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UDC 612.172.2:615.22:616.12
DINAMICS OF BLOOD PRESSURE AND HEART RATE VARIABILITY PARAMETERS DURING BIOFEEDBACK IN LOOP OF HEART RATE VARIABILITY AND PACED BREATHING IN PATIENTS WITH DIFFICULT-TO-CONTROL ARTERIAL HYPERTENSION ON THE BACKGROUND OF DRUG
Tymoshenko O. S., Yabluchansky M. I.
V. N. Karazin Kharkiv National University, Kharkiv, Ukraine
60 patients with difficult-to-control arterial hypertension (DTCAH) were examined (average age is 59.0 ± 9.4 years). The changes in blood pressure (BP) and parameters of heart rate variability (HRV) during biofeedback sessions (BFB) in loop of paced breathing (PB) in patients with DTCAH on the background of standard drug therapy were assessed. It has been established that the systematic sessions of BFB in loop of PB in patients with DTCAH allow to increase the total power of the HRV spectrum, VLF and HF, and also improve control of BP. BFB in loop of PB can be recommended as an adjunctive method to the standard drug therapy for patients with DTCAH.
KEY WORDS: biofeedback, heart rate variability, difficult-to-control hypertension
ДИНАМ1КА АРТЕР1АЛЬНОГО ТИСКУ ТА ПАРАМЕТР1В ВАР1АБЕЛЬНОСТ1 СЕРЦЕВОГО РИТМУ ПРИ ПРОВЕДЕНН1 СЕАНС1В Б1ОЛОГ1ЧНОГО ЗВОРОТНЬОГО ЗВ'ЯЗКУ З КОНТУРОМ МЕТРОНОМ1З1РОВАННОГО ДИХАННЯ У ХВОРИХ НА ВАЖКОКОНТРОЛЬОВАНУ АРТЕР1АЛЬНУ ГШЕРТЕНЗ1Ю НА ТЛ1 МЕДИКАМЕНТОЗНОÏ ТЕРАПП
Тимошенко О. С., Яблучанський М. I.
Харювський нацюнальний ушверситет ÎMem В. Н. Каразша, м. Харюв, Украша
Обстежено 60 пащенлв з важкоконтрольованою артерiальною гiпертензieю (ВАГ) (середнiй вiк 59,0 ± 9,4 рокiв). Були ощнеш змiни артерiального тиску (АТ) i параметрiв варiабельностi серцевого ритму (ВСР) при проведенш сеансiв бiологiчного зворотного зв'язку (БЗЗ) з контуром метрономiзiрованного дихання (МД) у пащенпв з ВАГ на тлi стандартно! медикаментозно! терапii. Встановлено, що систематичне проведення сеаншв БЗЗ в контурi МД у пащенпв з ВАГ дозволяе збiльшити загальну потужнiсть спектра ВСР, показниюв УЬГ i ИГ, а також покращуе контроль АТ. Сеанси БЗЗ в контурi МД можуть бути рекомендованi в якостi доповнення до стандартно! медикаментозно! терапii пащентам з ВАГ.
КЛЮЧОВ1 СЛОВА: бюлопчний зворотний зв'язок, варiабельнiсть серцевого ритму, важкоконтрольована артерiальна гiпертензiя
ДИНАМИКА АРТЕРИАЛЬНОГО ДАВЛЕНИЯ И ПАРАМЕТРОВ ВАРИАБЕЛЬНОСТИ СЕРДЕЧНОГО РИТМА ПРИ ПРОВЕДЕНИИ СЕАНСОВ БИОЛОГИЧЕСКОЙ ОБРАТНОЙ СВЯЗИ С КОНТУРОМ МЕТРОНОМИЗИРОВАННОГО ДЫХАНИЯ У ПАЦИЕНТОВ С ТРУДНОКОНТРОЛИРУЕМОЙ АРТЕРИАЛЬНОЙ ГИПЕРТЕНЗИЕЙ НА ФОНЕ МЕДИКАМЕНТОЗНОЙ ТЕРАПИИ
Тимошенко Е. С., Яблучанский Н. И.
Харьковский национальный университет имени В. Н. Каразина, г. Харьков, Украина
Обследовано 60 пациентов с трудноконтролируемой артериальной гипертензией (ТАГ) (средний возраст 59,0 ± 9,4 лет). Были оценены изменения артериального давления (АД) и параметров вариабельности сердечного ритма (ВСР) при проведении сеансов биологической обратной связи (БОС) с контуром метрономизированного дыхания (МД) у пациентов с ТАГ на фоне стандартной медикаментозной терапии. Установлено, что систематическое проведение сеансов БОС в контуре МД
© Tymoshenko O. S., Yabluchansky M. I., 2017
у пациентов с ТАГ позволяет увеличить общую мощность спектра ВСР, показателей УЬГ и ИГ, а также улучшает контроль АД. Сеансы БОС в контуре МД могут быть рекомендованы в качестве дополнения к стандартной медикаментозной терапии пациентам с ТАГ.
КЛЮЧЕВЫЕ СЛОВА: биологическая обратная связь, вариабельность сердечного ритма, трудноконтролируемая артериальная гипертензия
INTRODUCTION
The inability to achieve the target level of blood pressure (BP) using three- and more-component drug therapy characterizes the difficult-to-control arterial hypertension (DTCAH). The prevalence of DTCAH in the population of people with arterial hypertension (AH) is from 15 to 30 % [1]. And the incidence of true refractory hypertension reaches 30 % of the total number of patients with DTCAH [2]. An insufficient effect of drug therapy is a prerequisite for finding additional, non-pharmacological methods of treatment. One of such methods is biofeedback (BFB) in loop of heart rate variability and paced breathing (PB).
Data from clinical trials demonstrate the efficacy of BFB in loop of heart rate variability (HRV) and PB for the treatment of patients with AH [3]. Systematic sessions of BFB in loop of HRV and PB affect the balance of the sympathetic and parasympathetic components of the autonomic nervous system [4]. Accordingly, the method influences BP and helps in achieving its control. However, in patients with DTCAH, the effectiveness of the method was not studied. It seems interesting to assess the response of BP and HRV parameters in patients with DTCAH on the background of drug support.
OBJECTIVE
Assessment of changes in BP and parameters of HRV during sessions of BFB in loop of HRV and PB in patients with DTCAH on the background of standard drug therapy.
MATERIALS AND METHODS
On the clinical base of the Kharkov city outpatient clinic № 24 and the State Institution «Kharkov Clinical Hospital for Railway Transport № 1» 60 patients with DTCAH were examined. The study involved 32 men and 28 women. Average age 59 ± 9,4 years. All patients participating in the study were randomly divided into two subgroups: BFB group with PB (33 patients) - main subgroup, comparison subgroup (27 patients).
The criterion of DTCAH was the presence of a persistent increase in BP above the target level, despite the simultaneous use of three or more antihypertensive drugs of various classes in adequate therapeutic doses, including a diuretic.
Exclusion criteria were heart failure functional class IV, acute coronary syndrome, rhythm and conduction disorders, diabetes mellitus, chronic respiratory insufficiency, bronchial asthma, chronic obstructive pulmonary diseases, peptic ulcer and duodenal ulcer at the stage of exacerbation, systemic diseases of connective tissue, tumors.
BP was measured by the Korotkov method with the tonometer Little doctor LD-91 in the sitting position after 15-minute rest.
The BFB was held in a sitting position after a 15-minute rest using a computer system CardioLab 2009 («HAI-Medica», Ukraine) with the «Biofeedback» module. The calculation of HRV parameters was carried out in real time within the 7-minute session.
The following parameters of HRV were determined in all subjects in 5-minute intervals to assess the state of regulatory systems [5]:
• TP - total power of the spectrum, a measure of the power of the effects of neurohumoral reactions (ms2);
• VLF - the power of the very low-frequency spectrum is associated with thermoregulation, renin-angiotensin system and sympathetic nervous system (ms2);
• LF - the power of the low-frequency spectrum is associated mainly with the sympathetic and partially parasympathetic links of regulation (ms2);
• HF - the power of the high-frequency domain of the spectrum is associated mainly with the parasympathetic regulating unit (ms2).
Accordingly with the purpose of the study, all patients were divided into two subgroups: basic (with BFB and PB) and a subgroup of comparison. For patients in the main subgroup, the breathing rate was set by the Biofeedback program module under the control of HRV parameters using the algorithm for finding the
optimal frequency of PB at the start with free breathing, while for patients of the comparison subgroup BFB sessions were simulated with respiratory rate equal to the free breathing frequency.
All patients received the same therapy in accordance with the recommendations on the prevention and treatment of AH of the Ukrainian and European associations of cardiologists [6]. Given the severity of hypertension, the presence of target organ damage and concomitant pathology, the following combinations of antihypertensive drugs were prescribed:
- Angiotensin-converting enzyme (ACE) inhibitor / renin-angiotensin-aldosterone blocker (RAAB) + calcium channel blocker (CCB) + diuretic.
- ACE inhibitor / blocker RAAB + CCB + diuretic + mineralocorticoid antagonist.
- Beta-adrenoblockers + ACE inhibitor / blocker RAAB + CCB + diuretic.
- ACE inhibitor / blocker RAAB + CCB + diuretic + antihypertensive drug with central action.
Statistical analysis was performed by using Microsoft Excel. In the table were recorded average values (M) and standard deviations (sd) of TP, VLF, LF, HF in patients with BFB in loop of heart rate variability and PB and in patients of comparison subgroup. The significance of differences of each of the indexes was determined by using the Student's t-test for unrelated samples.
RESULTS AND DISCUSSION
Changes in BP in patients with DTCAH in the subgroup with BFB in loop of PB and in the comparison subgroup are presented in Table 1.
Table 1
Changes in blood pressure in subgroups of patients with DTCAH during treatment (M ± sd, mm Hg)
Subgroups of patients
BP Main subgroup Comparison subgroup
indexes Phases of research
Before treatment 3 month 6 month 1 year Before treatment 3 month 6 month 1 year
SBP (M ± sd, mm Hg) 181 ± 176 ± 155 ± 149 ± 180 ± 18,9 179 ± 168 ± 157 ±
20,8* 15,7* 10,7 6,2 21,5** 17,2** 7,9
DBP (M ± sd, mm Hg) 101 ± 12,2 95 ± 8,5# 92 ± 6,9# 88 ± 3,1 102 ± 13,2 96 ± 8,2 94 ± 7,4 95 ± 4,9
Note: * — P < 0.05 in the series against the initial values; ** — P < 0.05 between series at the current stage; # — P < 0.05 in the series against the previous stage.
Antihypertensive therapy in combination with BFB in loop of PB showed more significant decrease in BP in patients with DTCAH than in patients with BFB without PB. After a three-month treatment in patients of subgroups with BFB in loop of PB SBP decreased by 1.02 times, DBP - by 1.06 times. At the stage of half-yearly treatment the dynamics of BP was looked as follows: SBP decreased by 1.2 times, DBP - by 1.1 times. The results of one-year follow-up showed that
SBP decreased by 1.2 times, DBP - by 1.14 times.
After a three-month stage of therapy the SBP in the comparison group decreased by 1.005 times, DBP - by 1.06 times. After half a year the SBP decreased by 1.07 times, DBP -by 1.08 times. At the annual stage SBP decreased by 1.1 times, DBP - by 1.07 times.
Table 2 shows the parameters of HRV in the subgroup of patients with BFB in loop of PB and in the comparison subgroup.
Table 2
Change in HRV parameters in subgroups of patients with BFB in loop of PB and in the comparison subgroup (M ± sd, ms2)
Subgroups of patients
HRV indexes Main subgroup Comparison subgroup
Phases of research
Before treatment 3 month 6 month 1 year Before treatment 3 month 6 month 1 year
TP 1632 ± 1853 ± 1945 ± 1973 ± 1535 ± 1503 ± 1426 ± 1497 ±
1589 1736 1583 1496 1383 1175*** 1327*** 1425***
VLF 630 ± 783 ± 963 ± 836 ± 572 ± 528±517# 583 ± 595 ±
838 954** 825** 793** 521 536# 427
LF 637 ± 698 ± 665 ± 648 ± 560 ± 538 ± 603 ± 627 ±
757 730 835 698 867} 624} 674 526
HF 335 ± 472 ± 438 ± 416 ± 357 ± 372 ± 324 ± 363 ±
446* 528* 516 549 375 493 295 305
Note: * — P < 0.01 in the series against the initial values;} — P < 0.01 between series at the current stage; ** — P < 0.05 in the series against the initial values; *** — P < 0.05 between series at the current stage; # — P < 0.05 in the series against the previous stage.
The baseline values of TP and VLF in the subgroup of patients with BFB and patients from comparison subgroup were almost identical (P < 0.05). Starting from the three-month stage BFB in loop of PB showed a positive effect on the HRV parameters, their more significant increase was observed with further preservation of the trend, while in the comparison subgroup they did not change during the entire monitoring period.
The initial level of HF in the compare subgroups was comparable (P < 0.05). BFB in loop of PB provided an increase in the indicator during monitoring period, whereas in the comparison subgroup it did not change significantly. The LF value remained almost the same in both subgroups (P < 0.05).
Comparison of BP and HRV parameters in patients with DTCAH in the main subgroup showed their synchronous positive dynamics, whereas in the comparison subgroup there were no significant changes.
The obtained results indicate that addition of drug therapy with BFB in loop of HRV and PB allows achieving better BP control in patients with DTCAH, which corresponds to the data in
patients with controlled hypertension [3, 4]. There are no publications on the effectiveness of the use of BFB in loop of HRV and PB in patients with DTCAH in literature.
The results of the study indicate that BFB in loop of HRV and PB can be used in patients with DTCAH to improve the quality of its control, which makes it possible to recommend the method as a component of non-drug treatment for patients with DTCAH.
CONCLUSIONS
1. Systematic sessions of BFB in loop of PB in patients with DTCAH allow increasing the overall power of the spectrum of HRV, including its components - VLF and HF, and also improve control of BP, while one drug therapy does not significantly effect on them.
2. BFB sessions in loop of PB can be recommended as a supplement to standard medical therapy for patients with DTCAH.
The efficacy of BFB in loop of HRV and PB in patients with DTCAH and controlled hypertension is the interest to compare in the future.
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