Cardiac autonomic control in health and disease

Historical Perspective of the Cardiac Autonomic Nervous System

The contemporary history of the cardiac autonomic nervous system includes early descriptions of neuroanatomy in the 19th century, followed by an understanding of the physiologic determinants of neurocardiology in the 20th century. Neurology and cardiology preceded the arrival of clinical cardiac electrophysiology, a specialized field in medicine devoted to the diagnosis and treatment of cardiac arrhythmias. The rapid growth in pharmacology, ablation, pacing and defibrillation, associated with significant technological breakthroughs, have resulted in new opportunities for neuromodulation in the 21st century. Small changes in autonomic tone can potentially provide important therapeutic benefits for patients with cardiac and arrhythmia disorders.

Molecular and cellular neurocardiology in heart disease

This paper updates and builds on a previous White Paper in this journal that some of us contributed to concerning the molecular and cellular basis of cardiac neurobiology of heart disease. Here we focus on recent findings that underpin cardiac autonomic development, novel intracellular pathways and neuroplasticity. Throughout we highlight unanswered questions and areas of controversy. Whilst some neurochemical pathways are already demonstrating prognostic viability in patients with heart failure, we also discuss the opportunity to better understand sympathetic impairment by using patient specific stem cells that provides pathophysiological contextualization to study 'disease in a dish'. Novel imaging techniques and spatial transcriptomics are also facilitating a road map for target discovery of molecular pathways that may form a therapeutic opportunity to treat cardiac dysautonomia.

Relationship between Non-Invasive Brain Stimulation and Autonomic Nervous System

Non-invasive brain stimulation (NIBS) approaches have seen a rise in utilization in both clinical and basic neuroscience in recent years. Here, we concentrate on the two methods that have received the greatest research: transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS). Both approaches have yielded pertinent data regarding the cortical excitability in subjects in good health as well as pertinent advancements in the management of various clinical disorders. NIBS is a helpful method for comprehending the cortical control of the ANS. Previous research has shown that there are notable changes in muscular sympathetic nerve activity when the motor cortex is modulated. Furthermore, in NIBS investigations, the ANS has been employed more frequently as an outcome measure to comprehend the overall impacts of these methods, including their safety profile. Though there is ample proof that brain stimulation has autonomic effects on animals, new research on the connection between NIBS and the ANS has produced contradictory findings. In order to better understand NIBS processes and ANS function, it is crucial to take into account the reciprocal relationship that exists between central modulation and ANS function.

Opportunities and challenges of pain-related myocardial ischemia-reperfusion injury

Pain is one of the most serious problems plaguing human health today. Pain is not an independent pathophysiological condition and is associated with a high impact on elevated disability and organ dysfunction. Several lines of evidence suggested the associations of pain with cardiovascular diseases, especially myocardial ischemia-reperfusion (I/R) injury, while the role of pain in I/R injury and related mechanisms are not yet comprehensively assessed. In this review, we attempted to explore the role of pain in myocardial I/R injury, and we concluded that acute pain protects myocardial ischemia-reperfusion injury and chronic pain aggravates cardiac ischemia-reperfusion injury. In addition, the construction of different pain models and animal models commonly used to study the role of pain in myocardial I/R injury were discussed in detail, and the potential mechanism of pain-related myocardial I/R injury was summarized. Finally, the future research direction was prospected. That is, the remote regulation of pain to cardiac function requires peripheral pain signals to be transmitted from the peripheral to the cardiac autonomic nervous system, which then affects autonomic innervation during cardiac ischemia-reperfusion injury and finally affects the cardiac function.

Electrophysiology and Arrhythmogenesis in the Human Right Ventricular Outflow Tract

BACKGROUND

Right ventricular outflow tract (RVOT) is a common source of ventricular tachycardia, which often requires ablation. However, the mechanisms underlying the RVOT's unique arrhythmia susceptibility remain poorly understood due to lack of detailed electrophysiological and molecular studies of the human RVOT.

METHODS

We conducted optical mapping studies in 16 nondiseased donor human RVOT preparations subjected to pharmacologically induced adrenergic and cholinergic stimulation to evaluate susceptibility to arrhythmias and characterize arrhythmia dynamics.

RESULTS

We found that under control conditions, RVOT has shorter action potential duration at 80% repolarization relative to the right ventricular apical region. Treatment with isoproterenol (100 nM) shortened action potential duration at 80% repolarization and increased incidence of premature ventricular contractions (P=0.003), whereas acetylcholine (100 μM) stimulation alone had no effect on action potential duration at 80% repolarization or premature ventricular contractions. However, acetylcholine treatment after isoproterenol stimulation reduced the incidence of premature ventricular contractions (P=0.034) and partially reversed action potential duration at 80% repolarization shortening (P=0.029). Immunolabeling of RVOT (n=4) confirmed the presence of cholinergic marker VAChT (vesicular acetylcholine transporter) in the region. Rapid pacing revealed RVOT susceptibility to both concordant and discordant alternans. Investigation into transmural arrhythmia dynamics showed that arrhythmia wave fronts and phase singularities (rotors) were relatively more organized in the endocardium than in the epicardium (P=0.006). Moreover, there was a weak but positive spatiotemporal autocorrelation between epicardial and endocardial arrhythmic wave fronts and rotors. Transcriptome analysis (n=10 hearts) suggests a trend that MAPK (mitogen-activated protein kinase) signaling, calcium signaling, and cGMP-PKG (protein kinase G) signaling are among the pathways that may be enriched in the male RVOT, whereas pathways of neurodegeneration may be enriched in the female RVOT.

CONCLUSIONS

Human RVOT electrophysiology is characterized by shorter action potential duration relative to the right ventricular apical region. Cholinergic right ventricular stimulation attenuates the arrhythmogenic effects of adrenergic stimulation, including increase in frequency of premature ventricular contractions and shortening of wavelength. Right ventricular arrhythmia is characterized by positive spatial-temporal autocorrelation between epicardial-endocardial arrhythmic wave fronts and rotors that are relatively more organized in the endocardium.

Brainstem network connectivity with mid-anterior insula predicts lower systolic blood pressure at rest in older adults with hypertension

Central regulation of heart rate and blood pressure provides the bases for a neurogenic mechanism of hypertension (HTN). Post menopause (PM) age coincides with changes in resting state functional brain connectivity (rsFC) as well as increased risk for HTN. Whether the neural networks underpinning cardioautonomic control differ between PM women with and without HTN is unclear. Phenotypic and functional neuroimaging data from the Nathan Kline Institute was first evaluated for group differences in intrinsic network connectivity between 22 HTN post menopausal women and 22 normotensive controls. Intrinsic rsFC of the midbrain-brainstem-cerebellar network with bilateral mid-anterior insula was lower in women with HTN (FWE-corrected, p < 0.05). Z-scores indicating rsFC of these regions were extracted from the 44 PM women and a cohort of 111 adults, not presenting with metabolic or neurodegenerative disease, and compared to in-office systolic and diastolic blood pressure. Lower rsFC of the left (r  = -0.17, p = 0.019) and right (r  = -0.14, p = 0.048) mid-anterior insula with brainstem nuclei was associated with higher systolic blood pressure in the combined sample. The magnitude of this effect in men and women of post menopausal age supports a neurogenic mechanism for blood pressure regulation in older adults with HTN.

Autonomic modulation of ventricular electrical activity: recent developments and clinical implications

PURPOSE

This review aimed to provide a complete overview of the current stance and recent developments in antiarrhythmic neuromodulatory interventions, focusing on lifethreatening vetricular arrhythmias.

METHODS

Both preclinical studies and clinical studies were assessed to highlight the gaps in knowledge that remain to be answered and the necessary steps required to properly translate these strategies to the clinical setting.

RESULTS

Cardiac autonomic imbalance, characterized by chronic sympathoexcitation and parasympathetic withdrawal, destabilizes cardiac electrophysiology and promotes ventricular arrhythmogenesis. Therefore, neuromodulatory interventions that target the sympatho-vagal imbalance have emerged as promising antiarrhythmic strategies. These strategies are aimed at different parts of the cardiac neuraxis and directly or indirectly restore cardiac autonomic tone. These interventions include pharmacological blockade of sympathetic neurotransmitters and neuropeptides, cardiac sympathetic denervation, thoracic epidural anesthesia, and spinal cord and vagal nerve stimulation.

CONCLUSION

Neuromodulatory strategies have repeatedly been demonstrated to be highly effective and very promising anti-arrhythmic therapies. Nevertheless, there is still much room to gain in our understanding of neurocardiac physiology, refining the current neuromodulatory strategic options and elucidating the chronic effects of many of these strategic options.

Resting cardiac sympathetic firing frequencies suppress terminal norepinephrine transporter uptake

The prejunctional norepinephrine transporter (NET) is responsible for the clearance of released norepinephrine (NE) back into the sympathetic nerve terminal. NET regulation must be tightly controlled as variations could have important implications for neurotransmission. Thus far, the effects of sympathetic neuronal activity on NET function have been unclear. Here, we optically monitor single-terminal cardiac NET activity ex vivo in response to a broad range of sympathetic postganglionic action potential (AP) firing frequencies. Isolated murine left atrial appendages were loaded with a fluorescent NET substrate [Neurotransmitter Transporter Uptake Assay (NTUA)] and imaged with confocal microscopy. Sympathetic APs were induced with electrical field stimulation at 0.2-10 Hz (0.1-0.2 ms pulse width). Exogenous NE was applied during the NTUA uptake- and washout phases to investigate substrate competition and displacement, respectively, on transport. Single-terminal NET reuptake rate was rapidly suppressed in a frequency-dependent manner with an inhibitory EF₅₀ of 0.9 Hz. At 2 Hz, the effect was reversed by the α₂-adrenoceptor antagonist yohimbine (1 μM) (p < 0.01) with no further effect imposed by the muscarinic receptor antagonist atropine (1 μM). Additionally, high exogenous NE concentrations abolished NET reuptake (1 μM NE; p < 0.0001) and displaced terminal specific NTUA during washout (1-100 μM NE; p < 0.0001). We have also identified α₂-adrenoceptor-induced suppression of NET reuptake rate during resting stimulation frequencies, which could oppose the effect of autoinhibition-mediated suppression of exocytosis and thus amplify the effects of sympathetic drive on cardiac function.

Association between autonomic function and obstructive sleep apnea: A systematic review

Obstructive sleep apnea (OSA) is an independent risk factor for hypertension and cardiovascular disease. Effects of OSA on the autonomic nervous system may mediate this association. We performed a systematic literature review to determine the profile of autonomic function associated with OSA. Three electronic databases were searched for studies of OSA patients aged ≥18 years in which autonomic function was assessed. Studies comparing patients with and without OSA, or examining the association of OSA severity with changes in autonomic function were included. Seventy-one studies met the inclusion criteria and autonomic function has been assessed using a range of techniques. The profile of autonomic function found in OSA include increased sympathetic activity, reduced parasympathetic activity and less consistently found low heart rate variability. Altered autonomic function in OSA may explain the pathophysiology of increased cardiovascular risk. Evidence from intervention studies is required to determine if treatment improves autonomic function associated with OSA.

Autonomic Modulation for Cardiovascular Disease

Dysfunction of the autonomic nervous system has been implicated in the pathogenesis of cardiovascular disease, including congestive heart failure and cardiac arrhythmias. Despite advances in the medical and surgical management of these entities, progression of disease persists as does the risk for sudden cardiac death. With improved knowledge of the dynamic relationships between the nervous system and heart, neuromodulatory techniques such as cardiac sympathetic denervation and vagal nerve stimulation (VNS) have emerged as possible therapeutic approaches for the management of these disorders. In this review, we present the structure and function of the cardiac nervous system and the remodeling that occurs in disease states, emphasizing the concept of increased sympathoexcitation and reduced parasympathetic tone. We review preclinical evidence for vagal nerve stimulation, and early results of clinical trials in the setting of congestive heart failure. Vagal nerve stimulation, and other neuromodulatory techniques, may improve the management of cardiovascular disorders, and warrant further study.

Cardiac Autonomic Control in Women with Rheumatoid Arthritis During the Glittre Activities of Daily Living Test

Background: Cardiovascular autonomic dysfunction is one of the most common complications in rheumatoid arthritis (RA), which can be assessed by heart rate variability (HRV) analysis. Because the autonomic nervous system plays an important role in orchestrating the cardiovascular response to stressors, assessing HRV during exercise is critical. The Glittre Activities of Daily Living test (GA-T) was recently proposed as a multitask field test that requires the performance of the upper and lower limbs, both of which are affected in individuals with RA. Objectives: This study was conducted to evaluate autonomic impairment by HRV in women with RA using the GA-T and to correlate these changes with physical functioning and muscle strength. Methods: This cross-sectional study enrolled 20 women (median [interquartile range]: age 55 [47.5 - 68.8] years) with RA (time since diagnosis: 15 [6.50 - 23.5] years) who underwent HRV assessment during GA-T. They also underwent physical functioning assessment through the Health Assessment Questionnaire Disability Index (HAQ-DI) and handgrip strength (HGS) and quadriceps strength (QS) measures. Results: The GA-T time exhibited significant correlations with the following HRV indices: root mean square of successive differences (RMSSD, rs = -0.451, P = 0.041), proportion of iRR differing by > 50 ms from previous intervals (pNN50, rs = -0.697, P = 0.0006), high frequency (HF, rs = -0.693, P = 0.0007), standard deviation of the points perpendicular to the line-of-identity (SD1, rs = -0.476, P = 0.034), and approximate entropy (ApEn, rs = 0.545, P = 0.013). In addition, the HAQ-DI exhibited significant correlations with the following HRV indices: pNN50 (rs = -0.467, P = 0.038) and HF (rs = -0.444, P = 0.049). We did not observe significant correlation between the HRV indices during the GA-T and the muscle strength measures (HGS and QS). Conclusions: In women with RA, the longer the required to perform the GA-T the worse their parasympathetic modulation, sympathetic-vagal imbalance, and complexity of the autonomic nervous system (i.e., increased index of ApEn) were. Physical functioning level was also related to vagal modulation.

Take my breath away: Neural activation at breath-hold differentiates individuals with panic disorder from healthy controls

There is neuroanatomical evidence of an "extended fear network" of brain structures involved in the etiology of panic disorder (PD). Although ventilatory distrubance is a primary symptom of PD these sensations may also trigger onset of a panic attack (PA). Here, a voluntary breath-holding paradigm was used to mimic the hypercapnia state in order to compare blood oxygen level-dependent (BOLD) response, at the peak of a series of 18 s breath-holds, of 21 individuals with PD to 21 low anxiety matched controls. Compared to the rest condition, BOLD activity at the peak (12 - 18 s) of the breath-hold was greater for PD versus controls within a number of structures implicated in the extended fear network, including hippocampus, thalamus, and brainstem. Activation was also observed in cortical structures that are shown to be involved in interoceptive and self-referential processing, such as right insula, middle frontal gyrus, and precuneus/posterior cingulate. In lieu of amygdala activation, our findings show elevated activity throughout an extended network of cortical and subcortical structures involved in contextual, interoceptive and self-referential processing when individuals with PD engage in voluntary breath-holding.

Dynamic monitoring of single-terminal norepinephrine transporter rate in the rodent cardiovascular system: A novel fluorescence imaging method

Here, we validate the use of a novel fluorescent norepinephrine transporter (NET) substrate for dynamic measurements of transporter function in rodent cardiovascular tissue; this technique avoids the use of radiotracers and provides single-terminal resolution. Rodent (Wistar rats and C57BL/6 mice) hearts and mesenteric arteries (MA) were isolated, loaded with NET substrate Neurotransmitter Transporter Uptake Assay (NTUA) ex vivo and imaged with confocal microscopy. NTUA labelled noradrenergic nerve terminals in all four chambers of the heart and on the surface of MA. In all tissues, a temperature-dependent, stable linear increase in intra-terminal fluorescence upon NTUA exposure was observed; this was abolished by NET inhibitor desipramine (1 μM) and reversed by indirectly-acting sympathomimetic amine tyramine (10 μM). NET reuptake rates were similar across the mouse cardiac chambers. In both species, cardiac NET activity was significantly greater than in MA (by 62 ± 29% (mouse) and 21 ± 16% (rat)). We also show that mouse NET reuptake rate was twice as fast as that in the rat (for example, in the heart, by 94 ± 30%). Finally, NET reuptake rate in the mouse heart was attenuated with muscarinic agonist carbachol (10 μM) thus demonstrating the potential for parasympathetic regulation of norepinephrine clearance. Our data provide the first demonstration of monitoring intra-terminal NET function in rodent cardiovascular tissue. This straightforward method allows dynamic measurements of transporter rate in response to varying physiological conditions and drug treatments; this offers the potential to study new mechanisms of sympathetic dysfunction associated with cardiovascular disease.

Physiological changes in sleep that affect fMRI inference

fMRI relies on a localized cerebral blood flow (CBF) response to changes in cortical neuronal activity. An underappreciated aspect however is its sensitivity to contributions from autonomic physiology that may affect CBF through changes in vascular resistance and blood pressure. As is reviewed here, this is crucial to consider in fMRI studies of sleep, given the close linkage between the regulation of arousal state and autonomic physiology. Typical methods for separating these effects are based on the use of reference signals that may include physiological parameters such as heart rate and respiration; however, the use of time-invariant models may not be adequate due to the possibly changing relationship between reference and fMRI signals with arousal state. In addition, recent research indicates that additional physiological reference signals may be needed to accurately describe changes in systemic physiology, including sympathetic indicators such as finger skin vascular tone and blood pressure.

Cardiac sympathetic innervation, from a different point of (re)view

The audience of basic and clinical scientists is familiar with the notion that the sympathetic nervous system controls heart function during stresses. However, evidence indicates that the neurogenic control of the heart spans from the maintenance of housekeeping functions in resting conditions to the recruitment of maximal performance, in the fight-or-flight responses, across a whole range of intermediate states. To perform such sophisticated functions, sympathetic ganglia integrate both peripheral and central inputs, and transmit information to the heart via 'motor' neurons, directly interacting with target cardiomyocytes. To date, the dynamics and mode of communication between these two cell types, which determine how neuronal information is adequately translated into the wide spectrum of cardiac responses, are still blurry. By combining the anatomical and structural information brought to light by recent imaging technologies and the functional evidence in cellular systems, we focus on the interface between neurons and cardiomyocytes, and advocate the existence of a specific 'neuro-cardiac junction', where sympathetic neurotransmission occurs in a 'quasi-synaptic' way. The properties of such junctional-type communication fit well with those of the physiological responses elicited by the cardiac sympathetic nervous system, and explain its ability to tune heart function with precision, specificity and elevated temporal resolution.

Influence of cardiac nerve status on cardiovascular regulation and cardioprotection

Neural elements of the intrinsic cardiac nervous system transduce sensory inputs from the heart, blood vessels and other organs to ensure adequate cardiac function on a beat-to-beat basis. This inter-organ crosstalk is critical for normal function of the heart and other organs; derangements within the nervous system hierarchy contribute to pathogenesis of organ dysfunction. The role of intact cardiac nerves in development of, as well as protection against, ischemic injury is of current interest since it may involve recruitment of intrinsic cardiac ganglia. For instance, ischemic conditioning, a novel protection strategy against organ injury, and in particular remote conditioning, is likely mediated by activation of neural pathways or by endogenous cytoprotective blood-borne substances that stimulate different signalling pathways. This discovery reinforces the concept that inter-organ communication, and maintenance thereof, is key. As such, greater understanding of mechanisms and elucidation of treatment strategies is imperative to improve clinical outcomes particularly in patients with comorbidities. For instance, autonomic imbalance between sympathetic and parasympathetic nervous system regulation can initiate cardiovascular autonomic neuropathy that compromises cardiac stability and function. Neuromodulation therapies that directly target the intrinsic cardiac nervous system or other elements of the nervous system hierarchy are currently being investigated for treatment of different maladies in animal and human studies.

Cardioprotective Action of Ginkgo biloba Extract against Sustained β-Adrenergic Stimulation Occurs via Activation of M2/NO Pathway

Ginkgo biloba is the most popular phytotherapic agent used worldwide for treatment of several human disorders. However, the mechanisms involved in the protective actions of Ginkgo biloba on cardiovascular diseases remain poorly elucidated. Taking into account recent studies showing beneficial actions of cholinergic signaling in the heart and the cholinergic hypothesis of Ginkgo biloba-mediated neuroprotection, we aimed to investigate whether Ginkgo biloba extract (GBE) promotes cardioprotection via activation of cholinergic signaling in a model of isoproterenol-induced cardiac hypertrophy. Here, we show that GBE treatment (100 mg/kg/day for 8 days, v.o.) reestablished the autonomic imbalance and baroreflex dysfunction caused by chronic β-adrenergic receptor stimulation (β-AR, 4.5 mg/kg/day for 8 days, i.p.). Moreover, GBE prevented the upregulation of muscarinic receptors (M₂) and downregulation of β₁-AR in isoproterenol treated-hearts. Additionally, we demonstrated that GBE prevents the impaired endothelial nitric oxide synthase activity in the heart. GBE also prevented the pathological cardiac remodeling, electrocardiographic changes and impaired left ventricular contractility that are typical of cardiac hypertrophy. To further investigate the mechanisms involved in GBE cardioprotection in vivo, we performed in vitro studies. By using neonatal cardiomyocyte culture we demonstrated that the antihypertrophic action of GBE was fully abolished by muscarinic receptor antagonist or NOS inhibition. Altogether, our data support the notion that antihypertrophic effect of GBE occurs via activation of M₂/NO pathway uncovering a new mechanism involved in the cardioprotective action of Ginkgo biloba.