Effects of hemorrhage on renal nerve activity in conscious dogs

Integrated cardiorespiratory system model with short timescale control mechanisms

A compartmental model of the cardiorespiratory system featuring pulsatile blood flow and gas transport, as well as closed loop mechanisms of cardiorespiratory regulation is presented. Short timescale regulatory action includes baroreflex, peripheral and central chemoreflex feedback. The cardiorespiratory model is composed by compartments to describe blood flow and gas exchange in the major systemic and pulmonic regions. The control systems include formulations to afferent activity of arterial baroreceptor and peripheral and central chemoreceptors. Simulations described here include situations of hypoxia, hypercapnia, and hemorrhage. The overall responses of our simulations agree with physiological (experimental) and theoretical data. Our results suggest that the present model could be used to further understand the interplay among major regulatory mechanisms in the functioning of the cardiovascular and respiratory systems in cases of normal and abnormal physiological conditions.

Cardiovascular correlates of human emotional vasovagal syncope differ from those of animal freezing and tonic immobility

It has been suggested that vertebrate freezing and tonic immobility (TI) represent the antecedents of human emotional vasovagal syncope. When a prey detects an approaching predator, it suddenly interrupts its ongoing activity and behaves according to the predator's distance. A prey enters TI when the fight or flight reaction is not feasible and the animal is captured. TI is defined as a post-contact, all or none, innate immobility reflex response that persists after the end of the prey-predator contact. In humans, vasovagal syncope, a reversible adaptive response frequently associated with fainting, occurs in response to emergency conditions such as strong emotions, orthostatic stress, anoxia, visceral pain and decrease in blood volume. The aim of the present review is to dispute the hypothesis that human vasovagal syncope represents the evolution of the bradycardia observed during freezing in a prey-predator condition in other vertebrates. The hypothesis does not take into account three crucial issues: 1) freezing and TI are defence responses which differ from each other in behavioural, cardiovascular and neurophysiological correlates; 2) the initial phase of vasovagal syncope is associated with tachycardia, whereas freezing is associated with a sudden fast-developing bradycardia; 3) the second phase of vasovagal syncope terminates with a blood pressure collapse, whereas blood pressure levels remain at basal levels during both freezing and TI.

Biphasic Renal Sympathetic Response to Hemorrhagic Hypotension in Mice

AIM

The inhibitory responses of renal sympathetic nerve activity (RSNA) and heart rate (HR) to sustained hemorrhagic shock occurred in anesthetized rats, but have not yet been determined in mice. Here, we investigated the responses of RSNA and HR to hemorrhagic hypotension in anesthetized mice, with an emphasis on the molecule-based mechanism for roles of afferent vagal nerves.

METHODS

RSNA, HR, and mean systemic arterial pressure were continuously measured in male pentobarbital-anesthetized C57BL/6N mice. Hemorrhagic hypotension of 50 mmHg was evoked and maintained for 10 min.

RESULTS

During hemorrhagic hypotension, RSNA initially increased and then sustainedly decreased, while HR progressively decreased. Vagotomy eliminated the second-phase sympathoinhibition and bradycardia, and carotid sinus denervation with vagotomy abolished the initial renal sympathoexcitation. The renal sympathoinihibition during hemorrhagic hypotension of 50 mmHg was eliminated in mice pretreated with a transient receptor potential vanilloid type 1 channel (TRPV1) inhibitor, capsazepine, and in TRPV1 knockout (TRPV1) mice, but not in TRPV4 knockout mice. The bradycardia response to hemorrhagic hypotension was also absent in TRPV1 mice and mice pretreated with capsazepine.

CONCLUSION

Hemorrhagic hypotension in anesthetized mice causes biphasic responses of RSNA with an initial increase, followed by a sustained decrease, and a progressive decrease in HR. The initial sympathoexcitation is mediated by carotid sinus baroreceptors, while the later sympathoinhibition and bradycardia are mediated via the TRPV1 signals of vagal afferents.

Adrenaline: insights into its metabolic roles in hypoglycaemia and diabetes

Adrenaline is a hormone that has profound actions on the cardiovascular system and is also a mediator of the fight-or-flight response. Adrenaline is now increasingly recognized as an important metabolic hormone that helps mobilize energy stores in the form of glucose and free fatty acids in preparation for physical activity or for recovery from hypoglycaemia. Recovery from hypoglycaemia is termed counter-regulation and involves the suppression of endogenous insulin secretion, activation of glucagon secretion from pancreatic α-cells and activation of adrenaline secretion. Secretion of adrenaline is controlled by presympathetic neurons in the rostroventrolateral medulla, which are, in turn, under the control of central and/or peripheral glucose-sensing neurons. Adrenaline is particularly important for counter-regulation in individuals with type 1 (insulin-dependent) diabetes because these patients do not produce endogenous insulin and also lose their ability to secrete glucagon soon after diagnosis. Type 1 diabetic patients are therefore critically dependent on adrenaline for restoration of normoglycaemia and attenuation or loss of this response in the hypoglycaemia unawareness condition can have serious, sometimes fatal, consequences. Understanding the neural control of hypoglycaemia-induced adrenaline secretion is likely to identify new therapeutic targets for treating this potentially life-threatening condition.

Impaired blood pressure compensation following hemorrhage in conscious obese Zucker rats

AIMS

Hemorrhagic shock leads to a higher risk of mortality and morbidity in obese patients, however the mechanisms for these outcomes are unclear. We hypothesized that following severe hemorrhage, blood pressure control in conscious obese Zucker rats (OZ) is impaired.

MAIN METHODS

Experiments were performed in conscious lean Zucker rats (LZ) and OZ. Blood pressure, heart rate, cardiac output, total peripheral resistance (TPR), plasma renin activity (PRA), plasma antidiuretic hormone (ADH), and blood gasses were measured before and after severe hemorrhage (35% of the total blood volume).

KEY FINDINGS

Basal blood pressure, cardiac output, TPR, PRA, and ADH levels were not different between LZ and OZ. Compared to LZ, OZ exhibited impaired baroreflex control of heart rate and showed higher levels of vascular adrenergic tone. One hour after the hemorrhage, LZ and OZ exhibited similar decreases in cardiac output. However, blood pressure, heart rate, TPR, PRA, and ADH levels were lower in OZ than in LZ.

SIGNIFICANCE

These results indicate that conscious OZ has impaired blood pressure compensation after hemorrhage due to a blunted increase in TPR. This is due at least in part to an impaired regulation of vasoconstrictor hormones. To our knowledge, the current study is the first to demonstrate that hemodynamic responses and associated hormone secretion are impaired in a conscious obese model.

Negative feedforward control of body fluid homeostasis by hepatorenal reflex

The liver, well known for its role in metabolism, clearance and storage can also be regarded as a sensory organ. The liver is an ideal place to monitor the quality and quantity of absorbed substances, because portal blood delivers substances absorbed from the intestine to the liver and these substances circulate in the hepatic vasculature before substances enter the systemic circulation. Sodium (Na(+))-sensitive mechanism exists in the liver; it is stimulated by the increase in Na(+) concentration in the portal vein, and then hepatorenal reflex is triggered. Renal sympathetic nerve activity is reflexively decreased and urinary Na(+) excretion is increased. This Na(+)-sensitive hepatorenal reflex has a significant role in post-prandial natriuresis. However, the long-term role of this reflex in Na(+) homeostasis may be less important, probably because of the desensitization of Na(+)-sensitive mechanisms. Na(+)-K(+)-2Cl(-) cotransporter (NKCC1) is involved in the hepatoportal Na(+)-sensitive mechanism, and NKCC1 expression is reduced if the hepatoportal region is exposed to high Na(+) concentrations for a long time. This situation occurs when animals intake a high-sodium chloride diet for a long time. Liver cirrhosis also impairs the Na(+)-sensitive hepatorenal reflex. Hepatoportal baroreceptor-induced renal sympathetic excitation and the impaired Na(+)-sensitive hepatorenal reflex may partially explain the Na(+) retention in liver cirrhosis.

Discharge properties of cardiac and renal sympathetic nerves and their impaired responses to changes in blood volume in heart failure

Sympathetic nerve activity (SNA) consists of discharges that vary in amplitude and frequency, reflecting the level of recruitment of nerve fibers and the rhythmic generation and entrainment of activity by the central nervous system. It is unknown whether selective changes in these amplitude and frequency components account for organ-specific changes in SNA in response to alterations in blood volume or for the impaired SNA responses to volume changes in heart failure (HF). To address these questions, we measured cardiac SNA (CSNA) and renal SNA (RSNA) simultaneously in conscious, normal sheep and sheep in HF induced by rapid ventricular pacing. Volume expansion decreased CSNA (-62 +/- 10%, P < 0.05) and RSNA (-59 +/- 10%, P < 0.05) equally (n = 6). CSNA decreased as a result of a reduction in burst frequency, whereas RSNA fell because of falls in burst frequency and amplitude. Hemorrhage increased CSNA (+74 +/- 9%, P < 0.05) more than RSNA (+21 +/- 5%, P < 0.09), in both cases because of increased burst frequency, whereas burst amplitude decreased. In HF, burst frequency of CSNA (from 26 +/- 3 to 75 +/- 3 bursts/min) increased more than that of RSNA (from 63 +/- 4 to 79 +/- 4 bursts/min). In HF, volume expansion caused no change in CSNA and an attenuated decrease in RSNA, due entirely to decreased burst amplitude. Hemorrhage did not significantly increase SNA in either nerve in HF. These findings support the concept that the number of sympathetic fibers recruited and their firing frequency are controlled independently. Furthermore, afferent stimuli, such as changes in blood volume, cause organ-specific responses in each of these components, which are also selectively altered in HF.

The dmNTS is not the source of increased blood pressure variability in baroreflex denervated rats

A consistent and prominent feature, observed across many species, including our neuromuscular blocked (NMB) rat preparation, is that obliterating the baroafferent inputs to the brainstem, e.g., by sinoaortic denervation (SAD), significantly increases blood pressure variability (BPV). The sources of the BPV, however, are not completely understood, but involve both the central and the peripheral mechanisms. The key central noise source is likely in the brainstem. Previously, in NMB rats, we showed that the maximum gain of the baroreflex system is in the very low frequency (VLF) range of 0.01-0.2 Hz. In this study, using the same NMB preparation, we demonstrated that, after SAD, there was a significant increase in the VLF power of the expiratory systolic blood pressure (EsBP) spectrum, but a decrease in the VLF power of the expiratory heart inter-beat-interval (EIBI) spectrum. Because dmNTS is the only major common anatomic node for the vascular sympathetic and the cardiac parasympathetic pathways, the opposite changes in the post-SAD VLF powers of the EsBP and EIBI spectra suggest that dmNTS is unlikely the major noise source for the post-SAD BPV. Supporting this finding, we found that the dmNTS evoked response to single pulse baroreflex afferent aortic depressor nerve (ADN) stimuli was substantially more reliable than the evoked systolic blood pressure responses to the same stimuli.

Investigation of Various Types of Neurocardiogenic Response to Head-Up Tilting by Extended Hemodynamic and Neurohumoral Monitoring

BACKGROUND

The pathophysiology of neurocardiogenic syncope is heterogeneous. This study aim was to analyze whether extended monitoring during tilt-table testing provided additional information on the hemodynamic and vegetative state prior to neurocardiogenic syncope.

METHODS

This retrospective analysis is based on data of head-up tilt-table testing of 40 unselected consecutive patients with a history of unexplained syncope. For optimized characterization of the type of syncope, monitoring included electrocardiogram (ECG), blood pressure measurements and cardiac output, peripheral vascular resistance and contractility index measurements by impedance cardiography, as well as epinephrine and norepinephrine plasma levels in supine position and every 5 min during tilting.

RESULTS

Seven of 40 patients were unsuitable for analysis because of incomplete data sets. Tilt-table was positive in 26 patients, negative in 7. Groups did not differ in hemodynamic and catecholaminergic parameters at baseline. Responses to tilting were VASIS 1 (mix of cardioinhibitory and vasodepressor) in 5 patients, VASIS 2B (cardioinhibitory with asystole >3 sec) in 3, VASIS 3 (vasodepressor) in 16, orthostatic dysregulation in 2. In VASIS 1, the catecholamine measurement 4 min before syncope showed a proportionally larger increase of the epinephrine level than of norepinephrine. This disproportion was not observed in VASIS 2B and 3. In VASIS 2B, strong vasoconstriction and negative inotropy were evident in the presyncopal period. In VASIS 3, vascular resistance decreased continuously before syncope, while contractility index increased inadequately. Presyncopal epinephrine surge or norepinephrine loss was not observed in this group, suspecting other vasodilating factors.

CONCLUSIONS

Extended monitoring by impedance cardiography and plasma catecholamine measurements during tilt-table testing gave further insight into different hemodynamic and neurohumoral presyncopal patterns among the various types of neurocardiogenic syncope and may thereby help to develop individualized therapeutic concepts.

Sex differences in the respiratory response to hemorrhage in the conscious, New Zealand white rabbit

In conscious animals, the response to hemorrhage is biphasic. During phase 1, arterial pressure is maintained. Phase 2 is characterized by profound hypotension. Despite allied roles, less is known about the integrated cardiovascular and respiratory response to blood loss in conscious animals. We evaluated cardiorespiratory changes during hemorrhage to test the hypotheses that 1) respiratory rate (RR) and blood gases do not change during phase 1; 2) RR increases during phase 2; and 3) RR and blood gas changes during hemorrhage are similar in males and females. We measured mean arterial pressure, RR, and blood gases during hemorrhage in 16 conscious, chronically prepared, male and female New Zealand white rabbits. We removed venous blood until mean arterial pressure was ≤40 mmHg. Sex did not affect mean arterial pressure, heart rate, PaO2, PaCO2, or pH during hemorrhage or the blood loss required to induce phase 2. PaCO2 decreased significantly from 37 ± 1 to 33 ± 1 and 29 ± 1 mmHg ( P < 0.001) during phase 1 and 2, respectively. Before hemorrhage, PaO2 was 87 ± 2 mmHg. PaO2 was unchanged in phase 1 (92 ± 2 mmHg) but increased in phase 2 (101 ± 2 mmHg; P < 0.001). Body temperature, PvCO2 (thoracic vena cava), and ventilation-perfusion mismatch (A-a gradient) were unchanged during phases 1 and 2. Neither sex increased RR during phase 1. While males doubled RR during phase 2, RR in females did not change ( P < 0.001). Thus, while PaCO2 decreases in phase 1 and phase 2, the decreases are achieved in different ways across the two phases and in the two sexes.

Normovolaemia defined by central blood volume and venous oxygen saturation

1. The intravenous administration of fluid and blood has to balance the danger of unexpected death in response to a reduction of central blood volume (CBV) against that of developing pulmonary and/or peripheral oedema. 2. The initial cardiovascular response to haemorrhage is similar to that developed in response to standing. In the upright position, adults are subjected to a reduction of CBV of approximately 0.5 L and can therefore tolerate a blood loss of approximately 1 L when supine. 3. However, volume administration directed by cardiovascular variables is seldom precise, even with integration of the bradycardia and hypotension developed when CBV decreases by approximately 30%. Immediate intervention is needed because such a reduction in CBV raises the lower limit of cerebral autoregulation to approximately 80 mmHg compared with the commonly considered value of approximately 60 mmHg with an associated risk of developing brain ischaemia and irreversible shock. 4. Alternatively, the volume load can be monitored both directly and accurately by means of thoracic electrical admittance. A functional definition of normovolaemia may be the filling of the heart that ensures cardiac output and oxygen delivery. From that perspective, supine humans are normovolaemic in that a maximal venous oxygen saturation (Svo2) is established. 5. Conversely, Svo2 decreases in the upright position and, with a blood loss of approximately 100 mL, Svo2 is reduced by 1%. It is suggested that, in supine humans and guided by Svo2, normovolaemia may be established to an accuracy of approximately 100 mL and that its adequacy is controlled by recording cerebral oxygenation.

Lower body negative pressure as a model to study progression to acute hemorrhagic shock in humans

Hemorrhage is a leading cause of death in both civilian and battlefield trauma. Survival rates increase when victims requiring immediate intervention are correctly identified in a mass-casualty situation, but methods of prioritizing casualties based on current triage algorithms are severely limited. Development of effective procedures to predict the magnitude of hemorrhage and the likelihood for progression to hemorrhagic shock must necessarily be based on carefully controlled human experimentation, but controlled study of severe hemorrhage in humans is not possible. It may be possible to simulate hemorrhage, as many of the physiological compensations to acute hemorrhage can be mimicked in the laboratory by applying negative pressure to the lower extremities. Lower body negative pressure (LBNP) sequesters blood from the thorax into dependent regions of the pelvis and legs, effectively decreasing central blood volume in a similar fashion as acute hemorrhage. In this review, we compare physiological responses to hemorrhage and LBNP with particular emphasis on cardiovascular compensations that both share in common. Through evaluation of animal and human data, we present evidence that supports the hypothesis that LBNP, and resulting volume sequestration, is an effective technique to study physiological responses and mechanisms associated with acute hemorrhage in humans. Such experiments could lead to clinical algorithms that identify bleeding victims who will likely progress to hemorrhagic shock and require lifesaving intervention(s).

Pathophysiology of syncope

Syncope or near-syncope is a not uncommon effect of gravitational or other stresses and it occurs when cerebral blood flow falls to below about half the normal value. It is not necessarily abnormal, and individuals who are usually asymptomatic show the same reaction if a stress is sufficiently great to result in hypotension. Blood pressure is regulated mainly by baroreceptor reflexes by their control of vascular resistance and heart rate. The ability to vasoconstrict powerfully is important in resisting syncope; heart rate responses are of much less physiological significance. The intriguing unanswered question is what suddenly changes vasoconstriction and tachycardia to vasodilatation and bradycardia. It is now known not to be due to stimulation of cardiac receptors and some cerebral signal is more probable. People are more likely to faint when upright, motionless, warm, following meals, dehydrated or emotionally stressed, and these factors may be involved in some reflex syncopes including micturition and defaecation syncopes. Plasma volume is of considerable importance and increasing this by interventions such as salt loading, exercise training, and even sleeping with the bed head raised can often be of clinical benefit.

Evidence that venoconstriction reverses the phase II sympathoinhibitory and bradycardic response to haemorrhage

Severe hypotensive haemorrhage results in a biphasic response, characterized by an initial increase in heart rate and sympathetic vasomotor activity (phase I) followed by a life-threatening hypotension, accompanied by profound sympathoinhibition and bradycardia (phase II). The phase II response is believed to be dependent on inputs from cardiopulmonary receptors, and may be triggered by the reduction in venous return and cardiac filling associated with severe haemorrhage. In this study, we tested the hypothesis that the phase II response could be reversed by venoconstriction, which is known to enhance venous return and cardiac filling, by comparing the effects of phenylephrine (which constricts veins as well as arterioles) with that of vasopressin (which constricts arterioles but not veins). In sodium pentobarbitone-anaesthetised rats, haemorrhage evoked an initial increase in heart rate (HR) and renal sympathetic activity (RSNA) followed by a large decrease in both variables to levels below the pre-haemorrhage baseline levels (phase II response). During the phase II response, an intravenous injection of phenylephrine, sufficient to restore mean arterial pressure to the pre-haemorrhage level, resulted in a gradually developing increase (over 3-4 min) in HR and RSNA back to the baseline levels. In contrast, intravenous injection of an equipressor dose of vasopressin did not result in any increase in RSNA and only a transient increase in HR. Injection of phenylephrine, but not vasopressin, also increased the pulsatile component of central venous pressure, indicative of reduced venous capacitance. The findings indicate that venoconstriction reverses the phase II sympathoinhibition and bradycardia.

5-HT1A receptor agonist 8-OH-DPAT acts in the hindbrain to reverse the sympatholytic response to severe hemorrhage

Central administration of serotonergic 5-HT1A receptor agonists delays the reflex sympatholytic response to severe hemorrhage in conscious rats. To determine the region where 5-HT1A receptor agonists act to mediate this response, recovery of mean arterial pressure (MAP), heart rate (HR), and renal sympathetic nerve activity (RSNA) was compared in hemorrhaged rats after injection of the selective 5-HT1A agonist, (+)-8-hydroxy-2-(di-n-propylamino)tetralin (8-OH-DPAT), in various regions of the cerebroventricular system or the systemic circulation. Three minutes after injection of 8-OH-DPAT (48 nmol/kg), MAP and RSNA were higher in hemorrhaged rats given drug in the fourth ventricle (94 +/- 5 mmHg, 82 +/- 18% of baseline) or the systemic circulation (90 +/- 4 mmHg, 113 +/- 15% of baseline) than in rats given drug in the Aqueduct of Sylvius (63 +/- 4 mmHg, 27 +/- 11% of baseline), the lateral ventricle (42 +/- 3 mmHg, -8 +/- 18% of baseline), or in rats given saline in various brain regions (47 +/- 5 mmHg, -42 +/- 10% of baseline). A lower-dose injection of 8-OH-DPAT (10 nmol/kg) also accelerated the recovery of MAP and RSNA in hemorrhaged rats when given in the fourth ventricle (94 +/- 26 mmHg, 72 +/- 33% of baseline 3 min after injection) but not the systemic circulation (46 +/- 4 mmHg, -25 +/- 30% of baseline). These data indicate that 8-OH-DPAT acts on receptors in the hindbrain to reverse the sympatholytic response to hemorrhage in conscious rats.

Implantable microelectrodes with new electro-conductive materials for recording sympathetic neural discharge

We have developed two new types of bipolar cuff microelectrodes (volume size, 2-3 mm(3)) using electro-conductive rubber or water-absorbent polymer, either of which can be applied to measure sympathetic nerve activity in small animals. A renal nerve bundle of an anesthetized rat was inserted into the center hole of the electrode (diameter, 0.15 mm) through a slit and had good contact with the electrodes. Renal sympathetic nerve activity, which was verified by sympathetic ganglionic blockade, could be recorded using either type of implantable cuff electrode.

Effect of carotid or aortic baroreceptor denervation on arterial pressure during hemorrhage in conscious dogs

We studied the effect of chronically denervating aortic baroreceptors (ABR; n = 6) or carotid baroreceptors (CBR; n= 7) on mean arterial pressure (MAP) and heart rate (HR) responses to hemorrhage in the dog. Neither denervation had a significant effect on basal MAP, the variability (standard deviation) of MAP, or resting HR. However, the breakpoint of MAP (defined as the volume of blood removed when MAP fell more than 10% below control and declined monotonically thereafter) was significantly reduced in dogs with only ABR functional (12.4 ± 1.4 ml/kg) compared with the volume in the intact condition (18.9 ± 1.8 ml/kg). In contrast, there was no difference in the breakpoint or the MAP at any time during hemorrhage in dogs with both CBR functional compared with their intact responses. In a different group of dogs ( n = 6), responses were determined with both CBR operating and again after unilateral denervation, leaving only one CBR (1CBR) functional. Basal MAP and the variability of MAP were not altered in dogs with only 1CBR functional, but the breakpoint (11.7 ± 1.4 ml/kg) during hemorrhage was significantly different compared with responses with two CBR (21.2 ± 2.3 ml/kg), and MAP fell to much lower levels. These results indicate that the CBR can compensate fully for loss of ABR during hemorrhage but not vice versa; and bilateral CBR inputs are required for normal responses to hemorrhage.

Perioperative bradycardia and asystole: relationship to vasovagal syncope and the Bezold-Jarisch reflex

Reflex cardiovascular depression with vasodilation and bradycardia has been variously termed vasovagal syncope, the Bezold-Jarisch reflex and neurocardiogenic syncope. The circulatory response changes from the normal maintenance of arterial pressure, to parasympathetic activation and sympathetic inhibition, causing hypotension. This change is triggered by reduced cardiac venous return as well as through affective mechanisms such as pain or fear. It is probably mediated in part via afferent nerves from the heart, but also by various non-cardiac baroreceptors which may become paradoxically active. This response may occur during regional anaesthesia, haemorrhage or supine inferior vena cava compression in pregnancy; these factors are additive when combined. In these circumstances hypotension may be more severe than that caused by bradycardia alone, because of unappreciated vasodilation. Treatment includes the restoration of venous return and correction of absolute blood volume deficits. Ephedrine is the most logical choice of single drug to correct the changes because of its combined action on the heart and peripheral blood vessels. Epinephrine must be used early in established cardiac arrest, especially after high regional anaesthesia.

Neural mechanisms in the cardiovascular responses to acute central hypovolaemia

1. The haemodynamic response to acute central hypovolaemia consists of two phases. During phase I, arterial pressure is well maintained in the face of falling cardiac output (CO) by baroreceptor-mediated reflex vasoconstriction and cardio-acceleration. Phase II commences once CO has fallen to a critical level of 50-60% of its resting value, equivalent to loss of approximately 30% of blood volume. 2. During phase II, sympathetic vasoconstrictor and cardiac drive fall abruptly and cardiac vagal drive increases. In humans, this response is invariably associated with fainting and has been termed vasovagal syncope. 3. In both experimental animals and in humans, the responses to acute central hypovolaemia are greatly affected by anaesthetic agents, in that the compensatory responses during phase I (e.g. halothane) or their failure during phase II (e.g. alfentanil) are blunted or abolished. 4. Therefore, our present knowledge of the neurochemical basis of the response to hypovolaemia depends chiefly on the results of experiments in conscious animals. Use of techniques for simulating haemorrhage has greatly enhanced this research effort, by allowing the effects of multiple treatments on the response to acute central hypovolaemia to be tested in the same animal. 5. The results of such experiments indicate that phase II of the response to hypovolaemia is triggered, at least in part, by a signal from cardiac vagal afferents. There is also strong evidence that phase II depends on brainstem delta-opioid receptor and nitrergic mechanisms and can potentially be modulated by circulating or neuronally released adrenocorticotropic hormone, brainstem serotonergic pathways operating through 5-HT1A receptors and opioids acting through mu- and kappa-opioid receptors in the brainstem. 6. Phase II also appears to require input from supramedullary brain centres. Future studies should determine how these neurotransmitter systems interact and their precise neuroanatomical arrangements.

Injection of muscimol in dorsomedial hypothalamus and stress-induced Fos expression in paraventricular nucleus

Prior microinjection of the GABA(A)-receptor agonist muscimol into the dorsomedial hypothalamus (DMH) in conscious rats attenuates the increases in heart rate, blood pressure, and circulating adrenocorticotrophic hormone seen in air stress. Here, we examined the effect of similar treatment on air stress- or hemorrhage-induced Fos expression in the paraventricular nucleus (PVN). Muscimol (80 pmol/100 nl per side) or saline (100 nl per side) was microinjected bilaterally into the DMH in conscious rats before either air stress, an emotional or neurogenic stressor, or graded hemorrhage, a physiological stressor. Each stressor evoked a characteristic pattern of Fos expression in the parvocellular and magnocellular PVN after saline. Injection of muscimol into the DMH suppressed Fos expression in the PVN associated with air stress but not with hemorrhage. Injection of muscimol at sites anterior to the DMH and closer to the PVN had no effect on Fos expression in the PVN after air stress. Thus activation of neurons in the DMH is necessary for excitation of neurons in the PVN during air stress but not during hemorrhage.

Caudal midline medulla mediates behaviourally-coupled but not baroreceptor-mediated vasodepression

Within the caudal medulla there are two regions whose activation leads to vasodepression and bradycardia, the caudal ventrolateral medulla and a discrete region of the caudal midline medulla. This study investigated, in the halothane anaesthetized rat, the contribution of these two vasodepressor regions to "homeostatic" and "behaviourally-coupled" cardiovascular regulation. In an initial set of experiments the contribution of each of these two regions to the hypotension and bradycardia evoked by acute hypovolaemia (15% haemorrhage) was investigated. It was found that inactivation of the caudal midline medulla significantly attenuated (cobalt chloride) or completely blunted (lignocaine) the hypotension and bradycardia evoked by acute hypovolaemia. In contrast, inactivation of the caudal ventrolateral medulla using cobalt chloride, although attenuating the magnitude of the hypotension and completely blocking the bradycardia, did not delay the onset of the hypotension evoked by acute hypovolaemia. The caudal ventrolateral medulla is known to be critical in homeostatic cardiovascular control through the expression of the "baroreceptor reflex" and the hypotension and bradycardia evoked by activation of cardiopulmonary afferents. In a second series of experiments we found inactivation of the caudal midline medulla played no role in baroreflex-evoked bradycardia (i.v. phenylephrine) or the hypotension and bradycardia evoked by cardiopulmonary afferent activation (i.v. 5-hydroxytryptamine). These data suggest that the caudal midline medulla and caudal ventrolateral medulla play different roles in cardiovascular control. The caudal ventrolateral medulla is involved in mediating cardiovascular changes associated with a variety of stimuli including "homeostatic" and "behaviourally-coupled" cardiovascular changes, whereas the caudal midline medulla is critical for mediating "behaviourally-coupled" changes in arterial pressure and heart rate.

Heart rate variability during massive hemorrhage and progressive hemorrhagic shock in dogs

PURPOSE

To investigate the sequential changes in heart rate (HR), autonomic nervous activity presented by the spectral analysis of heart rate variability (HRV), hemodynamics and metabolism during massive hemorrhage and progressive hemorrhagic shock in dogs.

METHODS

Twelve dogs were subjected to acute massive hemorrhage until mean arterial pressure (MAP) reached 50 mm Hg. Then bleeding was stopped and they were allowed to reach a plateau phase. They were divided, post hoc, into bradycardic or tachycardic groups according to their HR response to the acute massive hemorrhage. After reaching a plateau phase, the dogs were further bled to keep their MAP around 50 mmHg (progressive hemorrhagic shock). Their heart rate power spectra were quantified into low-frequency (LF) (0.04-0.15 Hz) and high-frequency (HF) (0.15-0.4 Hz) components.

RESULTS

In the bradycardic group, both LF and HF increased after massive hemorrhage, but during progressive hemorrhagic shock these components decreased while HR increased. In the tachycardic group, LF increased after massive hemorrhage, but during progressive hemorrhagic shock LF decreased with continuous suppression of HF CONCLUSION: Massive hemorrhage caused two types of HR response: bradycardia and tachycardia. The HRV profile showed differential autonomic characteristics, and could be a valuable tool in assessing various degrees of hemorrhagic shock.

Acute responses of renal nerve activity to microgravity induced by free drop in anesthetized rats

To examine acute cardiovascular and autonomic responses to microgravity (microG), arterial pressure (AP), aortic flow velocity (AFV), central venous pressure (CVP), and renal nerve activity (RNA) were measured in anesthetized rats during 4.5 s of microG produced by free drop. A smooth and immediate reduction in gravity occurred during free drop, microG being achieved 100 ms after the start of the drop. Acute microG elicited an immediate and striking, but transient, decrease in RNA with no significant change in AP and AFV, but a significant decrease in CVP. The decrease in RNA lasted 2 s, then RNA recovered to the control level despite the G value remaining at < 0.001 for 4.5 s. The RNA decrease was attenuated or completely abolished by sinoaortic denervation, vagotomy, or sinoaortic denervation plus vagotomy. These results suggest that acute microG conditions stimulate sinoaortic and cardiopulmonary mechanoreceptors and suppress RNA.

Role of the vestibular system in sudden shutdown of renal sympathetic nerve activity during microgravity in rats

The purpose of this study was to examine the effect of microgravity (muG) on renal sympathetic nerve activity (RNA) in rats. Additionally, we estimated the participation of the vestibular system in the response of RNA to muG. Eight normal Sprague-Dawley (SD) rats and five chemically and bilaterally labyrinthectomied SD rats were used to measure RNA during free-drop examination (4.5-s duration of muG); arterial pressure (AP) and aortic flow velocity (AFV) were additionally monitored. Although AFV showed no particular change, AP tended to decrease during muG in the later phase. Prior to this AP fall-off, RNA was immediately and markedly attenuated by muG. This attenuation was transient and RNA returned to 1G level within the mu;muG condition. Interestingly, this phenomenon remained even in labyrinthectomied rats. In conclusion, cephalad shift of the body fluid by loading of muG may cause cardiopulmonary low-pressure receptor activation and consequent RNA attenuation, but the participation of the vestibulosympathetic reflex in this phenomenon is not obvious.

Arterial baroreceptors control plasma vasopressin responses to graded hypotension in conscious dogs

We studied the role of cardiac and arterial baroreceptors in the reflex control of arginine vasopressin (AVP) and renin secretion during graded hypotension in conscious dogs. The dogs were prepared with Silastic cuffs on the thoracic inferior vena cava and catheters in the pericardial space. Each experiment consisted of a control period followed by four periods of inferior vena caval constriction, during which mean arterial pressure (MAP) was reduced in increments of approximately 10 mmHg. The hormonal responses were measured in five dogs under four treatment conditions: 1) intact, 2) acute cardiac denervation (CD) by intrapericardial infusion of procaine, 3) after sinoaortic denervation (SAD), and 4) during combined SAD+CD. The individual slopes relating MAP to plasma AVP and plasma renin activity (PRA) were used to compare the treatment effects using a 2 x 2 factorial analysis. There was a significant (P < 0.01) effect of SAD on the slope relating plasma AVP to MAP but no effect of CD and no SAD x CD interaction. In contrast, the slope relating PRA and MAP was increased (P < 0.05) by SAD but was not affected by CD. These results support the hypothesis that stimulation of AVP secretion in response to graded hypotension is primarily driven by unloading arterial baroreceptors in the dog.

A review of pathophysiology and therapy of patients with vasovagal syncope

Vasovagal syncope is a common disorder that can compromise quality of life and lead to significant morbidity. It is characterized by an initial exaggerated sympathetic output followed by parasympathetic activation and sympathetic withdrawal, as shown by diagnostic head-up tilt (HUT) table testing. Numerous drugs have been evaluated for treating this disorder. beta-Blockers are well studied and commonly administered but are specifically more efficacious in patients with isoproterenol HUT than in those with regular HUT. The role of the serotonergic system has captured new interest. Selective serotonin reuptake inhibitors show promising results in preventing vasovagal syncope in treatment-refractory patients. Also, new investigations suggest that serotonin receptor antagonism may be beneficial. Despite these findings, definitive treatment does not exist.

Pathophysiology and differential diagnosis of neurocardiogenic syncope

Syncope, the transient loss of consciousness and postural tone, is both a sign and a syndrome and may result from very diverse causes. Over the last decade, considerable attention has been focused on neurocardiogenic syncope, also known as vasovagal syncope. Research has demonstrated that the disorder is one aspect of a much broader group of disturbances of the autonomic nervous system that may lead to hypotension, orthostatic intolerance, and ultimately syncope. Recent discoveries have caused us to reevaluate our classification of autonomic disorders and to develop a new system that reflects current knowledge. A basic understanding of syncope and related disorders is essential to diagnosis and proper treatment. This article provides an overview of these conditions, their pathophysiology, and diagnosis.

Effect of N(G)-nitro-L-arginine methyl ester on autonomic modulation of heart rate variability during hypovolemic shock

OBJECTIVE

To study the changes in neuroautonomic regulation of heart rate and the effects of N(G)-nitro-L-arginine methyl ester (L-NAME), a competitive inhibitor of nitric oxide synthase, on efferent sympathetic cardiac activity and blood pressure during hypovolemic shock. Hypotension during hypovolemic shock may be attributable, in part, to the failure of neuroautonomic regulation of heart rate and blood pressure. In addition, the release of nitric oxide may contribute to hypotension through vasodilation and inhibition of efferent sympathetic activity.

DESIGN

Prospective, controlled trial.

SETTING

Experimental laboratory in a university hospital.

SUBJECTS

Seventeen anesthetized adult male New Zealand White rabbits.

INTERVENTIONS

The rabbits were divided into four groups: control (n = 3), control plus L-NAME (n = 5), hypovolemic (n = 4), and hypovolemic plus L-NAME (n = 5). Hypovolemic rabbits were bled of 10% of their circulating blood volume (85 mL/kg) every 10 mins until 30% cumulative hypovolemia was reached. Rabbits received either three doses of saline 1 mL/kg every 10 mins or L-NAME 10 mg/kg in 1 mL/kg of saline solution administered after each hemorrhage for a total of three doses. Changes in heart rate, respiratory rate, mean arterial pressure, plasma catecholamine levels, and heart rate power spectra were recorded every 10 mins during serial hypovolemia and during a 30-min recovery period.

MEASUREMENTS AND MAIN RESULTS

During hypovolemic shock there was a decrease in log low-frequency heart rate power (p = .001) and in systolic (p = .003), diastolic (p < .001), and mean (p < .001) blood pressures compared with control rabbits. Treatment with L-NAME during hypovolemia resulted in increased log low-frequency heart rate power (p = .03) and systolic (p = .01), diastolic (p = .007), and mean (p = .009) blood pressures compared with hypovolemic rabbits who received saline placebo.

CONCLUSIONS

We found that treatment with L-NAME increased efferent sympathetic cardiac activity and mean arterial pressure during hypovolemic shock compared with control rabbits. We conclude that L-NAME may blunt hypotension during hypovolemic shock by inhibiting nitric oxide synthase and may act to restore neuroautonomic cardiovascular reactivity. Spectral analysis of heart rate variability may allow for insights into the pathophysiology of shock and provide a means of monitoring the neuroautonomic cardiovascular response to therapy.

Role of nitric oxide in regulation of renal sympathetic nerve activity during hemorrhage in conscious rats

The effect of inhibition of nitric oxide (NO) synthesis on the responses of blood pressure (BP), heart rate (HR), and renal sympathetic nerve activity (RSNA) during hemorrhaging was examined with the use of an NO synthase inhibitor, N(G)-nitro-L-arginine methyl ester (L-NAME), in conscious rats. In the 0.9% saline group, hemorrhage (10 ml/kg body wt) did not alter BP but significantly increased HR and RSNA by 88 +/- 12 beats/min and 67 +/- 12%, respectively. Intravenous infusion of L-NAME (50 microg. kg(-1). min(-1)) significantly attenuated these tachycardic and sympathoexcitatory responses to hemorrhage (14 +/- 7 beats/min and 26 +/- 12%, respectively). Pretreatment of L-arginine (87 mg/kg) recovered the attenuation of HR and RSNA responses induced by L-NAME (92 +/- 6 beats/min and 64 +/- 10%, respectively). L-NAME by itself did not alter the baroreceptor reflex control of HR and RSNA. Hemorrhage increased the plasma vasopressin concentration, and its increment in the L-NAME-treated group was significantly higher than that in the 0.9% saline group. Pretreatment with the vascular arginine vasopressin V(1)-receptor antagonist OPC-21268 (5 mg/kg) recovered the attenuation of RSNA response induced by L-NAME (54 +/- 7%). These results indicate that NO modulated HR and RSNA responses to hemorrhage but did not directly affect the baroreceptor reflex arch. It can be assumed that NO modulated the baroreflex function by altering the secretion of vasopressin induced by hemorrhage.

Mechanism of biphasic response of renal nerve activity during acute cardiac tamponade in conscious rabbits

Renal sympathetic nerve activity (RSNA) responses to acute cardiac tamponade were studied in conscious rabbits with all reflexes intact (Int) or after either surgical sinoaortic denervation (SAD) or administration of intrapericardial procaine (ip-Pro) or intravenous procaine (iv-Pro). In Int rabbits, the mean arterial pressure (MAP) remained relatively constant until the pericardial volume reached 7. 7 ml, whereas the RSNA increased to 226% [compensated cardiac tamponade (CCT)], then, at a pericardial volume of 9.3 ml, the MAP fell sharply and RSNA decreased to 34% [decompensated cardiac tamponade (DCT)]; 1 min after cessation of pericardial infusion, an intravenous injection of naloxone resulted in increases in both MAP and RSNA. In SAD rabbits, RSNA did not alter throughout CCT and DCT, but increased on injection of naloxone. In ip-Pro rabbits, RSNA increased during CCT but did not decrease during DCT, whereas, in iv-Pro rabbits, the RSNA response was similar to that in Int rabbits. These results indicate that RSNA responses to cardiac tamponade are biphasic, with an increase during CCT and a decrease during DCT. Sinoaortic baroreceptors are involved in mediating the increase in RSNA, whereas cardiac receptors may be involved in mediating the decrease in RSNA. An endogenous opioid may be responsible for the decrease in RSNA seen during DCT.

Using a tilt table to evaluate syncope

Upright tilt testing is commonly used in the evaluation of patients with syncope to provoke hypotension and/or bradycardia in the laboratory. The most common type of response is provocation of neurally mediated syndrome (vasovagal syncope). The American College of Cardiology Expert Consensus has proposed indications for tilt testing. The most common indication is recurrent syncope of unexplained cause. Upright tilt testing methods have not been standardized. The most common protocols in this country use a tilt angle of 60-80 degrees and use isoproterenol infusion after a period of drug-free tilt testing. The sensitivity of upright tilt testing is estimated to be 67-83%, and the specificity is between 75 and 100%. The reproducibility of the test has been variable. In patients with unexplained syncope, positive responses are found to be 50% without the use of isoproterenol and 64% with the use of isoproterenol. Many different treatments have been used. At this time, there is no consensus regarding the most effective treatment. Beta-blockers and fludrocortisone plus salt are the most commonly used drugs. Pacemakers have been used, but their role is ill-defined at this time.

Yohimbine in neurally mediated syncope. Pathophysiological implications

In this study, we evaluated if increased sympathetic stimulation is an essential requirement for the development of neurally mediated syncope (NMS) by manipulating overall sympathetic outflow in subjects susceptible to tilt-induced syncope. Eight previously characterized patients with recurrent NMS (five females and three males; 34+/-2 yr) were recruited from the Vanderbilt Syncope Unit and eight age-matched controls underwent initial administration of clonidine (CLO) or yohimbine (YHO). This was done, prospectively, to determine doses of these agents that would increase or decrease plasma norepinephrine levels by >/= 30%. On a different day, in all subjects we determined intraarterial blood pressure, EKG and muscle sympathetic nerve activity (MSNA) both supine and during upright tilt. After this, subjects randomly received either CLO or YHO, and 3 h later another tilt was performed. After 1 wk, a similar procedure with the other drug was performed. During the two basal tilts, all the control subjects completed the study, whereas all the NMS patients developed syncope. Reduction in sympathetic tone by CLO resulted in a decreased tolerance to tilt in three out of eight controls and in all the NMS patients. In contrast, YHO not only increased basal plasma NorEpi levels and MSNA, but also prevented syncope in seven out of eight patients. In a selected population of patients, increased sympathetic activity is not a prerequisite for the development of syncope. Yohimbine-induced enhancement of sympathetic tone in patients with NMS improves orthostatic tolerance and raises the possibility that this drug may be a useful agent in the treatment of NMS.

Heterogeneous neurochemical responses to different stressors: a test of Selye's doctrine of nonspecificity

Selye defined stress as the nonspecific response of the body to any demand. Stressors elicit both pituitary-adrenocortical and sympathoadrenomedullary responses. One can test Selye's concept by comparing magnitudes of responses at different stress intensities and assuming that the magnitudes vary with stress intensity, with the prediction that, at different stress intensities, ratios of increments neuroendocrine responses should be the same. We measured arterial plasma ACTH, norepinephrine, and epinephrine in conscious rats after hemorrhage, intravenous insulin, subctaneous formaldehyde solution, cold, or immobilization. Relative to ACTH increments, cold evoked large norepinephrine responses, insulin large epinephrine responses, and hemorrhage small norepinephrine and epinephrine responses, whereas immobilization elicited large increases in levels of all three compounds. The ACTH response to 25% hemorrhage exceeded five times that to 10%, and the epinephrine response to 25% hemorrhage was two times that to 10%. The ACTH response to 4% formaldehyde solution was two times that to 1%, and the epinephrine response to 4% formaldehyde solution exceeded four times that to 1%. These results are inconsistent with Selye's doctrine of nonspecificity and the existence of a unitary "stress syndrome," and they are more consistent with the concept that each stressor has its own central neurochemical and peripheral neuroendocrine "signature."

Do different levels and patterns of sympathetic activation all provoke renal vasoconstriction?

Renal sympathetic nerve activity (RSNA) is postulated to influence renal function in selective ways with changes in renal hemodynamics only occurring during high stimulus intensities. The aim of this study was to determine the renal blood flow (RBF) response to a number of stimuli designed to increase RSNA by a modest amount and assess the possibility that different afferent stimuli produce differential levels of vasoconstriction by differentially altering the pattern of RSNA. Experiments were performed in eight conscious rabbits subjected to 20 min periods of three stimuli noise stress, air jet stress or hypoxia (10% O2). RSNA was significantly increased 12 +/- 4, 31 +/- 8 and 14 +/- 5% (means of 20 min periods +/- SEM) and these effects were mirrored in the significant changes in RBF over the period of each stimuli with mean reductions of 8 +/- 1, 10 +/- 3 and 8 +/- 4% during noise, air jet stress and hypoxia respectively. Changes in plasma renin activity did not occur without changes in RBF. With regard to the pattern of RSNA discharges, hypoxia selectively increased the amplitude (number of recruited nerves) while noise and air jet stress increased both the amplitude and frequency of discharges. The role of the renal nerves in these responses and in providing a tonic level of vasoconstriction within the kidney, was demonstrated in experiments on a group of eight renal denervated animals. The renal denervated rabbits had greater resting RBF than the intact rabbits (54 +/- 1 denervated vs. 38 +/- 1 ml min(-1) intact), and RBF was not altered by any of the afferent stimuli. We conclude that small changes in RSNA, irrespective of the stimulus, modulate renal blood flow.

Efficacy of intravenous granisetron in suppressing the bradycardia and hypotension associated with a rabbit model of the Bezold-Jarisch reflex

This study investigated whether granisetron, a 5-HT3 receptor antagonist, can alter the Bezold-Jarisch reflex (i.e., hypotension and inappropriate heart rate slowing). A hemorrhagic rabbit model that has been shown to induce the Bezold-Jarisch reflex was used. In 11 rabbits (3.8 kg), catheters were placed in the carotid arteries one day before experimental hemorrhage. On the day of the study, the rabbits were given intravenous granisetron (50 micrograms/kg) or an equal volume of saline. Five minutes after administration of granisetron or saline, hemorrhage was induced by continuous blood withdrawal at 5 mL/min and blood pressure (BP) and heart rates were obtained at frequent intervals until systolic BP declined to 80 mmHg. Six rabbits received saline and five granisetron. An average of 77.6 mL +/- 16.4 mL of blood was removed in the group receiving granisetron (compared with 56.5 mL +/- 13.1 mL for the saline group) before achieving the target systolic BP of 80 mmHg. The group receiving granisetron demonstrated the same ability to increase their heart rate from baseline as the saline group. However, the granisetron group had a final heart rate that was closer to their maximal heart rate than the saline group. In this animal model, granisetron was significantly more effective at preventing inappropriate heart rate slowing and allowed significantly more blood to be removed before reaching the target blood pressure. This implies that granisetron may be effective in preventing vasovagal syncope, although further study should be carried out to verify these potentially interesting findings.

Severe haemorrhage partially reverses moderate haemorrhage-induced decrease in intestinal vascular capacitance

The purpose of the present study was to compare the effect of severe haemorrhage with moderate haemorrhage on intestinal vascular capacitance. In 12 chloralose-anaesthetized pigs, moderate and subsequent severe haemorrhage was induced by removal of 15 and 25% of blood volume, respectively. Six of the animals were vagotomized prior to induction of haemorrhage. The portal vein pressure/intestinal blood volume (P-V) relationship was measured by using blood pool scintigraphy and varying portal vein pressure. Moderate haemorrhage resulted in a leftward shift of the P-V relationship towards the pressure axis with decreases in cardiac output, portal blood flow and arterial pressure, and an increase in heart rate. Severe haemorrhage shifted the P-V relationship back towards the volume axis compared with moderate haemorrhage, with further decreases in cardiac output, portal blood flow and arterial pressure. While moderate haemorrhage reduced intestinal blood volume at a portal vein pressure of 7 mmHg (Vp7) to 81 +/- 3% of the control value (P < 0.01), severe haemorrhage increased Vp7 to 88 +/- 1% of the control value (P < 0.05 compared with moderate haemorrhage). After vagotomy, moderate haemorrhage decreased Vp7 to 84 +/- 4% of the control value (P < 0.01), whereas Vp7 did not change significantly after severe haemorrhage (Vp7 increased to 86 +/- 1% of the control value). Thus, severe haemorrhage is associated with an increase in intestinal vascular capacity compared with moderate haemorrhage. This increase is mediated in part via the cardiac vagal reflex. The attenuation of intestinal venoconstriction during severe haemorrhage probably contributes to further decreases in cardiac output and arterial pressure by redistribution of blood to the peripheral circulation.

Pathophysiologic basis for vasodepressor syncope

The current knowledge regarding the pathophysiologic basis of the vasodepressor response was reviewed. The balance of evidence indicates that the mechanoreceptor hypothesis seems unlikely to be the sole afferent alteration that leads to the vasodepressor response. Alternative afferent mechanisms should include neurohumoral mediated sympathoinhibition triggered by opioid mechanisms as well as impaired endothelial and NO responses to orthostatic stress in susceptible individuals. It is possible that impaired cardiovagal and sympathetic outflow control of arterial baroreceptors is enhanced by the aforementioned mechanisms. The role of central sympathoinhibition and vagal excitation triggered directly from pathways within the temporal lobe or triggered by alterations in regional cerebral blood flow should be considered as potential alternative mechanisms. Efferent autonomic outflow during vasodepressor syncope include sympathetic neural outflow withdrawal in addition to activation of parasympathetic outflow to the heart and abdominal viscera. Further human research is needed to understand the underlying mechanisms that result in the described neural and vascular responses.

Induction of paradoxic bradycardia in rats by inferior vena cava occlusion during the administration of isoproterenol: the essential role of augmented sympathetic tone

INTRODUCTION

Testing human susceptibility for vasodepressor reactions involves combining venous return restriction by passive upright tilting and administering isoproterenol. While sympathetic tone is usually increased by the stimuli that incite a vasodepressor reaction, it is not known if the increased sympathetic tone is an essential or passive component of the mechanism that triggers the reaction. Given that paradoxic bradycardia is a major manifestation of vasodepressor reactions and allowing for the possible extrapolation between paradoxic bradycardia in rats and vasodepressor reactions, we examined the role of sympathetic tone in the paradoxic bradycardia reaction. Paradoxic bradycardia was induced in rats by inferior vena cava occlusion during an isoproterenol infusion. To examine the role of increased sympathetic tone on this reaction, we studied whether carotid artery perfusion (80 to 100 mmHg) during inferior vena cava occlusion, a maneuver that blunts the rise in sympathetic tone, inhibits paradoxic bradycardia.

METHODS AND RESULTS

The maximum changes in R-R were measured during 60 seconds of inferior vena cava occlusion as follows: (a) in control the heart rate accelerated (delta R-R - 10.2 +/- 2.3 msec, P < 0.001); (b) during an infusion of isoproterenol, paradoxic bradycardia occurred (delta R-R + 140.6 +/- 18.2 msec, P < 0.001), and this was inhibited by common carotid artery perfusion (delta R-R - 6.6 +/- 1.5 msec, P < 0.001); and (c) following carotid sinus denervation and during an infusion of isoproterenol, paradoxic bradycardia was induced without and with carotid artery perfusion (delta R-R + 122.6 +/- 12.0 msec, P < 0.001; delta R-R + 151.8 +/- 12.7 msec, P < 0.001, respectively).

CONCLUSIONS

Since carotid artery perfusion during inferior vena cava occlusion inhibits paradoxic bradycardia only when the carotid sinus is innervated, we conclude that carotid artery perfusion blocks the reaction by increasing carotid sinus afferents, thereby limiting the increased sympathetic tone during inferior vena cava occlusion, and not as a result of cerebral perfusion. Thus, the paradoxic bradycardia resulting from inferior vena cava occlusion requires activation of sympathetic tone as a result of carotid sinus hypotension.

Neural circulatory control in vasovagal syncope

The orthostatic volume displacement associated with the upright position necessitates effective neural cardiovascular modulation. Neural control of cardiac chronotropy and inotropy, and vasomotor tone aims at maintaining venous return, thus opposing gravitational pooling of blood in the lower part of the body. The present concept of the vasovagal response or "common faint" implicates the development of inappropriate cardiac slowing due to sudden augmentation of efferent vagal activity, and arteriolar dilatation by sudden reduction or cessation of sympathetic activity. The venous pooling associated with lasting orthostatic stress results in development of central hypovolemia. At a certain point during the ongoing reflex adaptation to the hypovolemia in progress, a depressor reflex is set in train. The depressor reflex input along this second "peripheral" afferent pathway is postulated to originate from various sites in the cardiovascular system but remains uncertain. The common faint in humans is of both vaso- and vagal origin; the pure vagal response is less common than its vasodepressor variant. There is strong evidence for an early loss of vasomotor tone in the majority of fainting subjects. Blocking the vagus nerve or cardiac pacing is not of much help in preventing vasovagal syncope; though atropine or pacing may prevent bradycardia in vasovagal fainting, they have never been proven to prevent hypotension. Baroreflex modulation of autonomic outflow remains present during the presyncopal stages until it becomes offset by an opposing depressor reflex with relative bradycardia and relaxation of arterial resistance vessels. The nature of the vasodilatation associated with the vasovagal response has still not been settled.

Mechanisms of heart rate and arterial blood pressure control: implications for the pathophysiology of neurocardiogenic syncope

Neurocardiogenic syncope is a general term that describes syncope resulting from altered autonomic activity, as manifested by abnormal regulation of peripheral vascular resistance and heart rate. Although there has been great interest in the contribution of heart rate to this form of syncope, the peripheral circulation plays the dominant role in the induction of neurocardiogenic syncope in most patients. We review in this brief article the physiology of cardiovascular reflexes, which are important for short-term arterial pressure control, and their potential contribution to the pathophysiology of neurocardiogenic syncope. This type of syncope represents a profound failure of the normal mechanisms for short-term regulation of arterial pressure. Any therapeutic strategies for the management of neurocardiogenic syncope must deal with alterations in vascular control, which contribute to its pathogenesis.

Intravenously-injected naloxone reverses the decrease in renal sympathetic nerve activity seen during hypotensive hemorrhage in conscious rabbits by acting through central mechanisms

The response of renal sympathetic nerve activity (RNA) to hemorrhage was examined in chronically-instrumented conscious rabbits. Hemorrhage was induced at a rate of 5 ml/kg per min until the mean arterial pressure fell below 40 mmHg. The mean arterial pressure then remained at around 80 mmHg until 10 ml/kg of hemorrhage (normotensive hemorrhage) before falling to below the pre-hemorrhagic control level (hypotensive hemorrhage). The RNA response showed a biphasic pattern, i.e., it increased during normotensive hemorrhage, then fell below the control level during hypotensive hemorrhage. To examine the mechanism involved in this decrease in RNA, naloxone (7.5 mumol/kg), an opioidergic receptor antagonist, was intravenously injected 1 min after the end of hemorrhage. Intravenous injection of naloxone caused an increase in mean arterial pressure and RNA to the level seen during normotensive hemorrhage. These results indicate that the decrease in RNA induced by hypotensive hemorrhage is mediated by opioidergic receptors. To determine whether the effects of naloxone are mediated via central or peripheral opioidergic receptors, naloxone was replaced by an equimolar solution of methylnaloxone, a form unable to cross the blood-brain barrier. Neither the mean arterial pressure nor RNA was significantly altered by administration of methyl naloxone. These results suggest that the effects of naloxone on both the RNA and the mean arterial pressure are mediated via central opioidergic receptors, i.e., the sympathoinhibition induced by hypotensive hemorrhage is mediated via the stimulation of central opioidergic receptors.

Effects of various stressors on in vivo norepinephrine release in the hypothalamic paraventricular nucleus and on the pituitary-adrenocortical axis

The hypothalamic-pituitary adrenocortical (HPA) system and sympathoneural and adrenomedullary systems are major effector systems that serve to maintain homeostasis during stress. Corticotropin-releasing hormone (CRH) in the paraventricular nucleus (PVN) of the hypothalamus, a determinant of both HPA and autonomic responses to stress, is under the control of many neurotransmitters and neuropeptides. Norepinephrine (NE) potently stimulates CRH neurons in the PVN; however, the physiologic role of NE in stress-induced activation of the HPA is unknown. In the present study we exposed animals to various stressors (immobilization (IMMO), cold (COLD), hemorrhage (HEM), hypoglycemia elicited by insulin administration (INS), pain and tissue damage caused by formalin injection (FORM) and sc injection of physiological saline (SAL), all of which are known to activate the HPA axis. Injection of physiological saline iv was used as a control. In vivo microdialysis was used to assess stressor- and intensity-specific activation of the PVN noradrenergic system, based on measurements of NE, its intraneuronal metabolite dihydroxyphenylglycol (DHPG), and the dopamine metabolite, dihydroxyphenylacetic acid (DOPAC). Simultaneously with microdialysate collections, blood samples were obtained via catheters in the femoral artery to measure plasma ACTH and corticosterone (CORT) levels as dependent measures, to assess stress-induced activation of the HPA axis. At their highest intensities, all the stressors significantly increased levels of PVN microdialysate NE, DHPG, and DOPAC, and plasma ACTH and CORT. PVN NE levels varied across stressors, with IMMO and FORM more potent than INS, COLD, or HEM. INS and HEM evoked proportionately larger plasma ACTH responses than did IMMO, FORM, and COLD. Plasma CORT responses were largest during IMMO, FORM, and HEM. Except for COLD and HEM, there was a strong correlation of plasma ACTH levels with levels of NE, DHPG, and DOPAC in PVN microdialysate. The data suggest that, except for COLD or HEM, there is a strong positive correlation of PVN noradrenergic activation and activity of the HPA axis. With stressors such as IMMO and FORM, NE synthesis, reflected by DOPAC changes, is strongly positively correlated with activity of the HPA axis. Furthermore, the results indicate substantial stressor specificity of PVN catecholaminergic and of HPA responses to different stressors and are inconsistent with a founding tenet of Selye's stress theory, the doctrine of nonspecificity, which defines stress as the nonspecific response of the body to any demand.

Modulation of erythropoietin formation by changes in blood volume in conscious dogs

1. A possible influence of the filling of the circulatory system on the plasma concentration of erythropoietin, which is the major regulator of erythrocyte formation, was investigated in conscious dogs. 2. Over an experimental period of 5 h, the animals were subjected to either haemorrhage (hypovolaemia), blood volume expansion (hypervolaemia), or exchange transfusion of blood with dextran (isovolaemic anaemia). 3. A reduction of blood volume by 20% induced by haemorrhage increased plasma erythropoietin levels approximately 1.5-fold in the absence of significant changes in haematocrit. 4. An expansion of blood volume by 12% induced by an intravenous infusion of dextran did not change plasma erythropoietin levels, although the haematocrit decreased by 0.04. 5. A reduction of the haematocrit by 0.12 in the absence of changes in blood volume induced by an isovolaemic exchange transfusion (dextran vs. blood) increased plasma erythropoietin levels approximately 3-fold. 6. Total renal oxygen supply did not change in any of the three experimental protocols. 7. These data indicate that in dogs the erythropoietin production rate is modulated by changes in blood volume, and suggest a possible role of erythropoietin in the regulation of blood volume.

The clinical spectrum of neurocardiogenic syncope

Neurocardiogenic syncope is a collective term used to describe the clinical syndromes of syncope that result from inappropriate, and often excessive, autonomic reflex activity, and manifest as abnormalities in the control of vascular tone and heart rate. These include carotid sinus syndrome, vasovagal syncope, and the syndromes of cough, deglutition, and micturition syncope. Orthostatic hypotension, which, in contrast, results from a failure of autonomic reflexes, is not considered part of this family of closely related syndromes. This review will focus on vasovagal and carotid sinus syndromes.

Cardiac baroreflex in hypertension: role of the heart and angiotensin II

Sigmoid logistic function curves provide a powerful means of characterizing the baroreceptor-heart rate reflex. In hypertension the operating range of the reflex is reset in the direction of the elevated resting BP; this can be accounted by rapid resetting of the threshold of the arterial baroreceptors. In addition, there is a deficit in the vagal component of the heart rate (HR) range. Reduction in gain occurs in moderate/severe hypertension, but may be absent in young primary hypertensives. All the changes are reversible, and reversibility of HR range and gain is related to reducing left ventricular hypertrophy or central blood volume rather than to reduction in BP. High plasma angiotensin II can further accentuate the vagal deficit. An input-output model has been developed from comparison of perivascular cuff and drug methods for eliciting the reflex, which place different loads on the heart; the greater load changes simulate many of the alterations in reflex properties observed in hypertension. We conclude that during changes in vasomotor tone in normal animals, about 70% of the drive for the cardiac baroreflex comes from arterial baroreceptors and about 30% from low threshold cardio-pulmonary baroreceptors. In hypertension, the vagal deficit in HR range is due to afferent interactions involving arterial and low and high threshold cardio-pulmonary baroreceptors.

Differential therapeutic responses of patients with isoproterenol-dependent and isoproterenol-independent vasodepressor syncope

Orthostatic stress during tilt table testing (TTT) is used to examine patients who may have vasodepressor syncope. This response is thought to be mediated by activation of left ventricular mechanoreceptors. Isoproterenol, by increasing the rate of discharge of these mechanoreceptors, has been proposed to increase the sensitivity of TTT without decreasing its specificity. This mechanism is not, however, totally consistent with recent observations of vasodepressor responses after cardiac transplantation in patients with denervated hearts. These reports and data showing that not all sympathomimetic agents increase the sensitivity of TTT suggest that more than one mechanism may be responsible for a positive TTT result. Therefore we hypothesized that patients with positive TTT results tests not requiring isoproterenol (iso-independent) would have a different clinical and therapeutic response than patients who required isoproterenol (iso-dependent). One hundred sixty-one consecutive patients who underwent TTT for the evaluation of unexplained syncope were included in the study. TTT was performed without and during isoproterenol infusion. A positive TTT result was defined as syncope or presyncope with a sudden decrease in systolic blood pressure and reproduction of the patient's clinical symptoms. Patients with a positive TTT result underwent a second test after 1 to 2 weeks of therapy with an oral beta-blocking agent; if the result remained positive, TTT was performed again with other agents until a satisfactory therapeutic response was obtained. Sixty-six (41%) of 161 patients had a positive result; 18 (27%) were iso-independent, and 48 (73%) were iso-dependent. There were no significant differences in age, gender, or presence of underlying heart disease between these two groups.(ABSTRACT TRUNCATED AT 250 WORDS)