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Dani M, Taraborrelli P, Panagopoulos D, Dirksen A, Torocastro M, Sutton R, Lim PB. New horizons in the ageing autonomic nervous system: orthostatic hypotension and supine hypertension. Age Ageing 2022; 51:6653480. [PMID: 35930723 PMCID: PMC9724614 DOI: 10.1093/ageing/afac150] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Indexed: 01/25/2023] Open
Abstract
Blood pressure regulation is an automatic, moment-by-moment buffering of the blood pressure in response to physiological changes such as orthostasis, exercise and haemorrhage. This finely orchestrated reflex is called the baroreflex. It is a regulated arc of afferent, central and efferent arms. Multiple physiological changes occur with ageing that can disrupt this reflex, making blood pressure regulation less effective. In addition, multiple changes can occur with ageing-related diseases such as neurodegeneration, atherosclerosis, deconditioning and polypharmacy. These changes commonly result in orthostatic hypotension, hypertension or both, and are consistently associated with multiple adverse outcomes. In this article, we discuss the healthy baroreflex, and physiological and pathophysiological reasons for impaired baroreflex function in older people. We discuss why the common clinical manifestations of orthostatic hypotension and concomitant supine hypertension occur, and strategies for balancing these conflicting priorities. Finally, we discuss strategies for treating them, outlining our practice alongside consensus and expert guidance.
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Affiliation(s)
- Melanie Dani
- Address correspondence to: Melanie Dani, Imperial Syncope Unit, Hammersmith Hospital, London W12 0HS, UK.
| | | | | | - Andreas Dirksen
- Imperial Syncope Unit, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Miriam Torocastro
- Imperial Syncope Unit, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Richard Sutton
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Phang Boon Lim
- Imperial Syncope Unit, Imperial College Healthcare NHS Trust, London W12 0HS, UK
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2
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Wang W, Zhornitsky S, Le TM, Zhang S, Li CSR. Heart Rate Variability, Cue-Evoked Ventromedial Prefrontal Cortical Response, and Problem Alcohol Use in Adult Drinkers. BIOLOGICAL PSYCHIATRY: COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2020; 5:619-628. [PMID: 32061544 DOI: 10.1016/j.bpsc.2019.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 11/25/2019] [Accepted: 12/13/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Many studies employed cue exposure paradigms to investigate the neural processes underlying cue-elicited alcohol craving. Cue exposure elicits robust autonomic reactivity. However, whether or how cue-elicited autonomic response relates to the severity of alcohol misuse and the neural bases underlying the potential relationship remain unclear. METHODS We examined cue-related brain activations in association with heart rate variability, as indexed by the root mean square of the successive differences (RMSSD), during alcohol versus neutral cue blocks in 50 adult alcohol drinkers (24 men). Imaging and heart rate variability data were collected and processed with published routines. Mediation analyses were conducted to examine the interrelationship between regional activities, cue-elicited changes in RMSSD, and the severity of problem alcohol use, as assessed with the Alcohol Use Disorders Identification Test (AUDIT). RESULTS The results showed higher RMSSD during alcohol than during neutral cue exposures, with alcohol (vs. neutral) cue-evoked RMSSD positively correlated with AUDIT score. Further, alcohol (vs. neutral) cue-elicited activity in the ventromedial prefrontal cortex was negatively correlated both with increases in RMSSD and with the AUDIT score. Mediation analyses suggested that the RMSSD mediated the relationship between ventromedial prefrontal cortex cue activity and the AUDIT score. CONCLUSIONS These findings substantiate the neural correlates of the presumably parasympathetic response during alcohol cue exposure and the interrelationship among ventromedial prefrontal cortex activity, autonomic response, and problem alcohol use.
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Affiliation(s)
- Wuyi Wang
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
| | - Simon Zhornitsky
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
| | - Thang M Le
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
| | - Sheng Zhang
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
| | - Chiang-Shan R Li
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut; Department of Neuroscience, Yale University School of Medicine, New Haven, Connecticut; Department of Interdepartmental Neuroscience Program, Yale University, New Haven, Connecticut.
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Bozhokin SV, Lesova EM, Samoilov VO, Barantsev KA. Nonstationary Heart Rate Variability during the Head-Down Tilt Test. Biophysics (Nagoya-shi) 2020. [DOI: 10.1134/s0006350920010029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Cutsforth-Gregory JK, Sandroni P. Clinical neurophysiology of postural tachycardia syndrome. HANDBOOK OF CLINICAL NEUROLOGY 2019; 161:429-445. [PMID: 31307619 DOI: 10.1016/b978-0-444-64142-7.00066-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Postural tachycardia syndrome (POTS) is one of several disorders of orthostatic intolerance (OI). It is defined by the development of symptoms of cerebral hypoperfusion or sympathetic activation and a sustained heart rate increment of 30 beats/min or more (40 beats/min for teenagers) within 10min of standing or head-up tilt in the absence of orthostatic hypotension; the standing heart rate is often 120 beats/min or higher. POTS is approximately five times more common in women than men. This heterogeneous syndrome is caused by several pathophysiologic mechanisms (limited autonomic neuropathy, hyperadrenergic state, hypovolemia, venous pooling, deconditioning), which are not mutually exclusive. Anxiety and somatic hypervigilance play significant roles in POTS. Common comorbidities include visceral pain and dysmotility, chronic fatigue and fibromyalgia, migraine, joint hypermobility, mitral valve prolapse, and inappropriate sinus tachycardia. Patients with suspected POTS should undergo comprehensive cardiac and neurologic examinations and autonomic and laboratory tests to determine the most likely pathophysiologic basis of OI. The objectives of POTS management are to (1) increase the time that patients can stand, perform daily activities, and exercise and (2) avoid syncope. Management involves nonpharmacologic (fluid and salt loading, physical countermaneuvers, compression garments, exercise training) and pharmacologic (β-blockers, pyridostigmine, fludrocortisone, midodrine) approaches.
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Affiliation(s)
| | - Paola Sandroni
- Department of Neurology, Mayo Clinic, Rochester, MN, United States.
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Sklerov M, Dayan E, Browner N. Functional neuroimaging of the central autonomic network: recent developments and clinical implications. Clin Auton Res 2018; 29:555-566. [PMID: 30470943 PMCID: PMC6858471 DOI: 10.1007/s10286-018-0577-0] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/07/2018] [Indexed: 12/08/2023]
Abstract
Purpose The central autonomic network (CAN) is an intricate system of brainstem, subcortical, and cortical structures that play key roles in the function of the autonomic nervous system. Prior to the advent of functional neuroimaging, in vivo studies of the human CAN were limited. The purpose of this review is to highlight the contribution of functional neuroimaging, specifically functional magnetic resonance imaging (fMRI), to the study of the CAN, and to discuss recent advances in this area. Additionally, we aim to emphasize exciting areas for future research. Methods We reviewed the existing literature in functional neuroimaging of the CAN. Here, we focus on fMRI research conducted in healthy human subjects, as well as research that has been done in disease states, to understand CAN function. To minimize confounding, papers examining CAN function in the context of cognition, emotion, pain, and affective disorders were excluded. Results fMRI has led to significant advances in the understanding of human CAN function. The CAN is composed of widespread brainstem and forebrain structures that are intricately connected and play key roles in reflexive and modulatory control of autonomic function. Conclusions fMRI technology has contributed extensively to current knowledge of CAN function. It holds promise to serve as a biomarker in disease states. With ongoing advancements in fMRI technology, there is great opportunity and need for future research involving the CAN.
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Affiliation(s)
- Miriam Sklerov
- Department of Neurology, University of North Carolina, 170 Manning Drive, CB# 7025, Chapel Hill, NC, 27599, USA.
| | - Eran Dayan
- Department of Radiology and Biomedical Research Imaging Center, University of North Carolina, 130 Mason Farm Road, CB# 7513, Chapel Hill, NC, 27599, USA
| | - Nina Browner
- Department of Neurology, University of North Carolina, 170 Manning Drive, CB# 7025, Chapel Hill, NC, 27599, USA
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Edgell H, Grinberg A, Beavers KR, Gagné N, Hughson RL. Efficacy of fluid loading as a countermeasure to the hemodynamic and hormonal changes of 28-h head-down bed rest. Physiol Rep 2018; 6:e13874. [PMID: 30298552 PMCID: PMC6175712 DOI: 10.14814/phy2.13874] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 08/26/2018] [Indexed: 11/24/2022] Open
Abstract
After exposure to microgravity, or head-down bed rest (HDBR), fluid loading is often used with the intent of increasing plasma volume and maintaining mean arterial pressure during orthostatic stress. Nine men (aged 18-32 years) underwent three randomized trials with lower body negative pressure (LBNP) before and after: (1) 4-h of sitting with fluid loading (1 g sodium chloride/125 mL of water starting 2.5-h before LBNP), (2) 28-h of 6-degree HDBR without fluid loading, and (3) 28-h of 6-degree HDBR with fluid loading. LBNP was progressive from 0 to -40 mmHg. After 28-h HDBR, fluid loading did not protect against the loss of plasma volume (-280 ± 64 mL without fluid loading, -207 ± 86 with fluid loading, P = 0.472) nor did it protect against a drop of mean arterial pressure (P = 0.017) during LBNP (Post-28 h HDBR response from 0 to -40 mmHg LBNP: 88 ± 4 to 85 ± 4 mmHg without fluid loading and 93 ± 4 to 88 ± 5 mmHg with fluid loading, P = 0.557 between trials). However, fluid loading did protect against the loss of stroke volume index and central venous pressure observed after 28-h HDBR. Fluid loading also attenuated the increase of angiotensin II seen after 28-h HDBR and throughout the LBNP protocol (Post-28 h HDBR response from 0 to -40 mmHg LBNP: 16.6 ± 3.4 to 23.7 ± 5.0 pg/mL without fluid loading and 6.1 ± 0.8 to 12.2 ± 2.3 pg/mL with fluid loading, P < 0.001 between trials). Our results indicate that fluid loading did not protect against plasma volume loss due to HDBR or change blood pressure responses to LBNP. However, changes in central venous pressure, stroke volume and fluid regulatory hormones could potentially influence longer duration studies and those with more severe orthostatic stress.
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Affiliation(s)
- Heather Edgell
- Faculty of Applied Health SciencesUniversity of WaterlooWaterlooOntarioCanada
- School of Kinesiology and Health SciencesYork UniversityTorontoOntarioCanada
| | - Anna Grinberg
- Faculty of Applied Health SciencesUniversity of WaterlooWaterlooOntarioCanada
| | - Keith R. Beavers
- Faculty of Applied Health SciencesUniversity of WaterlooWaterlooOntarioCanada
| | - Nathalie Gagné
- Faculty of Applied Health SciencesUniversity of WaterlooWaterlooOntarioCanada
| | - Richard L. Hughson
- Faculty of Applied Health SciencesUniversity of WaterlooWaterlooOntarioCanada
- Schlegel‐University of Waterloo Research Institute for AgingWaterlooOntarioCanada
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A review of human neuroimaging investigations involved with central autonomic regulation of baroreflex-mediated cardiovascular control. Auton Neurosci 2017; 207:10-21. [DOI: 10.1016/j.autneu.2017.05.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 03/10/2017] [Accepted: 05/13/2017] [Indexed: 12/30/2022]
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Koppelmans V, Bloomberg JJ, De Dios YE, Wood SJ, Reuter-Lorenz PA, Kofman IS, Riascos R, Mulavara AP, Seidler RD. Brain plasticity and sensorimotor deterioration as a function of 70 days head down tilt bed rest. PLoS One 2017; 12:e0182236. [PMID: 28767698 PMCID: PMC5540603 DOI: 10.1371/journal.pone.0182236] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 07/15/2017] [Indexed: 12/18/2022] Open
Abstract
Background Adverse effects of spaceflight on sensorimotor function have been linked to altered somatosensory and vestibular inputs in the microgravity environment. Whether these spaceflight sequelae have a central nervous system component is unknown. However, experimental studies have shown spaceflight-induced brain structural changes in rodents’ sensorimotor brain regions. Understanding the neural correlates of spaceflight-related motor performance changes is important to ultimately develop tailored countermeasures that ensure mission success and astronauts’ health. Method Head down-tilt bed rest (HDBR) can serve as a microgravity analog because it mimics body unloading and headward fluid shifts of microgravity. We conducted a 70-day 6° HDBR study with 18 right-handed males to investigate how microgravity affects focal gray matter (GM) brain volume. MRI data were collected at 7 time points before, during and post-HDBR. Standing balance and functional mobility were measured pre and post-HDBR. The same metrics were obtained at 4 time points over ~90 days from 12 control subjects, serving as reference data. Results HDBR resulted in widespread increases GM in posterior parietal regions and decreases in frontal areas; recovery was not yet complete by 12 days post-HDBR. Additionally, HDBR led to balance and locomotor performance declines. Increases in a cluster comprising the precuneus, precentral and postcentral gyrus GM correlated with less deterioration or even improvement in standing balance. This association did not survive Bonferroni correction and should therefore be interpreted with caution. No brain or behavior changes were observed in control subjects. Conclusions Our results parallel the sensorimotor deficits that astronauts experience post-flight. The widespread GM changes could reflect fluid redistribution. Additionally, the association between focal GM increase and balance changes suggests that HDBR also may result in neuroplastic adaptation. Future studies are warranted to determine causality and underlying mechanisms.
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Affiliation(s)
- Vincent Koppelmans
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan, United States of America
| | | | | | - Scott J. Wood
- NASA Johnson Space Center, Houston, TX, United States of America
| | | | | | - Roy Riascos
- The University of Texas Health Science Center, Houston, TX, United States of America
| | | | - Rachael D. Seidler
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan, United States of America
- Department of Psychology, University of Michigan, Ann Arbor, Michigan, United States of America
- Neuroscience Program, University of Michigan, Ann Arbor, Michigan, United States of America
- * E-mail:
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Cassady K, Koppelmans V, Reuter-Lorenz P, De Dios Y, Gadd N, Wood S, Castenada RR, Kofman I, Bloomberg J, Mulavara A, Seidler R. Effects of a spaceflight analog environment on brain connectivity and behavior. Neuroimage 2016; 141:18-30. [DOI: 10.1016/j.neuroimage.2016.07.029] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 06/22/2016] [Accepted: 07/12/2016] [Indexed: 01/25/2023] Open
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Ruiz Vargas E, Sörös P, Shoemaker JK, Hachinski V. Human cerebral circuitry related to cardiac control: A neuroimaging meta-analysis. Ann Neurol 2016; 79:709-716. [DOI: 10.1002/ana.24642] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Revised: 03/14/2016] [Accepted: 03/16/2016] [Indexed: 12/30/2022]
Affiliation(s)
| | - Peter Sörös
- Department of Neurology; University of Lübeck; Lübeck Germany
| | - J. Kevin Shoemaker
- School of Kinesiology; University of Western Ontario; London Ontario Canada
| | - Vladimir Hachinski
- Department of Clinical Neurological Sciences, London Health Sciences Centre; Western University; London Ontario Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry; Western University; London Ontario Canada
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Shoemaker JK, Goswami R. Forebrain neurocircuitry associated with human reflex cardiovascular control. Front Physiol 2015; 6:240. [PMID: 26388780 PMCID: PMC4555962 DOI: 10.3389/fphys.2015.00240] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 08/10/2015] [Indexed: 12/30/2022] Open
Abstract
Physiological homeostasis depends upon adequate integration and responsiveness of sensory information with the autonomic nervous system to affect rapid and effective adjustments in end organ control. Dysregulation of the autonomic nervous system leads to cardiovascular disability with consequences as severe as sudden death. The neural pathways involved in reflexive autonomic control are dependent upon brainstem nuclei but these receive modulatory inputs from higher centers in the midbrain and cortex. Neuroimaging technologies have allowed closer study of the cortical circuitry related to autonomic cardiovascular adjustments to many stressors in awake humans and have exposed many forebrain sites that associate strongly with cardiovascular arousal during stress including the medial prefrontal cortex, insula cortex, anterior cingulate, amygdala and hippocampus. Using a comparative approach, this review will consider the cortical autonomic circuitry in rodents and primates with a major emphasis on more recent neuroimaging studies in awake humans. A challenge with neuroimaging studies is their interpretation in view of multiple sensory, perceptual, emotive and/or reflexive components of autonomic responses. This review will focus on those responses related to non-volitional baroreflex control of blood pressure and also on the coordinated responses to non-fatiguing, non-painful volitional exercise with particular emphasis on the medial prefrontal cortex and the insula cortex.
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Affiliation(s)
- J Kevin Shoemaker
- School of Kinesiology, The University of Western Ontario London, ON, Canada ; Department of Physiology and Pharmacology, The University of Western Ontario London, ON, Canada
| | - Ruma Goswami
- School of Kinesiology, The University of Western Ontario London, ON, Canada
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Hughson RL, Shoemaker JK. Autonomic responses to exercise: Deconditioning/inactivity. Auton Neurosci 2015; 188:32-5. [DOI: 10.1016/j.autneu.2014.10.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 10/13/2014] [Indexed: 12/29/2022]
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Benarroch EE. Postural tachycardia syndrome: a heterogeneous and multifactorial disorder. Mayo Clin Proc 2012; 87:1214-25. [PMID: 23122672 PMCID: PMC3547546 DOI: 10.1016/j.mayocp.2012.08.013] [Citation(s) in RCA: 241] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 08/28/2012] [Accepted: 08/28/2012] [Indexed: 02/07/2023]
Abstract
Postural tachycardia syndrome (POTS) is defined by a heart rate increment of 30 beats/min or more within 10 minutes of standing or head-up tilt in the absence of orthostatic hypotension; the standing heart rate is often 120 beats/min or higher. POTS manifests with symptoms of cerebral hypoperfusion and excessive sympathoexcitation. The pathophysiology of POTS is heterogeneous and includes impaired sympathetically mediated vasoconstriction, excessive sympathetic drive, volume dysregulation, and deconditioning. POTS is frequently included in the differential diagnosis of chronic unexplained symptoms, such as inappropriate sinus tachycardia, chronic fatigue, chronic dizziness, or unexplained spells in otherwise healthy young individuals. Many patients with POTS also report symptoms not attributable to orthostatic intolerance, including those of functional gastrointestinal or bladder disorders, chronic headache, fibromyalgia, and sleep disturbances. In many of these cases, cognitive and behavioral factors, somatic hypervigilance associated with anxiety, depression, and behavioral amplification contribute to symptom chronicity. The aims of evaluation in patients with POTS are to exclude cardiac causes of inappropriate tachycardia; elucidate, if possible, the most likely pathophysiologic basis of postural intolerance; assess for the presence of treatable autonomic neuropathies; exclude endocrine causes of a hyperadrenergic state; evaluate for cardiovascular deconditioning; and determine the contribution of emotional and behavioral factors to the patient's symptoms. Management of POTS includes avoidance of precipitating factors, volume expansion, physical countermaneuvers, exercise training, pharmacotherapy (fludrocortisone, midodrine, β-blockers, and/or pyridostigmine), and behavioral-cognitive therapy. A literature search of PubMed for articles published from January 1, 1990, to June 15, 2012, was performed using the following terms (or combination of terms): POTS; postural tachycardia syndrome, orthostatic; orthostatic; syncope; sympathetic; baroreceptors; vestibulosympathetic; hypovolemia; visceral pain; chronic fatigue; deconditioning; headache; Chiari malformation; Ehlers-Danlos; emotion; amygdala; insula; anterior cingulate; periaqueductal gray; fludrocortisone; midodrine; propranolol; β-adrenergic; and pyridostigmine. Studies were limited to those published in English. Other articles were identified from bibliographies of the retrieved articles.
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