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Circadian heart rate and blood pressure variability in autonomic failure.

Autonomic failure (AF) induces disabling orthostatic symptoms. Short-term heart rate (HR) and blood pressure (BP) orthostatic patterns are well characterized in these patients but data on long-term blood pressure and heart rate monitoring is lacking. The aim of this study was to assess circadian HR and BP variation in AF patients. We studied 8 patients with severe AF (7 with TTRmet30+ familial amyloidotic polyneuropathy and 1 with pure autonomic fairure)--Group A, and 2 control groups (8 asymptomatic TTRmet30+ patients--Group B, and 16 normal aged-matched controls--Group C). All groups underwent 24h HR and BP monitoring. Twenty-four-hour systolic (SBP) and diastolic BP (DBP) were similar in all groups (114.5+/-10.6 and 73.2+/-6.7; 123.0+/-6.2 and 79.0+/-9.5; 118.6+/-10.1 and 71.4+/-9.4 mmHg for groups A, B and C respectively). BP dipping was attenuated or even inverted (p < 0.01) in AF patients (SBP and DBP differences between day and night: -1.6+/-11.6 and 3.3+/-6.3; 10.0+/-1.0 and 11.7+/-1.5; 15.6+/-7.9 and 16.2+/-5.8 mmHg for groups A, B and C respectively; p < 0.01). Although mean 24h HR was similar between patients and controls (80.9+/-14.0, 87.0+/-4.6 and 80.7+/-5.2 bpm for groups A, B and C respectively), there were striking differences in heart rate variability between groups (max-min 24h HR difference: 46+/-16, 89+/-11 and 91+/-9 bpm; pNN50: 0+/-0, 6+/-2 and 12+/-6%; SDRR 68+/-24, 128+/-10 and 148+/-32 ms for groups A, BB and C; p < 0.01). There were significant differences between normal controls and asymptomatic TTRmet30+ controls in mean HR, diastolic blood pressure dipping and pNN50; p < 0.05. Autonomic failure can be suspected by simple 24h blood pressure evaluation and heart rate monitoring. Asymptomatic TTRmet30+ patients may already show some degree of autonomic impairment, particularly early vagal dysfunction.     

Acid and pepsin responses to graded doses of pentagastrin in duodenal and corporeal gastric ulcer patients before and after selective proximal vagotomy

The dose response curves for acid and pepsin output to increasing intravenous doses of pentagastrin (0.01, 0.02, 2, 8, and 16 micrograms/kg per hour) were determined in six male patients with duodenal ulcer and six with type 1 corporeal gastric ulcer before and 3 to 6 months after selective proximal vagotomy and excision of the gastric ulcer. The maximal secretory capacity (maximal response) of acid and pepsin was greater in the duodenal ulcer patients than in the corporeal gastric ulcer patients, but the sensitivity of the oxyntic and peptic cells to pentagastrin (the dose required for half the maximal response) was equal for the two ulcer groups. Selective proximal vagotomy reduced the acid response to insulin by 96 to 100 percent. The acid secretory capacity and the sensitivity of the oxyntic cells to pentagastrin was reduced by selective proximal vagotomy to the same extent in the duodenal ulcer patients and the corporeal gastric ulcer patients. Selective proximal vagotomy reduced the pepsin secretory capacity in the duodenal ulcer patients but did not reduce the already low capacity in the corporeal gastric ulcer patients. Selective proximal vagotomy decreased the sensitivity of the peptic cells in both ulcer groups. Similar results were obtained when the dose response curves were analyzed according to Michaelis-Menten kinetics. Our results justify clinical trials of selective proximal vagotomy with complete ulcer excision for treatment of type 1 corporeal gastric ulcer.