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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-.

(continued )

This quantity can be minimized by taking its partial derivativewith respectto eachof the coefficientsand settingthe resultingequationequalto zeroThe outcomeof this process is the normal equations that can be expressed conciselyin matrix form as

Noninvasive bedside tests Blood-pressure response to standing or vertical tilt Heart rate response to standing Isometric exercise Heart rate variation with respiration Valsalva ratio (see text) Sweat tests Axon re ex Plasma noradrenaline level Plasma vasopressin level Fall in BP 30/15 mmHg Afferent and sympathetic efferent limbs Vagal afferent and efferent limbs Sympathetic efferent limb Vagal afferent and efferent limbs Afferent and efferent limbs Sympathetic efferent limb Postganglionic sympathetic efferent bers Sympathetic efferent limb Afferent limb

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Increase 11 90 beats/min; 30:15 ratio 104 Increase in diastolic BP, 15 mmHg Maximum-minimum heart rate 15 beats/min; E:I ratio 12a 14a Sweating over all body and limbs Local piloerection, sweating Rises on tilting from horizontal to vertical Rise with induced hypotension Invasive tests

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Valsalva maneuver (BP response with indwelling arterial catheter or continuous noninvasive BP measurement) Barore ex sensitivity

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Phase I: Rise in BP Phase II: Gradual reduction of BP to plateau; tachycardia Phase III: Fall in BP Phase IV: Overshoot of BP, bradycardiaa (1) Slowing of heart rate with induced rise of BPa (2) Steady-state responses to induced rise and fall of BP (1) Rise in BP (2) Slowing of heart rate Other tests of vasomotor control

It can be shownthat Eq (14l0) is, in fact,equivalenf the normalequations to developed previouslyfor simple linear,polynomial, and multiple linear regression The coefficientof determination and the standard error can alsobe formulatedin terms of matrix algebra Recallthat r: is definedas t S,-S, -

7:

(1) Parasympathetic afferent and efferent limbs (2) Afferent and efferent limbs (1) Adrenergic receptors (2) Afferent and efferent parasympathetic limbs

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Increased hand blood ow Increased blood ow of opposite hand Reduced blood ow, rise in BP Increased BP Tests of pupillary innervation

11 Open the Manage Styles tool, and select Attach Style Sheet 12 When the Select Style Sheet window opens, select Simplecss As soon as you make the

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Sympathetic efferent limb Sympathetic efferent limb Sympathetic efferent limb Sympathetic efferent limb

selection and click OK, the styles appear in the CSS Styles area in the Manage Styles window as shown in Figure 7-16

Sympathetic innervation Postganglionic sympathetic innervation Postganglionic sympathetic innervation Parasympathetic innervation

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shown in Figure 7-16

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where! : the predictionof the least-squares The residualsbetweenthe best-fit curve fit and the data,y; - j, can be expressed vector form as in

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