CLINICAL GUIDE TO CARDIAC AUTONOMIC TESTS

CLINICAL GUIDE TO CARDIAC AUTONOMIC TESTS Edited by

MAREK MALIK Department of Cardiological Sciences, St. George's Hospital Medical School, London

Springer-Science+Business Media, B.V.

A C.I.P. Catalogue record for this book is available from the Library ofCongress.

ISBN 978-90-481-5071-7 DOI 10.1007/978-94-017-1057-2

ISBN 978-94-017-1057-2 (eBook)

Printed on acid-free paper

AlI Rights Reserved © 1998 Springer Science+Business Media Dordrecht Originally published by Kluwer Academic Publishers in 1998

No part ofthe material protected by this copyright notice may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission from the copyright owner

to

Daniel, Natalie, Michal and David

CONTENTS List of contributors Introduction ..... .

PART ONE: I

IX

xiii

PHYSIOLOGY

Physiology of the cardiac autonomic system

3

Roger Hainsworth

II

Pathophysiology of cardiac autonomic disorders

29

Christopher J Mathias

PART Two:

III

AUTONOMIC TESTS

Basic autonomic tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Stefan H Hohnloser, Thomas Klingenheben

IV

Tilt table testing ..... .

............................ 67

Steve W Parry, Rose Anne Kenny

V

Autonomic responses to blockades and provocations

101

Laurence Keselbrener, Solange Akselrod

VI

Short-term measurement of heart rate variability

149

Juha EK Hartikainen. Kari UO Tahvanainen. Tom A Kuusela

VII

Physiological interpretation of spectral components of heart rate variability

177

Alberto Malliani

VIII Long-term measurement of heart rate variability ......... 195 Antti E Hedman, Marek Malik

IX

Neural recordings in the assessment ........................... 239 of cardiac autonomic balance Nicola Montano, Virend K Somers, Alberto Porta, Massimo Pagani

X

Assessment of baroreflex sensitivity ............................ 257 Maria Teresa La Rovere, Gian Domenico Pinna, Andrea Mortara

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CONTENTS

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PART THREE: XI

CLINICAL PRACTICE

Ageing and cardiac autonomic status

. 285

Bohvoj Semrad, Bohumil Fiser, Natasa Honzikova

XII

Concomitant therapy and autonomic tests Xavier Copie, Louis Guize, Jean-Yves Le Heuzey

301

XIII Influence of smoking, alcohol, caffeine ............ 331 and recreational drugs on cardiac autonomic tests Azad V Ghuran, Marek Malik

XIV Cardiac autonomic syndromes

.............. 357

Roy Freeman

XV

Clinical perspective Yee Guan Yap, A John Camm

Index

393

.. 415

LIST OF CONTRIBUTORS Solange Akselrod Center for Medical Physics, School of Physics, Tel Aviv University, Tel Aviv, Israel

A John Camm Department of Cardiological Sciences, St. George's Hospital Medical School, London, United Kingdom

Xavier Copie Departement de Cardiologie, Hopital Broussais, Paris, France

Bohumil Fiser Department of Physiology, Masaryk University, Brno, Czech Republic

Roy Freeman Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA

Louis Guize Departement de Cardiologie, Hopital Broussais, Paris, France

Azad V Ghuran Department of Cardiology, North Staffordshire City General Hospital, Stoke on Trent, United Kingdom

Roger Hainsworth Institute for Cardiovascular Research, University of Leeds, Leeds, United Kingdom

Juha EK Hartikainen Department of Medicine, Kuopio University Hospital, Kuopio, Finland

Antti E Hedman Department of Medicine, Kuopio University Hospital, Kuopio, Finland

Jean-Yves Le Heuzey Departement de Cardiologie, Hopital Broussais, Paris, France

IX

X

LIST OF CONTRIBUTORS

Stefan H Hohnloser JW Goethe University, Department of Internal Medicine, Division of Cardiology, Frankfurt am Main, Germany

Natasa Honzikova Department of Physiology, Masaryk University, Brno, Czech Republic

Rose Anne Kenny Cardiovascular Investigation Unit, Royal Victoria Infirmary, University of Newcastle upon Tyne & Institute for the Health of the Elderly, Newcastle upon Tyne, United Kingdom

Laurence Keselbrener Center for Medical Physics, School of Physics, Tel Aviv University, Tel Aviv, Israel

Thomas Klingenheben JW Goethe University, Department of Internal Medicine, Division of Cardiology, Frankfurt am Main, Germany

Tom A Ku.usela Department of Applied M!lthematics and Department of Physics, Turku University, Turku, Finland

Marek Malik Department of Cardiological Sciences, St. George's Hospital Medical School, London, United Kingdom

Alberto Malliani Centro Ricerche Cardiovascolari, CNR, Centro LITA-Vialba, Medicina Interna II, Ospedale "L. Sacco", Universita degli Studi, Milano, Italy

Christopher J Mathias Neurovascular Medicine Unit, Division of Neuroscience & Psychological Medicine, Imperial College School of Medicine at StMary's & Autonomic Unit, University Department of Clinical Neurology National Hospital for Neurology & Neurosurgery, Queen Square & Institute of Neurology, University College London, London, United Kingdom

Nicola Montano Centro Ricerche Cardiovascolari, CNR, Centro LITA-Vialba, Ospedale "L. Sacco", Universita degli Studi, Milano, Italy

LIST OF CONTRIBUTORS

Xl

Andrea Mortara Divisione di Cardiologia, Fondazione "S. Maugeri", IRCCS, Centro Medico Montescano, Pavia, Italy

Massimo Pagani Centro Ricerche Cardiovascolari, CNR, Centro LITA-Vialba, Ospedale "L. Sacco", Universita degli Studi, Milano, Italy

Steve W Parry Cardiovascular Investigation Unit, Royal Victoria Infirmary, University of Newcastle upon Tyne & Institute for the Health of the Elderly, Newcastle upon Tyne, United Kingdom (presently supported by the British Heart Foundation, London)

Gian Domenico Pinna Divisione di Bioingegneria, Fondazione "S. Maugeri", IRCCS, Centro Medico Montescano, Pavia, Italy

Alberto Porta Centro Ricerche Cardiovascolari, CNR, Centro LITA-Vialba, Ospedale "L. Sacco", Universita degli Studi, Milano, Italy

Maria Teresa La Rovere Divisione di Cardiologia, Fondazione "S. Maugeri", IRCCS, Centro Medico Montescano, Pavia, Italy

Bofivoj Semrad First Department of Medicine, University Hospital, Masaryk University, Brno, Czech Republic

Virend K Somers Cardiovascular Division, Department of Internal Medicine, University of Iowa, Iowa City, USA

Kari UO Tahvanainen Department of Clinical Physiology, Tampere University Hospital, Tampere, Finland

Yee Guan Yap Department of Cardiological Sciences, St. George's Hospital Medical School, London, United Kingdom

INTRODUCTION The existence of physiological mechanisms controlling cardiac cunction and periodicity has been appreciated for centuries. Rathet recently, we started to realise that disturbances of the cardiac autonomic regulations may have profound clinical consequences. The seminal studies showing that the physiological autonomic regulations of the heart are an important part of the natural antitachycardia defence have only been conducted some decades ago. Together with clinical observations of the possible prophylaxis guided by the assessment of cardiac autonomic status, these physiological and pathophysiological iiwestigations demonstrated the potential of cardiac autonomic testing to both research and clinical communities. The research and clinical interest in the assessment of cardiac autonomic status was further promoted by the recent development and advances of technologies that enable detailed dynamic recording of electrocardiograms, continuos blood pressure tracings, neural activity, etc. Indeed, many aspects of cardiac autonomic regulations are so subtle that without proper precise investigation techniques, they would be completely out of our reach. All these advances in investigation capabilities, physiological understanding and clinical potential led to the development of a whole spectrum of simple as well as rather complex tests that are able to quantify and classify cardiac autonomic reflexes and regulations. Numerous scientific reports have emerged showing the value of the individual tests in various physiological circumstances and clinical conditions. From these reports and from consensus debates organised by scientific societies, technical standards and critically reviewed experience emerged offering a guide to proper conduct, physiological interpretation and clinical appraisal of the individual tests. Although some of these standards, especially those related to direct clinical use of selected autonomic tests, will need to be broaden and deepened in the future, it is now proper to disseminate the present state-of-the-art of cardiac autonomic tests among a wider clinical community. For all these reasons, I was pleased when I was approached by Kluwer Academic Publishers with the request to edit a book aimed at providing a practical guide to researchers and clinical physicians interested in autonomic investigations of the heart. I was even more

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iNTRODUCTION

pleased when joined in my enthusiasm for the book by the specialists in the field whom I invited to write the individual chapters. To offer the reader a comprehensive coverage of the subject, the book is structured in three parts. The first part deals with the physiology of cardiac autonomic system that creates the background of the particular tests. The second part contains chapters describing specific autonom1c tests and investigations. The last part summarises the value of autonomic testing in clinical practice and describes conditions which might alter the results of autonomic investigations. As with every other multi-authored book, I faced the usual editorial dilemma of finding the proper balance between having the book compact with cross-references between individual chapters, and having the chapters suited for separate reading. Eventually, I felt that with a book aimed at providing a source of standards and references, each chapter should contain a standalone coverage of its subject. Consequently, I am happy to recommend the reader to select chapters corresponding to his or her particular needs and interest. Needless to say, reading the book in its entirety offers much more comprehensive learning of the whole field. Finally, my deep thanks go all the contributors to the book. Without their kind help, it would have never been published. My apologies go to my family whom editing the book deprived of every moment of my free time.

Aprill998 Marek Malik