ARRHYTHMIAS RELATED TO CARDIOVERSION

DC countershock abolished 92 of 101 episodes of atrial fibrillation in 86 patients, an incidence of 91 per cent. Supraventricular arrhythmias were not infrequent immediately after countershock. These were transient and did not complicate the procedure nor were they hazardous to the patient. On two occasions a slow atrioventricular nodal rhythm appeared followed by recurrence of atrial fibrillation a few hours later. Sinus node activity did not return in these patients. Ventricular tachycardia, fibrillation, or standstill did not occur in this series.

The following arrhythmias were observed immediately after countershock but prior to the establishment of a regular sinus rhythm: atrioventricular dissociation, 12 times; passive atrioventricular nodal rhythm, five times; atrioventricular nodal tachycardia, five times; atrial flutter or tachycardia, four times.

The conversion of fibrillation to flutter by countershock implies that the effect of the electric current was merely to shorten the length of the circulating wave, a phenomenon that can also be observed in the treatment of atrial fibrillation with quinidine.

Disorders of rhythm, probably having a different mechanism, were also observed after countershock had established a regular sinus pacemaker. In the group not treated with quinidine prior to countershock (74 episodes) atrial extrasystoles were seen 26 times (35 per cent); atrioventricular nodal extrasystoles or escapes, 18 times (24.3 per cent); atrial flutter or tachycardia, six times (8.1 per cent); atrial fibrillation, eight times (18 per cent); atrioventricular nodal tachycardias, twice (2.6 per cent); and a bizarre, multifocal atrial arrhythmia, once (1.3 per cent). The arrhythmias considered to be responsible for the recurrence of atrial fibrillation and also the possible mechanisms involved were discussed.

Pretreatment with quinidine was effective in reducing the incidence of arrhythmias occurring after conversion (27 episodes), atrial extrasystoles six times (22 per cent), atrioventricular nodal extrasystoles or escapes six times (22 per cent); atrial flutter or tachycardia three times (11 per cent); atrial fibrillation once (3.7 per cent); and atrioventricular nodal tachycardia once (3.7 per cent).

Postural effect on respiratory sinus arrhythmia with various respiratory frequencies

Heart rate variations during steady state respiration with various frequencies were studied on seven healthy male students at two different body positions. Respiration was controlled at four different frequencies (0.083, 0.100, 0.200, 0.250Hz), and the tidal volume was simultaneously controlled at 1500ml (0.083, 0.100Hz) or 1000ml (0.200, 0.250Hz). A tilting bed was used for changing body position, and the measurements were conducted at horizontal and vertical position. RSA (respiratory sinus arrhythmia) amplitude at 0.250Hz was significantly decreased at vertical position compared with horizontal position. At 0.200Hz the significant decrease could not be obtained although some tendency of decrease appeared. Contrary to these high frequencies, the amplitudes at low frequencies (0.083, 0.100Hz) were significantly increased (p < 0.01) during vertical position. This postural effect on the low frequency RSA could be regarded as a similar result on MWSA (Mayer wave relate sinus arrhythmia) which reflects sympathetic nervous activity. Furthermore, the ratio between the amplitude at 0.100Hz and that at 0.250Hz was significantly correlated with mean heart rate (n = 56, r = 0.73). From these results it was assumed that the RSA amplitude at low frequency associate a with not only parasympathetic nerves but also sympathetic nerves whereas the amplitude at high frequency was solely mediated by parasympathetic nerves.

Appraisal support predicts age-related differences in cardiovascular function in women

The influence of appraisal support on age-related differences in cardiovascular function was examined. Resting assessments of heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), respiratory sinus arrhythmia (RSA), and preejection period were obtained from 45 young and 20 elderly women. Consistent with prior research, results revealed that the elderly women had higher blood pressure and lower RSA than the young women. More important, appraisal support predicted age-related differences in SBP and DBP: Age predicted elevated blood pressure for women low in appraisal support, whereas age was unrelated to blood pressure for women high in appraisal support. These preliminary data suggest that appraisal support may be an important predictor of long-term physiological function and health.

Heart rate fluctuations of lower frequencies than the respiratoryrhythm but caused by it

In conscious adult rabbits, "classical" respiratory sinus arrhythmia does not occur because the respiratory frequency (RF) always exceeds half the heart rate (HR). However, slow HR fluctuations, not synchronous with the respiratory rhythm but affected by it, occur systematically. We have shown that these can be calculated by using aliasing rules. During general anaesthesia, when the RF decreases so that respiratory frequency is less than half the heart rate, classical respiratory sinus arrhythmia occurs and can be greatly reduced by vagal blockade. The slow HR fluctuations which are not synchronous with the respiratory rhythms, but are affected by it are mainly vagally mediated, because vagal blockade virtually eliminates them.

Cluster analyses of cardiovascular responsivity to three laboratory stressors

Seventy-three young normotensive male subjects were tested with an experimental protocol that included a reaction time, a mental arithmetic, and a cold pressor task. Physiological variables that were recorded included heart rate, stroke volume, pre-ejection period, blood pressure, total peripheral resistance, and respiratory sinus arrhythmia. In order to identify subgroups of subjects who differed in their pattern of autonomic responses to the tasks, the physiological change scores from baseline to the tasks for each subject were entered into a cluster analysis for each task. Ward's method was used as the clustering algorithm. The cluster analyses identified four clusters for the reaction time and mental arithmetic tasks, and five clusters for the cold pressor task. Although there was a wide range of patterns exhibited by cluster subgroups, most subjects who were reactive to the tasks showed response patterns that were qualitatively similar to the pattern of overall mean response by all subjects, albeit varying considerably in terms of quantitative response. Little evidence was generated for the consistency of extreme beta-adrenergic response from one task to another, although significant consistency was noted when milder beta-responders were included in the comparisons. Some consistency of alpha-adrenergic response noted across tasks, as well as significant consistency of being relatively nonreactive to the tasks.

Respiratory sinus arrhythmia is reversed during positive pressure ventilation

In order to study the relationship between heart rate and depth of anaesthesia, respiratory sinus arrhythmia (RSA) was investigated during enflurane and isoflurane anaesthesia in 28 patients (15-39 years). Positive pressure ventilation (six breaths min-1) was used. Respiratory sinus arrhythmia was evaluated during light anaesthesia, deep anaesthesia (burst suppression in EEG) and light anaesthesia again by using signal averaging technique. In most patients, decrease of the heart rate was seen during inspiration (positive tracheal pressure), and increase during expiration. Respiratory sinus arrhythmia did not disappear in deep anaesthesia. Inter-individual variation in the magnitude and phase relationship of respiratory sinus arrhythmia was considerable, and was not associated to the level of anaesthesia.

Respiratory sinus arrhythmia in the denervated human heart

We performed this study to test whether the denervated human heart has the ability to manifest respiratory sinus arrhythmia (RSA). With the use of a highly sensitive spectral analysis technique (cross correlation) to define beat-to-beat coupling between respiratory frequency and heart rate period (R-R) and hence RSA, we compared the effects of patterned breathing at defined respiratory frequency and tidal volumes (VT), Valsalva and Mueller maneuvers, single deep breaths, and unpatterned spontaneous breathing on RSA in 12 normal volunteers and 8 cardiac allograft transplant recipients. In normal subjects R-R changes closely followed changes in respiratory frequency (P less than 0.001) but were little affected by changes in VT. On the R-R spectrum, an oscillation peak synchronous with respiration was found in heart transplant patients. However, the average magnitude of the respiration-related oscillations was 1.7-7.9% that seen in normal subjects and was proportionally more influenced by changes in VT. Changes in R-R induced by Valsalva and Mueller maneuvers were 3.8 and 4.9% of those seen in normal subjects, respectively, whereas changes in R-R induced by single deep breaths were 14.3% of those seen in normal subjects. The magnitude of RSA was not related to time since the heart transplantation, neither was it related to patient age or sex. Thus the heart has the intrinsic ability to vary heart rate in synchrony with ventilation, consistent with the hypothesis that changes, or rate of changes, in myocardial wall stretch might alter intrinsic heart rate independent of autonomic tone.

Heart rate variability analysis in full-term infants: spectral indices for study of neonatal cardiorespiratory control

The heart rate and respirations of twenty healthy full-term infants between 30 and 60 h postnatal age were studied during quiet sleep with the objective of defining spectral indices which represent normal neonatal heart rate variability (HRV) characteristics. Total HRV power and the distribution of power across different frequency bands varied considerably among infants. Cluster analysis on the measured variables indicated that the population divided into two groups that represented significantly different patterns of HRV behavior. In one group (11 subjects), infants had lower breathing rates and HRV power in a band about the respiration frequency [respiratory sinus arrhythmia (RSA) band] was more than 20% of the total power (TP). Additionally, the ratio of low frequency band power to RSA band power was less than 4. The other group of neonates (nine subjects) had relatively higher breathing rates, RSA power less than 20% of total power, and low frequency to RSA power ratio greater than 4. Regression analysis of low frequency versus TP and RSA versus TP graphs gave strong support to the hypothesis that there were indeed two distinct patterns of HRV behavior. Separation of apparently normal neonates into two groups may be attributed partially to differences in respiratory rates and breathing patterns. However, it is possible that differences in the balance between sympathetic and parasympathetic nervous system control, perhaps related to autonomic maturation, also contribute to group separation. The indices developed from HRV spectral analysis in this investigation may be of value in the study of cardiorespiratory control in neonates.

Comparing the cardiac vagolytic effects of atropine and methylatropine in rhesus macaques

Atropine and methylatropine (190 nmol/kg) were compared in rhesus monkeys (Macaca mulatta) for their ability to produce a cardiac vagal blockade using a noninvasive estimate of respiratory sinus arrhythmia (RSA). Twelve monkeys received both drugs via intravenous (IV) and intramuscular (IM) routes of administration and were monitored for 3 hr after treatment. Both drugs, regardless of the route of administration, reduced RSA amplitude. At this dose, methylatropine was more effective than atropine in its ability to reduce RSA amplitude, heart period (HP; beat-to-beat interval), and overall heart period variability (HPV). Estimated RSA amplitude and HPV returned to basal levels significantly earlier after IM atropine administration than after IV treatment. Methylatropine did not exhibit any route effects. In addition, the mean decrease in RSA amplitude and HPV for the IM route of atropine sulfate was significantly less than that for the IV route. Serum atropine concentrations correlated significantly with all variables after IM treatment but only with RSA and HPV after IV treatment. Methylatropine may therefore be more useful than atropine as a pharmacologic challenge drug for detecting organophosphorus (OP) exposure because of its longer duration of action, lack of route of administration differences, and less likelihood of crossing the blood-brain barrier. Further studies are needed to fully evaluate methylatropine's potential in the challenge method of OP detection.

Diagnostic value of the Valsalva ratio reduction in diabetic autonomic neuropathy: use of an age-related normal range

A curvilinear age-related normal range for the Valsalva ratio is presented. Application of this range was used to identify abnormalities in ratios obtained from 59 patients with diabetes mellitus aged 16-60 years. It was found that 35 had normal, 6 had borderline and 18 had abnormal results. Comparison with other autonomic function tests of the cardiovascular and pupillary systems showed that abnormalities of the Valsalva ratio correlated most highly with the sinus arrhythmia test results. Repeat measurements of ratios in healthy and diabetic subjects yielded coefficients of variation of 15.4% and 10.5% respectively.

Multiple system atrophy. Clinical aspects, pathophysiology, and treatment

Progressive autonomic failure is a clinical syndrome of autonomic dysfunction that may occur in isolation as in idiopathic orthostatic hypotension (IOH) or in association with a central neurologic disorder, multiple system atrophy (MSA). MSA and IOH can be distinguished on the basis of biochemical and pharmacologic tests. Plasma norepinephrine levels are low in IOH and normal in MSA; neither group increases the plasma norepinephrine level adequately in response to postural change. Both MSA and IOH manifest an exaggerated pressor response to administered norepinephrine. However, only patients with IOH have true adrenergic receptor supersensitivity. The autonomic dysfunction in IOH primarily involves the peripheral autonomic neurons whereas the defect in MSA is the failure to activate appropriately an intact distal sympathetic nervous system. Neuropathologic studies reveal a multisystem degeneration in MSA; the few postmortem examinations of the central nervous system in IOH reveal lesions confined to the intermediolateral columns of the spinal cord. Orthostatic hypotension may be treated with a number of medications although supine hypertension limits the usefulness of these drugs. Further development and testing of a sympathetic neural prosthesis may help to resolve this therapeutic dilemma. Only the parkinsonian features in MSA respond to treatment with anticholinergic drugs.

[Mathematical model of the sinus rhythm of the heart]

As a result of mathematical simulation a group of signs was formed necessary and sufficient for the description of the oscillatory structure of the cardiac sinus rhythm at the quasi-stationary sections of the recording. The practical employment of the "adjustable" model permits one to obtain the present statistical accuracy of the assessment of signs with a lesser amount of baseline data. A procedure for the automatic measurement of signs by a mini-computer has been elaborated.