Impaired cardiovascular autonomic response to passive tilting in cirrhosis with ascites

Abstract

The autonomic regulation of cardiovascular function was evaluated in 15 cirrhotic patients with ascites and in 13 healthy subjects by the autoregressive power spectral analysis (PSA) of the intervals between adjacent R waves of the electrocardiogram (RR) interval and arterial pressure variability. Total power, low frequency (LF; index of the sympathetic activity of the heart and circulation), and high frequency (HF; index of vagal tone to the heart) components of the RR interval, systolic, and diastolic arterial pressure were evaluated in the supine position and during passive tilting, together with plasma norepinephrine levels. In the supine position, no significant differences in the PSA data were observed between the control subjects and cirrhotic patients, who had higher plasma norepinephrine levels. In healthy subjects, tilting was associated with an increase in the LF of the RR interval and arterial pressure and a decrease in the HF of the RR interval. In contrast, patients with cirrhosis showed a decrease of both LF and HF. Consequently, the LF/HF ratio significantly increased in healthy subjects, whereas it was unchanged in cirrhotic patients. The LF component of the diastolic pressure also decreased during tilting in cirrhotic patients. Plasma norepinephrine increased after tilting in both groups. These results indicate that the autonomic response to passive tilting is impaired in cirrhotic patients with ascites at both the cardiac and vascular levels, as a result of an altered sympatho-vagal balance, with reduced sympathetic predominance. These alterations occurred despite an appropriate response to the tilting of plasma norepinephrine, pointing to a receptorial or postreceptorial site of the autonomic impairment.

Cardiovascular effects of canrenone in patients with preascitic cirrhosis

“…Cirrhotic patients have an impaired autonomic regulation of cardiovascular function, 32,33 which may explain the altered cardiac response to standing. Experimental data suggest that aldosterone influences the autonomic nervous system in animal models 34 and in man.…”

Autonomic dysfunction and hyperdynamic circulation in cirrhosis with ascites

“…2,16,18 Disparate events may contribute to the development of AD, including factors affecting nerve integrity, such as alterations in lipid metabolism, vitamin E deficiency, alcohol intake, immunologic mechanisms, and retention of toxic metabolites. 13,17 Moreover, vagal function may be inhibited by elevated angiotensin II production 37 and the sympathetic function may be impaired by a blunted end-organ responsiveness 9,12 owing to either a production of weak neurotransmitters 15 or a receptorial and postreceptorial defect. 12,38 In addition to these factors, vasodilating substances have to be taken into account.…”

“…4,6 The autonomic nervous system plays a central role in modulating cardiac performance and vasomotor activity. The presence of an autonomic dysfunction (AD) in cirrhosis has been clearly shown through different experimental approaches, including the evaluation of the cardiovascular and sudomotor responses to physiological and pharmacological stimulation, [7][8][9][10][11][12][13] and by showing a hyperproduction of weak adrenergic neurotransmitters. 14,15 It has also been reported that the severity of AD is proportional to the severity of cirrhosis, 9,10 and its presence is an indicator of poor prognosis in patients with both early and advanced liver disease.…”

Autonomic dysfunction in end-stage liver disease manifested as defecation syncope: Impact of orthotopic liver transplantation

“…9,10 Other parasympathetic test results (standing to lying, Valsalva ratio, and HR variation with deep breathing) have also been shown to be abnormal in these patients. 7 Test results of sympathetic function (passive tilting and isometric exercise) are also abnormal and again point to decreased end-organ responsiveness to NE.…”