Fadel, Paul J.

Heart rate variability (HRV) is a widely utilized approach for investigating cardiovascular health and human performance. Methodological approaches, analyses, and interpretations of HRV can vary extensively, and scientific debates on HRV reliability and utility remain. These debates have been amplified in recent years by the rapid growth and ubiquity of wearable devices, and their incorporation into scientific research studies. The present guidelines paper takes an evidence-based approach to propose more consistent and rigorous measurement and interpretation of HRV within human cardiovascular research and application. First, HRV has some utility as a cardiovascular risk stratification tool, but is not appropriate to employ as a specific marker of cardiac sympathetic outflow or sympathovagal balance. While time-domain and spectral analysis can more accurately reflect respiratory modulation of cardiac vagal (parasympathetic) activity, caution is necessary to avoid overinterpretation, particularly with respect to the concept of “vagal tone”. Numerous experimental, demographic, and environmental factors influence HRV assessment, interpretation, and reliability. Specifically, it is critical to account for non-modifiable (age, sex, race/ethnicity, etc.) and modifiable (i.e., exercise, physical fitness, etc.) factors within participant samples. Furthermore, technical approaches such as the HRV input signal (e.g., electrocardiography vs. photoplethysmography), length of recording, location of recordings (i.e., laboratory vs. field), respiratory rate and depth, and analytical approaches (i.e., time vs. frequency domain) can all impact rigor, reliability, and study interpretations. Finally, with respect to the rapid advancements of HRV assessment using wearable technology, investigators should interpret and contextualize findings within the limitations outlined in this guideline review.

Previous studies have indicated that acute slow‐paced breathing (6 breaths/min) significantly decreases arterial blood pressure (BP) in both normotensive and hypertensive individuals. More recent work suggested that muscle sympathetic nerve activity (MSNA) was unchanged during acute slow‐paced breathing, however, the pattern of MSNA firing was altered in that more periods of MSNA quiescence were present. Herein, we examined the ability of MSNA to modulate BP on a beat‐to‐beat basis. We hypothesized that the magnitude of the increase in BP following a burst of MSNA is attenuated during acute slow‐paced breathing contributing to the reduction in BP previously reported. BP (brachial catheter) and MSNA (peroneal microneurography) were continuously measured in 10 young (27 ± 1 years), healthy men during 10 minutes of normal spontaneous breathing (baseline) or paced breathing at six breaths per minute. Signal averaging was used to characterize changes in mean BP for 15 cardiac cycles following heartbeats associated with and without MSNA bursts. MSNA bursts were segregated as either single bursts (directly bordered by ≥1 heartbeat lacking MSNA) or multiple bursts (any burst positioned directly adjacent to another MSNA burst). Respiratory rate was 12 ± 1.1 breaths/min during baseline and 6 ± 0.7 breaths/min during slow‐paced breathing. Compared to baseline, mean BP was decreased during slow‐paced breathing (88±2 vs. 85±2 mmHg, P<0.05), whereas MSNA burst frequency was unchanged (13±2.2 vs. 13±2.4 bursts/min, P>0.05). At baseline, mean BP significantly increased following MSNA bursts (+3.2± 0.2 mmHg, P<0.05) and this increase was augmented during slow‐paced breathing (+5.0± 0.5 mmHg, P<0.05). There was a greater increase in mean BP following single as well as multiple MSNA bursts during slow‐paced breathing. In contrast, cardiac cycles without MSNA bursts (non‐bursts) were associated with a significant decrease in mean BP (−0.7± 0.1 mmHg, P<0.05), which was also augmented during slow‐paced breathing (−1.3± 0.3 mmHg, P<0.05). In summary, the pressor and depressor responses coupled to spontaneous oscillations in MSNA are augmented during slow paced breathing with a net effect of reduced BP. Thus, changes in MSNA firing pattern, without changes in burst frequency, can modulate resting BP. Support or Funding Information Funding: NIH HL‐083947 (MJJ)

Insulin acts centrally to stimulate sympathetic vasoconstrictor outflow to skeletal muscle and peripherally to promote vasodilation. Given these divergent actions, the “net effect” of insulin on the transduction of muscle sympathetic nerve activity (MSNA) into vasoconstriction and thus, blood pressure (BP) remains unclear. We hypothesized that sympathetic transduction to BP would be attenuated during hyperinsulinemia compared with baseline. In 22 young healthy adults, MSNA (microneurography), and beat-to-beat BP (Finometer or arterial catheter) were continuously recorded, and signal-averaging was performed to quantify the mean arterial pressure (MAP) and total vascular conductance (TVC; Modelflow) responses following spontaneous bursts of MSNA at baseline and during a euglycemic-hyperinsulinemic clamp. Hyperinsulinemia significantly increased MSNA burst frequency and mean burst amplitude (baseline: 46 ± 6 au; insulin: 65 ± 16 au, P < 0.001) but did not alter MAP. The peak MAP (baseline: 3.2 ± 1.5 mmHg; insulin: 3.0 ± 1.9 mmHg, P = 0.67) and nadir TVC ( P = 0.45) responses following all MSNA bursts were not different between conditions indicating preserved sympathetic transduction. However, when MSNA bursts were segregated into quartiles based on their amplitudes at baseline and compared with similar amplitude bursts during hyperinsulinemia, the peak MAP and TVC responses were blunted (e.g., largest burst quartile: MAP, baseline: Δ4.4 ± 1.7 mmHg; hyperinsulinemia: Δ3.0 ± 0.8 mmHg, P = 0.02). Notably, ∼15% of bursts during hyperinsulinemia exceeded the size of any burst at baseline, yet the MAP/TVC responses to these larger bursts (MAP, Δ4.9 ± 1.4 mmHg) did not differ from the largest baseline bursts ( P = 0.47). These findings indicate that increases in MSNA burst amplitude contribute to the overall maintenance of sympathetic transduction during hyperinsulinemia.

Slow‐paced breathing is a simple strategy to reduce psychological stress. We tested the hypothesis that slow paced breathing would decrease muscle sympathetic nerve activity (MSNA). Ten young, healthy males were studied. The subjects were instructed to rest supine and breathe normally (baseline) or at six breaths per minute, each for 20 minutes. MSNA was measured (peroneal microneurography) and analyzed 5 minutes into each stage for a steady state measurement. Statistical analysis was completed using one way RM ANOVA and Tukey’s posthoc analysis (reported mean±SEM). Average respiratory rate was 11.9 ± 1.1 breaths/min during baseline and 5.8 ± 0.7 breaths/min during slow‐paced breathing. There was no significant difference from baseline compared to slow paced breathing in MSNA burst frequency (18±2.0 vs 18±2.40 bursts/min), burst incidence (31.2±4.01 vs. 30.4±3.80 bursts/100 heartbeats) or burst area (12.70±2.18 vs 13.02±1.98%). However, there was a change in the pattern of burst firing with a significant increase in quiescent periods between burst clusters during slow paced breathing compared to baseline (6.50±0.61 vs. 3.59±0.41 seconds), which was accompanied by a significant decrease in the number of bursts/cluster (2.9±0.38 vs. 5.6±0.8 bursts). This has physiological relevance since there was a significant decrease in plasma norepinephrine, increase in blood flow, and a reduction in mean arterial pressure during these same periods. These findings indicate that despite no change in burst incidence, slow paced breathing alters the pattern of MSNA firing, which may contribute to favorable cardiovascular changes. Grant Funding Source : Supported by NIH HL‐083947

Insulin plays an important role in post‐prandial blood pressure (BP) regulation. Within the central nervous system insulin acts to stimulate sympathetic outflow to skeletal muscle. Concurrently, insulin acts locally in the periphery to promote vasodilation and is suggested to also attenuate sympathetically‐mediated vasoconstriction. Given these divergent actions, the ‘net effect’ of insulin on the sympathetic control of BP remains incompletely understood. Therefore, the purpose of this study was to examine the effect of hyperinsulinemia on sympathetic transduction to BP. To accomplish this, in 10 young healthy men, heart rate (ECG), BP (finometer or brachial arterial line) and muscle sympathetic nerve activity (MSNA) were measured at rest and during euglycemic‐hyperinsulinemia. Signal‐averaging was used to characterize the changes in mean arterial pressure (MAP) and total vascular conductance (TVC; derived from ModelFlow) over 10 cardiac cycles following spontaneous bursts of MSNA at rest and during hyperinsulinemia. No significant differences were found in the peak MAP (Rest: ∆2.8 ± 0.3; Insulin: ∆2.4 ± 0.2 mmHg, P=0.15) or TVC (Rest: ∆‐3.0 ± 0.4; Insulin: ∆‐2.7 ± 0.5 mL/min/mmHg, P=0.38) responses following bursts of MSNA between rest and hyperinsulinemia (i.e., ‘net’ sympathetic transduction was unchanged). Notably, the average size of normalized MSNA bursts was increased during hyperinsulinemia (Rest: 45.6 ± 1.8; Insulin 65.3 ± 5.0 Au, P<0.01). To take into account changes in burst height, MSNA bursts were divided into amplitude‐matched bins. When MSNA burst amplitude bins were matched between rest and hyperinsulinemia, sympathetic transduction for a given burst amplitude was blunted during insulin infusion (e.g., largest resting bursts: MAP, Rest: ∆4.4 ± 0.5; Insulin: ∆3.0 ± 0.3 mmHg, P=0.02; TVC, Rest: ∆‐5.2 ± 0.8; Insulin: ∆‐3.1 ± 0.7 mL/min/mmHg, P=0.05). However, it is important to note that 15 ± 5% of MSNA bursts exhibited amplitudes greater than that which existed at rest and overall during hyperinsulinemia ~50% of all MSNA bursts were comparable or greater in amplitude to the largest bursts present at rest. Collectively, these preliminary findings suggest that during hyperinsulinemia, sympathetic transduction for a given burst amplitude is attenuated while ‘net’ sympathetic transduction remains unchanged due to the generation of larger MSNA bursts.

The introduction of duplex Doppler ultrasound almost half a century ago signified a revolutionary advance in the ability to assess limb blood flow in humans. It is now widely used to assess blood flow under a variety of experimental conditions to study skeletal muscle resistance vessel function. Despite its pervasive adoption, there is substantial variability between studies in relation to experimental protocols, procedures for data analysis, and interpretation of findings. This guideline results from a collegial discussion among physiologists and pharmacologists, with the goal of providing general as well as specific recommendations regarding the conduct of human studies involving Doppler ultrasound-based measures of resistance vessel function in skeletal muscle. Indeed, the focus is on methods used to assess resistance vessel function and not upstream conduit artery function (i.e., macrovasculature), which has been expertly reviewed elsewhere. In particular, we address topics related to experimental design, data collection, and signal processing as well as review common procedures used to assess resistance vessel function, including postocclusive reactive hyperemia, passive limb movement, acute single limb exercise, and pharmacological interventions. Listen to this article’s corresponding podcast at https://ajpheart.podbean.com/e/guidelines-for-doppler-ultrasound-and-resistance-vessel-function/ .

Evidence from animal studies indicates that hyperinsulinemia, without changes in glucose, increases ventilation via a carotid body-mediated mechanism. However, whether insulin elevates ventilation in humans independently of changes in glucose remains unclear. Therefore, we tested the hypothesis that insulin increases ventilation in humans during a hyperinsulinemic-euglycemic clamp in which insulin was elevated to postprandial concentrations while glucose was maintained at fasting concentrations. First, in 16 healthy young men ( protocol 1), we retrospectively analyzed respiration rate and estimated tidal volume from a pneumobelt to calculate minute ventilation during a hyperinsulinemic-euglycemic clamp. In addition, for a direct assessment of minute ventilation during a hyperinsulinemic-euglycemic clamp, we retrospectively analyzed breath-by-breath respiration rate and tidal volume from inspired/expired gasses in an additional 23 healthy young subjects ( protocol 2). Clamp infusion elevated minute ventilation from baseline in both protocols ( protocol 1: +11.9 ± 4.6% baseline, P = 0.001; protocol 2: +9.5 ± 3.8% baseline, P = 0.020). In protocol 1, peak changes in both respiration rate (+13.9 ± 3.0% baseline, P < 0.001) and estimated tidal volume (+16.9 ± 4.1% baseline, P = 0.001) were higher than baseline during the clamp. In protocol 2, tidal volume primarily increased during the clamp (+9.7 ± 3.7% baseline, P = 0.016), as respiration rate did not change significantly (+0.2 ± 1.8% baseline, P = 0.889). Collectively, we demonstrate for the first time in humans that elevated plasma insulin increases minute ventilation independent of changes in glucose.

The sympathetic nervous system is critical for the beat-to-beat regulation of arterial blood pressure (BP). Although studies have examined age- and sex-related effects on BP control, findings are inconsistent and limited data are available in postmenopausal women. In addition, the majority of studies have focused on time-averaged responses without consideration for potential beat-to-beat alterations. Thus we examined whether the ability of muscle sympathetic nerve activity (MSNA) to modulate BP on a beat-to-beat basis is affected by age or sex. BP and MSNA were measured during supine rest in 40 young (20 men) and 40 older (20 men) healthy subjects. Beat-to-beat fluctuations in mean arterial pressure (MAP) were characterized for 15 cardiac cycles after each MSNA burst using signal averaging. The rise in MAP following an MSNA burst was similar between young men and women (+2.64 ± 0.3 vs. +2.57 ± 0.3 mmHg, respectively). However, the magnitude of the increase in MAP after an MSNA burst was reduced in older compared with young subjects ( P < 0.05). Moreover, the attenuation of the pressor response was greater in older women (+1.20 ± 0.1 mmHg) compared with older men (+1.72 ± 0.2 mmHg; P < 0.05). Interestingly, in all groups, MAP consistently decreased after cardiac cycles without MSNA bursts (nonbursts) with the magnitude of fall greatest in older men. In summary, healthy aging is associated with an attenuated beat-to-beat increase in BP after a spontaneous MSNA burst, and this attenuation is more pronounced in postmenopausal women. Furthermore, our nonburst findings highlight the importance of sympathetic vasoconstrictor activity to maintain beat-to-beat BP, particularly in older men.

Aging has been recently associated with increased retrograde and oscillatory shear in peripheral conduit arteries, a hemodynamic environment that favors a proatherogenic endothelial cell phenotype. We evaluated whether nitric oxide (NO) bioavailability in resistance vessels contributes to age-related differences in shear rate patterns in upstream conduit arteries at rest and during rhythmic muscle contraction. Younger (n=11, age 26±2 years) and older (n=11, age 61±2 years) healthy subjects received intra-arterial saline (control) and the NO synthase inhibitor N G -Monomethyl- l -arginine. Brachial artery diameter and velocities were measured via Doppler ultrasound at rest and during a 5-minute bout of rhythmic forearm exercise. At rest, older subjects exhibited greater brachial artery retrograde and oscillatory shear (−13.2±3.0 s −1 and 0.11±.0.02 arbitrary units, respectively) compared with young subjects (−4.8±2.3 s −1 and 0.04±0.02 arbitrary units, respectively; both P <0.05). NO synthase inhibition in the forearm circulation of young, but not of older, subjects increased retrograde and oscillatory shear (both P <0.05), such that differences between young and old at rest were abolished (both P >0.05). From rest to steady-state exercise, older subjects decreased retrograde and oscillatory shear (both P <0.05) to the extent that no exercise-related differences were found between groups (both P >0.05). Inhibition of NO synthase in the forearm circulation did not affect retrograde and oscillatory shear during exercise in either group (all P >0.05). These data demonstrate for the first time that reduced NO bioavailability in the resistance vessels contributes, in part, to age-related discrepancies in resting shear patterns, thus identifying a potential mechanism for increased risk of atherosclerotic disease in conduit arteries.