Device-based therapies for arterial hypertension.

Arterial hypertension is the most prevalent modifiable risk factor associated with cardiovascular morbidity and mortality. Although antihypertensive drugs are widely available, in many patients blood pressure control to guideline-recommended target values is not achieved. Several device-based approaches have been introduced to lower blood pressure; most of these strategies aim to modulate autonomic nervous system activity. Clinical trials have moved from including patients with resistant hypertension receiving intensive pharmacological treatment to including patients with mild-to-moderate hypertension in the presence or absence of antihypertensive medications. Renal sympathetic denervation is the most extensively investigated device-based therapy for hypertension, and randomized, sham-controlled trials have provided proof-of-principle data for its blood pressure-lowering efficacy. Unilateral electrical baroreflex activation, endovascular baroreflex amplification and pacemaker-mediated cardiac neuromodulation therapy have yielded promising results in observational trials, which need to be confirmed in larger, adequately powered, sham-controlled trials. Until further evidence becomes available, device-based therapy for hypertension should not be considered for routine treatment. However, when considering a device-based treatment for hypertension, the underlying pathophysiology in each patient has to be taken into consideration, and the procedural risks weighed against the cardiovascular risk attributable to the elevated blood pressure. This Review summarizes the pathophysiological rationale and the latest clinical evidence for device-based therapies for hypertension.

Hyperbaric Oxygen Therapy Improves Glucose Homeostasis in Type 2 Diabetes Patients: A Likely Involvement of the Carotid Bodies.

The carotid bodies (CBs) are peripheral chemoreceptors that respond to hypoxia increasing minute ventilation and activating the sympathetic nervous system. Besides its role in ventilation we recently described that CB regulate peripheral insulin sensitivity. Knowing that the CB is functionally blocked by hyperoxia and that hyperbaric oxygen therapy (HBOT) improves fasting blood glucose in diabetes patients, we have investigated the effect of HBOT on glucose tolerance in type 2 diabetes patients. Volunteers with indication for HBOT were recruited at the Subaquatic and Hyperbaric Medicine Center of Portuguese Navy and divided into two groups: type 2 diabetes patients and controls. Groups were submitted to 20 sessions of HBOT. OGTT were done before the first and after the last HBOT session. Sixteen diabetic patients and 16 control individual were included. Fasting glycemia was143.5 ± 12.62 mg/dl in diabetic patients and 92.06 ± 2.99 mg/dl in controls. In diabetic patients glycemia post-OGTT was 280.25 ± 22.29 mg/dl before the first HBOT session. After 20 sessions, fasting and 2 h post-OGTT glycemia decreased significantly. In control group HBOT did not modify fasting glycemia and post-OGTT glycemia. Our results showed that HBOT ameliorates glucose tolerance in diabetic patients and suggest that HBOT could be used as a therapeutic intervention for type 2 diabetes.

Cost-effectiveness of treating resistant hypertension with an implantable carotid body stimulator.

The purposes of this study are to investigate the cost-effectiveness of an implantable carotid body stimulator (Rheos; CVRx, Inc, Minneapolis, MN) for treating resistant hypertension and determine the range of starting systolic blood pressure (SBP) values where the device remains cost-effective. A Markov model compared a 20-mm Hg drop in SBP from an initial level of 180 mm Hg with Rheos to failed medical management in a hypothetical 50-year-old cohort. Direct costs (2007$), utilities, and event rates for future myocardial infarction, stroke, heart failure, and end-stage renal disease were modeled. Sensitivity analyses tested the assumptions in the model. The incremental cost-effectiveness ratio (ICER) for Rheos was $64,400 per quality-adjusted life-years (QALYs) using Framingham-derived event probabilities. The ICER was <$100,000 per QALYs for SBPs > or =142 mm Hg. A probability of device removal of <1% per year or SBP reductions of > or =24 mm Hg were variables that decreased the ICER below $50,000 per QALY. For cohort characteristics similar to Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure-Lowering Arm (ASCOT-BPLA) participants, the ICER became $26,700 per QALY. Two-way sensitivity analyses demonstrated that lowering SBP 12 mm Hg from 220 mm Hg or 21 mm Hg from 140 mm Hg were required. Rheos may be cost-effective, with an ICER between $50,000 and $100,000 per QALYs. Cohort characteristics and efficacy are key to the cost-effectiveness of new therapies for resistant hypertension .

Acute oxygen sensing in cellular models: relevance to the physiology of pulmonary neuroepithelial and carotid bodies.

The combination of studies in native tissues and immortalised model systems during the last decade has made possible a deeper understanding of the physiology and functional morphology of arterial and airway oxygen sensors. Complementary and overlapping information from these earlier studies has allowed a detailed description of the cellular events that link decreased environmental oxygen to the release of physiologically important vasoactive transmitters. Since these basic pathways have now been defined functionally, what remains to be determined is the molecular identity of the specific proteins involved in the signal transduction pathways, and how these proteins interact to produce a full physiological response. With these goals clearly in sight, we have embarked upon a strategy that is a novel combination of proteomics and functional genomics. It is hoped this strategy will enable us to develop and refine the initial models in order to understand more completely the process of oxygen sensing in health and disease.

The effect of chemoreceptor stimulation on the centripetal transfer of somatosensory information in the urethane-anaesthetized rat.

In urethane-anaesthetized rats, stimulation of carotid body chemoreceptors desynchronizes the cortical electroencephalogram and increases the sensitivity of thalamic and cortical somatosensory neurones to peripheral sensory nerve stimulation. Peripheral chemoreceptors were stimulated by injecting a bolus (30 ml) or infusing 100 ml of 0.18 M NaCl solution equilibrated with 100% CO2 into an internal carotid artery, the cortical electroencephalogram and ventilation were monitored routinely. This stimulus induced hyperventilation and desynchronization of the cortical electroencephalogram. Anaesthetized rats also showed spontaneous periodic increases in ventilation rate accompanied by changes of the cortical electroencephalogram from high-voltage low frequency to low-voltage high frequency which seemed to be identical with those evoked by stimulating chemoreceptors. The activity of identified somatosensory neurons in the thalamic ventrobasal complex, layer IV of the somatosensory cortex, or the cuneate nucleus was recorded extracellularly during and following chemoreceptor activation. Neurones in the ventrobasal thalamus and somatosensory cortex showed a decrease in latency and an increase in probability of discharge to supramaximal electrical stimulation of the forepaw which was more pronounced following infusion stimulation of the carotid body than following bolus stimulation. In contrast, neurons within the cuneate nucleus showed a slight increase in latency to onset and a decrease in the probability of firing following the same stimulus. The results indicate that stimulation of the carotid body chemoreceptors leads to an enhancement of the response of somatosensory neurons to their normal physiological input.

Nitric oxide synthase isoforms and peripheral chemoreceptor stimulation in conscious rats.

To test the effect of nitric oxide synthase (NOS) blockade on the ventilatory responses to carotid body chemoreceptor stimulation in freely behaving animals, chronically instrumented adult Sprague-Dawley rats received increasing intravenous doses of sodium cyanide (NaCN; 0-300 micrograms kg-1) before and after i.v. administration of either 100 mg kg-1 N-nitro-L-arginine methyl ester (L-NAME), a non-specific NOS blocker, or 10 mg kg-1 S-methyl-L-thiocitrulline (SMTC), a selective neuronal NOS inhibitor. SMTC did not modify the NaCN dose-response curve. In contrast, L-NAME significantly enhanced the ventilatory responses to NaCN. Western blots of equivalent amounts of protein from carotid body tissue homogenates revealed higher levels of endothelial NOS than of neuronal NOS. We conclude that endothelial NOS provides the major source for NO within the carotid body, and exerts a down-regulatory effect upon peripheral chemoreceptor responsivity.

Recovery of the hypoxic ventilatory drive of rats from the toxic effect of hyperbaric oxygen.

Hyperbaric oxygen (HBO) exposure reduces the hypoxic ventilatory drive (HVD), probably by damaging the carotid bodies. The recovery of the HVD from HBO exposure was studied. The HVD was calculated from whole body plethysmographic recordings of the ventilatory response to greater than 85% and 2% O2 in N2 mixtures. Five groups of rats were exposed to HBO for 9 h at pressures of 1.9, 2.0, 2.1, 2.2, and 2.4 ATA, respectively. Each rat underwent three control measurements on different days prior to HBO exposures and then at various intervals following the exposure. Postexposure HVD was reduced to 28% of control values in the high PO2s. Ninety percent recovery of pre-exposure HVD was evident by 12-48 h although in some animals exposed to relatively low PO2s (1.9 and 2.0 ATA) HVD stabilized at a level lower than 100%. The recovery of the HVD in percent during the first 4 d following exposure can be expressed as an exponential function of the time from the termination of HBO: HVD = 28 + 72(1 - exp-0.053t) (t in hours). This information may be of importance in cases of repeated exposures to HBO where one tries to avoid cumulative damage to the carotid bodies, and in the care of the poorly oxygenated patient after HBO treatment.

A ventromedullary relay involved in the hypothalamic and chemoreceptor activation of sympathetic postganglionic neurones to skeletal muscle, kidney and splanchnic area.

Bilateral application of glycine to the ventral surface of the medulla produces a profound hypotension during which sympathetic vasoconstrictor activity to splanchnic, renal and skeletal muscle vascular beds is reduced. The pattern of activation of sympathetic vasoconstrictor fibres to kidney and skeletal muscle, during carotid chemoreceptor activation and hypothalamic stimulation, is attenuated as tonic sympathetic activity diminishes. Functioning ventromedullary neurones are thus necessary for maintaining tonic sympathetic nerve activity, and for reflex and brain evoked patterns of sympathetic nerve activity, in the anaesthetized cat.

The afferent pathway for carotid body chemoreceptor input to the hypothalamic supraoptic nucleus in the rat.

The pathway for chemoreceptor input to hypothalamic supraoptic nuclei has been examined in anaesthetised lactating and non-lactating rats. In lactating rats, the increase in intramammary pressure following bilateral carotid occlusion, which is probably mainly due to vasopressin, was abolished by lesions in the septum, but not by lesions in more caudal regions of the hypothalamus. In non-lactating rats, electrophysiological experiments demonstrated that the input from carotid body chemoreceptors to phasically-discharging supraoptic neurones is ipsilateral only. The effects of chemoreceptor stimulation on the neurones can be mimicked by electrical stimulation within the medial preoptic area and anterior hypothalamus in a region medial and rostral to the supraoptic nuclei. Lesions within this region abolish the chemoreceptor input to the supraoptic nuclei, but leave the baroreceptor input intact. It is proposed that chemoreceptor afferents to the supraoptic nuclei pass in the lateral hypothalamus to the region of the septum where they turn medially and descent through the medial part of the rostral hypothalamus. The results are discussed in terms of the general role of the chemoreceptor reflex and, more specifically, with respect to the possible significance of vasopressin in the control of arterial blood pressure.

The sympathetic superior cervical ganglia as peripheral neuroendocrine centers.

The superior cervical ganglia (SCG) provide sympathetic innervation to the pineal gland, cephalic blood vessels, the choroid plexus, the eye, carotid body and the salivary and thyroid glands. Removal of the ganglia brings about several neuroendocrine changes in mammals, including the disruption of water balance in pituitary stalk-sectioned rats, and the alteration of normal photoperiodic control of reproduction in hamsters, ferrets, voles, rams and goats. These effects are commonly attributed to pineal denervation. However pinealectomy does not always mimic ganglionectomy in its neuroendocrine sequelae. This paper discusses several examples illustrating the lack of homology of ganglia and pineal removal, including the prolactin release brought about by gonadal steroids in spayed rats, the changes in drinking behaviour caused by ganglionectomy and the control of goitrogenic response to methylmercaptoimidazole in rats. All these examples indicate that SCG removal, at least as far as for neuroendocrinologists and pineal experimenters are concerned, should not be considered simply as "pineal denervation". A functionally relevant link between SCG and the hypothalamus may occur in rats inasmuch as ganglionectomy depresses norepinephrine uptake and increases the number and responses of alpha-adrenoceptors in medial basal hypothalamus. Lastly the SCG are active points of concurrency for hormone signals, as revealed by the metabolic changes induced by steroid and anterior pituitary hormones in these structures even in the absence of intact preganglionic connections, as well as by the existence of putative receptors for some of the hormones, namely, estradiol, testosterone and corticosteroids. The SCG appear to constitute a peripheral neuroendocrine center.

Influence of carotid and aortic baroreceptors on neurosecretory neurons in supraoptic nuclei.

(1) The effects of arterial baroreceptor stimulation on the activity of 'identified' neurosecretory cells in supraoptic nuclei (SON) of the hypothalamus were investigated in anesthetized cats. (2) Stimulation of baroreceptors by distension of an 'isolated' carotid sinus greatly inhibited SON activity. A linear relationship was found to exist between stimulus intensity (an increase in the sinus pressure) and the degree of inhibition of SON neuron activity. This inhibitory effect was abolished by section of the sinus nerve. (3) The inhibitory effect of baroreceptors on SON neuron activity was most pronounced in the first 5 sec during stimulation, and the effect became less when the stimulus lasted for a long period. At the end of stimulation there was a transient reversal of the response. (4) The excitation of aortic baroreceptors by occluding descending aorta strongly inhibited SON neuron activity. (5) Occlusion of carotid arteries augmented the SON neuron activity. Electrical stimulation of the sinus nerve caused an excitation or an inhibition of SON neurons, depending on the stimulus intensities. Apparently these stimuli produced different degrees of excitation in baro- and chemoreceptors. (6) Combination of chemo- and baroreceptor stimulations revealed that the excitatory effect exerted by chemoreceptor stimulation on SON neurons was reversed or blocked by baroreceptor activation, indicating the powerful inhibitory influence of baroreceptors.

Effects of chemoreceptor and baroreceptor stimulation on the discharge of hypothalamic supraoptic neurones in rats.

Experiments have been performed to examine the effects of activating the carotid body chemoreceptors and the arterial baroreceptors on the discharge of neurones within the hypothalamic supraoptic nucleus of the rat. Chemoreceptors were activated by intracarotid injection of 0.9% NaCl solution equilibrated with 100% CO2. The baroreceptors of the carotid sinus and aortic arch were activated by raising the blood pressure with an intravenous injection of phenylephrine. Chemoreceptor stimulation activated and baroreceptor stimulation inhibited the discharge of all the phasically discharging neurones tested. Neither stimulus had any consistent effect on non-phasically discharging neurones, although slight inhibition occasionally occurred. Anaesthesia of the carotid bifurcation abolished the effects of cardiovascular stimulation on the supraoptic neurones. Responses resumed when the anaesthesia wore off. However, the anaesthesia also seemed to alter the phasic pattern of discharge. The results are discussed with reference to the influence of the cardiovascular receptors upon the neurones in the supraoptic nucleus, and with reference to possible roles for the cardiovascular reflexes in control of vasopressin secretion.