Abstract
Objective: To review our studies of the ease and importance of parasympathetic and sympathetic (P&S) measures in managing cardiovascular patients. Background: The autonomic nervous system is responsible for the development or progression of hypertension (HTN), orthostasis, coronary disease (CAD), heart failure (CHF), and arrhythmias. Finally, new technology provides us with rapid, accurate P and S measures critically needed to manage these patients much more successfully. Methods: Using the ANX 3.0 autonomic monitor, P&S activity was recorded in 4 studies: 163 heart failure patients in total, mean follow-up (f/u) 12-24.5 months; 109 orthostasis patients, f/u 2.28 years (yr), and 483 patients with risk factors or known HTN, CAD, or CHF, f/u 4.92 yrs. All were on guideline-driven therapy. Results: Fifty-nine percent (59%) of CHF patients had dangerously high sympathovagal balance(SB) or cardiac autonomic neuropathy (CAN), and Ranolazine markedly improved 90% of these, improved left ventricular ejection fraction in 70% of patients on average 11.3 units, and reduced MACE (acute coronary syndromes, death, acute CHF, ventricular tachycardia/fibrillation[VT/VF]) 40%. Sixty-six-percent (66%) of orthostatic patients corrected with (r) alpha lipoic acid ([r]ALA); non-responders had the lowest S-tone. In the 483 patient study, SB>2.5 best predicted MACE when compared to nuclear stress and echocardiography (sensitivity 0.59, OR 7.03 [CI 4.59-10.78], specificity 0.83, positive predictive value 0.64, and negative predictive value 0.80).
Highlights
High Sympathetic (S) tone and cardiac autonomic neuropathy (CAN; defined as critically low resting Parasympathetic [P] tone, P < 0.10 beats per min.2 [bpm2]) have been associated with acute coronary syndromes (ACS), congestive heart failure (CHF), malignant ventricular arrhythmias, and increased mortality [1,2,3,4,5,6,7,8]
The following variables were recorded: 5 min. seated resting NOI-Neurogenic Orthostatic Intolerance (BP) and parasympathetic and sympathetic (P&S) activity [10,11,12,13,14]; Exhalation/Inhalation (E/I) ratio and RFa were computed in response to 1 min. of deep breathing [14]; Valsalva ratio and LFa & RFa were computed in response to a short series of Valsalva maneuvers (10 to 15 sec. each); and HR, BP, LFa, RFa and 30:15 ratio were computed in response to 5 min. of head-up postural change
Congestive Heart NORANCHF-No Ranolazine-Treated Heart Failure (Failure) In CHF, S is increased due to enhanced stimulatory input, increased adrenal catecholamine output, as well as reduction of restraining influences, including reduced vagal input, beta-1 adrenergic receptors (AR) are down regulated due to chronic stimulation
Summary
High Sympathetic (S) tone and cardiac autonomic neuropathy (CAN; defined as critically low resting Parasympathetic [P] tone, P < 0.10 beats per min.2 [bpm2]) have been associated with acute coronary syndromes (ACS), congestive heart failure (CHF), malignant ventricular arrhythmias, and increased mortality [1,2,3,4,5,6,7,8]. Upon assuming a head-up posture (e.g., standing) the proper dynamic balance is a slight decrease in P-tone quickly followed by a modest increase S-tone. This defeats the effect of gravity causing a shift in blood to the lower extremities and vasoconstricts the lower vasculature to support standing. The high resting BP is considered the primary and treated as such, yet the patients become more lightheaded and become non-compliant This is because the medication induced lower resting pressure, which results in poor diastolic coronary and brain perfusion caused by the decline in standing BP, and the patient’s body defeats the therapy to maintain proper perfusion. New technology provides us with rapid, accurate P and S measures critically needed to manage these patients much more successfully
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