The metabolic, catecholamine and cardiovascular effects of exercise in human sympathetic denervation

The cardiovascular and metabolic responses to supine leg exercise were measured in 9 healthy subjects (controls) and in 19 subjects with two primary forms of autonomic failure (11 with peripheral sympathetic denervation [pure autonomic failure; PAF], 8 with central sympathetic failure [multiple system atrophy; MSA]). With exercise, blood pressure increased in controls and fell markedly in subjects with PAF and MSA. Blood pressure returned to baseline in controls, but remained low in the PAF and MSA groups. With exercise, heart rate increased more in controls than the PAF and MSA groups. Resting plasma noradrenaline concentrations in controls and in subjects with MSA were similar, but were lower in subjects with PAF. With exercise, plasma noradrenaline concentrations increased in controls and were unchanged in subjects with PAF; there was no significant increase in the MSA group. Resting plasma lactate, pyruvate and lactate/pyruvate ratios were similar in all three groups. With exercise, lactate concentrations increased until 2 minutes post exercise in all groups. Pyruvate concentrations after 9 minutes' exercise were higher in controls than in the PAF group but were similar to the MSA group; thereafter, concentrations increased similarly in all groups. The lactate/pyruvate ratio increased until 2 minutes post exercise in all groups. Resting plasma free fatty acids, and beta-hydroxybutyrate were similar in all groups. Plasma glycerol concentrations in control and MSA subjects were similar; concentrations were lower in PAF subjects. With exercise, plasma free fatty acids and glycerol concentrations remained unchanged in all groups; beta-hydroxybutyrate concentrations decreased less in control subjects than in PAF and MSA subjects. In conclusion, there were similar concentrations of plasma free fatty acids, glycerol and beta-hydroxybutyrate in control, PAF and MSA subjects; this could indicate up-regulation of beta-receptors in AF, or that sympathetic activity plays a smaller role in lipolysis. Plasma lactate and pyruvate concentrations increased similarly in all groups, despite marked differences in BP; this suggested an impairment of production or clearance of lactate in AF. A role for lactate-induced vasodilatation, not compensated for by sympathetic vasoconstriction, remains speculative.

Contribution of nitric oxide to exercise-induced hypotension in human sympathetic denervation

The cardiovascular, catecholamine, and nitrate/nitrite (NO) responses to bicycle exercise were measured in 14 normal subjects (controls) and two groups with sympathetic denervation; 14 with peripheral autonomic failure (pure autonomic failure [PAF]); and 13 with central autonomic failure (multiple system atrophy [MSA]). With exercise, blood pressure increased in control subjects by 40 +/- 7/24 +/- 5 mm Hg (p < 0.001) and fell in PAF by 24 +/- 8/24 +/- 5 mm Hg (p < 0.02 and p < 0.007) and MSA by 31 +/- 7/11 +/- 3 mm Hg (p < 0.005 and p < 0.04). With exercise, the increase in heart rate was greater in control subjects (60 +/- 3 to 111 +/- 4/min; p < 0.0001) than in PAF (69 +/- 3 to 86 +/- 4/min; p < 0.0001) and MSA (70 +/- 4 to 90 +/- 4; p < 0.001). Resting plasma noradrenaline levels were similar in controls (291 +/- 51 pg ml(-1)) and MSA (257 +/- 49 pg ml(-1)), but lower in PAF (82 +/- 14 pg ml(-1)). With exercise, plasma noradrenaline increased in controls but was unchanged in PAF and MSA. Resting NOx was similar in controls (50 +/- 5 nmol/L; range, 23.3-87.6 nmol/L) and PAF patients (59+/-8 nmol/l; range, 19.3-116.4 nmol/L), but was higher in MSA patients (87 +/-14 nmol/L; p <0.025, range 15.4-157.2 nmol/L). With exercise, NOx was unchanged in control subjects and increased by 10% and 17% in PAF and MSA, respectively; these changes were not statistically significant. This study suggests that circulating changes in NOx levels do not exert a major role in exercise-induced hypotension in subjects with sympathetic denervation.

Superior mesenteric artery dilatation alone does not account for glucose-induced hypotension in human sympathetic denervation

Haemodynamic and hormonal effects of two oral isovolaemic, isoosmotic solutions of 0.5 g/kg and 1.0 g/kg glucose were studied in 10 humans with sympathetic denervation due to primary autonomic failure (AF). Measurements were made supine for 60 min, and also after 5 min 45 head-up tilt, before and 60 min after glucose. There was a similar fall in blood pressure (BP) after each dose, after 0.5 g/kg from 160+/-12 / 87+/-6 to 143+/-13 / 76+/-6 mm Hg, P < 0.05 and after 1.0 g/kg from 160+/-13 / 90+/-6 to 136+/-9 / 76+/-5 mm Hg, P < 0.05. Heart rate, cardiac index and forearm muscle blood flow did not change after either dose. After 0.5 g/kg, superior mesenteric artery blood flow was unchanged but rose significantly after 1.0 g/kg, from 243 (169-395) to 722 (227-982) ml/min, P < 0.05, 15 min after ingestion. BP fell further on tilt 60 min after each dose, but there was no difference between doses. Plasma glucose was higher after 1.0 g/kg but plasma insulin was similar after each dose. Thus, in AF with sympathetic denervation there was no dose-related effect of glucose on supine or postural hypotension. Supine hypotension after glucose was not attributable solely to increased splanchnic blood flow; other factors, including dilatation in other vascular beds may have contributed.

Hypotensive and regional haemodynamic effects of exercise, fasted and after food, in human sympathetic denervation

1. In human sympathetic denervation due to primary autonomic failure, food and exercise in combination may produce a cumulative blood pressure lowering effect due to simultaneous splanchnic and skeletal muscle dilatation unopposed by corrective cardiovascular reflexes. We studied 12 patients with autonomic failure during and after 9 min of supine exercise, when fasted and after a liquid meal. Standing blood pressure was also measured before and after exercise. 2. When fasted, blood pressure fell during exercise from 162 +/- 7/92 +/- 4 to 129 +/- 9/70 +/- 5 mmHg (mean arterial pressure by 22 +/- 5%), P < 0.0005. After the meal, blood pressure fell from 159 +/- 8/88 +/- 6 to 129 +/- 6/70 +/- 4 mmHg (mean arterial pressure by 22 +/- 3%), P < 0.0001, and further during exercise to 123 +/- 6/61 +/- 3 mmHg (mean arterial pressure by 9 +/- 3%), P < 0.01. The stroke distance-heart rate product, an index of cardiac output, did not change after the meal. During exercise, changes in the stroke distance-heart rate product were greater when fasted. 3. Resting forearm and calf vascular resistance were higher when fasted. Calf vascular resistance fell further after exercise when fasted. Resting superior mesenteric artery vascular resistance was lower when fed; 0.19 +/- 0.02 compared with 0.32 +/- 0.06, P < 0.05. After exercise, superior mesenteric artery vascular resistance had risen by 82%, to 0.53 +/- 0.12, P < 0.05 (fasted) and by 47%, to 0.29 +/- 0.05, P < 0.05 (fed). 4. On standing, absolute levels of blood pressure were higher when fasted [83 +/- 7/52 +/- 7 compared with 71 +/- 2/41 +/- 3 (fed), each P < 0.05]. Subjects were more symptomatic on standing post-exercise when fed. 5. In human sympathetic denervation, exercise in the fed state lowered blood pressure further than when fasted and worsened symptoms of postural hypotension.

Abnormal regional blood flow responses during and after exercise in human sympathetic denervation

1. Blood pressure, superior mesenteric artery (SMA) and skeletal muscle blood flow, cardiac index (CI) and systemic vascular resistance responses to supine leg exercise were measured in six age-matched normal subjects (controls) and in eleven subjects with sympathetic denervation due to primary autonomic failure (AF). 2. During exercise, blood pressure rose in controls but fell markedly in AF. After exercise, blood pressure rapidly returned to baseline in controls but remained low in AF. During exercise, systemic vascular resistance fell in controls and AF but tended to fall further in AF and remained low post exercise. CI increased similarly in controls and AF. 3. During exercise, SMA blood flow fell similarly in controls and AF, but the fall initially was slower in AF; recovery was more rapid post exercise in controls. SMA vascular resistance tended to rise less and more slowly in AF and remained elevated post exercise. 4. Forearm muscle (FM) blood flow and FM vascular resistance did not change from resting values in controls or AF post exercise. After exercise, leg muscle (LM) blood flow rose and LM vascular resistance fell equally in both groups although LM blood flow remained elevated, 10 min post exercise in AF. 5. In sympathetically denervated humans, increased blood flow (due to excessive vasodilatation, lack of sympathetic restraint, or both) in leg muscle during and after exercise in combination with impaired splanchnic vasoconstriction in the early stages of exercise may have contributed to exercise-induced hypotension.

Systemic and regional (including superior mesenteric) haemodynamic responses during supine exercise while fasted and fed in normal man

The systemic and regional (including superior mesenteric artery, SMA) responses to exercise in the fasting and fed state were studied in ten normal subjects before, during and after 9 min of graded supine bicycle exercise on two separate occasions, when fasted and after a liquid meal. During exercise, blood pressure (BP) and cardiac index rose similarly in both states. Resting SMA blood flow was higher when fed (519 (282-619) versus 240 (133-255) ml/min, p < 0.01). SMA blood flow fell during exercise in both states, to 98 (63-154) ml/min, p < 0.01 when fasted and to 55 (42-149) ml/min, p < 0.01 when fed. SMA vascular resistance rose during exercise in both states, but rose less when fasted by 36 (6-57)% versus 143 (36-240)% (NS). Resting forearm and leg blood flow (FBF and LBF) and vascular resistance (FVR and LVR) were similar fasted and fed. FBF and FVR did not change after exercise in either state. LBF rose and LVR fell similarly in both states. We conclude that in normal subjects, although splanchnic oxygen demand is likely to be greater after food, during light to moderate exercise splanchnic vasoconstriction contributes to maintenance of BP.

Haemodynamic and hormonal effects of two different oral glucose loads in normal human subjects

Systemic and regional haemodynamics and hormonal responses to two isovolaemic, iso-osmotic solutions of 0.5 and 1.0 g/kg of glucose were compared in ten normal young subjects (mean age 24 +/- 3 years). Measurements were made while subjects were supine before glucose and every 15 min for 60 min after ingestion of each solution. Superior mesenteric artery (SMA) blood flow rose similarly after each dose. There were corresponding reductions in SMA vascular resistance after each dose but no difference between doses. Pulsatility index of the SMA was lower after 1.0 g/kg. There was no change in blood pressure, heart rate, cardiac index or forearm muscle blood flow after either dose. Plasma glucose levels rose after each dose and were higher after 1.0 g/kg. There was no difference in the plasma insulin rise between doses. Plasma levels of noradrenaline and adrenaline did not change after either dose. These results suggest that with glucose loads within the ranges we used, changes in SMA blood flow are not dose-related and larger increases in SMA blood flow or in plasma insulin than we observed are needed to reflexly activate cardiac output and raise plasma noradrenaline levels in young normal subjects.

Effect of meal size on post-prandial blood pressure and on postural hypotension in primary autonomic failure

In chronic autonomic failure, food ingestion causes a profound and rapid fall in supine blood pressure and aggravates postural hypotension. Food volume and caloric load are important determinants of gastric emptying and postprandial splanchnic hyperaemia, which appears to be a major contributor to hypotension. We therefore compared the cardiovascular effects of three large meals with six small meals providing an identical daily caloric intake, in seven subjects with primary autonomic failure. Daytime ambulatory blood pressure (BP) was measured by Spacelabs 90207 every 30 min with additional recordings while lying, sitting and standing, 30 min after each meal. Systolic and diastolic BP were lower in all three positions after large meals; systolic 131 versus 151 mmHg (large versus small), p = 0.005, 109 versus 124 mmHg, 89 versus 103 mmHg and diastolic 76 versus 90 mmHg, p = 0.02, 66 versus 78 mmHg, p = 0.07 and 50 versus 66 mmHg, p = 0.06 for lying, sitting and standing, respectively. Between meals, BP fell to lower levels with large meals, 88 (20) mmHg versus 104 (19) mmHg, p = 0.002 and 48 (13) mmHg versus 63 (13), p = 0.0001 mmHg for systolic and diastolic pressure respectively. Five subjects had more symptoms of postural dizziness after large meals. In primary autonomic failure, smaller and more frequent meals reduce postprandial hypotension and diminish postural symptoms post-meal. This is likely to be a useful non-pharmacological method in the management of postprandial hypotension.