Learned control of ventricular rate in patients with atrial fibrillation

An essay on the circulation as behavior

Most conceptual models of the organization of the cardiovascular system begin with the premise that the nervous system regulates the metabolic and nonmetabolic reflex adjustments of the circulation. These models assume that all the neurally mediated responses of the circulation are reactive, i.e., reflexes elicited by adequate stimuli. This target article suggests that the responses of the circulation are conditional in three senses. First, as Sherrington argued, reflexes are conditional in that they never operate in a vacuum but in a context together with other reflexes. Guided by functional utility, they interact rather than add. Second, as Pavlov argued, stimuli acquire meanings as a result of experience. This notion of stimulus effect plus the Sherringtonian notion of conditionality suggest that association is one of the ways stimuli eliciting cardiovascular reflexes acquire their meanings and thus their relative strengths. Finally, as Skinner and others have argued, operants are responses that act upon the environment to obtain consequences – that is, stimuli. As operants, cardiovascular responses fulfill a major biological need, functioning proactively. The cardiovascular response is an integral component of the animal's behavior regardless of whether it is an elicited reflex or the eliciting stimulus acquired its properties as a result of the genetic inheritance of the animal or through experience, or the cardiovascular response is emitted in anticipation of an environmental consequence. The main theses of this essay are: (1) behavior is an integrated set of responses and the circulation is one of the response systems comprising behavior; (2) behavior is, in part, determined by its functional significance within a context; (3) the contextual factors operative at the time of the behavior have a major role in determining which of the set of possible responses will determine the final act, that is, which behavior will be the effective response and which other behaviors will be concomitants.

Power spectral analysis of heart rate variability in a horse with atrial fibrillation

This study has demonstrated the power spectral analysis of heart rate variability in a horse with atrial fibrillation. A large peak in the high frequency (HF) area of the power spectrum appeared in the horse. Hourly heart rate, the low frequency (LF) power, the HF power, and LF/HF ratio were almost constant during the recording period. The values of HF and LF power in the horse with atrial fibrillation were much larger than those in normal horses. The normalized unit of HF (HF n.u.) was much larger than that of LF (LF n.u.). Furthermore, the LF/HF ratio was very small in the horse. These results suggest that the ventricular rhythm has a respiratory related periodicity in the horse with atrial fibrillation and the predominant parasympathetic activity may modulate the intrinsic behavior of the atrioventricular node during atrial fibrillation.

Diurnal variation of ventricular response to atrial fibrillation in patients with advanced heart failure

Variability of ventricular rate was quantified by two measures of heart rate variability: the SD of the mean R-R interval (SDNN) and the SD of the 5-minute mean R-R interval (SDANN). In 35 patients with atrial fibrillation and advanced heart failure (left ventricular ejection fraction 20% +/- 9%, cardiac index 2.4 +/- 0.7 L/min/m2), SDNN and SDANN were compared to 13 preselected clinical and hemodynamic variables for prediction of outcome. During a 12-month follow-up period, 8 (23%) patients deteriorated clinically; 3 (9%) died, and 5 (14%) underwent heart transplantation. SDNN and SDANN correlated to the difference of the mean R-R interval between night (2 AM to 3 PM) and day (11 AM to noon) with r values of 0.62 and 0.77, respectively. From 15 preselected variables, only SDANN (chi 2 = 6.7, p = 0.01) was independently associated with survival on multivariate analysis. Dichotomized SDANN at 100 msec accurately predicted 12-month survival in 28 (80%) patients (relative risk = 9.77, p = 0.001). In conclusion, analysis of heart rate variability is useful in quantifying diurnal variation of ventricular rate in atrial fibrillation and might be useful in predicting survival in patients with advanced heart failure.

Autonomic behavior

This article summarizes a body of work which collectively shows that autonomic responses meet the criteria for behavior. They can be modified reliably through the systematic use of antecedent (cues) and consequent (contingencies) stimuli. This means that autonomic responses, which are usually characterized as elicited reflexes, can be learned responses (viz., behaviors). This review cites a number of experimental and clinical studies in which autonomic learning has been shown to occur and to have clinical importance. Of special interest to gerontologists are the clinical studies which show that incontinent and hypertensive elderly patients can be trained to normalize their pathognomic responses.

Cardiopulmonary adjustments during operant heart rate control

Twenty-three healthy men and women participated in a 5-session experiment in which they attempted to increase and decrease their heart rate with the assistance of visual analogue biofeedback. As a group subjects did successfully raise and lower heart rate from resting baseline. These changes in heart rate were closely paralleled by changes in V, a measure of cardiac vagal tone. Heart rate slowing was associated with increases in V, and heart rate speeding was associated with decreases in V. Respiration rate and amplitude did not differ significantly between heart rate slowing and speeding trials, and covariance analysis indicated that respiratory changes did not account for the heart rate or V effects. The weighted coherence between respiration and heart rate showed that cardiopulmonary coupling increased during heart rate slowing and decreased during heart rate speeding. Individual differences in cardiac vagal tone and cardiopulmonary coupling were unrelated to heart rate speeding and slowing performance.

Cardiovascular reactivity as behavior

The word, behavior, means action or reaction. Thus, all physiologic responses meet this definition and are behavior. Furthermore, if the response is neurally mediated, then there are only 3 possible behavioral mechanisms that can be operating to determine it: (1) The response is part of a reflex, elicited by an adequate stimulus. In this case, in an intact animal the expression of the response will be modulated by a variety of situational factors. (2) The response is part of a reflex. However, the capacity of the stimulus to elicit the response is acquired through association with an adequate stimulus. Thus, the reflex is learned rather than innate. (3) The response is part of a "central command" and is emitted in anticipation of a consequence whose likelihood of occurrence has been learned. Neurally mediated responses of the circulation meet all these criteria. Thus, circulatory responses not only are passive reflexes, they also are reactive and proactive behaviors, which permit animals to interact effectively with their environments, and which change with practice. These principles explain a variety of cardiovascular effects observed in experimental or clinical settings. Furthermore, by applying well-established behavioral principles to circulatory responses, it is possible to achieve clinically significant effects. This presentation will characterize the way in which behavioral mechanisms are expressed in the circulation, it will describe a number of clinically significant findings that illustrate the importance of these mechanisms, and it will propose a number of applications of behavioral principles that can be used in clinical practice.

Stress, predisposition and the onset of serious disease: implications about psychosomatic etiology

Based on the author's own work and a review of the literature, the hypothesis is made that potentially lethal disease does not usually occur in healthy animals or people but does so when covert or overt disease exists or when a predisposition for disease exists. The author supports this hypothesis in his assessment of the human literature on sudden death. Further support for the hypothesis is presented from 2 animal models being studied in his laboratory--stress-induced heart failure in the cardiomyopathic hamster and stress-induced sensitization of digitalis-toxic ventricular arrhythmias. This analysis suggests a different view from the classical one of what a psychosomatic disease might be.

Clinical biofeedback: a behavioral analysis

Clinical biofeedback studies have shown that patients can learn to control highly specific physiological responses such as relaxation of the internal anal sphincter, contraction of the external anal sphincter, heart rate and intracardiac conduction patterns, or blood pressure. Findings from a number of studies indicate that the ability to learn to control abnormal responses is highly reinforcing and facilitates further learning. Other findings indicate that learning tends to be specific to the response being trained. If it is desirable to teach patients to control more than one response, it may be necessary to teach each response independently.

Applied relaxation in treatment of "cardiac neurosis": a systematic case study

The treatment of a case of “cardiac neurosis” is described. Using an applied relaxation treatment program the client was taught relaxation as a coping skill to be used when she felt changes in cardiac activity. The therapy was conducted with minimal contact, the client did most of the training on her own with the help of taped instructions. The results showed a definite decrease in severity of the problem during the treatment period, and by the time of the follow-ups at 6 and 21 mo. after treatment, the client was almost completely relieved from these problems.

The role of behavioral conditioning in the cardiovascular adjustment to exercise

The purpose of this study was to determine if normal subjects could be trained to attenuate their cardiovascular responses while exercising on a bicycle ergometer. Ten young, untrained subjects exercised on a bicycle ergometer for five sessions. Half of the group was asked to slow their heart rate while exercising with heart rate feedback during exercise. Their average heart rate increase was 20% less than that of the control subjects, who exercised without feedback. The control subjects subsequently also received feedback during exercise and they were able to attenuate their heart rate responses comparably. Systolic blood pressure was not affected by feedback training. Changes in rate-pressure product paralleled changes in heart rate. These data show that autonomically mediated adjustments to exercise can be brought under experimental control through the use of appropriate behavioral techniques.

Instrumental cardiovascular conditioning: a review

This paper reviews experiments, hypotheses, and current controversies about instrumental cardiovascular conditioning. Demonstrations of such conditioning in curarized animals challenged a differentiation between instrumental and classical learning on the basis of their respective effector systems but did not prove direct operant learning by the autonomic nervous system. In humans, ethical prohibition of curarization and lack of adequate controls for respiration and muscle tension have resulted in incomplete understanding of the roles of voluntary, somatic mediators. Despite a variety of potential clinical applications of biofeedback, the available literature lacks studies of its efficacy compared to more standard modes of therapy. The physiological mechanisms and central neural pathways involved in instrumental cardiovascular conditioning remain almost totally unknown.

Biofeedback heart rate training during exercise

Eighteen healthy human subjects participated in weekly sessions of five 10-minute trials of walking on a treadmill at 2.5 mph and 6% grade. Eight experimental subjects received beat-to-beat heart rate biofeedback during the exercise and were instructed to try to lower their heart rates; ten control subjects did not receive feedback. By the end of 5 weeks (25 trials), the experimental group showed a significantly lower mean heart rate (96.8 vs. 108.6 bpm), systolic blood pressure (114.0 vs. 131.3 mmHg), and rate--pressure product (11.0 X 10(3) vs. 14.3 X 10(3) bpm-mmHg) during exercise than the control group. These differences were maintained after crossover of the feedback provision for five more weeks.

Psychological aspects of cardiac arrhythmia

A review of data from a wide spectrum of research studies suggests that psychological-emotional factors can significantly influence and alter the incidence of cardiac arrhythmia. While the existing data are, in many cases, difficult to interpret because of theoretical and methodological problems, sufficient evidence does exist to warrant a concerted investigation into the total involvement of psychological factors in cardiac arrhythmia.

Habituation and conditioning of the defense reactions and their cardiovascular components in cats and dogs

Cardiovascular and behavioural responses elicited by novel, noxious or aversive stimuli have been studied in dogs and cats. Hindlimb blood flow, heart rate and arterial blood pressure increased in dogs when an orienting response was elicited by a novel stimulus (a sound). Similar cardiovascular responses occurred in dogs to mild noxious stimulus and in cats displaying a threatening posture when confronted by a dog. The cardiovascular components of the orienting response to a sound habituated with repetition of the sound. In two dogs however sensitization (increase) of the response occurred with reped by repetition of the confrontations: the vasodilation in the muscles waned and eventually was replaced by vasoconstriction while the cardiac acceleration and pressor response persisted. The threatening response was the most persistent. The modification of the behavioural and cardiovascular aspect of the response was not developing in parallel. The cardiovascular pattern was altered before any apparent changes of the behavioural pattern occurred. The cardiovascular responses of the noxious stimulus in dogs and cardiovascular components of the defence reaction in cats were readily conditioned to a sound. The possible role of the modification of the cardiovascular pattern in defence reactions in pathogenesis of hypertension is discussed.

Learned heart-rate control by a patient with a ventricular parasystolic rhythm

A 31-year-old woman with a ventricular parasystolic rhythm is described. The arrhythmia was always absent below a rate of 72 per minute, and always present over a rate of 106 per minute. Voluntary heart-rate control was learned using a biofeedback techinque, as a result of which she could increase her rate by 25 per minute and decrease it by 1-2 per minute. Both voluntary speeding and exercise brought on the arrhythmia, but later in the training she could reach a higher heart-rate before the arrhythmia appeared. Propranolol inhibited the arrhythmia only to the extent that is slowed the heart.