The fundamental basis of palpitations: a neurocardiology approach

Background and Objective: Palpitations are a common symptom that may indicate cardiac arrhythmias, be a somatic complaint in anxiety disorders, and can be present in patients without either condition. The objective of this review was to explore the pathways and fundamental mechanisms through which individuals appreciate palpitations. Observations: Cardiac afferents provide beat-to-beat sensory information on the heart to the spinal cord, brain stem, and higher brain centers. Cardioception, a subset of interoception (‘the physiological sense of the condition of the body’), refers to sensing of the heartbeat. High cardioception is present in persons with lower body mass index, lower percentages of body fat, and anxiety disorders. Low cardioception (lower interoceptive awareness) is associated with psychiatric disorders, such as depression, personality disorders, and schizophrenia. CNS sites associated with heartbeat detection have been identified by functional magnetic resonance imaging studies and heartbeat-evoked electroencephalogram potentials. The right insula, cingulate gyrus, somatomotor and somatosensory cortices nucleus accumbens, left subthalamic nucleus, and left ventral capsule/striatum are implicated in both palpitations and heartbeat detection. Involvement of the brain as a primary modulator of palpitations rests on the data that various areas of the brain are activated in association with cardioception, the ability of focal brain stimulation to induce palpitations, the ability of central alpha receptor agonists and antagonists to modulate palpitations, and suppression of palpitations by transcranial repetitive magnetic stimulation (rTMS). Conclusions: Palpitations should be viewed as a pathway extending from the heart to the brain. Palpitations are, in part, a reflection of an individual’s cardioception awareness, which is modulated by body size, percentage of body fat, and psychological or psychiatric conditions. Palpitations can originate in the brain and involve central neurotransmitters. Treatment of palpitations unrelated to cardiac arrhythmias or anxiety disorders should consider the use of central alpha-2 agonists and possibly rTMS.

How Abnormal Sympatho-Activation Can Potentially Develop Heart Failure: A Mini Review

Cardiac sympathetic afferent that signal the sensation of cardiac pain, ostensibly, has more underlying mechanisms than what scientists have ever been led to believe. Cardiac sympathetic afferent reflex, also known as (CSAR), has been shown to be responsive to a variety of stimuli. Many of which scientists observed in increased levels during ischemia hydrogen ion, oxygen radicals, potassium, lactate, ATP, prostaglandins bradykinin, substance p and, finally and most importantly, endogenous substances (neurohormones) such as norepinephrine (NE). In the outset of chronic heart failure (HF), it has been known for a long time, that there are abnormalities in arterial baroreceptor input which depress its sensitivity, and arterial chemoreceptors seem augmented. Therefore, they tend to not only initiate sympathetic outflow but also to sensitise cardiac afferents which are appearing to do the same thing where there are abnormalities in vagus mechano-reflexes as well. Some of these receptors are in the spinal reticulate tract and interestingly these a third pathways give off neurons to the brainstem some in the hypothalamus and trance translate through the thalamus and then ultimately up into the cortex where we have sensation of pain. Here in this essay, we aim to discuss important aspects of cardiac failure in relation to abnormal sympatho-activators through evaluation of different available studies and animal models.

Abstract P311: Cardiac Sympathetic Afferents Does Not Initiate but Contributes to the Further Development of Hypertension in Spontaneous Hypertensive Rats

Sympatho-excitation plays a critical role in the pathogenesis of hypertension. However, it is unclear what factors initiate and maintain sympatho-excitation in hypertension. Our past studies have confirmed a critical role of cardiac sensory nerve endings that mediate a sympatho-excitatory reflex called the “cardiac sympathetic afferent reflex” (CSAR) in the setting of heart failure. However, whether/when the CSAR is activated and contributes to the development of hypertension remains unclear. To address this issue, we chronically abolished the CSAR by epidural application of a selective afferent neurotoxin, resiniferatoxin (RTX) at the level of the T1-T4 dorsal root ganglia (DRGs) by destroying TRPV1-expressing neuronal soma in 8-week and 16-w old spontaneous hypertensive rats (SHR). Conscious blood pressure was monitored before (baseline) and during 2 months post RTX using radio telemetry. As shown in Figure 1A, in early-hypertensive (8-w old) SHR rats, there was no difference in mean arterial pressure (MAP) between vehicle and RTX groups until 3 weeks post intervention. At that time, MAP in vehicle-treated SHR rats continued to increase whereas this increase was largely abolished in the RTX-treated group. In the established (16-w old) SHR rats (Figure 1B), treatment with RTX immediately reduced MAP by ~15 mmHg, which was maintained for the 2-month recording period. These data strongly suggest that although CSAR does not initiate hypertension at the early stage in SHR, it contributes to the further development of hypertension in the mid/late stages. These data support a potential novel therapy possibly involving cardiac afferents.

Abstract P220: Congestive Heart Failure in the Rat Induces Subtle Renal Damage via Neurogenic Pathways

Background: Cardiomyopathy in experimental renal insufficiency is putatively influenced by neurogenic pathways of renal origin. We wondered if cardiac neurogenic effects in congestive heart failure could likewise harm the kidney. We hypothesized that increased renal sympathetic nerve activity (RSNA) in rats with congestive heart failure after myocardial infarction (CHF) induces renal structural damage. Methods: 21 day after induction of CHF renal morphology was evaluated by immunohistology (interstitial and glomerular mononuclear cell infiltration (ED1), cell proliferation (PCNA), collagen I,III,IV,V,VI, laminin und fibronectin). RSNA was assessed by volume challenge (VE) to decrease RSNA. CHF and control rats were investigated with and without renal denervation (DNX). Blood pressure (BP), heart rate (HR) and RSNA were recorded. Nodose ganglion neurons (NGN) with vagal cardiac afferents were cultured for 1 day. Whole cell recordings were obtained and current-voltage relationships established. Cells were characterized by osmomechanical stress with a mannitol solution. Results: In CHF rats with intact renal nerves (nonDNX) formation of collagen I occurred, that was reduced after DNX (12.2+0.7 %area vs. 9.1+1.1 %area*, n=6, * p<0.05). VE-induced RSNA decreases were impaired in CHF vs controls suggesting increased RSNA (-α 34+8% vs. -α[[Unable to Display Character: &#61472;]]54+6% *, n=6, * p<0.05). NGN from CHF exhibited altered conductance in response to mechanical stress as compared to controls (change in holding current at -80 mV: control_normoosmotic: -144±30 pA; control_hypoos.: -282±34 pA vs CHF_normosmotic: - 230±55 pA; CHF_hypos.: -540±100* pA; *p<0.05 CHF vs. control). Conclusion: CHF induced subtle renal structural damage due to increased renal sympathetic tone which was likely due to altered NGN mechanosensitivity. Afferent nerve units from cardiovascular organs obviously form a complex sympathomodulatory network.

Functional role of peripheral opioid receptors in the regulation of cardiac spinal afferent nerve activity during myocardial ischemia

Thinly myelinated Aδ-fiber and unmyelinated C-fiber cardiac sympathetic (spinal) sensory nerve fibers are activated during myocardial ischemia to transmit the sensation of angina pectoris. Although recent observations showed that myocardial ischemia increases the concentrations of opioid peptides and that the stimulation of peripheral opioid receptors inhibits chemically induced visceral and somatic nociception, the role of opioids in cardiac spinal afferent signaling during myocardial ischemia has not been studied. The present study tested the hypothesis that peripheral opioid receptors modulate cardiac spinal afferent nerve activity during myocardial ischemia by suppressing the responses of cardiac afferent nerve to ischemic mediators like bradykinin and extracellular ATP. The nerve activity of single unit cardiac afferents was recorded from the left sympathetic chain (T2–T5) in anesthetized cats. Forty-three ischemically sensitive afferent nerves (conduction velocity: 0.32–3.90 m/s) with receptive fields in the left and right ventricles were identified. The responses of these afferent nerves to repeat ischemia or ischemic mediators were further studied in the following protocols. First, epicardial administration of naloxone (8 μmol), a nonselective opioid receptor antagonist, enhanced the responses of eight cardiac afferent nerves to recurrent myocardial ischemia by 62%, whereas epicardial application of vehicle (PBS) did not alter the responses of seven other cardiac afferent nerves to ischemia. Second, naloxone applied to the epicardial surface facilitated the responses of seven cardiac afferent nerves to epicardial ATP by 76%. Third, administration of naloxone enhanced the responses of seven other afferent nerves to bradykinin by 85%. In contrast, in the absence of naloxone, cardiac afferent nerves consistently responded to repeated application of ATP ( n = 7) or bradykinin ( n = 7). These data suggest that peripheral opioid peptides suppress the responses of cardiac sympathetic afferent nerves to myocardial ischemia and ischemic mediators like ATP and bradykinin.

Involvement of enhanced cardiac sympathetic afferent reflex in sympathetic activation in early stage of diabetes

Cardiac sympathetic afferent reflex (CSAR) is involved in sympathetic activation. The present study was designed to investigate the contribution of enhanced CSAR to sympathetic activation in the early stage of diabetes and the involvement of AT1 receptors in the paraventricular nucleus (PVN). Diabetes was induced by a single intravenous injection of streptozotocin in rats. Acute experiments were carried out under anesthesia after 3 wk. The CSAR was evaluated by the responses of renal sympathetic nerve activity (RSNA) and mean arterial pressure (MAP) to epicardial application of capsaicin or bradykinin. Sympathetic activity and CSAR were enhanced in diabetic rats. Plasma norepinephrine and angiotensin II were increased, but the transient receptor potential vanilloid 1 (TRPV1) in the left ventricle wall was not significantly increased in diabetic rats. Pericardial injection of resiniferatoxin to desensitize cardiac afferents or PVN microinjection of lidocaine attenuated the CSAR and decreased the RSNA and MAP in diabetic rats. The AT1 receptor expression in the PVN increased in diabetic rats. Angiotensin II in the PVN caused greater increases in the RSNA and MAP and enhancement in the CSAR in diabetic rats, which were abolished by the losartan pretreatment. Losartan decreased the RSNA and MAP and attenuated the CSAR in diabetic rats but not in control rats. These results indicate that the CSAR is enhanced in the early stage of diabetic rats, which contributes to the sympathetic activation. AT1 receptors in the PVN are involved in the enhanced CSAR in diabetic rats.

A new function for ATP: activating cardiac sympathetic afferents during myocardial ischemia

Myocardial ischemia activates cardiac sympathetic afferents leading to chest pain and reflex cardiovascular responses. Brief myocardial ischemia leads to ATP release in the interstitial space. Furthermore, exogenous ATP and α,β-methylene ATP (α,β-meATP), a P2X receptor agonist, stimulate cutaneous group III and IV sensory nerve fibers. The present study tested the hypothesis that endogenous ATP excites cardiac afferents during ischemia through activation of P2 receptors. Nerve activity of single unit cardiac sympathetic afferents was recorded from the left sympathetic chain or rami communicates (T2-T5) in anesthetized cats. Single fields of 45 afferents (conduction velocities = 0.25–4.92 m/s) were identified in the left ventricle with a stimulating electrode. Five minutes of myocardial ischemia stimulated 39 of 45 cardiac afferents (8 Aδ, 37 C fibers). Epicardial application of ATP (1–4 μmol) stimulated six ischemically sensitive cardiac afferents in a dose-dependent manner. Additionally, epicardial ATP (2 μmol), ADP (2 μmol), a P2Y agonist, and α,β-meATP (0.5 μmol) significantly activated eight other ischemically sensitive afferents. Third, pyridoxal phosphate-6-azophenyl-2′,4′-disulfonic acid, a P2 receptor antagonist, abolished the responses of six afferents to epicardial ATP (2 μmol) and attenuated the ischemia-related increase in activity of seven other afferents by 37%. In the absence of P2 receptor blockade, cardiac afferents responded consistently to repeated application of ATP ( n = 6) and to recurrent myocardial ischemia ( n = 6). Finally, six ischemia-insensitive cardiac spinal afferents did not respond to epicardial ATP (2–4 μmol), although these afferents did respond to epicardial bradykinin. Taken together, these data indicate that, during ischemia, endogenously released ATP activates ischemia-sensitive, but not ischemia-insensitive, cardiac spinal afferents through stimulation of P2 receptors likely located on the cardiac sensory neurites.

Bradykinin and thromboxane A2 reciprocally interact to synergistically stimulate cardiac spinal afferents during myocardial ischemia

Myocardial ischemia is a complex process leading to the simultaneous release of a number of mediators, including thromboxane A2 (TxA2) and bradykinin (BK), that activate cardiac spinal afferents. The present study tested the hypothesis that TxA2 and BK reciprocally interact to excite ischemically sensitive cardiac afferents. Nerve activity of single cardiac afferent units was recorded from the left sympathetic chain or rami communicantes (T2–T5) of anesthetized cats. Fifty-two ischemically sensitive afferents (conduction velocity = 0.27–3.35 m/s, 7 Aδ-fibers and 45 C-fibers) were identified. Repeated injections (1 μg) of BK into the left atrium (LA) 4 min after the administration of U-46619 (5 μg into the LA), a TxA2 mimetic, induced a significantly larger cardiac afferent response than the first response to BK (0.61 ± 0.14 to 1.95 ± 0.29 vs. 0.66 ± 0.09 to 2.75 ± 0.34 impulses/s, first injection vs. second injection, n = 8). Conversely, blockade of TxA2 receptors with BM-13,177 (30 mg/kg iv) attenuated the responses of eight other afferents to BK (1 μg into the LA) by 45%. In contrast, repeated BK (1 μg into the LA) induced consistent discharge activity in six separate afferents. We then observed that the coadministration of U-46619 (5 μg) and BK (1 μg into the LA) together caused a total response that was significantly higher than the predicted response by the simple addition of the individual responses. BK (1 μg) facilitated eight cardiac afferent responses to U-46619 (5 μg into the LA) by 64%. In contrast, repeated U-46619 (5 μg into the LA) without intervening BK stimulation evoked consistent responses in seven other ischemically sensitive afferents. Finally, inhibition of cyclooxygenase with indomethacin (5 mg/kg iv) eliminated the potentiating effects of BK on the cardiac afferent response to U-46619 (5 μg into the LA) but did not alter the afferent response to U-46619. These data suggest that BK and TxA2 reciprocally interact to stimulate ischemically sensitive cardiac afferent endings leading to synergistic afferent responses and that the BK sensitization effect is mediated by cyclooxygenase products.