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Animal model of neuropathic tachycardia syndrome.

Clinically relevant autonomic dysfunction can result from either complete or partial loss of sympathetic outflow to effector organs. Reported animal models of autonomic neuropathy have aimed to achieve complete lesions of sympathetic nerves, but incomplete lesions might be more relevant to certain clinical entities. We hypothesized that loss of sympathetic innervation would result in a predicted decrease in arterial pressure and a compensatory increase in heart rate. Increased heart rate due to loss of sympathetic innervation is seemingly paradoxical, but it provides a mechanistic explanation for clinical autonomic syndromes such as neuropathic postural tachycardia syndrome. Partially dysautonomic animals were generated by selectively lesioning postganglionic sympathetic neurons with 150 mg/kg 6-hydroxydopamine hydrobromide in male Sprague-Dawley rats. Blood pressure and heart rate were monitored using radiotelemetry. Systolic blood pressure decreased within hours postlesion (Delta>20 mm Hg). Within 4 days postlesion, heart rate rose and remained elevated above control levels. The severity of the lesion was determined functionally and pharmacologically by spectral analysis and responsiveness to tyramine. Low-frequency spectral power of systolic blood pressure was reduced postlesion and correlated with the diminished tyramine responsiveness (r=0.9572, P=0.0053). The tachycardia was abolished by treatment with the beta-antagonist propranolol, demonstrating that it was mediated by catecholamines acting on cardiac beta-receptors. Partial lesions of the autonomic nervous system have been hypothesized to underlie many disorders, including neuropathic postural tachycardia syndrome. This animal model may help us better understand the pathophysiology of autonomic dysfunction and lead to development of therapeutic interventions.

Adrenergic Agents↗

Uremic autonomic neuropathy: recovery following bicarbonate hemodialysis.

Autonomic function was followed in 8 chronic uremic patients on periodic hemodialysis over a period of almost eight years. The cardiovascular autonomic testing included R-R interval variation test, deep breathing, Valsalva manoeuvre, heart rate and blood pressure responses to standing, sustained handgrip. The patients were investigated on entry into the study and after 18, 56, and 92 months. Six months after the study at time 56 months, they switched from acetate to bicarbonate dialysis. The response to deep breathing test was significantly reduced at time 18 months versus baseline (P = 0.014), but significantly increased at time 92 months versus 56 months (P = 0.042). A significant decrease was found in the systolic blood pressure response to standing between baseline and 18 months (P = 0.014) and in the response to handgrip test between 18 and 56 months (P = 0.014). Multivariate analysis of the autonomic tests by a pattern recognition method (Bayesian analysis) showed that, at the time of entry into the study, two out of eight patients had autonomic damage. At 18 and 56 months, 6/8 patients had autonomic dysfunction. At the last time of investigation, 30 months after the onset of bicarbonate dialysis, all the patients showed a reversal of autonomic damage. Age and duration of dialysis on entry did not affect autonomic function. The present study is the first demonstration that autonomic neuropathy can recover after long-term dialysis. Since chronic hypoxemia is a cause of polyneuropathy, we postulate that: 1) hypoxemia in dialysis patients may have a role in the pathogenesis of uremic polyneuropathy, and particularly of autonomic dysfunction; 2) in patients on bicarbonate dialysis, a greater hemodynamic stability with less hypoxemia may lead to a recovery of autonomic function.

Acetates↗

[A case of transient ischemic attacks preceded by postprandial hypotension].

A 78-year-old man with a history of total gastrectomy, myocardial infarction and hypertension was admitted to our hospital because of frequent transient attacks of consciousness disturbance, aphasia and right hemiparesis after meals. His attacks occurred one to three times a day, 30 to 60 minutes after meals and lasted 120 to 180 minutes. At the time of the attacks his blood pressure decreased, but his pulse rate did not change. Cerebral angiography demonstrated atherosclerotic occlusion of the left internal carotid artery. There was no myocardial uptake of 123I-metaiodobenzylguanidine (MIBG). These results suggest that our patient had an autonomic dysfunction. Duplex carotid ultrasonography revealed that the blood flow velocity fell about 30% at the time of the attacks. His autonomic dysfunction and major artery occlusion may have produced a hemodynamic TIA following postprandial hypotension.

Aged↗

Myocardial ischaemia and angina in the early post-infarction period: a comparison with patients with stable coronary artery disease.

OBJECTIVE: To evaluate Holter and treadmill responses in patients with stable angina or recent myocardial infarction in order to compare the mechanisms of ischaemia and its symptomatic expression in these two groups. PATIENTS: 75 patients with ischaemic ST segment depression on both a treadmill stress test and ambulatory Holter monitoring. Group A comprised 35 patients with stable angina, and group B comprised 40 patients in the early period after infarction. SETTING: The coronary care unit and cardiology department of a district general hospital. DESIGN: A prospective, between group, comparative study. RESULTS: Treadmill test showed demand driven ischaemia in both groups. Although ST depression occurred at comparable rate-pressure products and workloads, it was associated with angina in 80% of group A compared with only 40% of group B (p < 0.005). During Holter monitoring, ST depression was associated with an attenuated increase in rate in group A and almost no increase in rate in group B (18.2% v 3.7%; p < 0.005), suggesting that reductions in myocardial oxygen delivery were contributing to the ischaemic episodes, particularly in group B. Ischaemic episodes were more commonly silent during Holter monitoring, particularly patients in group B, only two of whom experienced angina in association with ST depression. Spectral and non-spectral measures of heart rate variability were significantly reduced in group B compared with group A. Patients with silent exertional ischaemia in group A had significantly less heart rate variability than patients who experienced angina but this difference was not seen in group B. CONCLUSION: In stable angina, myocardial ischaemia is usually painful and demand driven, whereas in the early period after infarction silent, supply driven ischaemia predominates. The failure of myocardial ischaemia to provoke symptoms in some patients with stable angina may be related to autonomic dysfunction affecting the sensory supply to the heart. In the early period after infarction despite clear evidence of autonomic dysfunction, other mechanisms must also be important as there was no tendency for the reduction in heart rate variability to be exaggerated in the subgroup with silent exertional ischaemia.

Angina Pectoris↗

Effects of continuous subcutaneous insulin infusion and intensified conventional therapy on peripheral and autonomic nerve dysfunction.

The objective of this study was to determine whether a favorable effect of short term continuous sc insulin infusion (CSII) therapy on the peripheral and autonomic nervous system could be maintained by subsequent intensified conventional treatment (ICT). Nine type I diabetic patients, aged 18-32 yr, who had been diabetic for 4-23 yr and had reduced nerve conduction velocities received CSII for 4 weeks and subsequently ICT for up to 26 weeks. Motor and sensory nerve conduction velocities (MNCV and SNCV) and heart rate variations during deep breathing (E/I ratio), during lying and standing (30/15 ratio), and during the Valsalva maneuver (Valsalva ratio) were measured before CSII and at intervals of 1, 2, 4, 6, 10, and 26 weeks. During CSII, MNCV and SNCV increased significantly (P less than 0.01), the E/I ratio improved in seven patients (P less than 0.05), the Valsalva ratio increased in eight patients (P less than 0.01), and the 30/15 ratio increased in five patients. The E/I ratio increased significantly earlier than the Valsalva ratio (P less than 0.025). During ICT, nerve conduction velocity slightly, though not significantly, decreased, and the results of the cardiovascular reflex tests also gradually declined. The hemoglobin A1 concentration before initiation of CSII and the diminution of the hemoglobin A1 concentration during CSII therapy were inversely correlated to the increase in MNCV (P less than 0.01 and P less than 0.05, respectively). In conclusion, CSII improved peripheral and autonomic nervous system function, but the improvement diminished somewhat during ICT.

Adolescent↗

Noradrenergic nerve fibers of the rectal mucosa in autonomic disorders: comparison of histochemical study with clinical severity and changes in plasma noradrenaline induced by standing.

A histochemical study was carried out on the rectal mucosae biopsied from 20 patients with autonomic dysfunctions and 13 controls using a catecholamine fluorescent staining method, and the rectal noradrenergic nerve fiber lesions were compared with the severity of autonomic symptoms and disturbance of plasma noradrenaline increase in response to standing in 17 patients. In 9 patients with type I familial amyloid polyneuropathy and 1 with acute pandysautonomia, the number of fluorescent nerve fibers was greatly reduced, and the degree of depletion correlated well with the other 2 parameters showing the severity of autonomic dysfunction. In contrast, rectal noradrenergic nerve fibers were normally preserved in 10 patients with multiple system atrophy, although they suffered from severe autonomic symptoms with poor noradrenaline response to the postural loading. It is concluded that noradrenergic nerve fiber lesions in the biopsied rectal mucosa may represent the systemic involvement of sympathetic post-ganglionic nerves.

Adult↗

Sympathetic skin response in patients with cerebellar degeneration.

Sudomotor function was studied based on sympathetic skin responses (SSRs) in 87 patients with various types of cerebellar degeneration. Evaluations of orthostatic hypotension and the R-R interval variation were also performed in these patients. The respective incidences of SSR abnormality and orthostatic hypotension were 44 (50.6%) of 87 and 39 (44.8%) of 87. Fourteen percent of the patients with abnormal SSRs did not have orthostatic hypotension, but 8% of the patients with normal SSRs did have orthostatic hypotension. Sympathetic skin responses were abnormal in most patients with Shy-Drager syndrome, sporadic olivopontocerebellar atrophy (OPCA), and striatonigral degeneration, whereas SSRs were normal in patients with familial OPCA, sporadic cerebellar atrophy, and familial cerebellar atrophy. We demonstrated that SSR can be used to evaluate sudomotor function in degenerative disorders of the central nervous system as well as in peripheral neuropathies. The vasomotor and sudomotor functions usually are both disturbed in patients with cerebellar degeneration, and the SSR can detect autonomic dysfunction as sensitively as does the head-up tilt test. We also concluded that sporadic OPCA differs from familial OPCA in that it has a much higher incidence of autonomic dysfunction and that degeneration of the cerebellar cortex did not affect the autonomic regulation.

Adolescent↗

Autonomic neuropathy, I. Clinical features, investigation, pathophysiology, and treatment.

Autonomic dysfunction is a common complication of peripheral neuropathies. It is often of little clinical importance, but some conditions may cause profound disturbance of autonomic function, including postural hypotension, impotence and impairment of heart rate and bladder and bowel control. Autonomic function can be evaluated by a number of investigations, some of which can be performed in a neurophysiology laboratory. Diseases that primarily affect small nerve fibres or cause acute demyelination of small myelinated fibres are most likely to cause autonomic dysfunction. Management includes treating the underlying cause and symptomatic therapy.

Autonomic Nervous System Diseases↗

Post-exercise heart rate recovery and mortality in chronic obstructive pulmonary disease.

Abnormal heart rate recovery (HRR) after exercise, a marker of cardiac autonomic dysfunction, is associated with poor prognosis in various populations. As chronic obstructive pulmonary disease (COPD) is associated with cardiac autonomic dysfunction, we tested the hypothesis that patients with COPD have a lower HRR than healthy people, and evaluated whether a delay in HRR is associated with an increased risk of mortality in COPD. The records of 147 COPD patients were reviewed (65.1+/-9.1 years, mean+/-sd, 42 women/105 men, forced expiratory volume in 1s (FEV1): 42+/-15% predicted) and compared to 25 healthy subjects (61.6+/-4.5 years, 5 women/20 men, FEV1: 100+/-14% predicted) during recovery after an exercise test. Heart rate was measured at peak exercise and at 1-min recovery, the difference between the two being defined as HRR (11+/-9 beats in COPD patients vs. 20+/-9 beats in healthy subjects, P < 0.0001). During a mean follow-up of 43.1+/-22.0 months, 32 patients died. Abnormal HRR (14 beats) was a strong predictor of mortality in COPD patients (adjusted hazard ratio: 5.12, 95% CI [1.54-17.00]). In conclusion, COPD patients have a lower HRR than healthy subjects, and have a worse prognosis when presenting abnormal HRR.

Aged↗

QT interval and QT dispersion in multiple system atrophy (Shy-Drager syndrome).

To evaluate the influence of autonomic function on the QT interval and QT dispersion, 18 patients (10 males and 8 females; mean age 61 +/- 9 years) with multiple system atrophy (MSA, Shy-Drager syndrome) were studied. Cardiovascular tests were performed to assess the degree of autonomic dysfunction. The QT interval, corrected QT (QTc), QT dispersion (QTd), corrected and adjusted QTd were calculated from a standard 12-lead electrocardiogram. Fifteen healthy subjects matched for sex and age were studied as controls. Nine MSA patients showed severe autonomic dysfunction with orthostatic hypotension. In the remaining patients definite autonomic impairment was found. No statistically significant difference was found in QTd and only a trend towards higher values of maximal QTc was found in patients compared with controls. QTc prolongation, defined as greater than the mean +/- 2 SD of the controls, was detected only in three out of the 18 MSA patients (17%). No correlation was found between the severity of autonomic impairment and repolarization parameters. Our data suggest that chronic autonomic impairment in patients with MSA does not significantly affect ventricular repolarization and ventricular dispersion.

Adult↗

The influence of major depression and its treatment on heart rate variability and pupillary light reflex parameters.

BACKGROUND: The link between depression and autonomic dysfunction has attracted more attention since epidemiological studies have revealed that depressed patients have an augmented risk of cardiovascular morbidity and mortality. Former studies of autonomic dysfunction in major depression have shown inconclusive results. AIMS: To further elucidate the effect of depression and medication on autonomic function, 18 patients and 18 matched control subjects were comprehensively assessed once medicated and once non-medicated as well as after full clinical recovery. METHODS: Cardiac autonomic function was evaluated by measuring heart rate variability (HRV) parameters, and central autonomic tone was investigated by obtaining parameters of the pupillary light reflex (PLR). RESULTS: Acutely depressed patients who had not taken antidepressant medication for 8 weeks prior to the investigation differed significantly neither in heart rate parameters nor in parameters of the PLR from their controls. However, after 2 days of antidepressant treatment (SSRI and NaSSRI), parameters of heart rate analysis and PLR (except relative amplitude) changed significantly and remained significantly different after clinical recovery. LIMITATIONS: The study needs to be repeated using larger patient groups. Long-term studies are absolutely essential. CONCLUSION: The state of depression did not influence autonomic parameters significantly. In fact, treatment influenced autonomic function far more than the disease itself. Other branches of the autonomic nervous system (ANS), as well as new techniques should be applied to elucidate whether small changes in autonomic function exist. This might clarify whether disease or treatment might influence cardiac mortality in depression.

Adult↗

Substance P immunoreactivity in Rett syndrome.

Severe autonomic dysfunction occurs in Rett syndrome (RS). Substance P, a tachykinin peptide that localizes to several brain regions, including the autonomic nervous system, is reduced in the cerebrospinal fluid of patients with RS. The anatomic localization and intensity of substance P immunoreactivity and glial fibrillary acidic protein-positive astrocytes in the brains of 14 patients with RS were compared with those in the brains of 10 age-matched normal patients. Substance P immunoreactivity expression was significantly decreased in RS tissue compared with control tissue in the following regions: dorsal horns, intermediolateral column of the spinal cord, spinal trigeminal tract, solitary tract and nucleus, parvocellular and pontine reticular nuclei, and locus ceruleus. A less significant decrease of substance P immunoreactivity occurred in the substantia nigra, central gray of the midbrain, frontal cortex, caudate, putamen, globus pallidus, and thalamus. Antiglial fibrillary acidic protein-positive astrocytes were increased in the areas in which substance P immunoreactivity was decreased and in other brain regions. Because many of the brain regions with the greatest decrease in substance P immunoreactivity are involved in the control of the autonomic nervous system, especially the solitary tracts and reticular formation, reduced substance P may contribute to the autonomic dysfunction in RS.

Adolescent↗

Iris autonomic function in acute glaucoma.

Iris autonomic function was studied by binocular infrared pupillometry in 12 patients with acute primary angle closure glaucoma (APACG) and 28 control subjects. Light reflex amplitude and resting darkness pupil diameter were reduced and miotic response to pilocarpine 0.125% drops increased in APACG when compared to controls with anterior chamber depths (ACD) greater than 2.5 mm but not when compared to controls with ACD of 2.5 mm or less. These findings suggest relative autonomic dysfunction, predominantly parasympathetic, in the anterior segment of the eye in APACG. Correlation between results of pupil tests and ACD suggested reduced autonomic function in eyes with shallow anterior chambers. Iris autonomic dysfunction in patients with APACG appears to be a reflection of shallow anterior chambers rather than a specific feature of the condition.

Aged↗

Disorders of the autonomic nervous system: Part 2. Investigation and treatment.

Autonomic function may be adequately tested with noninvasive tests of sympathetic and parasympathetic pathways, including: the response of blood pressure to change in posture and isometric contraction, heart rate response to standing, variation in heart rate with respiration, Valsalva ratio, sweat tests, and plasma noradrenaline measurements. Abnormal results in two or more of these tests indicate autonomic dysfunction. Intraarterial catheterization and tests of vasomotor function are usually required only in doubtful cases or for research purposes. Treatment of autonomic dysfunction is focused primarily on bladder control and control of orthostatic hypotension. Orthostatic hypotension is best treated with physical measures, pharmacologically with 9-alpha-fluorohydrocortisone and dihydroergotamine mesylate. A number of other agents may be tried but results have been less effective.

Autonomic Nervous System Diseases↗

Heart rate variability monitoring in the detection of central nervous system complications in children with enterovirus infection.

PURPOSE: Previous studies suggest the possibility of autonomic dysfunction in patients with complicated hand, foot, and mouth disease (HFMD) and herpangina. Heart rate variability (HRV), an index for autonomic nervous system, may be useful to detect disease progression. MATERIALS AND METHODS: From 2001 to 2002, 66 patients (1-9 years old) were enrolled prospectively in either a control (20 patients) or disease (46 patients with HFMD or herpangina) group. The disease group was subdivided into stage I (fever only), stage II (with complications of encephalomyelitis), and stage III (with complications of encephalomyelitis as well as tachycardia, hyperglycemia, tachypnea, and hypertension or hypotension) groups. Data from electrocardiograms were transformed for HRV. RESULTS: The HRV parameters generally decreased and the low frequency (LF)/high frequency ratio (HF) increased in the disease groups. Patients in disease group stage II had significantly lower parameters of HRV (triangular index, total power, LF power, and HF power) and higher LF/HF ratio than those in disease group stage I. With this trend, patients with stage III disease had extremely low HRV parameters. The inferred criteria of HRV (standard deviation of normal-to-normal interval <17 milliseconds and HF power <24 milliseconds(2)) to define stage III patients (sensitivity, 100%; specificity, 71.4%) were also useful to predict disease progression. CONCLUSIONS: The HRV markedly decreased, most likely because of autonomic dysfunction, in patients with HFMD and herpangina when complicated with central nervous system involvement and cardiopulmonary failure and may be useful parameters to monitor disease progression.

Brain Diseases↗

[Mitral valve prolapse in patients with anorexia nervosa].

Mitral valve prolapse (MVP) is frequently observed in patients with low body weight and/or skeletal abnormalities such as pectus excavatum and straight spines. There may be a variety of associated autonomic dysfunctions. Whether MVP is a complication of anorexia nervosa which has similar clinical features, including weight loss, skeletal abnormalities and autonomic dysfunctions, has not been reported. The present study was an investigation of the incidence of MVP and cardiac function in anorexia nervosa by echocardiography. Two-dimensional and M-mode echocardiography, and systolic time intervals were evaluated for 19 women with anorexia nervosa, from 13 to 25 years of age and having a mean age of 18.2 years. Their body weights ranged from 23.9 to 43 kg with a mean of 33.5 kg, and were at least 25% less than their ideal body weights (ranges were from 25 to 52%). The same studies were performed for 19 women with MVP diagnosed echocardiographically and without anorexia nervosa as controls. Their ages ranged from 14 to 26 years. Results were as follows: MVP was observed in 74% of patients with anorexia nervosa. The mean heart rates were 51.7 and 70.5/min in the anorexia nervosa and control groups, respectively. A significant difference (p less than 0.001) was observed between the two groups. The mean heart rate of patients with anorexia nervosa having MVP of both leaflets and no MVP were 45.8 and 59.0/min, respectively. The difference between these two sub-groups was statistically significant (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗