Cryptogenic Stroke and underlying Atrial Fibrillation (CRYSTAL AF): design and rationale

BACKGROUND

Patients with atrial fibrillation (AF) are at increased risk for ischemic stroke. In patients who have suffered a stroke, screening for AF is routinely performed only for a short period after the stroke as part of the evaluation for possible causes. If AF is detected after an ischemic stroke, oral anticoagulation therapy is recommended for secondary stroke prevention. In 25% to 30% of stroke patients, the stroke mechanism cannot be determined (cryptogenic stroke). The incidence of paroxysmal AF undetected by short-term monitoring in patients with cryptogenic stroke is unknown, but has important therapeutic implications on patient care. The optimum monitoring duration and method of AF detection after stroke are unknown. The purpose of this study is to evaluate the incidence of AF and time to AF detection in patients with cryptogenic stroke using an insertable cardiac monitor.

STUDY DESIGN

The CRYSTAL AF trial is a randomized prospective study to evaluate a novel approach to long-term monitoring for AF detection in patients with cryptogenic stroke. Four hundred fifty cryptogenic stroke patients (by definition, without a history of AF) will be enrolled at approximately 50 sites in Europe, Canada, and the United States. Patients will be randomized in a 1:1 fashion to standard arrhythmia monitoring (control arm) or implantation of the subcutaneous cardiac monitor (Reveal XT; Medtronic, Inc, Minneapolis, MN) (continuous monitoring arm).

OUTCOMES

The primary end point is time to detection of AF within 6 months after stroke. The clinical follow-up period will be at least 12 months. Study completion is expected at the end of 2012.

Operational point of neural cardiovascular regulation in humans up to 6 months in space

Entering weightlessness affects central circulation in humans by enhancing venous return and cardiac output. We tested whether the operational point of neural cardiovascular regulation in space sets accordingly to adopt a level close to that found in the ground-based horizontal position. Heart rate (HR), finger blood and brachial blood pressure (BP), and respiratory frequency were collected in 11 astronauts from nine space missions. Recordings were made in supine and standing positions at least 10 days before launch and during spaceflight ( days 5– 19, 45– 67, 77– 116, 146– 180). Cross-correlation analyses of HR and systolic BP were used to measure three complementary aspects of cardiac baroreflex modulation: 1) baroreflex sensitivity, 2) number of effective baroreflex estimates, and 3) baroreflex time delay. A fixed breathing protocol was performed to measure respiratory sinus arrhythmia and low-frequency power of systolic BP variability. We found that HR and mean arterial pressure did not differ from preflight supine values for up to 6 mo in space. Respiration frequency tended to decrease during prolonged spaceflight. Concerning neural markers of cardiovascular regulation, we observed in-flight adaptations toward homeostatic conditions similar to those found in the ground-based supine position. Surprisingly, this was not the case for baroreflex time delay distribution, which had somewhat longer latencies in space. Except for this finding, our results confirm that the operational point of neural cardiovascular regulation in space sets to a level close to that of an Earth-based supine position. This adaptation level suggests that circulation is chronically relaxed for at least 6 mo in space.

Effects of mental stress on autonomic cardiac modulation during weightlessness

Sustained weightlessness affects all body functions, among these also cardiac autonomic control mechanisms. How this may influence neural response to central stimulation by a mental arithmetic task remains an open question. The hypothesis was tested that microgravity alters cardiovascular neural response to standardized cognitive load stimuli. Beat-to-beat heart rate, brachial blood pressure, and respiratory frequency were collected in five astronauts, taking part in three different short-duration (10 to 11 days) space missions to the International Space Station. Data recording was performed in supine position 1 mo before launch; at days 5 or 8 in space; and on days 1, 4, and 25 after landing. Heart rate variability (HRV) parameters were obtained in the frequency domain. Measurements were performed in the control condition for 10 min and during a 5-min mental arithmetic stress task, consisting of deducting 17 from a four-digit number, read by a colleague, and orally announcing the result. Our results show that over all sessions (pre-, in-, and postflight), mental stress induced an average increase in mean heart rate (Δ7 ± 1 beats/min; P = 0.03) and mean arterial pressure (Δ7 ± 1 mmHg; P = 0.006). A sympathetic excitation during mental stress was shown from HRV parameters: increase of low frequency expressed in normalized units (Δ8.3 ± 1.4; P = 0.004) and low frequency/high frequency (Δ1.6 ± 0.3; P = 0.001) and decrease of high frequency expressed in normalized units (Δ8.9 ± 1.4; P = 0.004). The total power was not influenced by mental stress. No effect of spaceflight was found on baseline heart rate, mean arterial pressure, and HRV parameters. No differences in response to mental stress were found between pre-, in-, and postflight. Our findings confirm that a mental arithmetic task in astronauts elicits sympathovagal shifts toward enhanced sympathetic modulation and reduced vagal modulation. However, these responses are not changed in space during microgravity or after spaceflight.

Cardiac autonomic regulation under hypnosis assessed by heart rate variability: spectral analysis and fractal complexity

OBJECTIVE

This study examined the effects of hypnosis on autonomic cardiac control. We hypothesized a modification of autonomic modulation of the heart rate with an enhanced vagal tone during hypnosis compared to baseline.

METHODS

In 12 healthy subjects (6 men and 6 women, 22.2 +/- 1.0 years of age) ECG was recorded at baseline and during hypnosis. Heart rate variability parameters were obtained in the frequency domain (LFnu: low frequency normalized units, and HFnu: high frequency normalized units) and from nonlinear analysis methods (detrended fluctuation analysis, DFA).

RESULTS

Compared to the control condition, hypnosis showed a significantly decreased LFnu, a significantly increased HFnu, and a significantly decreased LF/HF. DFA showed a significantly decreased short-range similarity. Heart rate remained unchanged.

CONCLUSION

Autonomic cardiac tone is significantly modified during hypnosis by shifting the balance of the sympathovagal interaction toward an enhanced parasympathetic modulation, accompanied by a reduction of the sympathetic tone and a decreased short-range similarity but without a concomitant change in heart rate. Central and secondary autonomous nervous system changes induced by hypnosis are a possible explanation for our results. Another highly probable explanation is given by a variation in the depth of respiration. Hypnosis appears to prevent the autonomic responses expected during neutral stimulation.

[Pulmonary nodules in underlying malignant diseases--not necessarily metastases of the primary tumour]

BACKGROUND

In this study the histological examination of pulmonary nodules and a comparison of the number of pre-, intra- and post-operative lung metastases in patients with a previous history of malignant disease were assessed.

PATIENTS AND METHODS

Between 1998 and 2003 we operated on 276 patients with suspected lung metastases. The histology of the primary tumour, the number of preoperatively diagnosed nodules, the number of lesions removed during surgery and the number of histologically confirmed metastases of 276 patients are presented.

RESULTS

In 276 patients a resection was performed. 161 of the patients were men (58.1%). The median age was 62 years (range: 21-86 years). In 110 cases a left-sided thoracotomy was performed (39.8%), in another 110 cases a right-sided thoracotomy was performed and in 56 cases we performed a bilateral thoracotomy (20.4%). In 15.2% the histology of the resected nodules was benign. In 8.6% of the cases the histological examination showed a primary lung cancer in stage I, in 74.4% of the cases the histology confirmed a metastasis of the primary cancer.

CONCLUSIONS

Solitary pulmonary nodules in patients with a previous history of malignant disease should always be resected for histological examination. Multiple pulmonary nodules should be histologically reappraised if there is any doubt about the entity.

Effect of 35 years beta-adrenergic blockade therapy on autonomic cardiovascular modulation. A case study

The influence of long duration beta-blockade on autonomic and cardiovascular function remains not completely understood. The aim of this study was to evaluate the effect of long duration beta-adrenergic blockade treatment for hypertension control, on autonomic cardiovascular control in a 78-year-old male patient in relation to population findings. Heart rate variability was determined in the frequency domain (Total power, low frequency power and high frequency power), during baseline (supine and standing) and during 24 hour Holter recording. Results were compared with heart rate and heart rate variability data obtained from a normal healthy male population as a function of age. Circadian rhythm remained present. Heart rate during daytime was lower compared to the population group. None of the heart rate variability parameters were different from the normal population age group. Our results show that after 35 years of beta-blockade treatment, autonomic modulation of cardiac function remains within normal limits for that age group. Blood pressure remained at the higher limits (120-150/60-80 mmHg), but under control.

The beta-barrel outer membrane protein assembly complex of Neisseria meningitidis

The evolutionarily conserved protein Omp85 is required for outer membrane protein (OMP) assembly in gram-negative bacteria and in mitochondria. Its Escherichia coli homolog, designated BamA, functions with four accessory lipoproteins, BamB, BamC, BamD, and BamE, together forming the beta-barrel assembly machinery (Bam). Here, we addressed the composition of this machinery and the function of its components in Neisseria meningitidis, a model organism for outer membrane biogenesis studies. Analysis of genome sequences revealed homologs of BamC, BamD (previously described as ComL), and BamE and a second BamE homolog, Mlp. No homolog of BamB was found. As in E. coli, ComL/BamD appeared essential for viability and for OMP assembly, and it could not be replaced by its E. coli homolog. BamE was not essential but was found to contribute to the efficiency of OMP assembly and to the maintenance of OM integrity. A bamC mutant showed only marginal OMP assembly defects, but the impossibility of creating a bamC bamE double mutant further indicated the function of BamC in OMP assembly. An mlp mutant was unaffected in OMP assembly. The results of copurification assays demonstrated the association of BamC, ComL, and BamE with Omp85. Semi-native gel electrophoresis identified the RmpM protein as an additional component of the Omp85 complex, which was confirmed in copurification assays. RmpM was not required for OMP folding but stabilized OMP complexes. Thus, the Bam complex in N. meningitidis consists of Omp85/BamA plus RmpM, BamC, ComL/BamD, and BamE, of which ComL/BamD and BamE appear to be the most important accessory components for OMP assembly.

Complexity of cardiovascular regulation in small animals

Oscillations of heart rate and blood pressure are related to the activity of the underlying control mechanism. They have been investigated mostly with linear methods in the time and frequency domains. Also, in recent years, many different nonlinear analysis methods have been applied for the evaluation of cardiovascular variability. This review presents the most commonly used nonlinear methods. Physiological understanding is obtained from various results from small animals.

Respiratory modulation of cardiovascular rhythms before and after short-duration human spaceflight

AIM

Astronauts commonly return from space with altered short-term cardiovascular dynamics and blunted baroreflex sensitivity. Although many studies have addressed this issue, post-flight effects on the dynamic circulatory control remain incompletely understood. It is not clear how long the cardiovascular system needs to recover from spaceflight as most post-flight investigations only extended between a few days and 2 weeks.

METHODS

In this study, we examined the effect of short-duration spaceflight (1-2 weeks) on respiratory-mediated cardiovascular rhythms in five cosmonauts. Two paced-breathing protocols at 6 and 12 breaths min(-1) were performed in the standing and supine positions before spaceflight, and after 1 and 25 days upon return. Dynamic baroreflex function was evaluated by transfer function analysis between systolic pressure and the RR intervals.

RESULTS

Post-flight orthostatic blood pressure control was preserved in all cosmonauts. In the standing position after spaceflight there was an increase in heart rate (HR) of approx. 20 beats min(-1) or more. Averaged for all five cosmonauts, respiratory sinus dysrhythmia and transfer gain reduced to 40% the day after landing, and had returned to pre-flight levels after 25 days. Low-frequency gain decreased from 6.6 (3.4) [mean (SD)] pre-flight to 3.9 (1.6) post-flight and returned to 5.7 (1.3) ms mmHg(-1) after 25 days upon return to Earth. Unlike alterations in the modulation of HR, blood pressure dynamics were not significantly different between pre- and post-flight sessions.

CONCLUSION

Our results indicate that short-duration spaceflight reduces respiratory modulation of HR and decreases cardiac baroreflex gain without affecting post-flight arterial blood pressure dynamics. Altered respiratory modulation of human autonomic rhythms does not persist until 25 days upon return to Earth.

Impact of age on the vasovagal response provoked by sublingual nitroglycerine in routine tilt testing

NTG (nitroglycerine) is used in routine tilt testing to elicit a vasovagal response. In the present study we hypothesized that with increasing age NTG triggers a more gradual BP (blood pressure) decline due to a diminished baroreflex-buffering capacity. The purpose of the present study was to examine the effect of NTG on baroreflex control of BP in patients with distinct age-related vasovagal collapse patterns. The study groups consisted of 29 patients (16-71 years old, 17 females) with clinically suspected VVS (vasovagal syncope) and a positive tilt test. Mean FAP (finger arterial pressure) was monitored continuously (Finapres). Left ventricular SV (stroke volume), CO (cardiac output) and SVR (systemic vascular resistance) were computed from the pressure pulsations (Modelflow). BRS (baroreflex sensitivity) was estimated in the time domain. In the first 3 min after NTG administration, BP was well-maintained in all patients. This implied an adequate arterial resistance response to compensate for steeper reductions in SV and CO with increasing age. HR (heart rate) increased and the BRS decreased after NTG administration. The rate of mean FAP fall leading to presyncope was inversely related to age (r=0.51, P=0.005). Accordingly, patients with a mean FAP fall >1.44 mmHg/s (median) were generally younger compared with patients with a slower mean FAP-fall (30+/-10 years compared with 51+/-17 years; P=0.001). The main determinant of the rate of BP fall on approach of presyncope was the rate of fall in HR (r=0.75, P<0.001). It was concluded that, in older patients, sublingual NTG provokes a more gradual BP decline compared with younger patients. This gradual decline cannot be ascribed to failure of the baroreflex-buffering capacity with increasing age. Age-related differences in the laboratory presentation of a vasovagal episode depend on the magnitude of the underlying bradycardic response.

Influence of supplemental magnesium, tryptophan, vitamin C, and vitamin E on stress responses of pigs to vibration

Our objectives were to investigate and compare the effects of supplemental Mg, Trp, vitamin E (vit E), and vitamin C (vit C) on stress responses of pigs undergoing transport simulation. In this study, 126 pigs (25.1 +/- 4.4 kg BW) were allocated to one of the six following treatments: 1) negative control (no supplementation); 2) positive control (i.m. injection with 0.5 mg of carazolol/20 kg BW 12 h before vibration, beta-blocker); 3) Trp (additional amount of 6 g/kg of feed for 5 d, as-fed basis); 4) Mg (3 g/L drinking water for 2 d); 5) vit E (additional amount of 150 mg/kg of feed for 21 d, as-fed basis); 6) or vit C (additional amount of 300 mg/kg of feed for 21 d, as-fed basis). Pigs were treated in groups of three, and each treatment was replicated seven times. Feed and water intake were not different among treatments. Heart rate variables (mean, peak, and minimum heart rate, ventricular ectopic beats, and ST elevation of Channels A and B) and heart rate variability were registered from the night before vibration. Pigs were subjected to vibration in a transport simulator (8 Hz, 3 m/s) for 2 h and allowed to recover for 2 h. Generally, the positive control pigs had the lowest heart rate values (mean, peak, minimum heart rate, ST elevation of Channel A; P < 0.05), whereas Mg and Trp decreased ventricular ectopic beats and ST elevation of Channel B, respectively. The effect of vit C and E as vagal stimulators was clearly visible, whereas carazolol and Mg clearly blocked the sympathetic pathways of the autonomic nervous system. During vibration, the negative control pigs lay the least, and Mg pigs the most (P < 0.05). Salivary cortisol concentrations (taken before and after vibration and after recovery) showed that vit E pigs produced the least cortisol during stress periods. Intermediary metabolites (glucose, lactate, creatine kinase, and NEFA) were analyzed in plasma from blood taken before and after vibration. At the two sampling points, the vit E and Mg pigs had the lowest NEFA concentrations (P < 0.05), and the vit E pigs also had the lowest lactate concentrations before vibration. Urine samples were collected before and after vibration to determine catecholamine concentrations; only negative control pigs had an increase (P = 0.04) in epinephrine concentration, despite large individual variation. In general, these results indicate that the supplementation of Trp, Mg, vit E, or vit C improved coping ability of pigs during vibration comparison with the negative control treatment. A muscular injection of carazolol influenced only the heart rate variables.

Self-terminating AF depends on electrical remodeling while persistent AF depends on additional structural changes in a rapid atrially paced sheep model

The development of atrial fibrillation (AF) is associated with electrical and structural remodeling. The aim of this study was to assess the contribution of electrical and structural remodeling to the development of AF in a rapid atrially paced ovine model with and without His bundle ablation and to determine the role of the angiotensin pathway and matrix metalloproteinases in this process. Thirty-five sheep were rapidly paced in the atrium and were randomized to undergo His bundle ablation (HBA) (21 sheep; HBA sheep) or not (14 sheep; non-HBA sheep). After HBA the ventricles were paced at 80 bpm. Both groups were subdivided to receive active treatment (quinapril+losartan) or placebo. Sheep were followed for 15 weeks. Inducible AF was defined as a rapid irregular atrial rhythm lasting >1 min. Inducible AF was considered to be persistent if during further follow-up no sinus rhythm (SR) was documented anymore. The inducibility of AF with atrial tachypacing was not different between the 4 groups. On the other hand, non-HBA sheep developed persistent AF significantly earlier than HBA sheep (p=0.028). They had elevated ventricular rates, diminished atrial MMP-2, increased TIMP-2 expression, and more extensive atrial fibrosis. Active treatment in these sheep significantly lowered AT-II (p=0.018), prevented atrial fibrogenesis (p<0.001) and slowed the development of persistent AF (p=0.049). Electrical remodeling is sufficient to induce AF, while structural changes are needed for persistent AF. Fibrosis development in our model is the result of an increased expression of AT-II in combination with changes in MMP expression. Inhibition of the angiotensin pathway suppresses atrial fibrosis and the development of persistent AF.

Low-dose exercise training does not influence cardiac autonomic control in healthy sedentary men aged 55-75 years

The purpose of this study was to evaluate the effects of a realistic, feasible, and commonly used fitness training programme on cardiac autonomic control in 14 sedentary men aged 62.0 +/- 6.1 years (mean +/- s). All participants performed a one-year fitness training programme in which training intensity and frequency were specifically chosen to be compliant for the majority of the participants (2-3 sessions per week at moderate intensity). At the same time, a reference group consisting of 15 sedentary age-matched men (age 64.2 +/- 6.5 years) did not change their habitual physical activity. Measurements were performed before and after the training intervention. Cardiac autonomic control was inferred from resting values (supine and standing) of heart rate variability (HRV) computed in the frequency domain over 10-min intervals. Endurance capacity was evaluated during a maximal incremental bicycle ergometer test. In spite of an increase in peak oxygen consumption (VO2peak) by 6.4% after training, heart rate in the training group remained unchanged at rest and at the same metabolic demand. No changes in resting parameters of HRV were shown for either groups or positions. Results from this study provide no evidence of a clinically meaningful increase in the vagal modulation to the sinus node at rest after one year of low-volume and moderate-intensity fitness training in men aged 55-75 years.

Cardiovascular function and gravity transitions during parabolic flight

Cardiovascular function and gravity transitions during parabolic flight.

Cardiovascular autonomic function in conscious rats: a novel approach to facilitate stationary conditions

BACKGROUND

An experimental setting and software were developed to evaluate cardiovascular autonomic function in conscious rats. A restrained approach was used, which, upon proper habituation, induced little or no stress in the rats and limited motion artifacts.

METHODS

The ECG and arterial blood pressure were recorded. Time- and frequency-domain indices of heart rate variability (HRV) and blood pressure variability (BPV) were calculated. The spontaneous baroreflex sensitivity (spBRS) was estimated using the method of statistical dependence.

RESULTS

The power spectra clearly concentrated in a frequency band with center frequency around 0.4 Hz, the low frequency (LF) component, and one at the respiratory frequency at 1.5 Hz, the high frequency (HF) component. In baseline conditions, a direct association existed between mean R-R and especially HRV parameters denoting vagal modulation such as rMSSD, pNN5, and HF power. Beta-adrenergic blockade by propranolol diminished basal heart rate. Vagal indices increased while there was an exclusive decrease in the low frequency band of HRV. Alpha-adrenergic blockade with phentolamine produced a depressor response with tachycardia, and a clear decrease in the LF component of BPV. Both the LF and HF component in the HRV spectrum were virtually absent. Cholinergic blockade with atropine did not significantly alter BP but induced a clear tachycardia with decreased vagal indices. The HF component of HRV was completely abolished and the LF band was reduced.

CONCLUSIONS

Both alpha- and beta-adrenergic blockade left spBRS virtually unaltered, while cholinergic blockade profoundly diminished spBRS. Spectral fluctuations of beta-sympathetic tone were restricted to the LF range of HRV, while the HF respiratory component represented vagal modulation. The alpha-sympathetic system played a dominant role in the LF oscillations of BPV. A role of the vagus in the HF oscillations of BPV in the rat is questioned. The baroreflex depended mainly on changes in vagal activity.

Fractal dimension in health and heart failure

BACKGROUND

Non-linear analysis of heart rate variability (HRV) can give additional information about autonomic control of the heart rate. This study applied the fractal dimension (FD) in a congestive heart failure (CHF) population.

METHODS

FD and HRV were evaluated in a healthy population (n=21) and an end-stage heart failure population (n=21) using 1-h segments during the day and night from Holter recordings.

RESULTS

CHF patients presented a loss of circadian variation in both FD and conventional time- and frequency-domain HRV indices. FD was higher in the CHF population both during the day and night. In the CHF population the correlation between FD and high-frequency power of HRV was lost.

CONCLUSION

Day-night variations of heart rate fluctuations are lost in heart failure. Changes in FD reflecting physiological and pathophysiological changes were observed.

EFFECTS OF AUTONOMIC BLOCKADE ON NON-LINEAR CARDIOVASCULAR VARIABILITY INDICES IN RATS

1. The present study assesses the effects of autonomic blockade (alpha- and beta-adrenoceptor and cholinergic) on cardiovascular function studied by heart rate variability (HRV), blood pressure variability (BPV) and baroreflex sensitivity in rats using non-linear dynamics. Little is known about the influence of pharmacological autonomic nervous system interventions on non-linear cardiovascular regulatory indices. 2. In 13 conscious rats, heart rate and aortic blood pressure were measured continuously before, during and after autonomic blockade with atropine, phentolamine and propranolol. Non-linear scaling properties were studied using 1/f slope, fractal dimension and long- and short-term correlation. Non-linear complexity was described with correlation dimension, Lyapunov exponent and approximate entropy. Non-linear indices were compared with linear time and frequency domain indices. 3. Beta-adrenoceptor blockade did not alter the non-linear characteristics of HRV and BPV, although low-frequency power of HRV was depressed. Alpha-adrenoceptor blockade decreased the scaling behaviour of HRV, whereas cholinergic blockade decreased the complexity of the non-linear system of HRV. For BPV, the scaling behaviour was increased during alpha-adrenoceptor blockade and the complexity was increased during cholinergic blockade. The linear indices of HRV and BPV were decreased. 4. The present results indicate that the beta-adrenoceptor system has little involvement in the generation of non-linear HRV and BPV in rats. 5. Alpha-adrenoceptor blockade mostly influenced the scaling properties of the time series, whereas cholinergic blockade induced changes in the complexity measures. 6. The absence of the baroreflex mechanism can trigger a compensatory feed-forward system increasing the complexity of BPV.