Reduction of maximal exercise heart rate at altitude and its reversal with atropine

Cardiovascular physiology and pathophysiology at high altitude

Oxygen is vital for cellular metabolism; therefore, the hypoxic conditions encountered at high altitude affect all physiological functions. Acute hypoxia activates the adrenergic system and induces tachycardia, whereas hypoxic pulmonary vasoconstriction increases pulmonary artery pressure. After a few days of exposure to low oxygen concentrations, the autonomic nervous system adapts and tachycardia decreases, thereby protecting the myocardium against high energy consumption. Permanent exposure to high altitude induces erythropoiesis, which if excessive can be deleterious and lead to chronic mountain sickness, often associated with pulmonary hypertension and heart failure. Genetic factors might account for the variable prevalence of chronic mountain sickness, depending on the population and geographical region. Cardiovascular adaptations to hypoxia provide a remarkable model of the regulation of oxygen availability at the cellular and systemic levels. Rapid exposure to high altitude can have adverse effects in patients with cardiovascular diseases. However, intermittent, moderate hypoxia might be useful in the management of some cardiovascular disorders, such as coronary heart disease and heart failure. The aim of this Review is to help physicians to understand the cardiovascular responses to hypoxia and to outline some recommendations that they can give to patients with cardiovascular disease who wish to travel to high-altitude destinations.

Global REACH 2018: increased adrenergic restraint of blood flow preserves coupling of oxygen delivery and demand during exercise at high-altitude

Chronic exposure to hypoxia (high-altitude, HA; >4000 m) attenuates the vasodilatory response to exercise and is associated with a persistent increase in basal sympathetic nerve activity (SNA). The mechanism(s) responsible for the reduced vasodilatation and exercise hyperaemia at HA remains unknown. We hypothesized that heightened adrenergic signalling restrains skeletal muscle blood flow during handgrip exercise in lowlanders acclimatizing to HA. We tested nine adult males (n = 9) at sea-level (SL; 344 m) and following 21-28 days at HA (∼4300 m). Forearm blood flow (FBF; duplex ultrasonography), mean arterial pressure (MAP; brachial artery catheter), forearm vascular conductance (FVC; FBF/MAP), and arterial and venous blood sampling (O₂ delivery ( DO2${D}_{{{\rm{O}}}_{\rm{2}}}$ ) and uptake ( V̇O2${\dot{V}}_{{{\rm{O}}}_{\rm{2}}}$ )) were measured at rest and during graded rhythmic handgrip exercise (5%, 15% and 25% of maximum voluntary isometric contraction; MVC) before and after local α- and β-adrenergic blockade (intra-arterial phentolamine and propranolol). HA reduced ΔFBF (25% MVC: SL: 138.3 ± 47.6 vs. HA: 113.4 ± 37.1 ml min^-1 ; P = 0.022) and Δ V̇O2${\dot{V}}_{{{\rm{O}}}_{\rm{2}}}$ (25% MVC: SL: 20.3 ± 7.5 vs. HA: 14.3 ± 6.2 ml min^-1 ; P = 0.014) during exercise. Local adrenoreceptor blockade at HA restored FBF during exercise (25% MVC: SL_{α-β blockade} : 164.1 ± 71.7 vs. HA_{α-β blockade} : 185.4 ± 66.6 ml min^-1 ; P = 0.947) but resulted in an exaggerated relationship between DO2${D}_{{{\rm{O}}}_{\rm{2}}}$ and V̇O2${\dot{V}}_{{{\rm{O}}}_{\rm{2}}}$ ( DO2${D}_{{{\rm{O}}}_{\rm{2}}}$ / V̇O2${\dot{V}}_{{{\rm{O}}}_{\rm{2}}}$ slope: SL: 1.32; HA: slope: 1.86; P = 0.037). These results indicate that tonic adrenergic signalling restrains exercise hyperaemia in lowlanders acclimatizing to HA. The increase in adrenergic restraint is necessary to match oxygen delivery to demand and prevent over perfusion of contracting muscle at HA. KEY POINTS: In exercising skeletal muscle, local vasodilatory signalling and sympathetic vasoconstriction integrate to match oxygen delivery to demand and maintain arterial blood pressure. Exposure to chronic hypoxia (altitude, >4000 m) causes a persistent increase in sympathetic nervous system activity that is associated with impaired functional capacity and diminished vasodilatation during exercise. In healthy male lowlanders exposed to chronic hypoxia (21-28 days; ∼4300 m), local adrenoreceptor blockade (combined α- and β-adrenergic blockade) restored skeletal muscle blood flow during handgrip exercise. However, removal of tonic adrenergic restraint at high altitude caused an excessive rise in blood flow and subsequently oxygen delivery for any given metabolic demand. This investigation is the first to identify greater adrenergic restraint of blood flow during acclimatization to high altitude and provides evidence of a functional role for this adaptive response in regulating oxygen delivery and demand.

Modeling the oxygen transport to the myocardium at maximal exercise at high altitude

Exposure to high altitude induces a decrease in oxygen pressure and saturation in the arterial blood, which is aggravated by exercise. Heart rate (HR) at maximal exercise decreases when altitude increases in prolonged exposure to hypoxia. We developed a simple model of myocardial oxygenation in order to demonstrate that the observed blunting of maximal HR at high altitude is necessary for the maintenance of a normal myocardial oxygenation. Using data from the available scientific literature, we estimated the myocardial venous oxygen pressure and saturation at maximal exercise in two conditions: (1) with actual values of maximal HR (decreasing with altitude); (2) with sea-level values of maximal heart rate, whatever the altitude (no change in HR). We demonstrated that, in the absence of autoregulation of maximal HR, myocardial tissue oxygenation would be incompatible with life above 6200 m-7600 m, depending on the hypothesis concerning a possible increase in coronary reserve (increase in coronary blood flow at exercise). The decrease in maximal HR at high altitude could be explained by several biological mechanisms involving the autonomic nervous system and its receptors on myocytes. These experimental and clinical observations support the hypothesis that there exists an integrated system at the cellular level, which protects the myocardium from a hazardous disequilibrium between O₂  supply and O₂ consumption at high altitude.

Limitation of Maximal Heart Rate in Hypoxia: Mechanisms and Clinical Importance

The use of exercise intervention in hypoxia has grown in popularity amongst patients, with encouraging results compared to similar intervention in normoxia. The prescription of exercise for patients largely rely on heart rate recordings (percentage of maximal heart rate (HR_max) or heart rate reserve). It is known that HR_max decreases with high altitude and the duration of the stay (acclimatization). At an altitude typically chosen for training (2,000-3,500 m) conflicting results have been found. Whether or not this decrease exists or not is of importance since the results of previous studies assessing hypoxic training based on HR may be biased due to improper intensity. By pooling the results of 86 studies, this literature review emphasizes that HR_max decreases progressively with increasing hypoxia. The dose–response is roughly linear and starts at a low altitude, but with large inter-study variabilities. Sex or age does not seem to be a major contributor in the HR_max decline with altitude. Rather, it seems that the greater the reduction in arterial oxygen saturation, the greater the reduction in HRmax, due to an over activity of the parasympathetic nervous system. Only a few studies reported HR_max at sea/low level and altitude with patients. Altogether, due to very different experimental design, it is difficult to draw firm conclusions in these different clinical categories of people. Hence, forthcoming studies in specific groups of patients are required to properly evaluate (1) the HR_max change during acute hypoxia and the contributing factors, and (2) the physiological and clinical effects of exercise training in hypoxia with adequate prescription of exercise training intensity if based on heart rate.

Control of breathing and the circulation in high-altitude mammals and birds

Hypoxia is an unremitting stressor at high altitudes that places a premium on oxygen transport by the respiratory and cardiovascular systems. Phenotypic plasticity and genotypic adaptation at various steps in the O2 cascade could help offset the effects of hypoxia on cellular O2 supply in high-altitude natives. In this review, we will discuss the unique mechanisms by which ventilation, cardiac output, and blood flow are controlled in high-altitude mammals and birds. Acclimatization to high altitudes leads to some changes in respiratory and cardiovascular control that increase O2 transport in hypoxia (e.g., ventilatory acclimatization to hypoxia). However, acclimatization or development in hypoxia can also modify cardiorespiratory control in ways that are maladaptive for O2 transport. Hypoxia responses that arose as short-term solutions to O2 deprivation (e.g., peripheral vasoconstriction) or regional variation in O2 levels in the lungs (i.e., hypoxic pulmonary vasoconstriction) are detrimental at in chronic high-altitude hypoxia. Evolved changes in cardiorespiratory control have arisen in many high-altitude taxa, including increases in effective ventilation, attenuation of hypoxic pulmonary vasoconstriction, and changes in catecholamine sensitivity of the heart and systemic vasculature. Parallel evolution of some of these changes in independent highland lineages supports their adaptive significance. Much less is known about the genomic bases and potential interactive effects of adaptation, acclimatization, developmental plasticity, and trans-generational epigenetic transfer on cardiorespiratory control. Future work to understand these various influences on breathing and circulation in high-altitude natives will help elucidate how complex physiological systems can be pushed to their limits to maintain cellular function in hypoxia.

Autonomic cardiovascular responses in acclimatized lowlanders on prolonged stay at high altitude: a longitudinal follow up study

Acute exposure to hypobaric hypoxia at high altitude is reported to cause sympathetic dominance that may contribute to the pathophysiology of high altitude illnesses. The effect of prolonged stay at high altitude on autonomic functions, however, remains to be explored. Thus, the present study aimed at investigating the effect of high altitude on autonomic neural control of cardiovascular responses by monitoring heart rate variability (HRV) during chronic hypobaric hypoxia. Baseline electrocardiography (ECG) data was acquired from the volunteers at mean sea level (MSL) (<250 m) in Rajasthan. Following induction of the study population to high altitude (4500–4800 m) in Ladakh region, ECG data was acquired from the volunteers after 6 months (ALL 6) and 18 months of induction (ALL 18). Out of 159 volunteers who underwent complete investigation during acquisition of baseline data, we have only included the data of 104 volunteers who constantly stayed at high altitude for 18 months to complete the final follow up after 18 months. HRV parameters, physiological indices and biochemical changes in serum were investigated. Our results show sympathetic hyperactivation along with compromise in parasympathetic activity in ALL 6 and ALL 18 when compared to baseline data. Reduction of sympathetic activity and increased parasympathetic response was however observed in ALL 18 when compared to ALL 6. Our findings suggest that autonomic response is regulated by two distinct mechanisms in the ALL 6 and ALL 18. While the autonomic alterations in the ALL 6 group could be attributed to increased sympathetic activity resulting from increased plasma catecholamine concentration, the sympathetic activity in ALL 18 group is associated with increased concentration of serum coronary risk factors and elevated homocysteine. These findings have important clinical implications in assessment of susceptibility to cardio-vascular risks in acclimatized lowlanders staying for prolonged duration at high altitude.

Cardiac adaptation to high altitude in the plateau pika (Ochotona curzoniae)

The aim of this study was to assess maximal heart rate (HR) and heart morphological changes in high altitude living “plateau pikas” and rats bred at 2260 m. Rats and pikas were catheterized to measure HR (2260 m). After baseline measurements, 1 mg/kg of atropine (AT) and increasing doses of isoproterenol (IsoP) (0.1, 1, 10, and 100 μg kg) were injected into animals. Right (RV) and left ventricles (LV) were removed to calculate Fulton's ratio (LV + septum (S) to RV weights) and to assess mRNA expression level of β1- and β2-adrenoceptors, muscarinic m1 and m2 receptors, and vascular endothelial growth factor (VEGF). Resting HR was significantly lower in rats than in pikas and increased after AT injection only in rats. IsoP injection induced a significant increase in HR in rat for all doses, which was systematically greater than in pikas. In pikas HR was slightly increased only after the two highest concentrations of IsoP. Fulton's ratio was greater in rats compared with pikas but the LV + S adjusted for body weight was greater in pikas. Pikas showed lower β1-adrenoceptors and muscarinic m2 receptors mRNA expression but larger VEGF mRNA expression than rats both in RV and LV. These results suggest that pikas have a lower maximal HR compared with rats certainly due to a decrease in β-adrenergic and muscarinic receptors mRNA expression. However, the LV hypertrophy probably led to an increase in stroke volume to maintain cardiac output in response to the cold and hypoxic environment.

Physiological adaptation of the cardiovascular system to high altitude. Prog Cardiovasc Dis. 2010;52:456-466. [PMID: 20417339 DOI: 10.1016/j.pcad.2010.03.004]

Altitude exposure is associated with major changes in cardiovascular function. The initial cardiovascular response to altitude is characterized by an increase in cardiac output with tachycardia, no change in stroke volume, whereas blood pressure may temporarily be slightly increased. After a few days of acclimatization, cardiac output returns to normal, but heart rate remains increased, so that stroke volume is decreased. Pulmonary artery pressure increases without change in pulmonary artery wedge pressure. This pattern is essentially unchanged with prolonged or lifelong altitude sojourns. Ventricular function is maintained, with initially increased, then preserved or slightly depressed indices of systolic function, and an altered diastolic filling pattern. Filling pressures of the heart remain unchanged. Exercise in acute as well as in chronic high-altitude exposure is associated with a brisk increase in pulmonary artery pressure. The relationships between workload, cardiac output, and oxygen uptake are preserved in all circumstances, but there is a decrease in maximal oxygen consumption, which is accompanied by a decrease in maximal cardiac output. The decrease in maximal cardiac output is minimal in acute hypoxia but becomes more pronounced with acclimatization. This is not explained by hypovolemia, acid-bases status, increased viscosity on polycythemia, autonomic nervous system changes, or depressed systolic function. Maximal oxygen uptake at high altitudes has been modeled to be determined by the matching of convective and diffusional oxygen transport systems at a lower maximal cardiac output. However, there has been recent suggestion that 10% to 25% of the loss in aerobic exercise capacity at high altitudes can be restored by specific pulmonary vasodilating interventions. Whether this is explained by an improved maximum flow output by an unloaded right ventricle remains to be confirmed. Altitude exposure carries no identified risk of myocardial ischemia in healthy subjects but has to be considered as a potential stress in patients with previous cardiovascular conditions.

Effects of altitude on exercise level and heart rate in patients with coronary artery disease and healthy controls

Background. To evaluate the safety and effects of high altitude on exercise level and heart rate in patients with coronary artery disease compared with healthy controls.Methods. Eight patients with a history of an acute myocardial infarction (ejection fraction >5%) with a low-risk score were compared with seven healthy subjects during the Dutch Heart Expedition at the Aconcagua in Argentina in March 2007. All subjects underwent a maximum exercise test with a cycle ergometer at sea level and base camp, after ten days of acclimatisation, at an altitude of 4200 m. Exercise capacity and maximum heart rate were compared between groups and within subjects.Results. There was a significant decrease in maximum heart rate at high altitude compared with sea level in both the patient and the control group (166 vs. 139 beats/min, p<0.001 and 181 vs. 150 beats/min, p<0.001). There was no significant difference in the decrease of the exercise level and maximum heart rate between patients and healthy controls (-31 vs. -30%, p=0.673).Conclusion. Both patients and healthy controls showed a similar decrease in exercise capacity and maximum heart rate at 4200 m compared with sea level, suggesting that patients with a history of coronary artery disease may tolerate stay and exercise at high altitude similarly to healthy controls. (Neth Heart J 2010;18:118-21.).

Maximum exercise responses of men and women mountaineering trainees on induction to high altitude (4350 m) by trekking

OBJECTIVE

Maximum aerobic capacity decreases at high altitude. This study was conducted to compare the changes in maximum aerobic capacity in men and women mountaineering trainees on induction to high altitude at 4350 m by trekking.

METHODS

Eight men and 8 women mountaineering trainees in a mountaineering course were selected for the study. The initial study was conducted at 2100 m (586 mm Hg) and then during 6 to 7 days of sojourn at 4350 m (435 mm Hg). Maximum oxygen consumption (VO(2max)), maximum heart rate (HR(max)), pulse arterial oxygen saturation (SaO(2)), and maximum ventilation (VE(max)) were measured.

RESULTS

VO(2max), HR(max), duration of work (minutes), and SaO(2) saturation decreased significantly (P < .05) with increasing altitude in both sexes. Conversely, VE(max) and ventilatory equivalent (VE/VO(2)) increased significantly (P < .05). Men showed a relatively higher value of maximum exercise variables (total exercise time, exercise intensity, and VO(2)) than women trainees at both altitude locations. The decrement of VO(2max) was 13% in women and 17% in men (P < .05).

CONCLUSIONS

The results indicate that the decrement of maximum aerobic capacity at 4350 m was less in women than in men under similar modes of ascent.

Propofol-fentanyl anaesthesia at high altitude: anaesthetic requirements and haemodynamic variations when compared with anaesthesia at low altitude

BACKGROUND

There are few published accounts of anaesthesia delivery at high altitude. Natives at high altitude are known to have altered cardiorespiratory reserve. This study seeks to demonstrate the safety of propofol-fentanyl anaesthesia at high altitude titrated to the bispectral index (BIS) (3505 metres above sea level) in native highlanders. It also shows the differential effects of anaesthesia and surgery on the haemodynamics of such individuals as compared with individuals living at low altitude.

METHODS

Fifteen consenting adults scheduled to undergo general surgical/orthopaedic procedures under general anaesthesia using fentanyl, and propofol infusions titrated to the BIS along with nitrous oxide in oxygen after intubation, were recruited in the high-altitude arm. Their anaesthesia record was compared with retrospective data from low altitude with respect to anaesthetic requirements, recovery after anaesthesia and the haemodynamic responses to surgical stress.

RESULTS

The high-altitude dwellers required significantly larger doses of propofol at anaesthetic induction (2.31+/-0.64 vs. 1.41+/-0.24 mg/kg, P<0.0001) and thereafter to maintain designated BIS than their low-altitude counterparts (6.22+/-1.14 vs. 4.61+/-1.29 mg/kg/h, P<0.01). They, however, had uneventful and short recovery times. The high-altitude population also had significantly lower baseline heart rates (72+/-9.83 vs. 88+/-12.1, P<0.04) as also the heart rate responses to noxious stimulation such as direct laryngoscopy or skin incision (P<0.04, P<0.005, respectively).

CONCLUSIONS

High-altitude dwellers require significantly larger amounts of intravenous anaesthetic propofol. Heart rate at rest as also the heart rate responses to surgical stress were significantly attenuated at high altitude.

Exercise and hypoxia: The role of the autonomic nervous system

The reduction in maximal oxygen consumption in hypoxia can be due to physiological factors, the relative importance of which depends on the degree of hypoxia: the reduction in inspired PO2, the impairment of lung gas exchange contributing to an exercise-induced decrease in arterial O(2) saturation, the reduction in maximal cardiac output and the limitation in tissue diffusion. This paper focuses on two aspects of this oxygen cascade. First, the decrease in heart rate at maximal exercise in prolonged exposure to hypoxia is discussed and the role of changes in the autonomous nervous system is emphasised. The desensitization of the beta-adrenergic pathway and the upregulation of the muscarinic pathway, both using G-protein systems, contribute to limit the myocardial O(2) consumption in face of reduced O(2) availability during maximal exercise in hypoxia. The changes in O(2) diffusion to the tissues are discussed in relation to the expression of hypoxia inducible factor (HIF-1alpha) and vascular endothelial growth factor (VEGF) and their possible changes induced by training and/or hypoxic exposure.

Autonomic nervous system interaction with the cardiovascular system during exercise

There is considerable recent evidence that parameters thought to reflect the complex interaction between the autonomic nervous system and the cardiovascular system during exercise testing can provide significant prognostic information. Specific variables of great importance include heart rate (HR) response to exercise (reserve), HR recovery after exercise, and multiple components of HR variability both at rest and with exercise. Poor HR response to exercise has been strongly associated with sudden cardiac death and HR recovery from a standard exercise test has been shown to be predictive of mortality. In addition, there are limited studies evaluating the components of HR variability at rest and during exercise and their prognostic significance. Research continues seeking to refine these exercise measurements and further define their prognostic value. Future findings should augment the power of the exercise test in risk-stratifying cardiovascular patients.

Second generation Tibetan lowlanders acclimatize to high altitude more quickly than Caucasians

Tibetan highlanders develop at altitude peak aerobic power levels close to those of Caucasians at sea level. In order to establish whether this feature is genetic and, as a consequence, retained by Tibetan lowlanders, altitude-induced changes of peak aerobic performance were assessed in four groups of volunteers with different ethnic, altitude exposure and fitness characteristics, i.e. eight untrained second-generation Tibetans (Tib 2) born and living at 1300 m; seven altitude Sherpas living at approximately 2800-3500 m; and 10 untrained and five trained Caucasians. Measurements were carried out at sea level or at Kathmandu (1300 m, Nepal) (PRE), and after 2-4 (ALT1), 14-16 (ALT2), and 26-28 (ALT3) days at 5050 m. At ALT3, of untrained and trained Caucasians was -31% and -46%, respectively. By contrast, of Tib 2 and Sherpas was -8% and -15%, respectively. At ALT3, peak heart rate (HR(peak)) of untrained and trained Caucasians was 148 +/- 11 and 149 +/- 7 beats min(-1), respectively; blood oxygen saturation at peak exercise was 76 +/- 6% and 73 +/- 6%, and haemoglobin concentration ([Hb]) was 19.4 +/- 1.0 and 18.6 +/- 1.2 g dl(-1), respectively. Compared to Caucasians, Tib 2 and Sherpas exhibited at ALT3 higher HR(peak) (179 +/- 9 and 171 +/- 4 beats min(-1), P < 0.001), lower [Hb] (16.6 +/- 0.6 and 17.4 +/- 0.9 g dl(-1), respectively, P < 0.001), and slightly but non-significantly greater average values (82 +/- 6 and 80 +/- 7%). The above findings and the time course of adjustment of the investigated variables suggest that Tibetan lowlanders acclimatize to chronic hypoxia more quickly than Caucasians, independent of the degree of fitness of the latter.

Beta-adrenergic or parasympathetic inhibition, heart rate and cardiac output during normoxic and acute hypoxic exercise in humans

Acute hypoxia increases heart rate (HR) and cardiac output (Qt) at a given oxygen consumption (VO2) during submaximal exercise. It is widely believed that the underlying mechanism involves increased sympathetic activation and circulating catecholamines acting on cardiac beta receptors. Recent evidence indicating a continued role for parasympathetic modulation of HR during moderate exercise suggests that increased parasympathetic withdrawal plays a part in the increase in HR and Qt during hypoxic exercise. To test this, we separately blocked the beta-sympathetic and parasympathetic arms of the autonomic nervous system (ANS) in six healthy subjects (five male, one female; mean +/- S.E.M. age = 31.7+/-1.6 years, normoxic maximal VO2 (VO2,max)=3.1+/-0.3 l min(-1)) during exercise in conditions of normoxia and acute hypoxia (inspired oxygen fraction=0.125) to VO2,max. Data were collected on different days under the following conditions: (1)control, (2) after 8.0 mg propranolol i.v. and (3) after 0.8 mg glycopyrrolate i.v. Qt was measured using open-circuit acetylene uptake. Hypoxia increased venous [adrenaline] and [noradrenaline] but not [dopamine] at a given VO2 (P<0.05, P<0.01 and P=0.2, respectively). HR/VO2 and Qt/VO2 increased during hypoxia in all three conditions (P<0.05). Unexpectedly, the effects of hypoxia on HR and Qt were not significantly different from control with either beta-sympathetic or parasympathetic inhibition. These data suggest that although acute exposure to hypoxia increases circulating [catecholamines], the effects of hypoxia on HR and Qt do not necessarily require intact cardiac muscarinic and beta receptors. It may be that cardiac alpha receptors play a primary role in elevating HR and Qt during hypoxic exercise, or perhaps offer an alternative mechanism when other ANS pathways are blocked.

Human autonomic activity and its response to acute oxygen supplement after high altitude acclimatization

It is well established that after acclimatization at high altitude, many sympathetic pathways are hyperactive yet heart rate (HR) remains unchanged. In this study, we attempted to determine if this unchanged heart rate is due to compensatory mechanisms such as changes in parasympathetic activity or levels of receptors for autonomic neurotransmitters. We also examined the role played by hypoxia in these autonomic adaptations to high altitude. Three experiments were carried out on five healthy lowlanders both at sea level (SL) and after 2 weeks of acclimatization at 3800 m (Post-Ac) with: (a) placebo (control); (b) acute beta-adrenergic receptor blockade by propranolol (PRO), or (c) acute parasympathetic receptor blockade by glycopyrrolate (GLY). Compared with SL control values, post-Ac venous norepinephrine (NE) and dopamine increased by 96% (p < 0.001) and 55% (p < 0.05), but epinephrine and HR did not change. PRO resulted in a smaller decrease in HR (bpm) Post-Ac than at SL (15 +/- 6 vs. 21 +/- 6, p < 0.05), while GLY caused a greater increase in HR Post-Ac than at SL (59 +/- 8 vs. 45 +/- 6, p < 0.05). Breathing oxygen at SL concentration while at altitude did not decrease NE, or alter the effect of PRO on HR, but reduced the chronotropic effect of GLY by 14% (p < 0.05). These results suggest that after acclimatization to altitude, increased parasympathetic neurotransmitter release and decreased beta-adenoreceptor activity account for the unchanged HR despite enhanced sympathetic activity. Acute oxygen replacement rapidly counteracted the parasympathetic, but not sympathetic hyperactivity that occurs at high altitude.

Effect of intermittent hypoxia on cardiovascular function, adrenoceptors and muscarinic receptors in Wistar rats

The usual model of intermittent hypoxia (sleep apnoea) corresponds to repeated episodes of hypoxia from a few seconds to a few hours interspersed with episodes of normoxia. The aim of this study was to evaluate in rats the effect of two periods of intermittent exposure for 2 months to hypoxia (IHX1, 24 h in hypoxia (428 Torr), 24 h in normoxia; IHX2, 48 h in hypoxia (428 Torr), 24 h in normoxia) as a new model of hypoxia simulating intermittent exposure to high altitude experienced by Andean miners. We assessed the haematological parameters, time course of resting heart rate and systolic blood pressure. We also evaluated the expression of adrenergic and muscarinic receptors. IHX1 and IHX2 produced an increase in haematocrit, haemoglobin concentration and mean corpuscular volume as previously seen in most hypoxic models. IHX1 and IHX2 induced a similar sustained elevation of systolic blood pressure (132 +/- 2 and 135 +/- 3 mmHg, respectively, vs. the control level of 121 +/- 16 mmHg) after 10 days of exposure without change in heart rate. Right ventricular (RV) hypertrophy (225 +/- 13 and 268 +/- 15 mg g(-1), vs. 178 +/- 7 mg g(-1) and downregulation of alpha1-adrenoceptor (RV: 127 +/- 21 and 94 +/- 16 fmol mg(-1) vs. 157 +/- 8 fmol mg(-1); left ventricle (LV): 141 +/- 5 and 126 +/- 9 fmol mg(-1) vs. 152 +/- 5 fmol mg(-1)) have been found in both groups, with right ventricular hypertrophy being greater and alpha1-adrenoceptor density being lower in IHX2 than in HX1 groups. These data indicate that both parameters are related to the time of exposure to hypoxia. IHX1 and IHX2 produced the same magnitude of upregulation of muscarinic receptors (LV, 60%; RV, 40%), and no change in beta-adrenoceptors. In conclusion, exposure to intermittent hypoxia led to polycythaemia and RV hypertrophy as observed in other types of hypoxia. A specific cardiovascular response was seen, that is an increase in blood pressure without change in heart rate, which was different from the one observed in episodic and chronic hypoxia. Furthermore, this model involved specific modifications of alpha1-adrenergic and muscarinic expression.

Role of the autonomic nervous system in the reduced maximal cardiac output at altitude

After acclimatization to high altitude, maximal exercise cardiac output (QT) is reduced. Possible contributing factors include 1) blood volume depletion, 2) increased blood viscosity, 3) myocardial hypoxia, 4) altered autonomic nervous system (ANS) function affecting maximal heart rate (HR), and 5) reduced flow demand from reduced muscle work capability. We tested the role of the ANS reduction of HR in this phenomenon in five normal subjects by separately blocking the sympathetic and parasympathetic arms of the ANS during maximal exercise after 2-wk acclimatization at 3,800 m to alter maximal HR. We used intravenous doses of 8.0 mg of propranolol and 0.8 mg of glycopyrrolate, respectively. At altitude, peak HR was 170 +/- 6 beats/min, reduced from 186 +/- 3 beats/min (P = 0.012) at sea level. Propranolol further reduced peak HR to 139 +/- 2 beats/min (P = 0.001), whereas glycopyrrolate increased peak HR to sea level values, 184 +/- 3 beats/min, confirming adequate dosing with each drug. In contrast, peak O(2) consumption, work rate, and QT were similar at altitude under all drug treatments [peak QT = 16.2 +/- 1.2 (control), 15.5 +/- 1.3 (propranolol), and 16.2 +/- 1.1 l/min (glycopyrrolate)]. All QT results at altitude were lower than those at sea level (20.0 +/- 1.8 l/min in air). Therefore, this study suggests that, whereas the ANS may affect HR at altitude, peak QT is unaffected by ANS blockade. We conclude that the effect of altered ANS function on HR is not the cause of the reduced maximal QT at altitude.

Peak heart rate decreases with increasing severity of acute hypoxia

The purpose of the present study was to investigate the degree to which peak heart rate is reduced during exhaustive exercise in acute hypoxia. Five sea-level lowlanders performed maximal exercise at normobaric normoxia and at three different levels of hypobaric hypoxia (barometric pressures of 518, 459, and 404 mmHg) in a hypobaric chamber and while breathing 9% O(2) in N(2). These conditions were equivalent to altitudes of 3300, 4300, 5300, and 6300 m above sea level, respectively. At 4300 m, maximal exercise was also repeated after 4 and 8 h. Peak heart rate (HR) decreased from 191 (182-202) (mean and range) at sea level to 189 (179-200), 182 (172-189), 175 (166-183), and 165 (162-169) in the acute hypoxic conditions. Peak HR did not decrease further after 4 and 8 h at 4300 m compared to the acute exposure at this altitude. Between barometric pressures of 518 and 355 mmHg (approximately 3300 and 6300 m), peak HR decreased linearly: peak HR(hypobaria) = peak HR(sea level) - 0.135 x [hypobaria(3100) - hypobaria (mmHg)]; or peak HR(altitude) = peak HR(sea level) - 0.15 x (altitude - 3100 m). This corresponds to approximately 1-beat x min(-1) reduction in peak HR for every 7-mmHg decrease in barometric pressure below 530 mmHg (approximately 130 m of altitude gained above 3100 m). At termination of exercise, maximal plasma lactate and norepinephrine concentrations were similar to those observed during maximal exercise in normobaric normoxia. This study clearly demonstrates a progressive decrease in peak HR with increasing altitude, despite evidence of similar exercise effort and unchanged sympathetic excitation.

The effect of altitude on cycling performance: a challenge to traditional concepts

Acute exposure to moderate altitude is likely to enhance cycling performance on flat terrain because the benefit of reduced aerodynamic drag outweighs the decrease in maximum aerobic power [maximal oxygen uptake (VO2max)]. In contrast, when the course is mountainous, cycling performance will be reduced at moderate altitude. Living and training at altitude, or living in an hypoxic environment (approximately 2500 m) but training near sea level, are popular practices among elite cyclists seeking enhanced performance at sea level. In an attempt to confirm or refute the efficacy of these practices, we reviewed studies conducted on highly-trained athletes and, where possible, on elite cyclists. To ensure relevance of the information to the conditions likely to be encountered by cyclists, we concentrated our literature survey on studies that have used 2- to 4-week exposures to moderate altitude (1500 to 3000 m). With acclimatisation there is strong evidence of decreased production or increased clearance of lactate in the muscle, moderate evidence of enhanced muscle buffering capacity (beta m) and tenuous evidence of improved mechanical efficiency (ME) of cycling. Our analysis of the relevant literature indicates that, in contrast to the existing paradigm, adaptation to natural or simulated moderate altitude does not stimulate red cell production sufficiently to increase red cell volume (RCV) and haemoglobin mass (Hb(mass)). Hypoxia does increase serum erthyropoietin levels but the next step in the erythropoietic cascade is not clearly established; there is only weak evidence of an increase in young red blood cells (reticulocytes). Moreover, the collective evidence from studies of highly-trained athletes indicates that adaptation to hypoxia is unlikely to enhance sea level VO2max. Such enhancement would be expected if RCV and Hb(mass) were elevated. The accumulated results of 5 different research groups that have used controlled study designs indicate that continuous living and training at moderate altitude does not improve sea level performance of high level athletes. However, recent studies from 3 independent laboratories have consistently shown small improvements after living in hypoxia and training near sea level. While other research groups have attributed the improved performance to increased RCV and VO2max, we cite evidence that changes at the muscle level (beta m and ME) could be the fundamental mechanism. While living at altitude but training near sea level may be optimal for enhancing the performance of competitive cyclists, much further research is required to confirm its benefit. If this benefit does exist, it probably varies between individuals and averages little more than 1%.

Parasympathetic neural activity accounts for the lowering of exercise heart rate at high altitude

BACKGROUND

In chronic hypoxia, both heart rate (HR) and cardiac output (Q) are reduced during exercise. The role of parasympathetic neural activity in lowering HR is unresolved, and its influence on Q and oxygen transport at high altitude has never been studied.

METHODS AND RESULTS

HR, Q, oxygen uptake, mean arterial pressure, and leg blood flow were determined at rest and during cycle exercise with and without vagal blockade with glycopyrrolate in 7 healthy lowlanders after 9 weeks' residence at >/=5260 m (ALT). At ALT, glycopyrrolate increased resting HR by 80 bpm (73+/-4 to 153+/-4 bpm) compared with 53 bpm (61+/-3 to 114+/-6 bpm) at sea level (SL). During exercise at ALT, glycopyrrolate increased HR by approximately 40 bpm both at submaximal (127+/-4 to 170+/-3 bpm; 118 W) and maximal (141+/-6 to 180+/-2 bpm) exercise, whereas at SL, the increase was only by 16 bpm (137+/-6 to 153+/-4 bpm) at 118 W, with no effect at maximal exercise (181+/-2 bpm). Despite restoration of maximal HR to SL values, glycopyrrolate had no influence on Q, which was reduced at ALT. Breathing FIO(2)=0.55 at peak exercise restored Q and power output to SL values.

CONCLUSIONS

Enhanced parasympathetic neural activity accounts for the lowering of HR during exercise at ALT without influencing Q. The abrupt restoration of peak exercise Q in chronic hypoxia to maximal SL values when arterial PO(2) and SO(2) are similarly increased suggests hypoxia-mediated attenuation of Q.

Human adaptation to high altitude: regional and life-cycle perspectives

Studies of the ways in which persons respond to the adaptive challenges of life at high altitude have occupied an important place in anthropology. There are three major regions of the world where high-altitude studies have recently been performed: the Himalayas of Asia, the Andes of South America, and the Rocky Mountains of North America. Of these, the Himalayan region is larger, more geographically remote, and likely to have been occupied by humans for a longer period of time and to have been subject to less admixture or constriction of its gene pool. Recent studies of the physiological responses to hypoxia across the life cycle in these groups reveal several differences in adaptive success. Compared with acclimatized newcomers, lifelong residents of the Andes and/or Himalayas have less intrauterine growth retardation, better neonatal oxygenation, and more complete neonatal cardiopulmonary transition, enlarged lung volumes, decreased alveolar-arterial oxygen diffusion gradients, and higher maximal exercise capacity. In addition, Tibetans demonstrate a more sustained increase in cerebral blood flow during exercise, lower hemoglobin concentration, and less susceptibility to chronic mountain sickness (CMS) than acclimatized newcomers. Compared to Andean or Rocky Mountain high-altitude residents, Tibetans demonstrate less intrauterine growth retardation, greater reliance on redistribution of blood flow than elevated arterial oxygen content to increase uteroplacental oxygen delivery during pregnancy, higher levels of resting ventilation and hypoxic ventilatory responsiveness, less hypoxic pulmonary vasoconstriction, lower hemoglobin concentration, and less susceptibility to CMS. Several of the distinctions demonstrated by Tibetans parallel the differences between natives and newcomers, suggesting that the degree of protection or adaptive benefit relative to newcomers is enhanced for the Tibetans. We thus conclude that Tibetans have several physiological distinctions that confer adaptive benefit consistent with their probable greater generational length of high-altitude residence. Future progress is anticipated in achieving a more integrated view of high-altitude adaptation, incorporating a sophisticated understanding of the ways in which levels of biological organization are articulated and a recognition of the specific genetic variants contributing to differences among high-altitude groups.

Inter and intra-species-related differences in the regulation of the cardiac autonomic system

The heart rate response to isoproterenol (HR-Iso), density and affinity (kd) of beta-adrenergic (beta-AR) and muscarinic (M2) receptors were compared among three rodents with different generation-life histories of confinement and of high altitude exposure. The European guinea pig (Cavia porcellus) (EGp), a laboratory animal that arrived in Europe after the Spanish Conquest of South America and the Peruvian guinea pig (C. porcellus) (PGp), a semi-wild animal that came from the altiplano to sea level at least 25 generations ago, were used for intra-species comparison. Wistar rats (WR) were used for inter-species comparison as representative of a typical sea level laboratory animal. The HR-Iso was lower in EGp than in the PGp. The PGp showed the highest beta-AR density (P < 0.0005) and the highest beta-AR kd values (P < 0.0005) when compared to both EGp and WR groups (beta-AR Bmax (fmol mg-1 prot), WR, 19 +/- 4; Egp, 34 +/- 10; PGp, 74 +/- 15. beta-AR kd (pM), WR, 24 +/- 10; Egp, 17 +/- 7; PGp, 39 +/- 14). In contrast, PGp showed lower M2 receptor density values than the EGp (P < 0.0005). The WR had the highest M2 receptor densities (M2 Bmax (fmol mg-1 prot), WR, 188 +/- 15; Egp, 147 +/- 9; PGp, 118 +/- 6 and M2 kd (pM), WR, 65 +/- 12; Egp, 67 +/- 6; PGp, 92 +/- 2). The inter and intra-species differences found may be related to their respective history of confinement rather than to their history of exposure to high altitude.

Human adaptation to high altitude: regional and life-cycle perspectives

Studies of the ways in which persons respond to the adaptive challenges of life at high altitude have occupied an important place in anthropology. There are three major regions of the world where high-altitude studies have recently been performed: the Himalayas of Asia, the Andes of South America, and the Rocky Mountains of North America. Of these, the Himalayan region is larger, more geographically remote, and likely to have been occupied by humans for a longer period of time and to have been subject to less admixture or constriction of its gene pool. Recent studies of the physiological responses to hypoxia across the life cycle in these groups reveal several differences in adaptive success. Compared with acclimatized newcomers, lifelong residents of the Andes and/or Himalayas have less intrauterine growth retardation, better neonatal oxygenation, and more complete neonatal cardiopulmonary transition, enlarged lung volumes, decreased alveolar-arterial oxygen diffusion gradients, and higher maximal exercise capacity. In addition, Tibetans demonstrate a more sustained increase in cerebral blood flow during exercise, lower hemoglobin concentration, and less susceptibility to chronic mountain sickness (CMS) than acclimatized newcomers. Compared to Andean or Rocky Mountain high-altitude residents, Tibetans demonstrate less intrauterine growth retardation, greater reliance on redistribution of blood flow than elevated arterial oxygen content to increase uteroplacental oxygen delivery during pregnancy, higher levels of resting ventilation and hypoxic ventilatory responsiveness, less hypoxic pulmonary vasoconstriction, lower hemoglobin concentration, and less susceptibility to CMS. Several of the distinctions demonstrated by Tibetans parallel the differences between natives and newcomers, suggesting that the degree of protection or adaptive benefit relative to newcomers is enhanced for the Tibetans. We thus conclude that Tibetans have several physiological distinctions that confer adaptive benefit consistent with their probable greater generational length of high-altitude residence. Future progress is anticipated in achieving a more integrated view of high-altitude adaptation, incorporating a sophisticated understanding of the ways in which levels of biological organization are articulated and a recognition of the specific genetic variants contributing to differences among high-altitude groups.

Cardiac beta-adrenergic receptor function in fetal sheep exposed to long-term high-altitude hypoxemia

In this study, we hypothesized that a reduction in beta-adrenergic receptor number or a decrease in functional coupling of the receptor to the adenylate cyclase system may be responsible for the blunted inotropic response to isoproterenol observed in fetal sheep exposed to high altitude (3,820 m) from 30 to 138-142 days gestation. We measured the contractile response to increasing doses of isoproterenol and forskolin in papillary muscles from both ventricles, estimated beta-adrenergic receptor density (Bmax) and ligand affinity (Kd) using [125I]iodocyanopindolol, and measured adenosine 3',5'-cyclic monophosphate (cAMP) levels before and after maximally stimulating doses of isoproterenol and forskolin. Left ventricular wet weight was unchanged, but right ventricular weight was 20% lower than controls. At the highest concentration of isoproterenol (10 microM), maximum active tension was 32 and 20% lower than controls in hypoxemic left and right ventricles, respectively. The contractile response to forskolin was severely attenuated in both hypoxemic ventricles. Bmax was unchanged in the left ventricle, but increased by 55% in the hypoxemic right ventricle. Kd was not different from controls in either ventricle. Basal cAMP levels were not different from controls, but isoproterenol-stimulated and forskolin-stimulated cAMP levels were 1.4- to 2-fold higher than controls in both hypoxemic ventricles. The results suggest mechanisms downstream from cAMP in the beta-adrenergic receptor pathway are responsible for the attenuated contractile responses to isoproterenol.

Exercise responses after altitude acclimatization are retained during reintroduction to altitude

Following 2 to 3 wk of altitude acclimatization, ventilation is increased and heart rate (HR), plasma volume (PV), and lactate accumulation ([La]) are decreased during submaximal exercise. The objective of this study was to determine whether some degree of these exercise responses associated with acclimatization would be retained upon reintroduction to altitude (RA) after 8 d at sea level (SL). Six male lowlanders (X +/- SE; 31 +/- 2 yr, 82.4 +/- 4.6 kg) exercised to exhaustion at the same relative percentages of peak oxygen uptake (VO2peak) at SL, on acute altitude (AA) exposure, after a 16-d chronic altitude (CA) exposure on Pikes Peak (4,300 m), and during a 3- to 4-h RA in a hypobaric chamber (4,300 m; 446 mm Hg) after 8 d at SL. The submaximal exercise to exhaustion time (min) was the same at SL (66.0 +/- 1.6), AA (67.7 +/- 7.3), CA (79.9 +/- 6.2), and RA (67.9 +/- 1.9). At 75% VO2peak: (1) arterial oxygen saturation (SaO2) increased from AA to CA (67.0 +/- 1.5 vs 78.5 +/- 1.8%; P < 0.05) and remained increased at RA (77.0 +/- 2.0%); (2) HR decreased from SL to CA (171 +/- 6 vs 152 +/- 9 beats x min-1; P < 0.05) and remained decreased at RA (157 +/- 5 beats x min-1); (3) calculated PV decreased 6.9 +/- 10.0% at AA, 21.3 +/- 11.1% at CA, and 16.7 +/- 5.4% at RA from SL baseline values, and (4) [La] decreased from AA to CA (5.1 +/- 0.9 vs 1.9 +/- 0.4 mmol x L-1; P < 0.05) and remained decreased at RA (2.6 +/- 0.6 mmol x L-1). Upon RA after 8 d at SL, the acclimatization responses were retained 92 +/- 9% for SaO2, 74 +/- 8% for PV, and 58 +/- 3% for [La] at 75% VO2peak. In conclusion, although submaximal exercise to exhaustion time is not improved upon reintroduction to altitude after 8 d at sea level, retention of beneficial exercise responses associated with altitude acclimatization is likely in individuals whose work, athletic competition, or recreation schedules involve intermittent sojourns to high elevations.

Cardiorespiratory response to exercise in elite Sherpa climbers transferred to sea level

Himalayan Sherpas are well known for their extraordinary adaptation to high altitude and some of them for their outstanding physical performance during ascents to the highest summits. To cast light on this subject, we evaluated the cardiorespiratory response during exercise at sea level of six of the most acknowledged Sherpa climbers, mean age (+/- SD) 37 (+/- 7) yr old. Continuous electrocardiogram and breath-by-breath pulmonary gas exchange until exhaustion were obtained by following the Bruce protocol. We detected a maximal oxygen uptake (VO2max) of 66.7 (+/- 3.7) mL-min-1.kg-1, maximal cardiac frequency of 199 (+/- 7) beats.min-1, and ventilatory anaerobic threshold at 62 (+/- 4) % of VO2max. These factors could help to explain the greater performance level shown by several elite climbers of this ethnic group. The high functional reserve demonstrated by this very select group of highlanders could be associated with natural selection and with special physiological adaptations probably induced by long-training in a hostile environment.

Hypoxia- and normoxia-induced reversibility of autonomic control in Andean guinea pig heart

We herein describe the regulation of cardiac receptors in a typical high-altitude native animal. Heart rate response to isoproterenol (HRIso) (beats.min-1.mg Iso.kg-1) and atropine, the density of beta-adrenergic (beta AR) and muscarinic (M2) receptors, and the ventricular content of norepinephrine (NE) and dopamine (DA) were studied in guinea pigs (Cavia porcellus). Animals native to Lima, Peru (150 m) were studied at sea level (SL) and after 5 wk at 4,300-m altitude (SL-HA). Animals native to Rancas [Pasco, Peru (4,300 m)] were studied at high altitude (HA) and after 5 wk at SL (HA-SL). HA animals had a lower HRIso, maximum number of beta AR binding sites (Bmax), beta AR dissociation constant (Kd), NE, and DA (P < 0.05) and a higher M2 Bmax (P < 0.001) when compared with the SL group. HA-SL showed an increase of the HRIso, beta Ar Kd, and NE (P < 0.05) and a decrease of the M2 Bmax and Kd (P < 0.0001) when compared with the HA group. The present study demonstrates the differential regulation and reversibility of the autonomic control in the guinea pig heart.

Cardiovascular response to exercise in humans following acclimatization to extreme altitude

The purpose of this study was to assess the effects of acclimatization to extreme altitude on the cardiovascular system, using vagal and adrenergic blockade and acute restoration of normoxia during exercise to maximum with one and two legs. Fourteen climbers on an expedition to the Himalayas were studied at a lower base camp (5250 m) following 56-81 days at altitudes between 5250 and 8700 m. After acclimatization, peak heart rate (HRpeak), oxygen uptake (VO2peak) and noradrenaline (NA) were similar during maximal one- and two-legged cycling, whereas peak plasma lactate was higher during the one-legged protocol. HRpeak (range 113-168 beats min-1) was lowest when subjects returned from the higher camps. The degree of partial restoration of HRpeak to more normal values within seconds of 60% O2 inhalation (range 5-35 beats min-1 HRpeak increase) was greatest in subjects with low HRpeak. HR responses to beta-1 blockade increased as a function of HRpeak and the HR responses to atropine were the least in subjects with high HRpeak. These findings suggest that (a) the reduction in HRpeak is linked to the duration and severity of the hypoxaemia, (b) the degree of restoration of HRpeak with acute normoxia is dependent on the level of attenuation or down-regulation of cardiac sympathetic activation (SNA), (c) cardiac vagal drive is masked to a lesser extent in chronic hypoxia because of attenuated SNA and lower HRpeak values, and (d) the lower blood lactate levels at altitude is a function of muscle mass involvement rather than adrenergic activation, as normal peak values were reached during exercise with a small muscle mass.

Autonomic nervous control of heart rate at altitude (5050 m)

To investigate possible changes in autonomic regulation of heart rate as a result of acclimatization to high altitude, indexes of autonomic nervous activity were obtained non invasively by spectrum analysis of heart rate variability on five healthy male subjects [age, 31 (SEM 2) years] during a postural change from supine to seated, both at sea level and after 1 month of exposure to an altitude of 5050 m. Heart rate fluctuations at the respiratory frequency (high frequency, HF) are mediated by the parasympathetic system whereas fluctuations at about 0.1 Hz (low frequency, LF) are due to both sympathetic and parasympathetic nervous systems. Maximal heart rate, as measured during an incremental exercise test, decreased from 184 (SEM 5) beats.min-1 at sea level to 152 (SEM 2) beats.min-1 at 5050 m. At sea level, the change in posture from supine to seated induced an increase in LF amplitude accompanied by an increase or a decrease in HF amplitude, whereas after 1 month at altitude the HF amplitude decreased in all subjects, with little or no change in LF amplitude. These results indicate a changed strategy of heart rate regulation after acclimatization to high altitude. At sea level, the postural change induced an increase in sympathetic activity in all subjects with different individual vagal responses, whereas at altitude the postural change induced a net decrease in vagal tone in all subjects, with little or no change in sympathetic activity. These results corroborate the reported reduced sensitivity of the heart to adrenergic drive in chronic hypoxia, which may, at least in part, explain the decreased maximal heart rate in altitude-acclimatized human subjects.

Myocardial oxygen supply and lactate metabolism during marked arterial hypoxaemia

Myocardial O2 delivery and changes in myocardial lactate metabolism during marked hypoxaemia (PaO2 5-5.4 kPa, Sa O2 70-75%) produced by 12% O2 breathing were studied in 12 healthy subjects at rest and during supine exercise up to maximal intensity. Blood for O2 and lactate analyses was sampled from catheters in an artery (a) and the coronary sinus (cs) and coronary sinus blood flow (CSBF) was measured by thermodilution. Lactate metabolism was evaluated in a subgroup of the subjects using i.v. infusion of [14C]lactate. At rest and during submaximal exercise up to heart rate 156 beats min-1 myocardial O2 uptake (MQO2) was maintained at the same level during hypoxaemia as during normoxaemia. This was achieved at rest mainly by a more complete O2 extraction, during exercise entirely by greater CSBF. During maximal exercise CSBF was 35% greater during hypoxaemia than normoxaemia, while there was no difference in cs O2 saturation. Maximal MQO2 was smaller during hypoxaemia than normoxaemia in spite of no difference in rate pressure product. The a-cs difference of lactate was reduced during hypoxaemia and there was a significant myocardial release of lactate, as calculated from [14C]lactate data, during hypoxaemic exercise, but not during hypoxaemic rest or normoxaemic rest and exercise. It is concluded that the heart has a coronary flow reserve of about 35%, which can be utilised under hypoxaemia. When this reserve is insufficient to supply the myocardium with oxygen lactate is produced to cover part of the myocardial ATP regeneration.

Operation Everest II: an indication of deterministic chaos in human heart rate variability at simulated extreme altitude

It has been shown that fluctuation of human heartbeat intervals (heart rate variability, HRV) reflects variations in autonomic nervous system activity. We studied HRV at simulated altitudes of over 6000 m from Holter electrocardiograms recorded during the Operation Everest II study (Houston et al. 1987). Stationary, approximately 30-min segments of HRV data from six subjects at sea level and over 6000 m were supplied to (1) spectral analysis to evaluate sympathetic and parasympathetic nervous system (SNS, PNS) activity, (2) the analysis of Poincaré section of the phase space trajectory reconstructed on a delayed coordinate system to evaluate whether there was fluctuation with deterministic dynamics, (3) the estimation of the correlation dimension to evaluate a static property of putative attractors, and (4) the analysis of nonlinear predictability of HRV time series which could reflect a dynamic property of the attractor. Unlike HRV at sea level, the recordings at over 6000 m showed a strong periodicity (period of about 20 s) with small cycle-to-cycle perturbation. When this perturbation was expressed on a Poincaré section, it seemed to be likely that the perturbation itself obeyed a deterministic law. The correlation dimensions of these recordings showed low dimensional values (3.5 +/- 0.4, mean +/- SD), whereas those of the isospectral surrogates showed significantly (P < 0.05) higher values (5.3 +/- 0.5) with embedding dimensions of 5.6 +/- 0.9.(ABSTRACT TRUNCATED AT 250 WORDS)

Myocardial blood flow and lactate metabolism at rest and during exercise with reduced arterial oxygen content

The effect of a reduction in arterial oxygen content, equivalent to acute exposure to an altitude of 2300 metres above sea level, on myocardial blood flow and oxygen and lactate exchange was studied by coronary sinus catheterization in 12 healthy men. Measurements were made at rest, during atrial pacing and during submaximal and maximal exercise both breathing air and breathing 15% oxygen (hypoxia). Coronary sinus blood flow was measured by thermodilution and the possibility of a simultaneous uptake and release of lactate by the heart was calculated using intravenous infusion of 14C lactate. At all levels of cardiac power output myocardial oxygen consumption was the same during hypoxia as during air breathing. At rest this was achieved entirely by a more complete extraction of oxygen from the coronary blood, during maximal exercise entirely by a greater coronary sinus blood flow, while at intermediate levels of cardiac power output a combination of these mechanisms prevailed. At rest and during submaximal work myocardial lactate extraction was lower with hypoxia than air breathing suggesting a change in myocardial redox state, while the 14C lactate data suggested no significant lactate release or possibly limited areas with some lactate production. During maximal exercise, however, there was no difference in myocardial lactate net extraction between hypoxia and air breathing, which together with the greater blood flow suggests that the heart has a 'coronary flow reserve' permitting maximal exercise at moderate altitude without anaerobic myocardial metabolism.

Saliva flow and composition in humans exposed to acute altitude hypoxia

The effects of acute hypoxia (2 days at 4350 m) on whole saliva flow and composition were studied on 12 sea-level natives, at rest and following a maximal exercise. Exercise, performed in normoxia and hypoxia, did not induce variations in saliva flow rate, saliva potassium or alpha-amylase concentrations. In contrast, acute hypoxia did lead to an increase in mean saliva flow rate both at rest (0.63 ml.min-1 to 0.93 ml.min-1, P less than 0.01) and after exercise (0.56 ml.min-1 to 1.06 ml.min-1, P less than 0.05) and a decrease in mean saliva potassium concentration at rest (20.8 mmol.l-1 to 14.7 mmol.l-1, P less than 0.01) as well as after exercise (21.7 mmol.l-1 to 16.5 mmol.l-1, P less than 0.05). This effect might be the consequence of a hypoxia-induced stimulation of the parasympathetic nervous system.

Maximal cardiorespiratory responses to one- and two-legged cycling during acute and long-term exposure to 4300 meters altitude

During exposure to altitudes greater than about 2200 m, maximal oxygen uptake (VO2max) is immediately diminished in proportion to the reduction in the partial pressure of oxygen in the inspired air. If the exposure lasts longer than a couple of days, an increase in arterial oxygen content (CaO2), due to a hemoconcentration and an increase in arterial oxygen saturation, occurs. However, there is also a reduction in maximal cardiac output (Qmax) at altitude which offsets the increase in CaO2 and, therefore, VO2max does not improve. The purpose of this investigation was to study the contribution of the increase in CaO2 to the working muscles without the potentially confounding problem of a reduced Qmax. The approach used was to have seven male subjects (aged 17 to 24 years) perform one- and two-legged VO2max tests on a cycle ergometer at sea level (SL, PIO2 = 159 Torr), after 1 h at 4300 m simulated altitude (SA, PIO2 = 94 Torr) and during two weeks of residence on the summit of Pikes Peak, CO. (PP, 4300 m, PIO2 = 94 Torr). Cardiac output limits maximal performance during two-legged cycling but does not limit performance during one-legged cycling. During the study, CaO2 changed from 189 +/- 3 (mean +/- SE) at SL to 161 +/- 4 ml.L-1 during SA (SL vs. SA, p less than 0.01) and to 200 +/- 6 ml.L-1 at PP (SL vs. PP, p less than 0.05; SA vs. PP, p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

After effects of chronic hypoxia on cardiac output and muscle blood flow at rest and exercise

Cardiac output (Q, by N2-CO2 rebreathing) and limb muscle blood flow (qm, from 133Xe clearance) were determined in eight male subjects at rest and during cycloergometric loads immediately before and 12 days after return from the 1981 Swiss Lhotse Shar (8,398 m) Expedition. Compared to control conditions, after exposure to hypoxia: 1) Q was unchanged at rest and at 75 watts (W) but was 18% less (P less than 0.01) at 150 W with constant heart rate (approximately 140 beats X min-1); 2) qm in the vastus lateralis was identical at rest but 26% and 39% less (P less than 0.05 and P less than 0.001, respectively) at two submaximal leg work loads (75 and 125 W); 3) qm in the biceps at 50 W was 34% less (P less than 0.01); 4) hemoglobin flow (QHb and qmHb), similarly to blood flow (Q and qm), was significantly reduced; 5) the qm adjustment rate, measured from the time required to attain a new steady state upon a square wave change of work load starting from rest, was slower, particularly at the lower work loads. From the above results as well as from corresponding morphometric findings showing in the same subjects: 1) a decrease of the ratio between fiber section and number of capillaries and 2) a rise of the mitochondrial to fiber volume ratio, it is concluded that during altitude acclimatization peripheral O2 delivery becomes more efficient.