Heart Failure Reviews

, Volume 16, Issue 2, pp 101–107 | Cite as

Sympathetic–parasympathetic interaction in health and disease: abnormalities and relevance in heart failure

  • Peter J. SchwartzEmail author
  • Gaetano M. De Ferrari


Sympathetic–parasympathetic interaction plays a major role in the evolution and outcome of many cardiovascular disorders. Nonetheless, a thorough understanding of this relationship and of its potential implications for prognosis and management still escapes many cardiologists. This article reviews the background of sympathetic–parasympathetic interactions focusing on the best direct evidence available, namely direct neural recordings of the activity of single vagal and sympathetic fibers directed to the heart. It examines indirect but highly reliable markers of this interaction as they can be studied in the clinical setting of ischemic heart disease and of heart failure, focusing primarily on the experimental and clinical studies of baroreflex sensitivity. It concludes by drawing inferences likely to lead to a novel approach to the management of heart failure, resulting from the knowledge gained about the vagal control of the heart and based on electrical vagal stimulation.


Heart failure Vagal stimulation Sympathetic activity Baroreflex sensitivity Neural recording 


  1. 1.
    Levy MN (1972) Sympathetic–parasympathetic interactions in the heart. Circ Res 29:437Google Scholar
  2. 2.
    Schwartz PJ, Brown AM, Malliani A, Zanchetti A (eds) (1978) Neural mechanisms in cardiac arrhythmias. Raven Press, New York, p 442Google Scholar
  3. 3.
    Schwartz PJ (1984) Sympathetic imbalance and cardiac arrhythmias. In: Randall WC (ed) Nervous control of cardiovascular function. Oxford University Press, New York, pp 225–251Google Scholar
  4. 4.
    Vanoli E, De Ferrari GM, Stramba-Badiale M, Hull SS Jr, Foreman RD, Schwartz PJ (1991) Vagal stimulation and prevention of sudden death in conscious dogs with a healed myocardial infarction. Circ Res 68:1471–1481PubMedGoogle Scholar
  5. 5.
    De Ferrari GM, Vanoli E, Schwartz PJ (1994) Vagal activity and ventricular fibrillation. In: Levy MN, Schwartz PJ (eds) Vagal control of the heart: experimental basis and clinical implications. Futura, Armonk, NY, pp 613–636Google Scholar
  6. 6.
    Levy MN, Schwartz PJ (eds) (1994) Vagal control of the heart: experimental basis and clinical implications. Futura, Armonk, NY, p 644Google Scholar
  7. 7.
    Malliani A, Schwartz PJ, Zanchetti A (1969) A sympathetic reflex elicited by experimental coronary occlusion. Am J Physiol 217:703–709PubMedGoogle Scholar
  8. 8.
    Schwartz PJ, Foreman RD, Stone HL, Brown AM (1976) Effect of dorsal root section on the arrhythmias associated with coronary occlusion. Am J Physiol 231:923–928PubMedGoogle Scholar
  9. 9.
    Rosenblueth A, Simeone FA (1934) Interrelations of vagal and accelerator effects on the cardiac rate. Am J Physiol 110:42–55Google Scholar
  10. 10.
    Cerati D, Schwartz PJ (1991) Single cardiac vagal fibers activity, acute myocardial ischemia, and risk for sudden death. Circ Res 69:1389–1401PubMedGoogle Scholar
  11. 11.
    Schwartz PJ, Pagani M, Lombardi F, Malliani A, Brown AM (1973) A cardiocardiac sympatho-vagal reflex in the cat. Circ Res 32:215–220PubMedGoogle Scholar
  12. 12.
    Kunze DL (1972) Reflex discharge patterns of cardiac vagal efferent fibres. J Physiol 222:1–15PubMedGoogle Scholar
  13. 13.
    Malliani A, Recordati G, Schwartz PJ (1973) Nervous activity of afferent cardiac sympathetic fibres with atrial and ventricular endings. J Physiol (London) 229:457–469Google Scholar
  14. 14.
    Gnecchi Ruscone T, Lombardi F, Malfatto G, Malliani A (1987) Attenuation of baroreceptive mechanisms by cardiovascular sympathetic afferent fibers. Am J Physiol 253(4 Pt 2):H787–H791PubMedGoogle Scholar
  15. 15.
    La Rovere MT, Schwartz PJ (2000) Baroreflex sensitivity. In: Zipes DP, Jalife J (eds) Cardiac electrophysiology. From cell to bedside, 3rd edn. WB Saunders, Philadelphia, pp 771–781Google Scholar
  16. 16.
    Billman GE, Schwartz PJ, Stone HL (1982) Baroreceptor reflex control of heart rate: a predictor of sudden cardiac death. Circulation 66:874–880PubMedGoogle Scholar
  17. 17.
    Kleiger RE, Miller JP, Bigger JT Jr, Moss AJ, the Multicenter Post Infarction Research Group (1987) Decreased heart rate variability and its association with increased mortality after acute myocardial infarction. Am J Cardiol 59:256–262CrossRefPubMedGoogle Scholar
  18. 18.
    Schwartz PJ, Vanoli E, Stramba Badiale M, De Ferrari G, Billman GE, Foreman RD (1988) Autonomic mechanisms and sudden death. New insights from analysis of baroreceptor reflexes in conscious dogs with and without a myocardial infarction. Circulation 78:969–979PubMedGoogle Scholar
  19. 19.
    Schwartz PJ, Billman GE, Stone HL (1984) Autonomic mechanisms in ventricular fibrillation induced by myocardial ischemia during exercise in dogs with healed myocardial infarction. An experimental preparation for sudden death. Circulation 69:790–800Google Scholar
  20. 20.
    La Rovere MT, Specchia G, Mortara A, Schwartz PJ (1988) Baroreflex sensitivity, clinical correlates and cardiovascular mortality among patients with a first myocardial infarction: a prospective study. Circulation 78:816–824PubMedGoogle Scholar
  21. 21.
    La Rovere MT, Bigger JT, Marcus F, Mortara A, Schwartz PJ (1998) ATRAMI (Autonomic Tone and Reflexes After Myocardial Infarction), Baroreflex sensitivity and heart-rate variability in prediction of total cardiac mortality after myocardial infarction. Lancet 351:478–484CrossRefPubMedGoogle Scholar
  22. 22.
    Schmidt G, Malik M, Barthel P, Schneider R, Ulm K, Rolnitzky L, Camm AJ, Bigger JT Jr, Schomig A (1999) Heart-rate turbulence after ventricular premature beats as a predictor of mortality after acute myocardial infarction. Lancet 353:1390–1396CrossRefPubMedGoogle Scholar
  23. 23.
    Cole CR, Blackstone EH, Pashkow FJ, Snader CE, Lauer MS (1999) Heart rate recovery immediately after exercise as a predictor of mortality. N Engl J Med 341:1351–1357CrossRefPubMedGoogle Scholar
  24. 24.
    Falcone C, Buzzi MP, Klersy C, Schwartz PJ (2005) Rapid heart rate increase at onset of exercise predicts adverse cardiac events in patients with coronary artery disease. Circulation 112:1959–1964CrossRefPubMedGoogle Scholar
  25. 25.
    Mortara A, La Rovere MT, Pinna GD, Prpa A, Maestri R, Febo O, Pozzoli M, Opasich C, Tavazzi L (1997) Arterial baroreflex modulation of heart rate in chronic heart failure: clinical and hemodynamic correlates and prognostic implications. Circulation 96:3450–3458PubMedGoogle Scholar
  26. 26.
    La Rovere MT, Pinna GD, Maestri R, Robbi E, Caporotondi A, Guazzotti G, Sleight P, Febo O (2009) Prognostic implications of baroreflex sensitivity in heart failure patients in the beta-blocking era. J Am Coll Cardiol 53:193–199CrossRefPubMedGoogle Scholar
  27. 27.
    Paintal AS (1963) Vagal afferent fibres. Ergeb Physiol 52:74–156PubMedGoogle Scholar
  28. 28.
    Recordati G, Schwartz PJ, Pagani M, Malliani A, Brown AM (1971) Activation of cardiac vagal receptors during myocardial ischemia. Experientia 27:1423–1424CrossRefPubMedGoogle Scholar
  29. 29.
    Billman GE, Schwartz PJ, Stone HL (1984) The effects of daily exercise on susceptibility to sudden cardiac death. Circulation 69:1182–1189PubMedGoogle Scholar
  30. 30.
    La Rovere MT, Bersano C, Gnemmi M, Specchia G, Schwartz PJ (2002) Exercise-induced increase in baroreflex sensitivity predicts improved prognosis after myocardial infarction. Circulation 106:945–949CrossRefPubMedGoogle Scholar
  31. 31.
    Schwartz PJ, De Ferrari GM, Sanzo A, Landolina M, Rordorf R, Raineri C, Campana C, Revera M, Ajmone-Marsan N, Tavazzi L, Odero A (2008) Long term vagal stimulation in patients with advanced heart failure. First experience in man. Eur J Heart Fail 10:884–891CrossRefPubMedGoogle Scholar
  32. 32.
    De Ferrari GM, Schwartz PJ (2010) Vagus nerve stimulation: from pre-clinical to clinical application: challenges and future directions. (This issue)Google Scholar
  33. 33.
    Heusch G (2009) A beautiful lesson—ivabradine protects from ischaemia, but not from heart failure: through heart rate reduction or more? Eur Heart J 30:2300–2301CrossRefPubMedGoogle Scholar
  34. 34.
    Tracey KJ (2002) The inflammatory reflex. Nature 420:853–859CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Peter J. Schwartz
    • 1
    • 2
    • 3
    • 4
    • 5
    Email author
  • Gaetano M. De Ferrari
    • 1
  1. 1.Department of CardiologyFondazione IRCCS Policlinico S. MatteoPaviaItaly
  2. 2.Department of Lung, Blood and HeartUniversity of PaviaPaviaItaly
  3. 3.Laboratory of Cardiovascular Genetics, IRCCS Istituto Auxologico ItalianoMilanItaly
  4. 4.Department of Medicine, Cardiovascular Genetics Laboratory, Hatter Institute for Cardiovascular ResearchUniversity of Cape TownCape TownSouth Africa
  5. 5.Chair of Sudden Death, Department of Family and Community Medicine, College of MedicineKing Saud UniversityRiyadhSaudi Arabia

Personalised recommendations