Convalescent or standard plasma versus standard of care in the treatment of COVID-19 patients with respiratory impairment: short and long-term effects. A three-arm randomized controlled clinical trial

BACKGROUND

The efficacy of early treatment with convalescent plasma in patients with COVID-19 is debated. Nothing is known about the potential effect of other plasma components other than anti-SARS-CoV-2 antibodies.

METHODS

To determine whether convalescent or standard plasma would improve outcomes for adults in early phase of Covid19 respiratory impairment we designed this randomized, three-arms, clinical trial (PLACO COVID) blinded on interventional arms that was conducted from June 2020 to August 2021. It was a multicentric trial at 19 Italian hospitals. We enrolled 180 hospitalized adult patients with COVID-19 pneumonia within 5 days from the onset of respiratory distress. Patients were randomly assigned in a 1:1:1 ratio to standard of care (n = 60) or standard of care + three units of standard plasma (n = 60) or standard of care + three units of high-titre convalescent plasma (n = 60) administered on days 1, 3, 5 after randomization. Primary outcome was 30-days mortality. Secondary outcomes were: incidence of mechanical ventilation or death at day 30, 6-month mortality, proportion of days with mechanical ventilation on total length of hospital stay, IgG anti-SARS-CoV-2 seroconversion, viral clearance from plasma and respiratory tract samples, and variations in Sequential Organ Failure Assessment score. The trial was analysed according to the intention-to-treat principle.

RESULTS

180 patients (133/180 [73.9%] males, mean age 66.6 years [IQR 57-73]) were enrolled a median of 8 days from onset of symptoms. At enrollment, 88.9% of patients showed moderate/severe respiratory failure. 30-days mortality was 20% in Control arm, 23% in Convalescent (risk ratio [RR] 1.13; 95% confidence interval [CI], 0.61-2.13, P = 0.694) and 25% in Standard plasma (RR 1.23; 95%CI, 0.63-2.37, P = 0.544). Time to viral clearance from respiratory tract was 21 days for Convalescent, 28 for Standard plasma and 23 in Control arm but differences were not statistically significant. No differences for other secondary endpoints were seen in the three arms. Serious adverse events were reported in 1.7%, 3.3% and 5% of patients in Control, Standard and Convalescent plasma arms respectively.

CONCLUSIONS

Neither high-titer Convalescent nor Standard plasma improve outcomes of COVID-19 patients with acute respiratory failure. Trial Registration Clinicaltrials.gov Identifier: NCT04428021. First posted: 11/06/2020.

Un raro caso di aplasia eritroide pura che occulta un carcinoma squamoso della lingua

We report a case of acquired pure red cell aplasia (APRCA) associated with carcinoma of the tongue: the first was considered a rare paraneoplastic syndrome. We point out that there is no case in literature with this association. After surgical operation (subglottic laryngectomy + right lymphadenectomy + laterocervical on the right) the transfusions required, at the beginning very frequent, decreased relevantly. This is a typical case where the paraneoplastic syndrome precedes the diagnosis of the primary carcinoma of the tongue (one year before what happens in bronchogenic carcinoma).

Methods to quantify sympathetic cardiovascular influences

This paper will critically review the main features of the various techniques (plasma noradrenaline assay, noradrenaline spillover technique, microneurographic recording of postganglionic muscle sympathetic nerve and power spectral analysis of blood pressure and heart rate signals in specific bands) currently employed to assess sympathetic cardiovascular control in humans. After highlighting the advantages and limitations of each approach, the paper will describe some of the results obtained by employing the above mentioned techniques to detect abnormalities in sympathetic cardiovascular tone in physiological and pathological conditions.

Sympathovagal interplay in the control of overall blood pressure variability in unanesthetized rats

The role of sympathetic and parasympathetic influences in the control of overall blood pressure variability was studied in chronically instrumented, freely behaving Wistar-Kyoto rats (WKY) and spontaneously hypertensive rats (SHR) subjected to sympathectomy by 6-hydroxydopamine (100 micrograms/kg ip) twice in 1 wk (effectiveness verified by abolition of pressor and tachycardic response to tyramine, 150 mg/kg i.v.) and/or to cholinergic blockade by atropine (0.7 mg/kg i.v.). Overall heart rate and blood pressure variabilities were measured as variation coefficients computed beat to beat on 90-min blood pressure recordings. As compared with the vehicle-treated controls, sympathectomized rats had much larger blood pressure variability (WKY, +61%, SHR, +86%, both P < 0.01). Cholinergic blockade superimposed to sympathectomy caused heart rate variability to markedly fall and the already augmented blood pressure variability to further rise 47% in WKY and 28% in SHR (both P < 0.01). Prolonged observation of the animals revealed the systematic occurrence of rapid blood pressure falls occurring at the onset of locomotor activity, accounting for a substantial fraction of the sympathectomy-related increase in blood pressure variability. It is concluded that 1) under undisturbed daily life conditions, sympathetic influences oppose blood pressure variations, presumably by adjusting their vasoconstrictor influences to compensate for the metabolic vasodilation occurring in functionally active tissues; 2) when sympathetic vascular control is lost, vagally mediated heart rate variations oppose the rise in blood pressure variability, possibly via rapid changes in cardiac output that partly offset the fluctuations in total peripheral resistance; and 3) chronic hypertension fails to alter these cardiovascular regulatory mechanisms.

Sympathetic, parasympathetic and non-autonomic contributions to cardiovascular spectral powers in unanesthetized spontaneously hypertensive rats

OBJECTIVE

To determine whether spectral powers of blood pressure and pulse interval can specifically reflect sympathetic and parasympathetic effects in unanesthetized, free-moving spontaneously hypertensive rats (SHR).

DESIGN

Spectral powers were observed before and after various autonomic interventions in chronically instrumented rats.

MATERIALS AND METHODS

Chemical sympathectomy was produced in 12-week-old SHR by repeated injections of 6-hydroxydopamine, while control rats were given vehicle alone. Chronic arterial and venous catheters were inserted in the femoral artery and vein. Blood pressure was recorded beat-to-beat for 90 min in free-moving rats; further recording sessions were obtained under additional alpha-receptor blockade with phenoxybenzamine at 1 mg/kg and/or additional cholinergic blockade with atropine at 0.8 mg/kg. Off-line computer analysis (fast Fourier transform) provided estimates of low- (0.025-0.1 Hz), mid- (0.1-0.6 Hz) and high-frequency (0.8-3.0 Hz) powers for blood pressure and pulse interval over consecutive periods of 100 s.

RESULTS

The most noticeable findings were that sympathectomy produced a striking increase in the low-frequency power of blood pressure and a tendency (borderline statistical significance) to reduce the mid-frequency power of blood pressure. Additional alpha-receptor blockade had no effect on any spectral power whereas additional cholinergic blockade caused a further increase in the low-frequency blood pressure power and a drastic reduction in all pulse interval powers.

CONCLUSIONS

In the unanesthetized SHR, sympathetic activity opposes low-frequency and marginally promotes mid-frequency blood pressure fluctuations; the pulse interval spectral expression of vagal effects is spread throughout the range of frequencies explored and is not confined to the high-frequency band. These data indicate that in SHR no spectral power can specifically reflect the effects of either autonomic limb.

Sympathectomy and cardiovascular spectral components in conscious normotensive rats

We examined the extent to which sympathetic influences are reflected by spectral powers of blood pressure and pulse interval in specific frequency bands in spontaneously behaving Wistar-Kyoto rats subjected to continuous intraarterial blood pressure recording. The rats were pretreated with 6-hydroxydopamine (150 mg/kg twice in 1 week, n = 19) to produce chemical sympathectomy or received vehicle (n = 15). In the sympathectomized group, additional monitoring sessions were performed with rats under alpha-adrenergic receptor blockade with phenoxybenzamine (n = 8), beta-receptor blockade with propranolol (n = 7), or cholinergic receptor blockade with atropine (n = 8). Blood pressure signals were analyzed by a computer to calculate spectral powers (fast Fourier transform) in the low-frequency (0.025 to 0.1 Hz), mid-frequency (0.1 to 0.6 Hz), and high-frequency (0.8 to 3.0 Hz) bands. In sympathectomized rats, low-frequency power of blood pressure was 70% greater than in intact rats, whereas mid-frequency power was 60% smaller (P < .05 for both) and high-frequency power was unchanged. High-frequency power of pulse interval was also unchanged in sympathectomized rats, whereas low- and mid-frequency powers were reduced by approximately 50% (P < .05). No further alterations in spectral powers were observed by adding alpha- or beta-adrenergic blockade to sympathectomy, whereas adding cholinergic blockade caused a striking reduction in all pulse interval powers. Thus, mid-frequency blood pressure power depends on sympathetic but also to a substantial extent on nonsympathetic influences. Sympathetic influences do not contribute to low-frequency blood pressure power, having instead a restraining effect. The low- and mid-frequency pulse interval powers depend on both sympathetic and vagal influences. Thus, no blood pressure or pulse interval power in the mid- and low-frequency ranges can be regarded as a specific marker of sympathetic activity.

Evaluating sympathetic activity in human hypertension

AIM

To review the use of plasma norepinephrine to evaluate sympathetic activity in humans, and to discuss the improvement in assessment of human sympathetic activity brought about by the norepinephrine spillover method and by microneurography.

METHOD

Literature survey.

RESULTS

These methods have limitations, and an accurate assessment of sympathetic cardiovascular control should not be limited to an investigation of sympathetic nerve firing or norepinephrine secretion but include cardiac and vascular responses. These responses can be assessed by traditional pharmacological means (for example, a reduction in vascular resistance induced by alpha-adrenergic blockade) or by a variety of approaches aimed at examining sympathetic cardiovascular modulation in a more integrated fashion, such as the recently developed power spectrum analysis of blood pressure and heart rate.

CONCLUSION

The sensitivity and specificity of all these methods is still under investigation, but in almost every case an increase in sympathetic cardiovascular influence has been reported to occur in hypertension, indicating that sympathetic activation has a pathogenic effect on this condition.

Spontaneous variability of regional haemodynamics in unanaesthetized rats

AIM

To study the spontaneous variability in regional haemodynamics.

METHODS

Twenty normotensive Wistar-Kyoto rats were chronically instrumented with an arterial catheter and with pulsed Doppler flowmeters on the distal aorta, and the superior mesenteric and left renal arteries. After surgical recovery, the rats were monitored in unrestrained conditions. The recorded signals were analysed beat-to-beat to obtain means and coefficients of variation for mean arterial pressure, heart rate, regional blood flow velocity (consecutive 0.8-s periods) and indices of regional vascular resistance (0.8-s ratio of mean arterial pressure to mean blood flow velocity).

RESULTS

Muscle and splanchnic blood flow velocities were markedly variable, with coefficients of variation of 12.8 +/- 0.8 and 12.2 +/- 1.7% (means +/- SEM), respectively, about twice as large as the coefficient of variation for mean arterial pressure (6.2 +/- 0.3%). The renal blood flow velocity was slightly less variable than the muscle and splanchnic blood flow velocities, with a coefficient of variation of 10.4 +/- 0.8%, but still markedly and significantly more variable than systemic arterial pressure. A contingency analysis of paired variations in any two given parameters (arterial blood pressure, heart rate, blood flow velocities and indices of vascular resistance) showed a concordant pattern, the only exception being a distinctly discordant trend for the covariations in muscle and splanchnic blood flow velocities.

CONCLUSIONS

Regional blood flow velocity and vascular resistance have a larger degree of spontaneous variability than systemic arterial pressure. Renal blood flow velocity is also highly variable, suggesting that short-term stimuli that affect the renal blood vessels are not countered by autoregulation to any great degree. We conclude that while central factors may drive concordant regional haemodynamic variations, some opposing changes in regional blood flow velocity may cancel each other out, thereby reducing the variability in systemic blood pressure.

Cardiac parasympathetic hyperresponsiveness in spontaneously hypertensive rats

The bradycardic response to baroreceptor stimulation is impaired in human and experimental hypertension. Because this bradycardia mainly depends on the vagus, this may reflect a reduced cardiac parasympathetic responsiveness, which would parallel the reduced cardiac adrenergic responsiveness observed in hypertension. To test this hypothesis, 12-week-old spontaneously hypertensive rats (n = 12) and normotensive Wistar-Kyoto rats (n = 11) were anesthetized with ketamine and underwent bilateral vagotomy. Cardiac parasympathetic responsiveness was assessed from the bradycardia induced by 1) graded electrical stimulation of the right efferent vagus (1-16 Hz) and 2) graded intravenous injections of methacholine (1-8 micrograms.kg-1). The slope of the linear regression between the bradycardiac response and the applied stimulus was taken as the measure of cardiac parasympathetic responsiveness. To identify the onset of possible alterations in cardiac parasympathetic responsiveness in hypertension, the study was extended to younger (8-week-old) spontaneously hypertensive (n = 11) and Wistar-Kyoto (n = 13) rats. With vagal stimulation, cardiac parasympathetic responsiveness was greater in 12-week-old spontaneously hypertensive rats than in 12-week-old Wistar-Kyoto rats (24.8 +/- 5.4 versus 10.1 +/- 1.2 beats per minute per hertz, mean +/- SEM, p less than 0.035). This was also the case with methacholine (18.8 +/- 3.5 versus 13.1 +/- 4.4 beats per minute per microgram per kilogram, p less than 0.045). In contrast, cardiac parasympathetic responsiveness was similar, with both vagal stimulation and methacholine, when tested in the younger spontaneously hypertensive and Wistar-Kyoto groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Potentiation of the baroreceptor-heart rate reflex by sympathectomy in conscious rats

In both animals and humans, stimuli leading to sympathetic activation are accompanied by an impairment of the baroreceptor-heart rate reflex. To determine whether sympathetic activity normally interferes with this reflex function we examined in conscious Wistar-Kyoto (WKY) rats the effect of chemical sympathectomy by 6-hydroxydopamine on the bradycardic response to baroreceptor stimulation induced by raising blood pressure via intravenous phenylephrine boluses; control rats received vehicle. Spontaneously hypertensive rats were also studied because in these animals there is both a baroreceptor reflex impairment and a sympathetic overactivity. Baroreceptor reflex sensitivity, calculated as the ratio of the peak increase in pulse interval to the peak increase in mean arterial pressure, was 75% greater in sympathectomized WKY rats than in control WKY rats (1.28 +/- 0.15 versus 0.73 +/- 0.10 msec/mm Hg, mean +/- SEM; p less than 0.01). The sympathectomy-induced increase in sensitivity was even larger in spontaneously hypertensive rats (SHR) (1.26 +/- 0.12 versus 0.44 +/- 0.06 msec/mm Hg in sympathectomized SHR versus control SHR, +186%; p less than 0.01) so that the impaired baroreceptor reflex sensitivity observed in control SHR as compared with control WKY rats (-40%, p less than 0.01) was no longer detectable in the sympathectomized groups. To establish whether the sympathectomy-induced potentiation of the reflex was due to an increase in cardiac responsiveness to vagal stimuli, we subjected separate groups of anesthetized, vagotomized SHR and WKY rats to graded electrical stimulation of the right efferent vagus. The bradycardic effects of vagal stimulation, however, were similar in sympathectomized and control animals.(ABSTRACT TRUNCATED AT 250 WORDS)

Differential effects of aging on the heart rate and blood pressure influences of arterial baroreceptors in awake rats

The effect of aging on arterial baroreceptor control of heart rate and blood pressure was evaluated in unanesthetized normotensive rats aged 5-6 (young), 12-16 (adult) and 75-90 (old) weeks. Each rat was chronically implanted with arterial and venous femoral catheters and with bilateral balloon-in-cuff occluders around the common carotid arteries. Baroreceptor control of heart rate was assessed by the bradycardic and tachycardic response to intravenous boluses of phenylephrine and nitroprusside, respectively. Carotid baroreceptor control of blood pressure was assessed by a 12-s bilateral common carotid occlusion (CCO). All baroreflex responses were similar in young and adult rats. Compared with the young group, old rats showed a marked reduction of the bradycardic and tachycardic baroreflex response (-42% and -46%, respectively, P less than 0.05). The initial pressor responses to CCO were also impaired in the old animals (3 s: -63%, 6 s: -54%; both P less than 0.01), whereas the peak pressor response (9 and 12 s) was virtually identical in the young and old groups. The preservation of the peak pressor response to CCO in old rats was independent of chemoreceptor activation, aortic baroreceptors or cerebral ischemia. Thus, aging impairs baroreceptor control of heart rate but alters baroreceptor control of blood pressure, as assessed by the pressor response to CCO, only in its fast-developing component, leaving its longer-term component unaffected.

Alterations in cardiac parasympathetic function in aged rats

Aging impairs sympathetic and parasympathetic cardiac control. Although the reduced sympathetic responses are known to depend on an age-related cardiac beta-adrenoceptor dysfunction, the hypothesis of a parallel cardiac muscarinic receptor dysfunction underlying the reduced parasympathetic responses has never been tested. We therefore measured the bradycardic responses to graded electrical stimulations of the right efferent vagus and to graded bolus intravenous injections of acetylcholine in anesthetized, vagotomized rats of young (16 wk) and old (103 wk) age. Unexpectedly, the bradycardia was markedly larger (greater than 2-fold) in old than in young rats with both the electrical and the pharmacological stimulus. This indicates that at variance with its effects on beta-adrenergic receptor responsiveness, aging not only fails to impair but actually enhances cardiac muscarinic receptor responsiveness. It also suggests the more general conclusion that aging has complex and diversified effects rather than simply and uniformly depressing biological functions.

Reflex control of circulation in the elderly

Baroreceptor control of heart rate is markedly reduced in elderly subjects. However, the effects of aging on baroreceptor control of blood pressure and on the vascular and neurohumoral influences of volume cardiopulmonary receptors are unknown. In this paper we report evidence that in both conscious rats and humans aging is associated with a fall in the baroreceptor ability to rapidly cause blood pressure changes, but that the more long-term carotid baroreceptor control of blood pressure remains similar to that observed in younger individuals. Early and late cardiopulmonary receptor modulation of vascular resistance is impaired by aging, which also reduces the influence of this reflex on renin secretion. These dynamic and steady-state alterations in reflex cardiovascular control account for several hemodynamic abnormalities of the advanced age.

Intra-arterial pressure alterations during tail-cuff blood pressure measurements in normotensive and hypertensive rats

The heating and restraint inherent to tail-cuff measurement of systolic blood pressure (SBP) in rats may alter SBP and introduce a 'biological' error in its estimation by this technique. This problem was examined in unanesthetized normotensive and hypertensive rats fitted with an arterial catheter. All SBP values recorded in unrestrained rats during a 2 h period were averaged by computer and compared with intra-arterial SBP measurements observed while the rat was being subjected to the tail-cuff procedure. With the latter procedure, SBP was 16 +/- 2 mmHg lower in normotensive rats (P less than 0.001) and 7 +/- 3 mmHg higher in hypertensive rats (P less than 0.05) than when the rats were unrestrained. The effects of heat and restraint, both separately and in combination, on SBP were evaluated during four additional 30-min monitoring periods. In both groups of rats, restraint failed to alter SBP and heat lowered it slightly. The two stimuli, combined, lowered SBP in normotensive rats, but raised it by 12 +/- 2 mmHg in hypertensive rats (P less than 0.01). Thus, tail-cuff SBP measurements represent under- and overestimates in normotensive and hypertensive rats, respectively, since the two groups respond to the procedure in opposite manners.

Atrial natriuretic factor and arterial baroreceptor reflexes in unanesthetized rats

The modulation exerted by atrial natriuretic factor (ANF) on the cardiac and vascular influences of arterial baroreceptors was investigated in two groups of unanesthetized, chronically instrumented normotensive rats. In group 1, the reflex control of heart rate was assessed by graded baroreceptor stimulations and deactivations obtained by intravenous boluses of phenylephrine and nitroprusside. Under either circumstance, baroreceptor reflex sensitivity was expressed as the linear regression slope relating the chronotropic responses to the drug-induced mean arterial pressure changes. In group 2, right common carotid occlusion was performed in rats with their aortic and left carotid sinus baroreceptors denervated to assess the baroreceptor control of blood pressure; the reflex response was quantitated as the peak blood pressure rise observed during the maneuver. The reflex studies were performed before and during atriopeptin III infusion (0.15-0.20 micrograms/kg/min for 60 minutes). ANF augmented the bradycardic response to phenylephrine by 102.5 +/- 29% (p less than 0.01), reduced the tachycardic response to nitroprusside by 67.7 +/- 6.4% (p less than 0.01), and failed to modify the pressor response to carotid occlusion (-6.8 +/- 2.1%, p = NS). In a separate group of rats infused with low dose nitroprusside, no change in the baroreceptor-heart rate reflex was observed. ANF infusion (0.20 micrograms/kg/min) performed in further separate groups of conscious rats raised plasma ANF to 480 +/- 58 fmol/ml. Values in control vehicle-infused rats were 50 +/- 8 fmol/ml. Vascular reactivity (pressor response to intravenous phenylephrine boluses in anesthetized, sinoaortic-denervated rats) was only minimally reduced by ANF.(ABSTRACT TRUNCATED AT 250 WORDS)

Age-related alterations in cardiac parasympathetic responsiveness: a preliminary report

Baroreceptor control of the heart rate is reduced by ageing in animals and man. This has been ascribed to an age-related reduction in beta-adrenergic receptor density and cardiac responsiveness to sympathetic modulation. However, the baroreceptor-heart rate reflex largely depends on the vagus and the age-related changes in cardiac parasympathetic responsiveness have never been tested directly. We examined the heart rate responses to acetylcholine in six young (3-5 months) and six old (22-24 months) ketamine-anaesthetized, bilaterally vagotomized Sprague-Dawley rats instrumented with arterial and venous catheters. The acetylcholine was given as 2, 4 and 8 micrograms/kg intravenous bolus injections. Linear regressions between each dose of acetylcholine and the ensuing bradycardia were calculated. The acetylcholine-induced bradycardia was strikingly larger in old than in young rats, amounting to 20.9 +/- 4.4 and 8.6 +/- 1.5 beats/min per microgram per kg, respectively (P less than 0.05). Thus cardiac muscarinic receptor responsiveness is increased rather than reduced by ageing. Therefore not all functions involved in cardiovascular regulation show an age-related impairment, and some may even be enhanced as age progresses. It is also clear that mechanisms other than attenuation of cardiac responses to autonomic stimuli (central and/or afferent) account for the age-related impairment in the baroreceptor-heart rate reflex.

Inverse relationship between heart rate and blood pressure variabilities in rats

The interplay of heart rate variability, baroreceptor control of heart rate, and blood pressure (BP) variability was examined in chronically instrumented, unanesthetized, freely moving rats in which the efferent neural influences on heart rate were pharmacologically altered. In each rat, BP was recorded continuously for 90 minutes in the control condition and in one or more of the following conditions: 1) beta-adrenergic receptor blockade by propranolol, 1 mg/kg; 2) cholinergic blockade by atropine, 0.75 mg/kg, and 3) combined blockade by propranolol plus atropine. Each BP recording was analyzed beat-to-beat by a computer that calculated heart rate and BP variabilities, both expressed as variation coefficients. In addition, under each condition the sensitivity of the arterial baroreceptor control of heart rate was assessed by measuring the reflex changes in pulse interval in response to BP changes induced by bolus i.v. injections of phenylephrine and nitroprusside. As compared with the control condition, 1) propranolol (n = 10) reduced heart rate variability by 23 +/- 4% (p less than 0.01), only slightly impaired baroreceptor reflex sensitivity, and did not significantly modify BP variability (+11 +/- 7%); 2) atropine (n = 11) reduced heart rate variability by 30 +/- 7% (p less than 0.01), drastically impaired baroreceptor reflex sensitivity, and increased BP variability (+40 +/- 8%, p less than 0.01); 3) combined blockade (n = 10) caused variability and baroreceptor reflex changes similar to those induced by atropine alone. Thus, heart rate variability depends on both vagal and sympathetic influences. However, only the former component affects BP variability, that is, it plays an antioscillatory role.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of altering the interval between the stimulus and the reflex response in the analysis of the baroreceptor control of the sinus and atrioventricular nodes in man

Baroreceptor control of the sinus node may be determined by raising or lowering blood pressure with intravenous bolus injections of phenylephrine or glyceryl trinitrate and calculating the slope of the linear regression between the drug induced changes in systolic blood pressure and RR interval using shift 1 coupling--namely, coupling of each systolic blood pressure value with the interval of the following cardiac cycle. To assess whether shift 1 coupling provides the best linear fit and the highest regression slope nine subjects received phenylephrine and glyceryl trinitrate injections both during spontaneous sinus rhythm and during atrial pacing to evaluate baroreflex control of the sinus and of the atrioventricular node respectively. In regression analysis of the data, for each drug injection nine different shifts (from 0 to 8) were used to couple systolic blood pressure with RR or StQ intervals. When the mean results from all subjects were compared the use of shift 1 was equal or superior to the use of any other shift for both the RR and the StQ interval responses evoked by either phenylephrine or glyceryl trinitrate. In many instances, however, the shift that provided the highest correlation and regression coefficient was different from shift 1, and the use of these best individual shifts provided results considerably different from those obtained with the standard shift 1. It is concluded that in the regression analysis of baroreflex cardiac responses to vasoactive drugs the regular use of shift 1 does not invariably provide the best estimation of baroreflex sensitivity. This is better achieved by calculating the best shift in individual responses.