Clinical Autonomic Research

, Volume 25, Issue 6, pp 383–390 | Cite as

Simple cardiovagal and adrenergic function tests in carotid artery stenosis patients as a potential tool for determining a transient autonomic dysfunction

  • Viktor Švigelj
  • Matjaž Šinkovec
  • Viktor Avbelj
  • Roman Trobec
Research Article



The arterial baroreflex depends on the integrity of the afferent limb, which can be quantified using the baroreceptor’s sensitivity (BRS) during the Valsalva maneuver (VM). The aim of this study was to evaluate, using autonomic nervous system tests, the autonomic function in patients after a carotid artery angioplasty (CAS).


We evaluated the changes in blood pressure (BP) during the VM (Valsalva ratio, BRS, sympathetic indexes) in 41 patients with symptomatic, unilateral, internal carotid artery stenosis.


The Valsalva ratio between the baseline and the post-procedural day (1.3 ± 0.1 vs 1.44 ± 0.3; P = 0.002) and the post-procedural day and a month later (1.44 ± 0.3 vs 1.3 ± 0.3; P = 0.0002) revealed significant differences. This was confirmed with a cardiovagal BRS test. However, the adrenergic BRS did not reveal any differences. Sympathetic indexes [BP fall (SI1) and recovery during phase 2 (SI2)] showed differences for the periods before and a day after the treatment (36.9 ± 18.0 vs 27.2 ± 21.4 and 7.1 ± 13.1 vs 3.0 ± 8.2, respectively; P = 0.004) and for SI1 a day and a month after the treatment (27.2 ± 21.4 vs 37.1 ± 21.8; P = 0.036). The dynamic ranges between S1 and S3 (the difference in the BP between the baseline and the end of phase 2) were also different (P = 0.007 and P = 0.044, respectively).


We found heterogeneous responses in the BP regulation obtained with the Valsalva maneuver in our patients; however, we could not confirm that CAS provoked any long-term autonomic dysfunction, except for 1 day after the procedure.


Angioplasty Baroreflex Carotid stenosis Autonomic dysreflexia Valsalva maneuver 



This work was partly supported by the Slovenian Research Agency under Grant P2-0095.

Compliance with ethical standards

Conflict of interest

The authors declare no financial or other conflicts of interest.


  1. 1.
    Roffi M, Sievert H, Gray WA et al (2010) Carotid artery stenting versus surgery: adequate comparisons? Lancet Neurol 9:339–341CrossRefPubMedGoogle Scholar
  2. 2.
    Brott TG, Hobson RW 2nd, Howard G et al (2010) Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 363:11–23PubMedCentralCrossRefPubMedGoogle Scholar
  3. 3.
    Coutts SB, Hill MD, Hu WY (2003) Hyperperfusion syndrome: toward a stricter definition. Neurosurgery 53:1053–1058CrossRefPubMedGoogle Scholar
  4. 4.
    Karapanayiotides T, Meuli R, Devuyst G et al (2005) Postcarotid endarterectomy hyperperfusion or reperfusion syndrome. Stroke 36:21–26CrossRefPubMedGoogle Scholar
  5. 5.
    Bouri S, Thapar A, Shalhoub J et al (2011) Hypertension and the post-carotid endarterectomy cerebral hyperperfusion syndrome. Eur J Vasc Endovasc Surg 41:229–237CrossRefPubMedGoogle Scholar
  6. 6.
    van Mook WN, Rennenberg RJ, Schurink GW et al (2005) Cerebral hyperperfusion syndrome. Lancet Neurol 4:877–888CrossRefPubMedGoogle Scholar
  7. 7.
    Canovas D, Estela J, Perendreu J et al (2012) Cerebral hyperperfusion syndrome after angioplasty. In: Forbes T (ed) Angioplasty, various techniques and challenges in treatment of congenital and acquired vascular stenoses. InTech, Rijeka, pp 9–40Google Scholar
  8. 8.
    Ogasawara K, Mikami C, Inoue T, Ogawa A (2004) Delayed cerebral hyperperfusion syndrome caused by prolonged impairment of cerebrovascular autoregulation after carotid endarterectomy: case report. Neurosurgery 54:1258–1262CrossRefPubMedGoogle Scholar
  9. 9.
    Ahn SS, Marcus DR, Moore WS (1989) Post-carotid endarterectomy hypertension: association with elevated cranial norepinephrine. J Vasc Surg 9:351–360CrossRefPubMedGoogle Scholar
  10. 10.
    Timmers HJ, Wieling W, Karemaker JM, Lenders JW (2004) Baroreflex failure: a neglected type of secondary hypertension. Neth J Med 62:151–155PubMedGoogle Scholar
  11. 11.
    Cayne NS, Faries PL, Trocciola SM et al (2005) Carotid angioplasty and stent-induced bradycardia and hypotension: impact of prophylactic atropine administration and prior carotid endarterectomy. J Vasc Surg 41:956–961CrossRefPubMedGoogle Scholar
  12. 12.
    Benarroch EE, Opfer-Gehrking TL, Low PA (1991) Use of the photoplethysmographic technique to analyze the Valsalva maneuver in normal man. Muscle Nerve 14:1165–1172CrossRefPubMedGoogle Scholar
  13. 13.
    Denq J-C, O’Brien PC, Low PA (1998) Normative data on phases of Valsalva maneuver. J Clin Neurophysiol 15:535–540CrossRefPubMedGoogle Scholar
  14. 14.
    von Reutern GM, Goertler MW, Bornstein NM et al (2012) Recommendations for grading carotid stenosis by means of ultrasonic methods. Stroke 43:916–921CrossRefGoogle Scholar
  15. 15.
    Hamilton WF, Woodbury RA, Harper HT Jr (1936) Physiologic relationships between intrathoracic, intraspinal and arterial pressures. JAMA 107:853–856CrossRefGoogle Scholar
  16. 16.
    LeWinter MM (2001) Normal physiology of the cardiovascular system. In: Fuster V, Alexander W, Wellens GJJ (eds) Hurst’s the heart, 10th edn. McGraw-Hill, Maidenheach, pp 63–94Google Scholar
  17. 17.
    Kjeldsen S, Feldman RD, Lisheng L et al (2014) Updated national and international hypertension guidelines: a review of current recommendations. Drugs 74:2033–2051PubMedCentralCrossRefPubMedGoogle Scholar
  18. 18.
    Low PA, Tomalia VA, Park KJ (2013) Autonomic function: some clinical applications. J Clin Neurol 9:1–8PubMedCentralCrossRefPubMedGoogle Scholar
  19. 19.
    Schrezenmaier C, Singer W, Muenter Swift N, Sletten D, Tanabe J, Low PA (2007) Adrenergic and vagal baroreflex sensitivity in autonomic failure. Arch Neurol 64:381–386CrossRefPubMedGoogle Scholar
  20. 20.
    Vogel ER, Sandroni P, Low PA (2005) Blood pressure recovery from Valsalva maneuver in patients with autonomic failure. Neurology 65:1533–1537CrossRefPubMedGoogle Scholar
  21. 21.
    Persson PB, DiRienzo M, Castiglioni P et al (2001) Time versus frequency domain techniques for assessing baroreflex sensitivity. J Hypertens 19:1699–1705CrossRefPubMedGoogle Scholar
  22. 22.
    Novak P (2011) Assessment of sympathetic index from Valsalva maneuver. Neurology 76:2010–2016PubMedCentralCrossRefPubMedGoogle Scholar
  23. 23.
    Weston PJ, James MA, Panerai R et al (1996) Abnormal baroreceptor-cardiac reflex sensitivity is not detected by conventional tests of autonomic function in patients with insulin-dependent diabetes mellitus. Clin Sci (London) 91:59–64CrossRefGoogle Scholar
  24. 24.
    Pitzalis MV, Mastropasqua F, Passantino A et al (1998) Comparison between noninvasive indices of baroreceptor sensitivity and the phenylephrine method in postmyocardial infarction patients. Circulation 97:1362–1367CrossRefPubMedGoogle Scholar
  25. 25.
    Pickering TG, Gribbin B, Sleight P (1972) Comparison of the reflex heart rate response to rising and falling arterial pressure in man. Cardiovasc Res 6:277–283CrossRefPubMedGoogle Scholar
  26. 26.
    Milic M, Sun P, Liu F et al (2009) A comparison of pharmacologic and spontaneous baroreflex methods in aging and hypertension. J Hypertens 27:1243–1251PubMedCentralCrossRefPubMedGoogle Scholar
  27. 27.
    Yakhou L, Constant I, Merle JC, Laude D, Becquemin JP, Duvaldestin P (2006) Noninvasive investigation of autonomic activity after carotid stenting or carotid endarterectomy. J Vasc Surg 44:472–479CrossRefPubMedGoogle Scholar
  28. 28.
    Huang C-C, Wu Y-S, Chen T et al (2010) Long-term effects of baroreflex function after stenting in patients with carotid artery stenosis. Auton Neurosci 158:100–104CrossRefPubMedGoogle Scholar
  29. 29.
    Bishop VS, Haywood JR, Shade RE, Siegel M, Hamm C (1986) Aortic baroreceptor deafferentation in the baboon. J Appl Physiol 60:798–801PubMedGoogle Scholar
  30. 30.
    Shade RE, Bishop VS, Haywood JR, Hamm CK (1990) Cardiovascular and neuroendocrine responses to baroreceptor denervation in baboons. Am J Physiol 258:R930–R938PubMedGoogle Scholar
  31. 31.
    Timmers HJ, Karemaker JM, Wieling W, Buskens FG, Lenders JW (2001) Arterial barroreflex function after unilateral carotid endarterectomy. Clin Auton Res 11:188–189Google Scholar
  32. 32.
    Mangin L, Medigue C, Merle JC et al (2003) Cardiac autonomic control during balloon carotid angioplasty and stenting. Can J Physiol Pharmacol 81:944–951CrossRefPubMedGoogle Scholar
  33. 33.
    Gianaros PH, Jennings JR, Olafsson GB et al (2002) Greater intima-media thickness in the carotid bulb is associated with reduced baroreflex sensitivity. Am J Hypertens 15:486–491PubMedCentralCrossRefPubMedGoogle Scholar
  34. 34.
    Lábrová R, Honzíková N, Maděrová E et al (2005) Age-dependent relationship between the carotid intima-media thickness, baroreflex sensitivity, and the inter-beat interval in normotensive and hypertensive subjects. Physiol Res 54:593–600PubMedGoogle Scholar
  35. 35.
    Fisher JP, Kim A, Young CN et al (2009) Influence of ageing on carotid baroreflex peak response latency in humans. J Physiol 587(22):5427–5439PubMedCentralCrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Viktor Švigelj
    • 1
  • Matjaž Šinkovec
    • 2
  • Viktor Avbelj
    • 3
  • Roman Trobec
    • 3
  1. 1.Neurological Intensive Care Unit, Division of Neurology, Department of Vascular Neurology and Intensive CareUniversity Medical Centre LjubljanaLjubljanaSlovenia
  2. 2.Division of Internal Medicine, Department of CardiologyUniversity Medical Centre LjubljanaLjubljanaSlovenia
  3. 3.Department of Communication SystemsJožef Stefan InstituteLjubljanaSlovenia

Personalised recommendations