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Regulation of Blood Pressure
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As was indicated brie y in Chap 18, blood pressure depends on the adequacy of intravascular blood volume, on systemic vascular resistance, and on the cardiac output Both the autonomic and endocrine systems in uence the muscular, cutaneous, and mesenteric (splanchnic) vascular beds, pulse rate, and stroke volume of the
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DISORDERS OF THE AUTONOMIC NERVOUS SYSTEM, RESPIRATION, AND SWALLOWING 459
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tionality, no consistent autonomic or endocrine dysfunction has been demonstrated except perhaps for diminished responses of growth hormone in panic disorders This has been disappointing, since Cannon, with his emergency theory of sympathoadrenal action, had provided such a promising concept of the neurophysiology of acute emotion, and Selye had extended this theory so plausibly to explain all the reactions to stress in animals and humans According to these theories, strong emotion, such as anger or fear, excites the sympathetic nervous system and the adrenal cortex [via corticotropin releasing factor (CRF) and adrenocorticotropic hormone (ACTH)], which are under direct neural as well as endocrine control These sympathoadrenal reactions are brief and sustain the animal in ight or ght (pages 443 and 447) Animals deprived of adrenal cortex or human beings with Addison disease cannot tolerate stress because they are incapable of mobilizing both the adrenal medulla and adrenal cortex Prolonged stress and production of ACTH activates all the adrenal hormones, referred to collectively as steroids (glucocorticoids, mineralocorticoids, and adrenocorticoids) In animals, exercise, cold, oxygen lack, and surgical injury are all said to evoke the same sympathoadrenal reactions as anger or fear Selye s extension of Cannon s theory to his more comprehensive theory of stress, although attractive, has received little support Critics have pointed out that the conditions to which his experimental animals had been subjected are so different from human disease that conclusions as to the similarities of the two cannot be drawn More critical studies of the anatomy and physiology of the hypothalamus, hypophysis, adrenal glands, and autonomic nervous system are still needed to fully test these hypotheses
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Tests for Abnormalities of the Autonomic Nervous System
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With few exceptions, such as testing pupillary reactions and examination of the skin for abnormalities of color and sweating, the neurologist tends to be casual in evaluating the function of the autonomic nervous system Nonetheless, several simple but informative tests can be used to con rm one s clinical impressions and to elicit abnormalities of autonomic function that may aid in diagnosis A combination of tests is usually necessary, because certain ones are particularly sensitive to abnormalities of sympathetic function and others to parasympathetic or baroreceptor afferent function These are described below and are summarized in Table 26-1 A scheme for the examination of pupillary abnormalities has been presented in Fig 14-8 Responses of Blood Pressure and Heart Rate to Changes in Posture and Breathing These are among the simplest and most important tests of autonomic function and are currently automated in most laboratories McLeod and Tuck state that in changing from the recumbent to the standing position, a fall of more than 30 mmHg systolic and 15 mmHg diastolic is abnormal; others give gures of 20 and 10 mmHg They caution that the arm on which the cuff is placed must be held horizontally when standing, so that the decline in arm pressure will not be obscured by the added hydrostatic pressure The main cause of an orthostatic drop in blood pressure is hypovolemia In the context of recurrent fainting, however, an excessive drop re ects inadequate sympathetic vasoconstrictor activity The use of a tilt table, as described on page 330, is the most sensitive means of inducing orthostatic changes and also elicits
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these changes in patients prone to syncope from an oversensitive cardiac re ex, ie, one that produces vasodilation (so-called neurocardiogenic syncope), as discussed in Chap 18 In response to the induced drop in blood pressure, the pulse rate (under vagal control) normally increases The failure of the heart rate to rise in response to the drop in blood pressure with standing is the simplest bedside indicator of vagal nerve dysfunction In addition, the pulse, after rising initially in response to upright posture, slows after about 15 beats to reach a stable rate by the 30th beat The ratio of R R intervals in the electrocardiogram (ECG), corresponding to the 30th and 15th beats (the 30:15 ratio), is an even more sensitive measure of the integrity of vagal inhibition of the sinus node A ratio in nonelderly adults of less than 105 is usually abnormal, indicating a loss of vagal tone Another simple procedure for quantitating vagal function consists of measuring the variation in heart rate during deep breathing (respiratory sinus arrhythmia) The ECG is recorded while the patient breathes at a regular rate of 6 to 12 per minute Normally, the heart rate varies by as many as 15 beats per minute or even more between expiration and inspiration; differences of less than 10 beats per minute may be abnormal A yet more accurate test of vagal function is the measurement of the ratio of the longest R R interval during forceful slow expiration to the shortest R R interval during inspiration, which allows the derivation of an expiration-inspiration (E:I) ratio This is the best-validated of all the pulse-rate measurements, particularly since computerized methods can be used to display the spectrum of beat-to-beat ECG intervals during breathing Always, the results of these tests must be compared with those obtained in normal individuals of the same age Up to age 40, E:I ratios of less than 12 (signifying a variation of 20 percent) are abnormal The ratio decreases with age, and markedly so beyond age 60 (at which time it approaches 104 or less), as it does also in the presence of even mild diabetic neuropathy Thus the test results must be interpreted cautiously in the elderly or diabetic individual Computerized methods of power spectral analysis may be used to express the variance in heart rate as a function of the beat-to-beat interval Several power peaks are appreciated: one related to the respiratory sinus arrhythmia and others that re ect baroreceptor and cardiac sympathetic activity All of these tests of heart rate variation are usually combined with measurement of pulse and blood pressure during the Valsalva maneuver, as described below, and with the prolonged tilt table test, as described in Chap 18 In the Valsalva maneuver, the subject exhales into a manometer or against a closed glottis for 10 to 15 s, creating a markedly positive intrathoracic pressure The sharp reduction in venous return to the heart causes a drop in cardiac output and in blood pressure; the response on baroreceptors is to cause a re ex tachycardia and, to a lesser extent, peripheral vasoconstriction With release of intrathoracic pressure, the venous return, stroke volume, and blood pressure rise to higher than normal levels; re ex parasympathetic in uence then predominates and a bradycardia results Failure of the heart rate to increase during the positive intrathoracic pressure phase of the Valsalva maneuver points to sympathetic dysfunction, and failure of the rate to slow during the period of blood pressure overshoot points to a parasympathetic disturbance In patients with autonomic failure, the fall in blood pressure is not aborted during the last few seconds of increased intrathoracic pressure, and there is no overshoot of blood pressure when the breath is released Tests of Vasomotor Reactions Measurement of the skin temperature is a useful index of vasomotor function Vasomotor pa-
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