Abstract
Purpose of review
This review aims to provide an overview of the neural innervation of the cardiovascular system and present a summary of current autonomic targets for a variety of cardiovascular diseases.
Recent findings
Autonomic modulation through targeting sympathetic and vagal tone is an emerging therapeutic approach to treat cardiovascular disease. Promising applications include the treatment of hypertension, heart failure, and cardiac arrhythmias.
Summary
Autonomic dysregulation is characteristic of a number of cardiovascular disease states. Successfully targeting the autonomic nervous system to treat disease critically requires understanding of anatomy, pathophysiology, and development of new technologies and approaches to deliver effective therapy to selected patients.
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References and Recommended Reading
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Vaduganathan M, et al. The global burden of cardiovascular diseases and risk. J Am Coll Cardiol. 2022;80(25):2361–71.
Kawashima T. The autonomic nervous system of the human heart with special reference to its origin, course, and peripheral distribution. Anat Embryol. 2005;209(6):425–38.
Pachon JC, et al. “Cardioneuroablation”–new treatment for neurocardiogenic syncope, functional AV block and sinus dysfunction using catheter RF-ablation. Europace. 2005;7(1):1–13.
• Chen PS, et al. Role of the autonomic nervous system in atrial fibrillation: pathophysiology and therapy. Circ Res. 2014;114(9):1500–15. This article provides an excellent description and summary of embrology and anatomy of the intrinsic autonomic innervation of the heart.
Florea VG, Cohn JN. The autonomic nervous system and heart failure. Circ Res. 2014;114(11):1815–26.
Mancia G, Grassi G. The autonomic nervous system and hypertension. Circ Res. 2014;114(11):1804–14.
Shen MJ, Zipes DP. Role of the autonomic nervous system in modulating cardiac arrhythmias. Circ Res. 2014;114(6):1004–21.
Liu C, et al. Vagal stimulation and arrhythmias. J Atr Fibrillation. 2020;13(1):2398.
Li YL. Stellate ganglia and cardiac sympathetic overactivation in heart failure. Int J Mol Sci. 2022;23(21).
• Wu P, Vaseghi M. The autonomic nervous system and ventricular arrhythmias in myocardial infarction and heart failure. Pacing Clin Electrophysiol. 2020;43(2):172–80. This article provides an excellent description of the cardiac autonomic system on cardiac electrophysiology and function.
Bettoni M, Zimmermann M. Autonomic tone variations before the onset of paroxysmal atrial fibrillation. Circulation. 2002;105(23):2753–9.
Bhatt DL, et al. A controlled trial of renal denervation for resistant hypertension. N Engl J Med. 2014;370(15):1393–401.
Weber MA, et al. The REDUCE HTN: REINFORCE: randomized, sham-controlled trial of bipolar radiofrequency renal denervation for the treatment of hypertension. JACC Cardiovasc Interv. 2020;13(4):461–70.
Azizi M, et al. Endovascular ultrasound renal denervation to treat hypertension (RADIANCE-HTN SOLO): a multicentre, international, single-blind, randomised, sham-controlled trial. The Lancet. 2018;391(10137):2335–45.
Azizi M, et al. Ultrasound renal denervation for hypertension resistant to a triple medication pill (RADIANCE-HTN TRIO): a randomised, multicentre, single-blind, sham-controlled trial. The Lancet. 2021;397(10293):2476–86.
Mahfoud F, et al. Long-term efficacy and safety of renal denervation in the presence of antihypertensive drugs (SPYRAL HTN-ON MED): a randomised, sham-controlled trial. The Lancet. 2022;399(10333):1401–10.
Böhm M, et al. Efficacy of catheter-based renal denervation in the absence of antihypertensive medications (SPYRAL HTN-OFF MED Pivotal): a multicentre, randomised, sham-controlled trial. The Lancet. 2020;395(10234):1444–51.
Azizi M, et al. Endovascular ultrasound renal denervation to treat hypertension: the RADIANCE II randomized clinical trial. JAMA. 2023;329(8):651–61.
Kario K, et al. Catheter-based ultrasound renal denervation in patients with resistant hypertension: the randomized, controlled REQUIRE trial. Hypertens Res. 2022;45(2):221–31.
Qian PC, et al. Transvascular pacing of aorticorenal ganglia provides a testable procedural endpoint for renal artery denervation. JACC: Cardiovasc Interv. 2019;12(12):1109–1120.
Zhou H, et al. Mapping renal innervations by renal nerve stimulation and characterizations of blood pressure response patterns. J Cardiovasc Transl Res. 2022;15(1):29–37.
Karaskov AM, et al. Perspective directions in management of severe group two pulmonary hypertension. Kardiologiia. 2017;57(11):23–8.
Zhang H, et al. Pulmonary artery denervation significantly increases 6-min walk distance for patients with combined pre- and post-capillary pulmonary hypertension associated with left heart failure. JACC: Cardiovasc Interv. 2019;12(3):274–284.
Romanov A, et al. Pulmonary artery denervation for patients with residual pulmonary hypertension after pulmonary endarterectomy. J Am Coll Cardiol. 2020;76(8):916–26.
Zheng Z, et al. A Meta-analysis of the efficacy of pulmonary artery denervation in the treatment of pulmonary hypertension. Heart Lung. 2022;53:42–50.
Gao JQ, Yang W, Liu ZJ. Percutaneous renal artery denervation in patients with chronic systolic heart failure: a randomized controlled trial. Cardiol J. 2019;26(5):503–10.
Chen W, et al. Preliminary effects of renal denervation with saline irrigated catheter on cardiac systolic function in patients with heart failure: a prospective, randomized, controlled, pilot study. Catheter Cardiovasc Interv. 2017;89(4):E153–61.
Xia Z, et al. Safety and efficacy of renal denervation in patients with heart failure with reduced ejection fraction (HFrEF): a systematic review and meta-analysis. Heliyon. 2022;8(1):e08847.
Kresoja K-P, et al. Renal sympathetic denervation in patients with heart failure with preserved ejection fraction. Circ Heart Fail. 2021;14(3):e007421.
Fudim M, et al. Splanchnic nerve block for decompensated chronic heart failure: splanchnic-HF. Eur Heart J. 2018;39(48):4255–6.
Fudim M, et al. Splanchnic nerve block for chronic heart failure. JACC: Heart Fail. 2020;8(9):742–752.
Fudim M, et al. Transvenous right greater splanchnic nerve ablation in heart failure and preserved ejection fraction: first-in-human study. JACC Heart Fail. 2022;10(10):744–52.
Fudim M, et al. Endovascular ablation of the right greater splanchnic nerve in heart failure with preserved ejection fraction: early results of the REBALANCE-HF trial roll-in cohort. Eur J Heart Fail. 2022;24(8):1410–4.
De Ferrari GM, et al. Chronic vagus nerve stimulation: a new and promising therapeutic approach for chronic heart failure. Eur Heart J. 2011;32(7):847–55.
Anand IS, et al. Comparison of symptomatic and functional responses to vagus nerve stimulation in ANTHEM-HF, INOVATE-HF, and NECTAR-HF. ESC Heart Fail. 2020;7(1):75–83.
Zannad F, et al. Chronic vagal stimulation for the treatment of low ejection fraction heart failure: results of the NEural Cardiac TherApy foR Heart Failure (NECTAR-HF) randomized controlled trial. Eur Heart J. 2015;36(7):425–33.
Gold MR, et al. Vagus nerve stimulation for the treatment of heart failure: the INOVATE-HF Trial. J Am Coll Cardiol. 2016;68(2):149–58.
De Ferrari GM, et al. Long-term vagal stimulation for heart failure: eighteen month results from the NEural Cardiac TherApy foR Heart Failure (NECTAR-HF) trial. Int J Cardiol. 2017;244:229–34.
Sharma K, et al. Long-term Follow-up of patients with heart failure and reduced ejection fraction receiving autonomic regulation therapy in the ANTHEM-HF pilot study. Int J Cardiol. 2021;323:175–8.
Konstam MA, et al. Impact of autonomic regulation therapy in patients with heart failure. Circulation: Heart Fail. 2019;12(11):e005879.
Butt MF, et al. The anatomical basis for transcutaneous auricular vagus nerve stimulation. J Anat. 2020;236(4):588–611.
Stavrakis S, et al. Neuromodulation of inflammation to treat heart failure with preserved ejection fraction: a pilot randomized clinical trial. J Am Heart Assoc. 2022;11(3):e023582.
Abraham WT, et al. Baroreflex activation therapy for the treatment of heart failure with a reduced ejection fraction. JACC: Heart Fail. 2015;3(6):487–496.
Zile MR, et al. Baroreflex activation therapy in patients with heart failure with reduced ejection fraction. J Am Coll Cardiol. 2020;76(1):1–13.
Abraham WL, McCann JP, Zile M. Baroreflex activation therapy (BAT) in patients with heart failure and a reduced ejection fraction (BeAT-HF): long-term outcomes. In Technol Heart Fail Ther. 2023. Ma, USA.
Pokushalov E, et al. A randomized comparison of pulmonary vein isolation with versus without concomitant renal artery denervation in patients with refractory symptomatic atrial fibrillation and resistant hypertension. J Am Coll Cardiol. 2012;60(13):1163–70.
Nawar K, et al. Renal denervation for atrial fibrillation: a comprehensive updated systematic review and meta-analysis. J Hum Hypertens. 2022;36(10):887–97.
Steinberg JS, et al. Effect of Renal denervation and catheter ablation vs catheter ablation alone on atrial fibrillation recurrence among patients with paroxysmal atrial fibrillation and hypertension: the ERADICATE-AF randomized clinical trial. JAMA. 2020;323(3):248–55.
Yan F, et al. Different effects of additional ganglion plexus ablation on catheter and surgical ablation for atrial fibrillation: a systemic review and meta-analysis. J Cardiovasc Electrophysiol. 2019;30(12):3039–49.
Kim MY, et al. Ectopy-triggering ganglionated plexuses ablation to prevent atrial fibrillation: GANGLIA-AF study. Heart Rhythm. 2022;19(4):516–24.
Mikhaylov E, et al. Outcome of anatomic ganglionated plexi ablation to treat paroxysmal atrial fibrillation: a 3-year follow-up study. EP Europace. 2010;13(3):362–70.
Stavrakis S, et al. Low-level vagus nerve stimulation suppresses post-operative atrial fibrillation and inflammation: a randomized study. JACC Clin Electrophysiol. 2017;3(9):929–38.
Stavrakis S, et al. TREAT AF (transcutaneous electrical vagus nerve stimulation to suppress atrial fibrillation): a randomized clinical trial. JACC Clin Electrophysiol. 2020;6(3):282–91.
Meng L, et al. Efficacy of stellate ganglion blockade in managing electrical storm: a systematic review. JACC Clin Electrophysiol. 2017;3(9):942–9.
Markman TM, et al. Effect of transcutaneous magnetic stimulation in patients with ventricular tachycardia storm: a randomized clinical trial. JAMA Cardiol. 2022;7(4):445–9.
Nonoguchi NM, et al. Stellate ganglion phototherapy using low-level laser. JACC: Clin Electrophysiol. 2021;7(10):1297–1308.
Vaseghi M, et al. Cardiac sympathetic denervation in patients with refractory ventricular arrhythmias or electrical storm: intermediate and long-term follow-up. Heart Rhythm. 2014;11(3):360–6.
Vaseghi M, et al. Cardiac sympathetic denervation for refractory ventricular arrhythmias. J Am Coll Cardiol. 2017;69(25):3070–80.
Lee ACH, Tung R, Ferguson MK. Thoracoscopic sympathectomy decreases disease burden in patients with medically refractory ventricular arrhythmias. Interact Cardiovasc Thorac Surg. 2022;34(5):783–90.
Markman TM, et al. Neuromodulation for the treatment of refractory ventricular arrhythmias. JACC: Clin Electrophysiol. 2023;9(2):161–169.
Olde Nordkamp LRA, et al. Left cardiac sympathetic denervation in the Netherlands for the treatment of inherited arrhythmia syndromes. Neth Heart J. 2014;22(4):160–166.
Antiel RM, et al. Quality of life after videoscopic left cardiac sympathetic denervation in patients with potentially life-threatening cardiac channelopathies/cardiomyopathies. Heart Rhythm. 2016;13(1):62–9.
Ukena C, et al. Renal sympathetic denervation for treatment of electrical storm: first-in-man experience. Clin Res Cardiol. 2012;101(1):63–7.
Liu KC, et al. Abstract 16805: Renal sympathetic denervation as an adjunctive therapy to radiofrequency ablation and cardiac sympathetic denervation for refractory ventricular tachycardia. Circulation. 2018;138(Suppl_1):A16805–A16805.
Bradfield JS, et al. Renal denervation as adjunctive therapy to cardiac sympathetic denervation for ablation refractory ventricular tachycardia. Heart Rhythm. 2020;17(2):220–7.
Hadaya J, et al. Vagal nerve stimulation reduces ventricular arrhythmias and mitigates adverse neural cardiac remodeling post–myocardial infarction. JACC: Basic Trans Sci.
Yu L, et al. Low-level tragus stimulation for the treatment of ischemia and reperfusion injury in patients with ST-segment elevation myocardial infarction: a proof-of-concept study. JACC Cardiovasc Interv. 2017;10(15):1511–20.
Pachon JC, et al. Catheter ablation of severe neurally meditated reflex (neurocardiogenic or vasovagal) syncope: cardioneuroablation long-term results. Europace. 2011;13(9):1231–42.
Vandenberk B, et al. Cardioneuroablation for vasovagal syncope: a systematic review and meta-analysis. Heart Rhythm. 2022;19(11):1804–12.
Piotrowski R, et al. Cardioneuroablation for reflex syncope: efficacy and effects on autonomic cardiac regulation—a prospective randomized trial. JACC: Clin Electrophysiol. 2023;9(1):85–95.
Shen MJ, Choi EK, Tan AY, Lin SF, Fishbein MC, Chen LS, Chen PS. Neural mechanisms of atrial arrhythmias. Nat Rev Cardiol. 2011;9(1):30–9. https://doi.org/10.1038/nrcardio.2011.139. PMID: 21946776.
Funding
Pierre Qian was supported by a NHMRC Investigator Emerging Leader 1 grant (GNT2018376) and a National Heart Foundation of Australia Future Leaders Fellowship and Paul Korner Award (106780).
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A.V. wrote the main manuscript and P.B. and P.C editted and reviewed the manuscript
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Vien, A., Balaji, P. & Qian, P.C. Autonomic Modulation Options in Cardiovascular Disease Treatment: Current and Emerging. Curr Treat Options Cardio Med 25, 753–770 (2023). https://doi.org/10.1007/s11936-023-01023-1
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DOI: https://doi.org/10.1007/s11936-023-01023-1