00 hr. The patients were free from antihypertensive agents during the study. The twenty-four-hour averages of both systolic and diastolic blood pressure in the chronic phase were lower than those in the acute phase (P < 0.05). A nighttime fall in blood pressure was observed in the subacute and chronic phases (P < 0.05), but not in the acute phase. Urinary excretion of epinephrine at night in the acute phase was significantly higher than that in the chronic phase (P < 0.05). Serum levels of cortisol at 17:00 and 21:00 hr in the acute phase also exceeded those in the chronic phase (P < 0.05 and P < 0.01, respectively). The authors conclude that an increased secretion of epinephrine and cortisol might, at least in part, contribute to a high blood pressure and a lack of circadian variation in blood pressure in the acute phase of lacunar stroke.

Diurnal blood pressure variation and hormonal correlates in fatal familial insomnia

Fatal familial insomnia is a prion disease in which a selective thalamic degeneration leads to total sleep deprivation, hypertension, dysautonomia, adrenal overactivity, and impaired motor functions. With patients under continuous recumbency and polysomnographic control, we assessed the changes in the 24-hour patterns of blood pressure, heart rate, plasma catecholamines, corticotropin, and serum cortisol in three patients at different stages of the disease. Six healthy volunteers were used as control subjects. A dominant 24-hour component was detected at rhythm analysis of all variables, both in patients and control subjects. In the patients, the amplitudes gradually decreased as the disease progressed, leading to the obliteration of any significant dirunal variation only in the preterminal stage. A shift in phase corresponded to the loss of the nocturnal fall in blood pressure in an early stage of the disease, when nocturnal bradycardia was still preserved. Plasma cortisol was high and became increasingly elevated, whereas corticotropin remained within normal levels; abnormal nocturnal peaks appeared in their circadian patterns. The disrupted patterns of cortisol and blood pressure preceded the development of hypertension and severe dysautonomia, which in turn were paralleled by increasing catecholamine and heart rate levels. Our data demonstrate that in patients with fatal familial insomnia the changes detectable in the rhythmic component of diurnal blood pressure variability result in a pattern of secondary hypertension. Disturbances in thalamic, pituitary-adrenal, and autonomic functions seem to be involved in mediating these changes.

Experimentally induced intermittent sinusoidal heart rate pattern and sleep cycle in fetal lambs

OBJECTIVE

Intermittent sinusoidal heart rate pattern, an early indicator of fetal anemia, has been speculated to have a positive correlation with fetal sleep cycles. To test this hypothesis, intermittent sinusoidal heart rate patterns were produced experimentally with arginine vasopressin in six methylatropinized fetal lambs that were demonstrating clear rapid-eye-movement and non-rapid-eye-movement sleep cycling.

STUDY DESIGN

Eleven trials of arginine vasopressin infusion (40 to 160 mIU per body per minute) were performed on each of six chronically instrumented fetal lambs subsequent to parasympathetic blocking doses of methylatropine (300 to 400 micrograms). An intermittent sinusoidal heart rate pattern was observed in relation to fetal sleep cycles.

RESULTS

Alteration between rapid-eye-movement and non-rapid-eye-movement sleep was observed in methylatropinized fetuses. In the six fetuses that showed intermittent sinusoidal heart rate patterns subsequent to arginine vasopressin infusion, the fetal heart rate tracing and fetal electrocorticogram demonstrated alternate sinusoidal pattern and reactive heart rate patterns during high- and low-voltage electrocorticogram activity, respectively.

CONCLUSION

These findings support the hypothesis that fetal sleep cycling has a positive correlation with the periodic appearance of intermittent sinusoidal heart rate patterns.

Autonomic nervous system regulation of baseline heart rate in the fetal lamb

OBJECTIVE

We examined 29 chronically instrumented fetal lambs from 125 to 143 days' gestation to investigate the effects of fetal behavioral states and autonomic nervous system maturation on baseline fetal heart rate.

STUDY DESIGN

Behavioral states were defined from electrocorticographic analysis as low-voltage fast activity or high-voltage slow activity. Decrease and increase in baseline fetal heart rate subsequent to administration of propranolol and methylatropine represented beta-sympathetic and parasympathetic activity.

RESULTS

Baseline fetal heart rate decreased with gestation in both states, with steeper regression in low-voltage fast activity (p less than 0.001). Positive correlation was noted between gestational age and percent decrease baseline fetal heart rate in both states with steeper regression in high-voltage slow activity (p less than 0.001), and between gestational age and percent increase baseline fetal heart rate with steeper regression in low-voltage fast activity (p less than 0.001). Fetal heart rate beta-sympathetic and parasympathetic tones increased with age in both states, with elevation of beta-sympathetic tone in high-voltage slow activity and parasympathetic tone in low-voltage fast activity.

CONCLUSION

Sympathetic and parasympathetic systems influence baseline fetal heart rate in these behavioral states and with age.

Altered circadian blood pressure rhythm in patients with Cushing's syndrome

The circadian blood pressure rhythm was compared in patients with Cushing's syndrome, essential hypertension, and primary aldosteronism. In patients with essential hypertension or primary aldosteronism, a clear nocturnal fall in systolic and diastolic blood pressure and heart rate was observed. This fall was seen in untreated subjects as well as in patients receiving combined treatment with a calcium antagonist, diuretic, converting enzyme inhibitor, alpha-blocker and beta-blocker, or sympatholytic drug. In these groups, there was a positive correlation between heart rate and systolic or diastolic blood pressure. On the other hand, in patients with Cushing's syndrome, there was no nocturnal fall in blood pressure but in some patients a rise was observed. In all patients there was a nocturnal fall in heart rate. Thus, there was no significant correlation between heart rate and blood pressure in these patients. Exogenous glucocorticoid eliminated the normal nocturnal fall of blood pressure in patients with chronic glomerulonephritis or systemic lupus erythematosus. These results suggest that the changed circadian blood pressure pattern in patients with Cushing's syndrome is not due to antihypertensive treatment or to the mineralocorticoid excess accompanying this disease, but it is attributable to excess glucocorticoid or the associated disturbance in the adrenocorticotropic hormone-glucocorticoid system (or both). This conclusion also implies that the normal circadian rhythm of blood pressure may be regulated at least in part by the adrenocorticotropic hormone-glucocorticoid system.

Relationship between fluctuations in heart rate and asymptomatic nocturnal ischaemia

In order to quantify autonomic changes related to asymptomatic nocturnal myocardial ischaemia, we analyzed heart rate fluctuations recorded during Holter monitoring in 9 subjects with coronary heart disease (21 episodes) and in 11 age-matched controls. R-R interval spectral analysis was computed in sequences of 256 heart beats, taken during the ischaemic episode, 4, 8 and 60 minutes before, and 4 and 60 minutes after. Mean heart rate, R-R interval variability (assessed by R-R interval standard deviation), low and high (respiration-linked) frequency components of R-R interval spectrum were evaluated. Mean heart rate and R-R interval variability increased only during ischaemia (from 62.9 to 73.3 beats/minute, P less than 0.02, and from 39 to 88 msec, P less than 0.01, respectively). While high-frequency components of heart rate variability remained unchanged, low-frequency peak increased during ischaemia (from 9.4 to 43.3 sec2 X 10(-3)/Hz, P less than 0.01) and also 8 minutes (P less than 0.05) and 4 minutes before (P less than 0.05). Despite a moderate increase of heart rate occurring only during ischaemia, the early rearrangement of heart rate fluctuations suggests the occurrence of changes of autonomic tone before the electrocardiographic onset of ischaemia. Due to its limited amount, this phenomenon appears to be a consequence, most likely unspecific, of factors responsible for the genesis of myocardial ischaemia.

Cyclic variation in fetal heart rate and sympathetic activity

The effects of alpha- and beta-adrenergic blockade on electrocortical activity-related cyclic variability in fetal heart rate and mean arterial pressure were investigated in eight fetal lambs between 119 and 138 days of gestation. In the absence of adrenergic blockade, fetal heart rate during high-voltage slow activity was significantly higher than that during low-voltage fast activity. Propranolol (2.0 mg/hr) produced a decrease in fetal heart rate, but the decrease was only statistically significant during high-voltage slow activity. Phentolamine (5.0 mg/hr) induced a significant increase in fetal heart rate with a small but statistically significant decrease in mean arterial pressure. The cyclic variability in fetal heart rate between low-voltage fast activity and high-voltage slow activity was abolished by propranolol and enhanced by phentolamine. These results indicate that the cyclic variability in the fetal heart rate associated with electrocortical activity can be accounted for by cyclic fluctuation in sympathetic activity.

Arterial baroreceptor fibers from the aortic region of the dog in the cervical vagus nerve

The neural pathways followed by sensory fibers from arterial baroreceptors in the aortic region of the dog were investigated with neurophysiological recording. Systemic arterial baroreceptor fibers separate from the depressor nerve were found in the left cervical vagus in each of five dogs investigated; at most two fibers were isolated from each dog due to the difficulty of the dissection. These fibers originated from or above the aortic arch region. One baroreceptor fiber had its arterial sensory ending below the fifth rib. In the right cervical vagus in six dogs, visual evidence of fiber activity from systemic arterial baroreceptors could not be produced; only subjective (auditory) evidence for the presence of systemic arterial baroreceptor fibers was obtained. The number of these arterial baroreceptor fibers, which run in the vagus nerve but are not part of the depressor nerve, appeared to be smaller than the number of arterial baroreceptor fibers in the depressor nerve.

Hemodynamic characteristics of chronic experimental neurogenic hypertension in unanesthetized dogs

The hemodynamic changes accompanying experimental neurogenic hypertension due to sinoaortic denervation were measured in unanesthetized dogs for 3 weeks with chronically implanted arterial catheters and aortic flow transducers. Hypertension was modest, the average increase in mean arterial pressure being 31 ± 5 (SE) mm Hg. In about half of the dogs it was due predominantly to increase in cardiac output and in the others to increase in peripheral resistance; one factor or the other tended to maintain the hypertension in each dog throughout the experiments. Arterial pressure became extremely labile during the first few days after denervation and remained so during the entire experiment. This lability was closely correlated with environmental stimuli; rather minor distractions caused a sharp fall in pressure due variably to decrease in both cardiac output and peripheral resistance; greater distractions or physical activity caused a rise in pressure due usually to increase in peripheral resistance. Mean arterial pressures were higher when measured by transcutaneous puncture of a femoral artery, presumably because of the necessity of restraint and the discomfort associated with passage of a needle. Before sinoaortic denervation, arterial pressures fell to basal levels during sleep. After denervation, unexpectedly and for an undetermined cause, pressures rose to very high levels during sleep; the rises were consistently due to increase in peripheral resistance. Awakening was accompanied by a sharp fall in pressure and peripheral resistance.

Hemodynamic patterns during desynchronized sleep in intact cats and in cats with sinoaortic deafferentation

In unanesthetized, unrestrained cats, placed in a sound-attenuated cage, stroke volume and cardiac output were continuously monitored by an electromagnetic flow transducer chronically implanted around the ascending aorta, arterial pressure was measured by means of a femoral catheter connected to a strain-gauge transducer, and heart rate by a cardiotachograph. Total resistance was computed by dividing arterial pressure by cardiac output. Electroencephalograms, cervical electromyogram, and ocular movements were also monitored to obtain evidence of naturally occurring sleep. In animals with intact sinoaortic reflexes the fall in arterial pressure occurring during desynchronized sleep was associated with a small decrease in cardiac output and a relatively greater reduction in total resistance. After sinoaortic deafferentation, the conspicuously exaggerated fall in arterial pressure occurring during the same type of sleep was almost entirely due to a parallel exaggeration of the reduction in total resistance; changes in cardiac output were only slightly greater than before deafferentation. Only in the few episodes of desynchronized sleep in which extreme hypotension was accompanied by signs of cerebral anoxia, did cardiac output greatly decrease; in these cases, calculated resistance was found to increase. Both small and large changes in cardiac output were independent of heart innervation.