Hypertension and Autonomic Control
1Physiotherapy Department, Faculdade de Ciências e Tecnologia da UNESP – FCT/UNESP, Presidente Prudente, Brazil
Arterial hypertension is considered one of the most important public health problems and had their development, progression and complications associated with the autonomic nervous system (ANS). In this context, the present systematic review aim at gathering recent studies (2003-2013) that addressed the relation between ANS and hypertension, in order to update the knowledge in the last 10 years. Searches were made onMedLine / PubMed, PEDro, SciELO, IBECS, COCHRAINE and LILACS databases using the intersection between the keywords hypertension, autonomic nervous system, sympathetic nervous system , parasympathetic nervous system and heart rate variability”. A total of 17 articles were included and main findings of this review indicating the acute influence of the ANS in different types of hypertension characterized by a reduction of the overall heart rate variability (HRV) and a reduction in the parasympathetic component of ANS evaluated by linear indexes. In addition, the behavior of the sympathetic component could present an increase or a reduction according to the study design. Thus further studies to assess the influence of chronic influence of ANS on hypertension as well as investigations by nonlinear HRV indexes are needed.
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Keywords: hypertension, autonomic nervous system, sympathetic nervous system, parasympathetic nervous system
American Journal of Medical Sciences and Medicine, 2014 2 (2),
Received February 01, 2014; Revised April 17, 2014; Accepted April 28, 2014Copyright © 2013 Science and Education Publishing. All Rights Reserved.
Cite this article:
- Silva, Natália Turri da, et al. "Hypertension and Autonomic Control." American Journal of Medical Sciences and Medicine 2.2 (2014): 48-53.
- Silva, N. T. D. , Giacon, T. R. , Vanderlei, F. M. , Vitor, A. L. R. , Pastre, C. M. , & Vanderlei, L. C. M. (2014). Hypertension and Autonomic Control. American Journal of Medical Sciences and Medicine, 2(2), 48-53.
- Silva, Natália Turri da, Thais Roque Giacon, Franciele Marques Vanderlei, Ana Laura Ricci Vitor, Carlos Marcelo Pastre, and Luiz Carlos Marques Vanderlei. "Hypertension and Autonomic Control." American Journal of Medical Sciences and Medicine 2, no. 2 (2014): 48-53.
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The arterial hypertension (AH) has a multifactorial nature, defined as constants high levels of blood pressure [1, 2] and presented in one in three adults worldwide , had their development, progression and complications associated with the autonomic nervous system (ANS) once the enhanced sympathetic activation is essential for the comprehension of human hypertension pathophysiology [3, 4, 5, 6].
The increment of muscle sympathetic nerve activity as well as the augmented cardiac and renal noradrenalin release from the sympathetic nerves is a feature in patients with essential hypertension . The sympathetic activation, a branch of autonomic control reaching about 20% to 30% of essential hypertension  and is evident even in very low risk subjects with high-normal blood pressure. Additionally, the resting sympathetic excitation may precede overt AH .
One method of assessing the ANS is by the heart rate variability (HRV), an investigative resource that informs the system situation. In general HRV describes the oscillations between consecutive hearts beat intervals (RR) that are related with the influences of ANS on sinus node [8, 9]. Considering the changes on HRV pattern offering a sensitive and advance indicator of health impairments , the interest from the perspective of hypertension is still greater. Additionally the AH is related with functional and structural alterations  of several organs as heart, brain, kidneys and blood vessels and considered as a risk factor to the development of clinical manifestations of atherosclerosis, that increase the probability of cardiac incidents (ischemic heart disease, sudden death and general mortality), placing the importance of controlling the related factors as a matter of public health .
In this context the present study aim at gathering recent studies that addressed the relation between ANS and hypertension in order to better understand the influence of ANS on the AH and provide an update of knowledge in the last 10 years.
2. Methods2.1. Search Strategy and Selection
The revision were made between March 2013 and April 2013 on Medical Literature Analysis and Retrieval System Online (MedLine/Pubmed), Physiotherapy Evidence Database (PEDro), Scientific Electronic Library Online (SciELO), Spanish Bibliographic Index of Health Sciences (IBECS), Cochraine Library and Latin American and Caribbean Literature on Health Sciences (LILACS) databases.
The keywords were chosen in advance by the Health Sciences Descriptors (DeCS) and their corresponding in English - Medical Subject Headings (MeSH). The keyword “hypertension” combined with the keyword “autonomic nervous system”, “sympathetic nervous system”, “parasympathetic nervous system” were used as well as to the non-descriptor but keyword of this study “heart rate variability”.2.2. Inclusion Criteria
The revision included studies with human samples from the period 2003 to 2013 in Portuguese, Spanish and English, that addressed hypertension and autonomic control jointly, under resting conditions, that used the heart rate variability to assess autonomic nervous system and it had theirs full texts available. All types of study design were included.2.3. Exclusion Criteria
The exclusion of studies was based on those with editorial format, who described the medicine intervention on autonomic nervous system and whose focuses were not population basis.2.4. Selection Strategy
Firstly all the studies were submitted on a title selection, according to the inclusion criteria established. For this, the title should express as focus of the study the following aspects: the autonomic analysis in hypertensive individuals, the hypertension influence on autonomic nervous system, the hypertension consequences on cardiovascular modulation and those related to hypertension or some information concerning this framework, such as high blood pressure, high systolic or diastolic pressure increased with the words parasympathetic and / or sympathetic nervous system.
In sequence, the results were filtered to identify repetitions due to the use of several databases. The titles chosen have their abstract read in order to select the articles that dealt specifically HRV in hypertensive individuals.
Subsequently, when the abstracts discoursed about the subject discussed, theirs complete articles were totally read. Furthermore, the references of the selection studies were revised in order to complementary the search. All senior reviewer who judged about the articles inclusion.2.5. Date Analysis
The data analyzed by a qualitative form and tabulated in accordance to the authors and year of the study, description of the population, protocol used, studied variables and outcomes. It was used the executive summary for selected articles that had no full version available.
The results had a total of 17 articles included. Initially 2941 items were found among all the databases listed (Medline, Lilacs, Pubmed, Ibecs, Cocrhane e Pedro) with the pre intersections established by the descriptors. All articles were listed on a Microsoft Excel spread sheet and after discard the repetitions among the databases, 112 articles were remained.
Among the 112 articles, just 25 were used HRV as autonomic nervous system tool and had their texts read integrally. After reading the texts, remained 17 articles, because five were not included due to the stipulated languages (English, Spanish or Portuguese), one, because the non-inclusion of hypertensive individuals diagnosed and two, non-population base studies.
Selected articles were organized into tables containing the following items: author / year, population, methods / indexes and conclusions, being divided into two groups according to their nature. In the first group of articles, the authors compared the ANS action in normotension and different types of hypertension describes as following normotension and essential hypertension [12, 13, 14, 15]; normotension, essential hypertension and white coat hypertension [16, 17]; normotension and recent hypertension ; normotension, essential hypertension and recent hypertension , hypertension associated or not associated with left ventricular dysfunction and normotension , white coat hypertension, masked hypertension and hypertension sustained , in recent hypertension and normotension  (Table 1).
The second group consists of articles assessing the ANS under different influences, such as time , circadian rhythm , age and posture , QT interval , awake state and sleep , menopause  (Table 2).
The review´s main findings the acute influence of the ANS in different types of hypertension, indicating a reduction in overall HRV [12, 13, 14, 19, 22, 23] evaluated by linear indexes and including present on primary hypertension in the adolescent period .
About the reduction of global variability, Çelik et al14 discussed the association with a inflammatory process present in hypertensive individuals, indicated in the study by the high values of the C- reative protein.
Table 1. Articles about the autonomic nervous system comparing normotension and different types of hypertension, organized in chronological order
Table 2. Articles about the autonomic nervous system evaluation related with the time, circadian rhythm, posture and age, QT interval, awake state and sleep, menopause, organized in chronological order
Different results were found regarding the behavior of the sympathetic nervous system (SNS). There isn´t a consented about the answers obtained by the HRV index analysed (LF, VLF) that can be occurred due to the use of different evaluation protocols of evaluation involving changing positions, permanence in different positions of rest(supine or standing) and evaluation in autonomic tests.
BajkóZoltán et al ; Neumann et al , Prakash et al , e Karas M et al  indicated lower simpathetic acting in hypertensive individuals when evaluated in rest and absoluted units of potence, however in the white coat hypertension was observed an increase in this component independing the rest position – supine or standing ; as well as along the day and in awake state in adolescents with a primary hypertension ; in hypertensive with or without the left ventricular dysfunction as in supine rest as post tilt test  and in decubit changes since rest to standing rest .
For intervention about this simpathetic increase Madsen et al  showed the respiratory control is able to reduce your action independent the kind of hypertension being the respiratory control a form to intervent on vagal balance.
In general the studies of Virtanen et al ; Neumann et al ; Prakash et al ; Piccirillo et al , Fagard RH ; Pavithran P ; Karas M et al  have demonstrated reduction in parassimpathetic nervous system, related by Pavithran et al  a lower parassimpathetic action in supine position.
Just one study ilustrated the cronic influence of the ANS in arterial hypertension, when did two evaluation, 9 years of interval between them, in more than 11 hundred individuals and showed further the reduction on HRV in hypertensive, pre disposition to arterial hypertension in normotensive individuals, but with low HRV in 9 years, sugaring the ANS is involved on development of arterial hypertension .
In general, the texts analysis in this revision indicated the HVR indexes commonly used to analyze hypertension are obtained by linear method at time and frequency domains, which can be related with already wide knowledge about this analyses type.
Referring to the hypertension characterization was observed that the studies published on the last 10 years have addressed it in different aspects such it pre hypertension, systemic arterial hypertension and white-coat hypertension, with the included subjects in each group according to previously established scientific nomenclatures.
An important highlight is the different methods of capturing HRV. Portable instruments such as heart monitors, electrocardiograms and new analysis tools were employed illustrating the possibility of multiple signal acquisition. Furthermore, it was observed in the analysis of the articles that the recommendation not to consume substances that could interfere with the autonomic balance was not always described, which may have influenced the autonomic behavior in some studies.
In relation to the participant population, the age of hypertensive individuals analyzed was in majority above 30 years old, being adolescent and infant population little explored. In this revision just Havlíceková  did an analysis of autonomic behavior in front of view the hypertensive in adolescent population, between 14 to 19 years old. Still regarding the participant population, a great variation at sampling number can be considered, including studies since 22  until 11061 individuals .
The studies selected for this review were developed in Hungary , Italy [20, 26], Slovakia , India [18, 19, 22], Canada , Japan , Germany , Denmark , Poland , Finland , Belgium , Pennsylvania  and Turkey . There was a European predominance concerning studies involving assessment of autonomic modulation in hypertensive patients.
The mainly aspects of this revision pointed to a acute influence of the autonomic nervous system in different kinds of arterial hypertension caracterized by a decrease in global variability and parassimpathetic component of autonomic nervous system elauated by linear índex. Furthermore, the sympathetic behavior reveal as an increase or decrease according the studies. In this context, more studies about the cronic influence on ANS are necessary and the exploration by non linear index.
It is strongly clarified that hypertension promotes an autonomic imbalance, engendering difficult of adaptation to minimum stress conditions, as physical as mental. This imbalance between SNS and PNS contributes to installation of diseases in different corporal system, mainly attacking the cardiovascular health [10, 30, 31]. Something to be considered is the non-linear behavior of RR intervals. In order to implement the knowledge about the autonomic nervous system behavior in hypertensive individuals, new studies must be done using this type of analysis.
To Laboratory of physiologist of stress
Statement of Competing Interests
There was no conflict of interest.
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