When enhanced awareness threatens: Interactive effects of domain-specific awareness and acceptance manipulations on cardiovascular indices of challenge and threat.

Mindfulness includes acceptance and awareness subcomponents, and emerging theories imply that cultivating both acceptance and awareness may benefit health by diminishing stress reactivity. Yet, no prior work has examined the effects of mindful acceptance and awareness on cardiovascular markers of threat and challenge-cardiac output and total peripheral resistance-despite the unique insights these indices yield into stress-related evaluations and motivation. The current research integrates Monitor and Acceptance Theory with the Biopsychosocial Model of Challenge and Threat to elucidate how an awareness manipulation and a brief acceptance training are associated with cardiovascular stress responses underlying states of challenge and threat. Healthy young adults (N = 202) were enrolled in a 2 × 2 between-subjects experimental design manipulating both awareness (enhanced awareness vs. no enhanced awareness) and acceptance (acceptance training vs. no acceptance training) of physiological responses to a social-evaluative cold pressor test. Cardiovascular indices were recorded throughout. The combination of enhanced awareness and acceptance training led to higher cardiac output and lower total peripheral resistance (indexing greater challenge, less threat) to the cold pressor test than the combination of enhanced awareness and no acceptance training. However, the combination of no enhanced awareness and no acceptance training also led to higher cardiac output and lower total peripheral resistance than the combination of enhanced awareness and no acceptance training. These results add to a growing body of work suggesting that mindful awareness and acceptance subcomponents interact to influence stress reactivity and imply that enhanced stressor awareness without acceptance may lead to increased threat.

Anxiety, depressive symptoms, and cardiac autonomic function in perimenopausal and postmenopausal women with hot flashes: a brief report.

OBJECTIVE: The aim of the study was to examine whether anxiety and depressive symptoms are associated with an adverse cardiac autonomic profile among midlife women with hot flashes. METHODS: Anxiety and depressive symptoms were evaluated by validated self-administered questionnaires among peri- and postmenopausal women in a randomized trial of slow-paced respiration for hot flashes. Pre-ejection period (PEP), a marker of sympathetic activation, and respiratory sinus arrhythmia (RSA), a marker of parasympathetic activation, were measured at baseline and 12 weeks using impedance cardiography and electocardiography. Multivariable repeated measures linear regression models examined associations between anxiety and depression symptoms and autonomic markers, corrected for multiple comparisons with Benjamini-Hochberg procedure, and adjusted for age and body mass index. RESULTS: Among the 121 participants, greater state anxiety was associated with shorter PEP, reflecting higher sympathetic activity (ß = -0.24, P = 0.02). Greater trait anxiety and cognitive anxiety were associated with lower RSA, reflecting decreased parasympathetic activity (ß = -0.03, P < 0.01 for Spielberger Trait Anxiety; ß = -0.06, P = 0.02 for Hospital Anxiety and Depression Scale [HADS] Anxiety Subscale). Greater depressive symptoms were associated with lower RSA (ß = -0.06, P = 0.03 for HADS Depression Subscale; ß = -0.03, P = 0.04 for Beck Depression Inventory). CONCLUSIONS: Among peri- and postmenopausal women with hot flashes, greater self-reported anxiety and depressive symptoms were associated with lower levels of resting cardiac parasympathetic activity, and greater state anxiety was associated with higher levels of cardiac sympathetic activity. Findings suggest that midlife women with increased anxiety and depressive symptoms may have an unfavorable cardiac autonomic profile with potential implications for their overall cardiovascular risk.

Association between transthoracic impedance and electrical cardioversion success with biphasic defibrillators: An analysis of 1055 shocks for atrial fibrillation and flutter.

BACKGROUND: The relevance of transthoracic impedance (TTI) to electrical cardioversion (ECV) success for atrial tachyarrhythmias when using biphasic waveform defibrillators is unknown. HYPOTHESIS: TTI is predictive of ECV success with contemporary defibrillators. METHODS: De-identified data stored in biphasic defibrillator memory cards from ECV attempts for atrial fibrillation (AF) or atrial flutter (AFL) over a 2-year period at our center were evaluated. ECV success, defined as arrhythmia termination and ≥ 1 sinus beat, was adjudicated by 2 blinded cardiac electrophysiologists. The association between TTI and ECV success was assessed via Cochrane-Armitage trend and Spearman rank correlation tests, as well as simple and multivariable logistic regression. The influence of TTI on the number of shocks and on cumulative energy delivered per patient was also examined. RESULTS: 703 patients (593 with AF, 110 with AFL) receiving 1055 shocks were included. Last shock success was achieved in 88.0% and 98.2% of patients with AF and AFL, respectively. In patients with AF, TTI was positively associated with last shock failure (Ptrend =0.019), the need for multiple shocks (Ptrend <0.001), and cumulative energy delivered (ρ = 0.348; P < 0.001). After adjusting for first shock energy, 10-Ω increments in TTI were associated with odds ratios of 1.36 (95% CI: 1.24-1.49) and 1.22 (95% CI: 1.09-1.37) for first and last shock failure, respectively (P < 0.001 for both). CONCLUSIONS: Although contemporary defibrillators are designed to compensate for TTI, this variable continues to be associated with ECV failure in patients with AF. Strategies to lower TTI during ECV for AF may improve procedural success.

Device malfunction caused by "auto-oversensing" of transthoracic impedance measurement test pulses in a modern minute ventilation dual-chamber pacemaker.

Oversensing of physiologic and non-physiologic electrical signals is a relevant cause of malfunctions in subjects with CIED. Physicians taking care of CIED patients must be aware of the potential causes of oversensing and their pattern in EGMs. The present case describes an uncommon source and unique underlying root cause for oversensing in a modern dual-chamber MV rate-adaptive pacemaker.

[Complex study of the rat heart at isoproterenol damage].

Introduction of isoproterenol (an agonist of beta-adrenoreceptors) to rats is one of the widespread experimental models of cardiac failure. It is caused by damage of cardiomyocytes with the subsequent development of substitutive fibrosis. The purpose of the given work was the complex characteristic of cardiac function by means of invasive and noninvasive (echocardiography and impedansometry) methods of research. Isoproterenol was injected twice with a daily interval in dozes 85, 120, 150 or 180 mg/kg. Echocardiographic study of the heart in 2 weeks revealed obvious attributes of cardiac failure (left ventricular dilatation, lowered ejection fraction) in the groups which have received high cumulative dozes of isoproterenol (300-360 mg/kg). The catheterization of the left ventricle in these groups has shown raised enddiastolic pressure, decreased maximal rate of pressure development and fall, and also lowered indices of myocardial contractility and relaxability. In the groups which have received smaller isoproterenol dozes, apparent decrease in relaxability parameters (constants of isovolumic and auxovolumic relaxation) has been revealed at only slightly changed parameters of contractility. A strong correlation between echocardiographic and invasive parameters of myocardial contractility has been found. The phase analysis of the cardiac cycle has shown a lengthening of isometric phases of contraction and relaxation, as well as duration of ejection due to shortening duration of filling of both ventricles. Cardiomyocytes isolated from hearts with obvious cardiac failure responded to electrostimulation by arrhythmic contractions and also by much slowed and incomplete removal of free Ca++ from the myoplasm. Results allow to conclude that relatively smaller extent of myocardial damage is accompanied by decreased relaxability at slightly changed contractility, while at greater degree of damage both processes fail, but delay of relaxation still prevails.

Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device.

BACKGROUND: A recent out-of-hospital cardiac arrest (OHCA) clinical trial showed improved survival to hospital discharge (HD) with favorable neurologic function for patients with cardiac arrest of cardiac origin treated with active compression decompression cardiopulmonary resuscitation (CPR) plus an impedance threshold device (ACD+ICD) versus standard (S) CPR. The current analysis examined whether treatment with ACD+ITD is more effective than standard (S-CPR) for all cardiac arrests of non-traumatic origin, regardless of the etiology. METHODS: This is a secondary analysis of data from a randomized, prospective, multicenter, intention-to-treat, OHCA clinical trial. Adults with presumed non-traumatic cardiac arrest were enrolled and followed for one year post arrest. The primary endpoint was survival to hospital discharge (HD) with favorable neurologic function (Modified Rankin Scale score ≤ 3). RESULTS: Between October 2005 and July 2009, 2738 patients were enrolled (S-CPR=1335; ACD+ITD=1403). Survival to HD with favorable neurologic function was greater with ACD+ITD compared with S-CPR: 7.9% versus 5.7%, (OR 1.42, 95% CI 1.04, 1.95, p=0.027). One-year survival was also greater: 7.9% versus 5.7%, (OR 1.43, 95% CI 1.04, 1.96, p=0.026). Nearly all survivors in both groups had returned to their baseline neurological function by one year. Major adverse event rates were similar between groups. CONCLUSIONS: Treatment of out-of-hospital non-traumatic cardiac arrest patients with ACD+ITD resulted in a significant increase in survival to hospital discharge with favorable neurological function when compared with S-CPR. A significant increase survival rates was observed up to one year after arrest in subjects treated with ACD+ITD, regardless of the etiology of the cardiac arrest.

The Changes of Noninvasive Hemodynamic Parameters after Device-Guided Slow Breathing Exercise in Hypertensive Patients

BACKGROUND: The device-guided breathing (DGB) exercise is a non-pharmacological treatment of high blood pressure (BP). Changes in hemodynamic variables after DGB remain to be defined. This study evaluated the hemodynamic effects of DGB in hypertensive patients. METHODS: Fifty-nine hypertensive individuals (male, 56%; age, 44 +/- 10 years) with systolic BP (SBP) in the range of 140 to169 mm Hg and diastolic BP (DBP) < 105 mm Hg were divided into two group: control group (n = 17) vs. DGB group (n = 42) who slowed respiratory rate by using 15 minutes daily DBG (RESPeRATE) over 8 weeks. Heart rate, BP and hemodynamic parameters including cardiac index (CI), thoracic fluid content (TFC), systemic vascular resistance index (SVRI) and total arterial compliance index (TACI) were measured using the ICG Monitor (CardioDynamics) at baseline and study end. RESULTS: Baseline characteristics were not different between the two groups. Office BP (SBP/DBP) was reduced from baseline to end value by 13.2 +/- 11.1/6.9 +/- 7.5 mm Hg in DGB group and 2.2 +/- 6.9/0.5 +/- 6.6 mm Hg in control group (p = 0.001, p = 0.004, respectively). Heart rate, CI, stroke index, and TFC were not changed in both groups. However, the SVRI was lower and the TACI was higher in DGB group than control group (SVRI: 2,728 +/- 599 vs. 3,141 +/- 714 dyne sec m2/cm5, p = 0.002; TACI: 0.845 +/- 0.194 vs. 0.761 +/- 0.184 mm Hg/mL/m2, p = 0.041). CONCLUSIONS: Daily device-guided breathing exercise for 8 weeks lowers the BP mediated by reducing the systemic vascular resistance and increasing the total arterial compliance without changes in heart rate and CI.

Implantable cardiovascular sensors and computers: interventional heart failure strategies.

Despite evidence-based medical and pharmacologic advances the management of heart failure remains challenging, whether in the ambulatory setting where daily weight monitoring has failed, or in the inpatient setting where readmission rates and morbidity remains high. There is an urgent need to develop strategies to reduce hospitalizations and readmission rates for heart failure in general. There may be a shift in the paradigm with respect to the treatment of heart failure, which may usher in an era of invasive heart failure therapies and specialists. Experimental invasive devices and monitors have the potential to be game-changing therapies, and cardiac resynchronization therapy has evolved beyond just resynchronization and has the potential to provide important real-time hemodynamic feedback.

Increased heart rate variability during nondirective meditation.

PURPOSE: Meditation practices are in use for relaxation and stress reduction. Some studies indicate beneficial cardiovascular health effects of meditation. The effects on the autonomous nervous system seem to vary among techniques. The purpose of the present study was to identify autonomic nerve activity changes during nondirective meditation. MATERIALS AND METHODS: Heart rate variability (HRV), blood pressure variability (BPV), and baroreflex sensitivity (BRS) were monitored in 27 middle-aged healthy participants of both genders, first during 20 min regular rest with eyes closed, thereafter practising Acem meditation for 20 min. Haemodynamic and autonomic data were collected continuously (beat-to-beat) and non-invasively. HRV and BPV parameters were estimated by power spectral analyses, computed by an autoregressive model. Spontaneous activity of baroreceptors were determined by the sequence method. Primary outcomes were changes in HRV, BPV, and BRS between rest and meditation. RESULTS: HRV increased in the low-frequency (LF) and high-frequency (HF) bands during meditation, compared with rest (p = 0.014, 0.013, respectively). Power spectral density of the RR-intervals increased as well (p = 0.012). LF/HF ratio decreased non-significantly, and a reduction of LF-BPV power was observed during meditation (p < 0.001). There was no significant difference in BRS. Respiration and heart rates remained unchanged. Blood pressure increased slightly during meditation. CONCLUSION: There is an increased parasympathetic and reduced sympathetic nerve activity and increased overall HRV, while practising the technique. Hence, nondirective meditation by the middle aged may contribute towards a reduction of cardiovascular risk.

Device monitoring strategies in acute heart failure syndromes.

Acute heart failure syndromes (AHFS) represent the most common discharge diagnoses in adults over age 65 and translate into dramatically increased heart failure-associated morbidity and mortality. Conventional approaches to the early detection of pulmonary and systemic congestion have been shown to be of limited sensitivity. Despite their proven efficacy, disease management and structured telephone support programs have failed to achieve widespread use in part due to their resource intensiveness and reliance upon motivated patients. While once thought to hold great promise, results from recent prospective studies on telemonitoring strategies have proven disappointing. Implantable devices with their capacity to monitor electrophysiologic and hemodynamic parameters over long periods of time and with minimal reliance on patient participation may provide solutions to some of these problems. Conventional electrophysiologic parameters and intrathoracic impedance data are currently available in the growing population of heart failure patients with equipped devices. A variety of implantable hemodynamic monitors are currently under investigation. How best to integrate these devices into a systematic approach to the management of patients before, during, and after AHFS is yet to be established.

Measurement of the local aortic stiffness by a non-invasive bioelectrical impedance technique.

Aortic stiffness measurement is well recognized as an independent predictor of cardiovascular mortality and morbidity. Recently, a simple method has been proposed for the evaluation of the local aortic stiffness (AoStiff) using a non-invasive bioelectrical impedance (BI) technique. This approach relies on a novel interpretation of the arterial stiffness where AoStiff is computed from the measurement of two new BI variables: (1) the local aortic flow resistance (AoRes) exerted by the drag forces onto the flow; (2) the local aortic wall distensibility (AoDist). Herein, we propose to detail and compare these three indices with the reference pulse wave velocity (PWV) measurement and the direct assessment of the aortic drag forces (DF) and distensibility (DS) obtained by the magnetic resonance imaging technique. Our results show a significant correlation between AoStiff and PWV (r = 0.79; P < 0.0001; 120 patients at rest; mean age 44 ± 16 years), and also between AoRes and DF (r = 0.95; P = 0.0011) and between AoDist and DS (r = 0.93; P = 0.0022) on eight patients at rest (mean age 52 ± 19 years). These first results suggest that local aortic stiffness can be explored reliably by the BI technique.

Brief effect of acupuncture on the peripheral arterial system of the upper limb and systemic hemodynamics in humans.

BACKGROUND: Pulse diagnosis of the peripheral artery is an important technique in Traditional Chinese Medicine, where, in acupuncture therapy, the treatment is adjusted according to the observed changes of the pulse. We investigated the change of blood flow in the peripheral artery and the cardiac index during acupuncture treatment. OBJECTIVES: The aim of this study is to explore the effect of acupuncture on radial and brachial artery blood flow volume and the cardiac index in healthy subjects. METHODS: Eighteen (18) healthy volunteers were enrolled. Acupuncture was performed bilaterally on LR-3 with manual rotation of the needles. The blood pressure and heart rate were measured at rest and 180 seconds after acupuncture. Radial and brachial artery blood flow volume was monitored continuously by an ultrasound with an echo-tracking system. Cardiac index was measured by impedance cardiography. The hemodynamic parameters were measured before, during, and 30, 60, 180 seconds after acupuncture. RESULTS: The peripheral artery blood flow volume decreased significantly during acupuncture (radial; p < 0.01, brachial; p < 0.05) but increased at 180 seconds after acupuncture (radial; p < 0.05, brachial; p < 0.05) compared with before acupuncture. The cardiac index did not change significantly after acupuncture, but systemic vascular resistance index significantly decreased (p < 0.05). CONCLUSIONS: The present study showed that radial and brachial artery blood flow volume decreased immediately during acupuncture on LR-3 acupoint, but increased at 180 seconds after acupuncture. This reaction is attributed to the change in peripheral vascular resistance.

Combined cardiopulmonary assessments with implantable telemetry device in conscious freely moving cynomolgus monkeys.

Female cynomolgus monkeys were surgically implanted with telemetry transmitters recording ECG (DII), arterial pressure, physical activity, body temperature, and tidal volume. Respiratory rate (RR) and tidal volume (TV) were monitored simultaneously with the telemetry transmitter using impedance. Impedance-based monitoring of RR and TV by telemetry correlated with controlled TV and with pneumotachometer (>98%) in restrained animals. Control drugs with cardiovascular and respiratory effects, including saline, medetomidine (0.01, 0.02 and 0.04mg/kg) and cocaine (0.5, 1.0 and 1.5mg/kg) were administered intravenously. An averaging epoch of 5min was used for analysis of respiratory data. Medetomidine induced significant respiratory depression with decrease in RR and TV in freely moving animals while cocaine increased TV, RR and minute ventilation (MV) with concomitant increase in heart rate when compared with time matched values from saline-treated animals. The onset, duration and magnitude of cardiovascular and respiratory changes were correlated. This highlights the dependency of the cardiovascular and respiratory systems. The use of cardiopulmonary monitoring can allow continuous monitoring including during night time when variability of respiratory parameters is lower. Monitoring of cardiovascular and respiratory parameters in the same animals could also help to decrease the number of animals used in research.

Intracardiac impedance monitors stroke volume in resynchronization therapy patients.

AIMS: Monitoring of haemodynamic parameters or surrogate parameters of the left ventricle is especially important for patients under cardiac resynchronization therapy (CRT). Intracardiac impedance reflects left ventricular (LV) volume changes well in animal models. Since it is unknown whether this also holds in humans with heart failure (HF), we examined the correlation of LV intracardiac impedance with haemodynamic parameters in CRT patients for different positions of the LV lead. METHODS AND RESULTS: In 14 HF patients with non-ischaemic cardiomyopathy (four female, age 70 +/- 6 years, NYHA 2.9 +/- 0.3, EF 26 +/- 6%), one or two suitable implantation sites for the LV lead were selected. Following atrial, right ventricular, and LV catheter positioning, a micro-manometer catheter was placed in the ascending aorta. Surface ECG, impedance, and aortic pressure were recorded during graded overdrive bi-ventricular pacing in DDD mode. The correlation between impedance and stroke volume (SV) or pulse pressure (PP) changes was compared for different LV lead positions. In total, 20 overdrive pacing tests were performed at six different LV lead positions. Strong correlations were found between stroke impedance (SZ) and SV (R = 0.82 +/- 0.16) as well as between SZ and PP (R = 0.81 +/- 0.16) without significant influence of LV lead position. CONCLUSION: In HF patients, a strong correlation between changes in intracardiac impedance and LV SV was found. Typical LV lead implant positions have been tested and all appear to be suitable for this method of LV volume monitoring.

Current procedural terminology coding in electrophysiology: focus on 2009 updates.

This article highlights the major changes in the current procedural terminology codes (CPT codes) that were announced by the American Medical Association in January 2009. These new CPT codes were developed to more accurately reflect current cardiac device monitoring capabilities, long-distance telemetry and remote interrogation as well as follow-up practices. Some of these new code sets are structured differently than the CPT codes that they replace. Specifically, the new codes for remote monitoring do not have separate professional (-26) and technical components (-TC) applied to an individual code. Instead, the new remote monitoring codes have separate CPT codes that represent the professional and technical components. The new device programming codes are generally defined by the number of leads, rather than the type of generator. Also, the period of time included in the specific type of service is indicated as per encounter, 30 or 90 days. Furthermore, two new periprocedural device evaluation and programming codes have been introduced.

Is running away right? The behavioral activation-behavioral inhibition model of anterior asymmetry.

The measurement of anterior electroencephalograph (EEG) asymmetries has become an important standard paradigm for the investigation of affective states and traits. Findings in this area are typically interpreted within the motivational direction model, which suggests a lateralization of approach and withdrawal motivational systems to the left and right anterior region, respectively. However, efforts to compare this widely adopted model with an alternative account-which relates the left anterior region to behavioral activation independent of the direction of behavior (approach or withdrawal) and the right anterior region to goal conflict-induced behavioral inhibition-are rare and inconclusive. Therefore, the authors measured the EEG in a sample of 93 young men during emotional imagery designed to provide a critical test between the 2 models. The results (e.g., a correlation between left anterior activation and withdrawal motivation) favor the alternative model on the basis of the concepts of behavioral activation and behavioral inhibition. In addition, the present study also supports an association of right parietal activation with physiological arousal and the conceptualization of parietal EEG asymmetry as a mediator of emotion-related physiological arousal.

Alterations in autonomic tone during trauma exposure using eye movement desensitization and reprocessing (EMDR)--results of a preliminary investigation.

EMDR combines stimuli that evoke divided attention--e.g. eye movements--with exposure to traumatic memories. Our objective was to investigate psycho-physiological correlates of EMDR during treatment sessions. A total of 55 treatment sessions from 10 patients with PTSD was monitored applying impedance cardiography. Onset of every stimulation/exposure period (n=811) was marked and effects within and across stimulation sets on heart rate (HR), heart rate variability (HRV), pre-ejection period (PEP) and respiration rate were examined. At stimulation onsets a sharp increase of HRV and a significant decrease of HR was noticed indicating de-arousal. During ongoing stimulation, PEP and HRV decreased significantly while respiration rate significantly increased, indicating stress-related arousal. However, across entire sessions a significant decrease of psycho-physiological activity was noticed, evidenced by progressively decreasing HR and increasing HRV. These findings suggest that EMDR is associated with patterns of autonomic activity associated with substantial psycho-physiological de-arousal over time.

Collaboration among general cardiologists, heart failure specialists, and electrophysiologists: what are the barriers?

Although ongoing research has focused on the reliability and accuracy of data derived from implanted devices, important challenges remain, among which is the development of a framework for handling the data, including delineation of responsibility for interpretation and management of the data. The barriers to a successful device-monitoring program include difficulties in data access, unfamiliarity with a new treatment approach, lack of sufficient knowledge and experience in data interpretation, and difficulty incorporating the program into the existing workflow. The dynamics of collaboration between heart failure and electrophysiology (EP) specialists may differ locally and regionally, but a common set of barriers resulting from traditional models of care constrains incorporation of device-based data into clinical practice. Active dialogue between EP and heart failure specialists that involves the sharing of experiences and practice models is an important first step to overcoming these barriers. In the future, a "virtual clinic" model of patient care can only be realized with the successful incorporation of remotely accessed device data.

[Individual heart functioning variability under exposure to equal physical factors in patients with different vegetative system tone].

The article describes changes in heart rhythm variability (HRV) as a response to equal complex physical factors (hyperthermia of 60 degrees C with low relative humidity of 8 to 15%, air ionization, thalasso, and relaxing music). The subjects of the study were 28 individuals having no verified chronic diseases, who underwent a course of five recovery procedures using exposure to a complex of weak physical factors realized in Ionic House technology (Japan). The study found that changes in heart functioning as a response to equal physical factors depended on the initial vegetative system tone. Patients with normotonic and sympathicotonic heart regulation displayed the activation of parasympathetic vegetative nervous system as a result of a single exposure to a complex of physical factors, whereas in vagotonic patients sympathetic heart regulation was activated under the same conditions.