Impaired heart rate variability in patients with chronic Chagas' disease

Guzzetti, Stefano; Iosa, Daniel; Pecis, Marica; Bonura, Luisa; Prosdocimi, Marco; Malliani, Alberto

doi:10.1016/0002-8703(91)90019-e

Cited by 92 publications

(61 citation statements)

References 28 publications

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“…Individually, chagasic subjects presented distinctive patterns of cardiac autonomic functional status, which includes depression, and less frequent enhancement or normality of the heart interval responses. Thus, the cardiac autonomic impairment previously detected in Chagas' heart disease patients by complex and invasive or simple noninvasive tests (Amorim et al, 1982;Gallo et al, 1987;Marin-Neto et al, 1980, 1998Junqueira, 1990;Guzzetti et al, 1991;Dávila et al, 1998) was also presently noted in chagasic patients with the apparent indeterminate form. This observation reinforces previous findings of suggestive cardiac dysautonomia in these chagasics based on different methodologies of cardiac autonomic evaluation (Macêdo et al, 1974;Iosa et al, 1980;Palmero et al, 1980;Guzzetti et al, 1991;Ribeiro et al, 2001).…”

Section: Discussionmentioning

confidence: 84%

“…Thus, the cardiac autonomic impairment previously detected in Chagas' heart disease patients by complex and invasive or simple noninvasive tests (Amorim et al, 1982;Gallo et al, 1987;Marin-Neto et al, 1980, 1998Junqueira, 1990;Guzzetti et al, 1991;Dávila et al, 1998) was also presently noted in chagasic patients with the apparent indeterminate form. This observation reinforces previous findings of suggestive cardiac dysautonomia in these chagasics based on different methodologies of cardiac autonomic evaluation (Macêdo et al, 1974;Iosa et al, 1980;Palmero et al, 1980;Guzzetti et al, 1991;Ribeiro et al, 2001). The prolonged time and the reduced velocity of heart interval change from the maximum tachycardia to maximum bradycardia post-manoeuvre may be consequent to delayed inhibition or reversion of the ongoing sympathetic hyperactivity in phases II and III with retarded suppression of tachycardia in phase III and installation of bradycardia in phase IV, or to delayed stimulation of the attenuated or normal parasympathetic activity in phases II and III with slow installation of bradycardia in phase IV.…”

Section: Discussionmentioning

confidence: 84%

“…Prolongation in the atrium -ventricular conduction at the electrocardiogram following pilocarpine administration (Macêdo et al, 1974), and deficient heart rate response to hyperventilation and tilting test were demonstrated. Depressed heart rate variability analysed in the frequencydomain during standing and handgrip exercise was shown, which suggests sympathetic and parasympathetic dysfunction (Guzzetti et al, 1991). In another study, respiratory sinus arrhythmia and heart rate variability in the timedomain and in return map were shown to be depressed, besides normal left ventricular function, demonstrating primary parasympathetic impairment (Ribeiro et al, 2001).…”

Section: Introductionmentioning

confidence: 90%

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Impaired autonomic control of heart interval changes to Valsalva manoeuvre in Chagas' disease without overt manifestation

Soares

2002

Autonomic Neuroscience

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Background: In the apparent indeterminate form of Chagas' disease, which lacks any overt clinical, electrocardiographic, and radiological manifestations of organ damage, lesions of the intrinsic autonomic innervation of heart are not striking features and evidences for cardiac autonomic dysfunction are elusive and conflicting. Objective: To evaluate the cardiac autonomic modulation based on Valsalva manoeuvreassociated heart interval variation in Chagas' disease subjects with apparent indeterminate form. Subjects and methods: We examined 36 outpatient volunteers aged 15 -51 years old (median: 36.5), in comparison with 52 healthy control individuals aged 17 -49 years old (median: 29) ( p < 0.001). Each subject sequentially performed in the supine position three to four manoeuvres at an intra-oral pressure of 40 mm Hg during 20 s, under continuous DII lead electrocardiographic registration, and rate-and time-dependent indices of Valsalva manoeuvre-associated R -R interval variation were obtained. The t-test or the Mann -Whitney test was employed to compare the data between the groups. Results: No correlation was found between every index and age for the control group ( p = 0.39 -0.71). The chagasic group presented similar basal to phase IV median increment (relative bradycardia) (23.7% vs. 22.7%; p = 0.63) and smaller basal to phase III median decrement of R -R interval (relative tachycardia) ( À 31.7% vs. À 35%; p = 0.02) in comparison to the control group, respectively. The median Valsalva ratio showed a tendency for reduction in chagasics (1.78 vs. 1.90; p = 0.08). Prolonged median time (14.2 vs. 10.3 s; p < 0.001) and slowed median velocity (5.1%/s vs. 8.9%/s; p < 0.001) of the phases III -IV bradycardia were also observed in chagasic group. The majority (58.3%) of the chagasics presented exclusively at least one depressed, and 8.3% presented at least one enhanced index of rateand/or time-dependent heart interval responses beyond the 25th or 75th control percentiles, and 27.8% presented at least one depressed and other enhanced index, while 5.6% showed all indices within the control interquartile range. All the indices outside the 25th or 75th control percentiles were noted in 13.9% of chagasics. Conclusion: Chagas' disease subjects without overt manifestations presented variable and subtle depression and less frequent enhancement or normality of the rate-and time-dependent tachycardia and bradycardia reflex responses related to Valsalva manoeuvre, which demonstrates distinct patterns of finely disturbed cardiac sinus parasympathetic and sympathetic modulation, probably due to inflammatory or autoimmunological damage of intrinsic innervation and/or to autoantibodies-induced derangement in neurotransmitter receptors. D

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Section: Discussionmentioning

confidence: 84%

Section: Discussionmentioning

confidence: 84%

Section: Introductionmentioning

confidence: 90%

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Impaired autonomic control of heart interval changes to Valsalva manoeuvre in Chagas' disease without overt manifestation

Soares

2002

Autonomic Neuroscience

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“…However, we [7][8][9]20,21,37 and other investigators 16 have found that chagasic patients who are in different stages of natural history of the disease may have normal, abnormal 2 or even enhanced responses to conventional cardiac autonomic tests 15,27 . Moreover, the frequency and time domain indexes of parasympathetic modulation may be suppressed in the supine position, but become similar to controls in the standing position and while performing isometric exercise 6,24,27,45 . Since, muscarinic auto-antibodies may behave as positive allosteric modulators of parasympathetic activity 25 ; a diminished high frequency component of heart rate variability 41 and the presence of a slow heart rate 44 could be an indirect expression of the agonist effect.…”

Section: Introductionmentioning

confidence: 92%

Muscarinic antibodies and heart rate responses to dynamic exercise and to the Valsalva maneuver in chronic chagasic patients

Neves¹,

Bacilio²,

Berrueta

et al. 2013

Rev. Inst. Med. trop. S. Paulo

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SUMMARYWe have studied the cardiac chronotropic responses to the Valsalva maneuver and to dynamic exercise of twenty chronic chagasic patients with normal left ventricular function and no segmental wall abnormalities by two-dimensional echocardiogram. The absolute increase in heart rate of the patients (∆ = 21.5 ± 10 bpm, M±SD) during the maneuver was significantly diminished when compared to controls (∆ = 31.30 ± 70, M±SD, p = 0.03). The minimum heart rate (58.24 ± 8.90 vs. 62.80 ± 10, p = 0.68) and the absolute decrease in heart rate at the end of the maneuver (∆ = 38.30 ± 13 vs. ∆ = 31.47 ± 17, p = 0.10) were not different from controls. The initial heart rate acceleration during dynamic exercise (∆ = 12 ± 7.55 vs. ∆ = 19 ± 7.27, M±SD, p = 0.01) was also diminished, but the heart rate recovery during the first ten seconds was more prominent in the sero-positive patients (Median: 14, Interquartile range: (9.75-17.50 vs. 5(0-8.75, p = 0.001). The serum levels of muscarinic cardiac auto-antibodies were significantly higher in the chagasic patients (Median: 34.58, Interquartile Range: 17-46.5, Optical Density) than in controls (Median: 0, Interquartile Range: 0-22.25, p = 0.001) and correlated significantly and directly (r = 0.68, p = 0.002) with early heart rate recovery during dynamic exercise. The results of this investigation indirectly suggest that, the cardiac muscarinic auto-antibodies may have positive agonist effects on parasympathetic heart rate control of chagasic patients.

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“…According to pioneer neurogenic hypothesis (Köberle, 1959), early and irreversible damage to the parasympathetic system during acute phase of the disease causes a cathecolaminergic cardiomyopathy, but this point of view has been debated and evidence is contradictory. Functional test performed in CCC patients demonstrated impaired parasympathetic heart rate regulation (metaraminol, phenylephrine and atropine intravenous injections, facial immersion, Valsalva maneuver, head-up and head-down tilt tests, respiratory sinus arrhythmia, handgrip, graded dynamic exercise, and spectral analysis of Holter recordings) (Amorim, et al, 1968, Amorim, et al, 1973, Guzzetti, et al, 1991, Junqueira Junior, et al, 1985, Manço, et al, 1969, Marin-Neto, et al, 1975, Sousa, et al, 1987. However, a careful analysis of these data showed that many patients had normal autonomic function and most patients had heart failure, that could explain autonomic dysfunction per se (Davila, et al, 1998).…”

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confidence: 99%