Abnormal Vascular Responses to Exercise in Patients with Aortic Stenosis

Mark, Allyn L.; Kioschos, J. Michael; Abboud, François M.; Heistad, Donald D.; Schmid, Phillip G.

doi:10.1172/jci107280

Cited by 127 publications

(37 citation statements)

References 16 publications

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“…This possibility is compatible with recent observations that reflex effects of lower body negative pressure are drastically reduced in cardiac transplantation patients, demonstrating their main dependence on receptors located in the heart. 26 -27 It is also compatible with previous observations that these effects are reduced in cardiac hypertrophies of a nonhypertensive nature 28 and with the present observation that the magnitude of the vascular and humoral responses to nonhypotensive and nontachycardic changes in central venous pressure was inversely related to left ventricular mass index. …”

Section: Mechanisms Of the Impairment Of The Cardiopulmonary Reflex Isupporting

confidence: 90%

Cardiopulmonary reflex before and after regression of left ventricular hypertrophy in essential hypertension.

et al. 1988

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SUMMARY Studies that have examined the cardiopulmonary receptor control of circulation in hypertension have produced conflicting results. In 10 normotensive subjects and in age-matched essential hypertensive subjects without (n = 10) or with left ventricular hypertrophy (n = 12), as well as in seven subjects of the latter group restudied after 1 year of treatment that induced regression of cardiac hypertrophy, we examined the cardiopulmonary reflex by increasing central venous pressure and stimulating cardiopulmonary receptors through passive leg raising and by reducing central venous pressure and deactivating cardiopulmonary receptors through nonhypotensive lower body negative pressure. Reflex responses were measured as changes in forearm vascular resistance (mean blood pressure divided by plethysmographically measured blood flow), plasma norepinephrine concentration, and plasma renin activity. In hypertensive subjects without left ventricular hypertrophy, stimulation and deactivation of cardiopulmonary receptors caused changes i n forearm vascular resistance, norepinephrine concentration, and plasma renin activity that were modestly reduced as compared with those in normotensive subjects. However, all these changes were markedly reduced i n hypertensive subjects with left ventricular hypertrophy. Following regression of left ventricular hypertrophy, the changes in vascular resistance, plasma norepinephrine, and plasma renin activity induced by cardiopulmonary receptor manipulation all unproved markedly. These results demonstrate that cardiopulmonary receptor regulation of peripheral vascular resistance and of neurohumoral variables is impaired in essential hypertension and that the impairment is much more pronounced when this condition is associated with cardiac structural alterations. Therapeutic regression of these alterations, however, leads to a marked improvement of this reflex, with consequent favorable effects on circulatory homeostasis. STUDIES performed in animals and humans have shown that reflex control of circulation depends not only on arterial baroreceptors but also, and to an important extent, on receptors located in the cardiopulmonary region. These receptors reduce sympathetic vasoconstrictor tone to skeletal muscle, splanchnic, and other regional circulations.'-3 Furthermore, they inhibit renin secretion from the kidney 1 -* -7 and, possibly, vasopressin

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Section: Mechanisms Of the Impairment Of The Cardiopulmonary Reflex Isupporting

confidence: 90%

Cardiopulmonary reflex before and after regression of left ventricular hypertrophy in essential hypertension.

et al. 1988

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“…[18][19][20][21] The relationship between an abnormal BP response during exercise and a family history of sudden death suggests that hemodynamic instability, most likely resulting from sympathetic dysfunction, plays a central role in sudden death in HCM.…”

Section: Discussionmentioning

confidence: 99%

Failure to Raise Blood Pressure During Exercise is a Poor Prognostic Sign in Patients With Hypertrophic Non-Obstructive Cardiomyopathy.

Isobe

Toyama

Taniguchi

et al. 2003

Circ J

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“…Older work has also suggested the possibility of a stretch-induced baroreceptor response that results in inappropriate peripheral vasodilation during states of extreme fiber stimulation and an increase in left ventricular wall stress. 15,16 With a decrease in cardiac output, coronary hypoperfusion may also be a component of this life-threatening complex. 15,16 Whether BNP has potential to predict this unusual event is uncertain.…”

Section: Article See P 69mentioning

confidence: 99%

“…15,16 With a decrease in cardiac output, coronary hypoperfusion may also be a component of this life-threatening complex. 15,16 Whether BNP has potential to predict this unusual event is uncertain.…”

Section: Article See P 69mentioning

confidence: 99%

Predicting Outcome in Patients With Asymptomatic Aortic Stenosis

Coglianese

Davidoff

2009

Circulation

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A lthough the annual risk of cardiovascular mortality has been well described for individuals with symptomatic aortic stenosis, the morbidity and mortality for those with asymptomatic severe aortic stenosis is not as well known. Currently the American Heart Association/American College of Cardiology recommends a "watchful waiting" strategy for those with asymptomatic aortic stenosis. 1 This involves clinical examinations every 6 to 12 months and annual echocardiograms; however, it is unclear what to do with these data in the patient who remains asymptomatic. The asymptomatic patient is generally not referred for aortic valve replacement surgery until the development of symptoms (unless concurrent coronary artery bypass grafting is required or if systolic dysfunction develops). Article see p 69Approximately 30% of asymptomatic patients will develop symptoms (angina, heart failure, syncope) within 2 years of diagnosis. 2,3 For those patients who do not develop symptoms, the risk of sudden cardiac death is less than 1% per year, assuming that patients are well monitored for the development of symptoms. 2,3 Although angina and syncope are relatively easy symptoms to elicit, manifestations of heart failure may be subtle. This is particularly true because many of these patients are elderly and attribute reduced exercise capacity to be part of the normal aging process or "slowing down." Vigilance and careful attention to a patient's history are important components of the regular evaluation of patients with aortic stenosis. However, even careful attention to the history may not predict sudden death in patients with severe aortic stenosis. The reluctance to perform surgery earlier than necessary is driven by the morbidity of cardiac surgery and a mortality rate for aortic valve surgery of approximately 3% to 5%, even in patients younger than 70 years. 4 Thus for truly asymptomatic patients, the risk of potential complications like sudden cardiac death and irreversible myocardial dysfunction must be weighed against the risk of surgery. Given the possibility of these outcomes before the development of overt symptoms, investigators have sought to find a reliable way in which to risk stratify patients with asymptomatic aortic stenosis into those who will derive benefit from surgery before symptom development and those who will not. A comprehensive objective approach that could facilitate decision making in such patients has long been sought but has been elusive.In this issue of Circulation, Monin et al 5 describe a scoring system for patients with asymptomatic severe aortic stenosis based on the premise that both the state of the valve and the ventricle must be considered when assessing risk in asymptomatic patients. The risk of valve-specific factors such as aortic valve area, aortic valve calcification, transvalvular gradients, and peak aortic velocity have been well described, but the prognostic value of each or a combination of anatomic and functional valve information has not been consistently predictive of outcome. 6 ...

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Abnormal Vascular Responses to Exercise in Patients with Aortic Stenosis

Cited by 127 publications

References 16 publications

Cardiopulmonary reflex before and after regression of left ventricular hypertrophy in essential hypertension.

Cardiopulmonary reflex before and after regression of left ventricular hypertrophy in essential hypertension.

Failure to Raise Blood Pressure During Exercise is a Poor Prognostic Sign in Patients With Hypertrophic Non-Obstructive Cardiomyopathy.

Predicting Outcome in Patients With Asymptomatic Aortic Stenosis

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