The baroreflex bandwagon: time to get off?

Baroreflex activation for the treatment of hypertension: principles and practice

This article reviews the history and current status of an innovative nonpharmacological approach for the treatment of resistant hypertension - chronic electrical activation of the afferent limb of the carotid baroreflex. Recent studies in both normotensive and hypertensive canine models have unambiguously demonstrated sustained and clinically relevant reductions in arterial pressure and sympathetic activity in the course of prolonged baroreflex activation. Clinical trials designed to evaluate the efficacy and safety of this therapy in patients with resistant hypertension are now underway in both Europe and the USA.

Prolonged activation of the baroreflex: A viable approach for the treatment of hypertension?

In most patients with hypertension, arterial pressure is above the target level for control, even in those individuals taking multiple antihypertensive drugs. In this article, we review the history and current status of a nonpharmacologic approach for the treatment of hypertension--chronic electrical activation of the afferent limb of the carotid baroreflex. Recent studies in normotensive and hypertensive dogs have clearly demonstrated impressive and sustained reductions in arterial pressure and sympathetic activity during prolonged baroreflex activation. Clinical trials are now underway in Europe, and clinical investigation in the United States will begin this year to evaluate the efficacy of this therapy in patients with resistant hypertension.

Nonlinearities and asymmetries of the human cardiovagal baroreflex

To determine whether an approach such as the modified Oxford technique can consistently produce data that reveal the nonlinear nature of the cardiovagal baroreflex and to ascertain whether the model parameters provide unique insight into baroreflex function, we retrospectively examined 91 baroreflex trials (38 subjects, 27 men and 11 women, ages 22-72 yr). The modified Oxford technique (bolus sodium nitroprusside followed by bolus phenylephrine) was used to perturb blood pressure, and the resulting systolic blood pressure-R-R interval responses were plotted and modeled using a linear, a four-parameter symmetric, and a five-parameter asymmetric model. Several issues, such as the effect of data averaging, various approaches to gain estimation, and the predictive value of model parameters, were examined during reflex modeling. Sigmoid models accounted for a greater amount of the variance than did the linear model: linear r2=0.81+/-0.01, four-parameter r2=0.90+/-0.08, and five-parameter r2=0.90+/-0.08 (P<0.05, linear vs. sigmoid models). Data averaging did not affect model fits. Although the four gain estimates (linear remodel, 1st derivative, peak, and set point) were statistically related, the set point gain was significantly lower than other estimates (P<0.05). Subgroup comparisons between young and older healthy subjects revealed differences in all indexes of cardiovagal baroreflex gain, as well as R-R interval operating range and curvature parameters. In conclusion, the modified Oxford technique consistently reveals the nonlinear nature of the human cardiovagal baroreflex. Moreover, of the parameters produced by the symmetric sigmoid model, only the response range provides unique information beyond that of reflex gain.

Overexpression of eNOS in RVLM improves impaired baroreflex control of heart rate in SHRSP. Rostral ventrolateral medulla. Stroke-prone spontaneously hypertensive rats

We previously demonstrated that the overexpression of endothelial nitric oxide synthase (eNOS) in the rostral ventrolateral medulla (RVLM) decreases blood pressure, heart rate (HR), and sympathetic nerve activity and that these effects are enhanced in stroke-prone spontaneously hypertensive rats (SHRSP). The aim of this study was to determine if an increase in NO production in the RVLM caused by the overexpression of eNOS improves the impaired baroreflex control of HR in SHRSP. We transfected adenovirus vectors encoding eNOS (AdeNOS) into the RVLM of SHRSP or Wistar-Kyoto rats (WKY). Mean arterial pressure and HR were measured by a radio-telemetry system in the conscious state. Reflex changes in HR were elicited by intravenous infusion of either phenylephrine, sodium nitroprusside, or hydralazine at day 7 after the gene transfer. The maximum gain of the baroreflex control of HR was significantly decreased in SHRSP compared with WKY. Overexpression of eNOS in the RVLM of SHRSP improved the impaired maximum gain of the baroreflex control of HR. After treatment with atropine, the maximum gain was still significantly greater in SHRSP in the AdeNOS-transfected group than in the nontransfected group, although it was decreased in both groups. In contrast, after treatment with metoprolol, the maximum gain did not differ between the two groups. These results indicate that an increase in NO production in the RVLM improves the impaired baroreflex control of HR in SHRSP and that these effects may have resulted from a cardiac sympathoinhibitory effect of NO in the RVLM of SHRSP.

Chronic inhibition of endothelial nitric oxide synthase activity in nucleus tractus solitarii enhances baroreceptor reflex in conscious rats

In acute experiments, we demonstrated previously that nitric oxide (NO) donors exogenously applied to the nucleus tractus solitarii (NTS) depressed the baroreceptor cardiac reflex. In this study, we determined a role for endogenous endothelial nitric oxide synthase (eNOS) activity in the NTS for chronically regulating baroreceptor reflex function in conscious rats. A recombinant adenoviral vector directing expression of a truncated form of eNOS was microinjected bilaterally into the NTS to inhibit endogenous eNOS activity. Arterial pressure was monitored continuously using radio-telemetry in freely moving animals and spontaneous baroreceptor reflex gain (sBRG) determined by a time-series method. sBRG showed a gradual increase from day 7 to 21 after gene transfer and the value at day 21 (1.68 +/- 0.20 ms mmHg(-1), n = 6) was significantly higher than that before gene transfer (1.13 +/- 0.09 ms mmHg(-1), P < 0.001). This value was also significantly higher than that in rats in which enhanced green fluorescent protein (eGFP) was expressed in the NTS (1.04 +/- 0.21 ms mmHg(-1); n = 6, P < 0.01) and saline-treated groups (1.12 +/- 0.15 ms mmHg(-1); n = 4, P < 0.05), which did not change from control levels. In addition, heart rate decreased from 336 +/- 6 to 318 +/- 8 b.p.m. (P < 0.05) 21 days after gene transfer. This value was also significantly lower than that in control groups (eGFP: 348 +/- 9 b.p.m., n = 6, P < 0.01; saline: 347 +/- 5 b.p.m., n = 4, P < 0.05). Gene transfer did not affect arterial pressure. These findings suggest that in the conscious rat eNOS is constitutively active within the NTS and is a factor regulating baroreceptor reflex gain and heart rate.