Findings of ambulatory blood pressure monitoring and heart rate variability in patients with Behcet's disease

Heart Rate Variability as an Indicator of Autonomic Nervous System Disturbance in Behcet's Disease

Background

Behçet’s disease (BD) is a multisystemic vasculiti where cardiac involvement is not common. Previous studies have shown that the incidence of ventricular arrhythmia and sudden cardiac death (SCD) is higher in patients with BD than in the healthy population. Among various possible explanations, autonomic nervous system (ANS) dysfunction has been suggested. Few studies have evaluated ANS function in patients with BD, and the results obtained are controversial.

Objective

We aimed to assess cardiac autonomic function by heart rate variability (HRV) in patients with BD; to evaluate circadian changes in HRV; and to study the relationship between HRV parameters and disease parameters.

Methods

Thirty-six patients with Behçet’s disease (median age 42 years, 28 men) and 36 age- and sex-matched healthy volunteers were included. HRV analyses were performed in the time and frequency domains for the entire 24-hour period and for the daytime and nighttime periods. BD activity was studied with Behcet’s disease current activity form (BDCAF).

Results

Patients with BD had significantly lower values of SDNN compared to controls. PNN50, RMSSD, and HF components mean values were significantly reduced in patients than in controls implying parasympathetic impairment. LF was comparable between the two groups, whereas LF/HF ratio was significantly higher in BD group. The circadian rhythm of HRV was preserved in patient group. There was no significant correlation of CRP or disease duration with HRV indices in Behçet’s subjects. BDCAF score was found to be negatively correlated with LF/HF.

Conclusion

Patients with BD, despite no cardiovascular involvement, have reduced parasympathetic activity compared with controls. However, circadian rhythms of autonomic function were preserved. As known, there is strong evidence for the role of the ANS in the pathogenesis of ventricular arrhythmias. Thus, being a practical tool, HRV can be an interesting approach for the rhythmic follow-up of BD patients.

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Behçet's Disease with Severe Autonomic Disorders Developing after Herpes Zoster

A 58-year-old Japanese woman with herpes zoster developed Behçet's disease (BD) with symptoms including orthostatic intolerance as an autonomic disorder. Multiple immune-suppressive therapies and a β-blocker successfully controlled both the disease activity of BD and the autonomic disorders. A cytokine multiplex analysis of her serum revealed the elevation of proinflammatory cytokines [interleukin (IL)-1, IL-6, IL-12, tumor necrosis factor alfa (TNFα), and interferon gamma (IFN-γ)] and a low IL-10 concentration. IL-10 production is reported to be important for defense against herpes zoster virus (VZV). Insufficient IL-10 production is reported in BD. The reactivation of VZV with this cytokine profile suggests that BD will develop with various symptoms, including severe autonomic disorders.

Heart rate variability in familial Mediterranean fever patients

OBJECTIVE

Familial Mediterranean fever (FMF) is an autosomal recessive autoimmune disease, presenting with the attacks of fever and inflammation of serous membranes. One of the leading causes of death in autoimmune rheumatologic diseases is cardiovascular events. The purpose of this study is to evaluate the effects of FMF on the autonomic nerve and cardiovascular systems by measuring the indices of heart rate variability (HRV).

MATERIAL AND METHODS

Thirty FMF patients and the same number of healthy volunteers were enrolled to the study. Standard deviation of all R-R intervals (SDNN), the square root of the sum of the square of the differences between successive R-R intervals (RMSSD), standard deviation of 5-minute mean values of R-R interval (SDANN), low frequency (LF), and high frequency (HF) were measured.

RESULTS

Time domain indices (SDNN, SDANN, and RMSSD) were: 124.67±40.79, 129.87±36.43 (p=0.605); 11.43±38.41, 11.23±38.98 (p=0.984); and 33.43±17.39, 38.17±12.8 (p=0.235) for FMF patients and controls, respectively, and similar in both groups. Frequency domain indices (HF, LF, and LF/HF) were: 290.41±290.25, 322.20±222.54 (p=0.639); 596.16±334.07, 805.80±471.00 (p=0.051); and 3.57±2.57, 3.05±1.40 (p=0.338) for FMF patients and controls, respectively, and similar in both groups.

CONCLUSION

The HRV parameters were similar in both groups. However, studies including larger populations and using different methods are required to clarify if autonomic dysfunction exists in patients with FMF.

Autonomic neural control of the cardiovascular system in patients with Behçet's disease in the absence of neurological involvement

Behçet's disease (BD) is a chronic multi-system disease presenting with recurrent oral and genital ulceration, and relapsing uveitis. Heart rate recovery (HRR) after exercise is a marker of parasympathetic activity. A delayed recovery of systolic blood pressure (SBP) after exercise might reflect sympathetic hyperactivity. The analysis of variations in heart rate has also been used to determine the balance between sympathetic and vagal nerve activities in the heart. Our objective was to determine HRR, the SBP response to exercise and heart rate variability (HRV) in patients with BD in the absence of neurological involvement. The study population consisted of 32 patients with BD and 30 healthy controls who were matched with respect to age, sex, and physical activity. Heart rate recovery was calculated as the difference between heart rate at peak exercise and heart rate at 1, 2, and 3 min of recovery. Blood pressure recovery indexes were determined by dividing the systolic blood pressure at 2 and 3 min in recovery to the systolic blood pressure at peak exercise. In patients with BD, mean HRR at 1 min (HRR1) were not significantly different than that of controls (21 ± 7 vs 20 ± 7 bpm, p = 0.50). Although, resting mean SBP of patients with BD was higher than controls (121 ± 13 vs 115 ± 12 mmHg, p = 0.039), the SBP recovery indices of the patients with BD at 2 and 3 min were similar to those of controls (0.84 ± 0.07 vs 0.84 ± 0.09, p = 0.89 and 0.78 ± 0.09 vs 0.78 ± 0.08, p = 0.93, respectively). Both time domain and frequency domain parameters of patients with BD were similar to that of controls. This study shows that the patients with BD have normal HRR1 and normal SBP response to exercise and normal HRV. These findings might suggest unaltered autonomic neural control of the cardiovascular system in this disorder in the absence of neurological involvement.

The subclinic autonomic dysfunction in patients with Behçet disease: an electrophysiological study

Studies that have evaluated autonomic nervous system (ANS) function in Behçet disease (BD) are rare and have indicated conflicting results with different degrees of involvement. The aim of this study was to investigate ANS function by using electrophysiological tests in patients with BD and to determine the relationship between the disease activity parameters and the indicators of autonomic activity. We included 70 BD patients and 50 healthy controls. Demographic characteristics including age, sex, and disease duration were recorded. A detailed neurological examination was performed, and clinical autonomic symptoms were recorded. The Behçet Disease Current Activity Form (BDCAF) was used to determine the disease activity. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels were determined for laboratory activity. The electrophysiological assessments of ANS function were performed by sympathetic skin response (SSR) and R-R interval variation (RRIV) tests. The mean values of sympathetic (SSR latency and amplitude) and parasympathetic (RRIV at rest [R%] and deep breathing [D%], D% - R%, and D%/R%) parameters were compared, and any correlations between ANS parameters and clinical disease characteristics were determined. Seventy BD patients (23 males, 47 females) with a mean age of 41.2 ± 10.01 years and 50 control subjects (18 males, 32 females) with a mean age of 39.5 ± 8.94 years were included in the study. All the subjects were totally symptom free with respect to ANS involvement, and the subjects in both groups had normal neurological examination findings. The demographic characteristics were similar between the groups. The mean latency of SSR was increased (1.4 ± 0.4 vs 0.7 ± 0.8), and R% (0.3 ± 0.3 vs 0.5 ± 0.4) and D% (0.3 ± 0.3 vs 0.6 ± 0.5) values were decreased in BD patients compared to control subjects. No correlation was found between BDCAF scores and ANS variables. However, there was a significant correlation between SSR latency and ESR and CRP values (p < 0.01, r = -0.25, r = -0.31, respectively) in the patient group, indicating a more sympathetic dysautonomia in patients with active laboratory parameters. In conclusion, our study indicates a subclinical sympathetic and parasympathetic autonomic dysfunction in patients with BD, which may be related with disease activity. As the early recognition of abnormalities in ANS may be very important in order to prevent excessive morbidity, simple electrophysiological methods are suggested to identify Behçet patients at high risk for symptomatic dysautonomia.

The effects of trimetazidine on heart rate variability in patients with slow coronary artery flow

OBJECTIVE

We sought to examine the effect of trimetazidine (TMZ) on heart rate variability (HRV), endothelin-1 (ET-1), NO, and anginal symptoms in patients with slow coronary artery flow (SCAF).

METHODS

The 48 patients with SCAF (29 women and 19 men; mean age, 52 +/- 9 years) were included in the study. Twenty milligrams TMZ 3 times a day or matched placebo were given randomly in a double-blinded fashion for 4 weeks. Patients were divided into 4 groups as follows: exercise-positive, TMZ-given group (group A, n = 12); exercise-positive, placebo-given group (group B, n = 12); exercise-negative, TMZ-given group (group C, n = 12); and exercise-negative, placebo-given group (group D, n = 12).

RESULTS

After TMZ treatment, HRV parameters, including SD of the all R-R intervals, SD of the averages of R-R intervals in all 5-minute segments of the entire recording, percentage of R-R intervals with more than 50-millisecond variation, and the square root of the mean of the sum of the squares of differences between adjacent R-R intervals, significantly improved both in exercise-positive and exercise-negative groups when compared with baseline. After TMZ treatment, ET-1 and NO levels significantly altered both in exercise-positive and exercise-negative groups when compared with baseline (17.7 +/- 2.7 vs 13.9 +/- 2.8 pg/mL [P = .01] and 18.1 +/- 3.8 vs 14.2 +/- 2.6 pg/mL [P = .01], respectively). After TMZ treatment, NO levels significantly increased in both exercise-positive and exercise-negative groups when compared with baseline (36.4 +/- 5.4 vs 43.3 +/- 6.8 micromol/L [P = .01] and 36.8 +/- 7.8 vs 43.3 +/- 4.8 micromol/L [P = .01], respectively). However, in placebo group, neither HRV parameters nor ET-1 and NO levels altered when compared with baseline. Also, after treatment, a significant correlation was detected between HRV parameters, including SD of the averages of R-R intervals in all 5-minute segments of the entire recording, SD of the all R-R intervals, percentage of R-R intervals with more than 50-millisecond variation, and the square root of the mean of the sum of the squares of differences between adjacent R-R intervals, and NO and ET-1 levels in TMZ group but not placebo.

CONCLUSION

Short-term TMZ therapy improved HRV parameters and endothelial products such as ET-1 and NO as well as anginal symptom in patients with SCAF. Improvement in HRV parameters was correlated with ET-1 and NO levels.

Tissue Doppler velocities of the right and left ventricles and their association with C-reactive protein and homocysteine levels in Behcet's disease

In the present study, we aimed to investigate whether tissue Doppler imaging could provide more information than standard echocardiography about left and right ventricular functions and their relations to homocysteine and C-reactive protein (CRP) levels in the course of Behcet's disease (BD). In the right ventricle, patients with BD had lower early diastolic tricuspid annular velocity and early diastolic/late diastolic tricuspid annular velocity ratios than the control group. Mitral and tricuspid annular systolic velocities did not significantly differ; however, diastolic velocities were correlated with duration of the disease. In addition, early/late diastolic mitral annular velocity ratio and early/late diastolic tricuspid annular velocity ratios showed an inverse relation with ocular involvement, serum homocysteine, and CRP levels in patients with BD.

Evaluation of myocardial perfusion in patients with Behçet’s disease

AIM

To estimate the prevalence of silent myocardial ischemia (SMI) in patients with Behçet's disease (BD) and to identify a subgroup of patients at higher risk for the presence of SMI.

MATERIALS AND METHODS

We evaluated 41 patients (mean age 42.8 +/- 12.3 years) with BD and 35 healthy control subjects. Treadmill exercise test and thallium-201 myocardial perfusion single photon emission computed tomography (SPECT) were performed in all subjects. Coronary angiography was performed in all patients with a diagnosis of SMI in Behçet's group.

RESULTS

All subjects had normal resting electrocardiograms. Eight patients with BD (19.5%) had evidence of ischemia on exercise testing and myocardial perfusion SPECT. Only one SMI positivity (2.9%) was recorded in the control group. Significant coronary stenosis was not found with coronary angiography in the patients with a diagnosis of SMI in Beçet's group. SMI positivity was recorded in 2 of 18 female patients (11%) and in 6 of 23 male patients (26.1%) with BD (p = 0.429). The mean duration of BD was 13.8 +/- 2.6 years in patients with SMI and 7 +/- 4.1 in patients without it (p < 0.001). Seven of the 8 patients (87.5%) with SMI had a duration of BD of greater than 10 years.

CONCLUSIONS

The results of this study show that the prevalence of SMI is high in patients with BD. Based on our findings, screening with myocardial perfusion scintigraphy may be recommended for patients with duration of BD greater than 10 years.

Vascular endothelial function and plasma homocysteine levels in Behcet's disease

The purpose of the present study was to test endothelial function and to determine if plasma homocysteine levels are associated with endothelial injury in patients with Behcet's disease (BD). Flow-mediated dilation in patients with BD was smaller than that of control subjects (p = 0.001), and mean plasma homocysteine levels in patients with BD were significantly higher (p = 0.0001). On regression analysis, only mean plasma homocysteine concentration was independently related to flow-mediated dilation (F = 5.7, p = 0.001).