International Journal of Cardiology 190 (2015) 9–10
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Unilateral low-level transcutaneous electrical vagus nerve stimulation: A novel noninvasive treatment for myocardial infarction Zhuo Wang a,1, Xiaoya Zhou a,1, Xia Sheng b, Lilei Yu a,⁎, Hong Jiang a,⁎⁎ a b
Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China Department of Cardiology, Sir Run Run Shaw Hospital Affiliated to Medical College of Zhejiang University, Hangzhou, China
a r t i c l e
i n f o
Article history: Received 8 April 2015 Accepted 12 April 2015 Available online 14 April 2015 Keywords: Unilateral transcutaneous vagus nerve stimulation Myocardial infarction Remodeling
Cardiac dysfunction caused by interstitial fibrosis after myocardial infarction (MI) is referred to post-MI remodeling [1]. Following MI, the activity of sympathetic nerve system was heightened and the extent of interstitial fibrosis, which was influenced by the enhancing sympathetic nerve activity, determined the prognosis [2]. Some studies found that the vagus nerve stimulation (VNS) could regulate the imbalance of autonomic nervous system by enhancing vagal nerve activity to ameliorate post-MI remodeling [3]. The low-level VNS could suppress sympathetic nerve over-activity and some cytokine such as nitric oxide, transforming growth factor β and matrix metalloproteinases were involved in the low-level VNS-mediated attenuation of cardiac remodeling [4,5]. The right- or left-sided vagus nerve stimulation had previously been shown to be cardio-protective via the amelioration of LV remodeling in animal models [6] and had both improved cardiac function in patients with heart failure [7]. There is a cardiac neuronal hierarchy between the extrinsic and intrinsic cardiac autonomic nerve system in which the activity of the intrinsic nerve system may be under the control of the extrinsic nerve system. The VNS treatment was applied on the extrinsic vagal nerve to activate the afferent and efferent vagus nerve system. The central nerve system was modulated by the afferent nerve stimulation and the major intrinsic nerve system – ganglionated plexus and left stellate ganglion – was regulated by efferent vagus nerve stimulation [2]. All ⁎ Corresponding author. ⁎⁎ Correspondence to: H. Jiang, Department of Cardiology, Renmin Hospital of Wuhan University, No. 99 Zhangzhi Dong Road, Wuchang District, Wuhan City, Hubei Province 430060, China. E-mail addresses: [email protected] (L. Yu), [email protected] (H. Jiang). 1 Dr. Wang and Zhou contributed equally to this work.
http://dx.doi.org/10.1016/j.ijcard.2015.04.087 0167-5273/© 2015 Published by Elsevier Ireland Ltd.
cardio-protective effects caused by low-level VNS could be achieved by right-sided low-level transcutaneous VNS, which could not only stimulate the afferent vagus nerve to activate the nucleus tractus solitarius neurons that is an important neural substrate in the regulation of cardiovascular functions [3], but also simulate efferent vagus nerve to inhibit the activity of the major atrial ganglionated plexus [8]. The right low-level transcutaneous electrical stimulation of the auricular branch of vagus nerve could be substituted for VNS to regulate the imbalance of the autonomic nerve activity. Our previous researches found that bilateral low-level transcutaneous VNS improved cardiac function and prevents cardiac remodeling in beagle dog post-MI model [5], rightsided low-level transcutaneous VNS could reverse rapid atrial pacing induced atrial remodeling [9] and left-sided transcutaneous VNS against cardiac diseases with cardiac autonomic dysfunction will be as equally safe and efficacious as the right-sided [10]. Therefore, we think that unilateral low-level transcutaneous electrical vagus nerve stimulation could be a noninvasive approach to attenuate LV post-MI remodeling and a novel noninvasive treatment for myocardial infarction. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. Acknowledgment This work was supported by the grants from the National Natural Science Foundation of China No. 81270339 and No. 81300182, grant from the Natural Science Foundation of Hubei Province No. 2013CFB302, grant from the Natural Science Foundation of Zhejiang Province No. LY13H020003, and grants from the Fundamental Research Funds for the Central Universities No. 2042014kf0110 and No. 2042015kf0187. References [1] N. Ohmichi, N. Iwai, K. Maeda, H. Shimoike, Y. Nakamura, M. Izumi, Y. Sugimoto, M. Kinoshita, Genetic basis of left ventricular remodeling after myocardial infarction, Int. J. Cardiol. 53 (1996) 265–272. [2] M. Ogawa, S. Zhou, A.Y. Tan, J. Song, G. Gholmieh, M.C. Fishbein, H. Luo, R.J. Siegel, H.S. Karagueuzian, L.S. Chen, S.F. Lin, P.S. Chen, Left stellate ganglion and vagal nerve activity and cardiac arrhythmias in ambulatory dogs with pacing-induced congestive heart failure, J. Am. Coll. Cardiol. 50 (2007) 335–343.
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Z. Wang et al. / International Journal of Cardiology 190 (2015) 9–10
[3] Z. Wang, L. Yu, M. Chen, S. Wang, H. Jiang, Transcutaneous electrical stimulation of auricular branch of vagus nerve: A noninvasive therapeutic approach for postischemic heart failure, Int. J. Cardiol. 177 (2014) 676–677. [4] K.E. Brack, V.H. Patel, R. Mantravardi, J.H. Coote, G.A. Ng, Direct evidence of nitric oxide release from neuronal nitric oxide synthase activation in the left ventricle as a result of cervical vagus nerve stimulation, J. Physiol. 587 (2009) 3045–3054. [5] Z. Wang, L. Yu, S. Wang, B. Huang, K. Liao, G. Saren, T. Tan, H. Jiang, Chronic intermittent low-level transcutaneous electrical stimulation of auricular branch of vagus nerve improves left ventricular remodeling in conscious dogs with healed myocardial infarction, Circ. Heart Fail. 7 (2014) 1014–1021. [6] Z. Wang, L. Yu, B. Huang, S. Wang, K. Liao, G. Saren, X. Zhou, H. Jiang, Low-level transcutaneous electrical stimulation of the auricular branch of vagus nerve ameliorates left ventricular remodeling and dysfunction by downregulation of matrix metalloproteinase 9 and transforming growth factor beta1, J. Cardiovasc. Pharmacol. 65 (2015) 342–348.
[7] H.C. Patel, S.D. Rosen, A. Lindsay, C. Hayward, A.R. Lyon, C. di Mario, Targeting the autonomic nervous system: measuring autonomic function and novel devices for heart failure management, Int. J. Cardiol. 170 (2013) 107–117. [8] S. Stavrakis, M.B. Humphrey, B.J. Scherlag, Y. Hu, W.M. Jackman, H. Nakagawa, D. Lockwood, R. Lazzara, S.S. Po, Low-level transcutaneous electrical vagus nerve stimulation suppresses atrial fibrillation, J. Am. Coll. Cardiol. 65 (2015) 867–875. [9] L. Yu, B.J. Scherlag, S. Li, Y. Fan, J. Dyer, S. Male, V. Varma, Y. Sha, S. Stavrakis, S.S. Po, Low-level transcutaneous electrical stimulation of the auricular branch of the vagus nerve: a noninvasive approach to treat the initial phase of atrial fibrillation, Heart Rhythm. 10 (2013) 428–435. [10] M. Chen, L. Yu, F. Ouyang, Q. Liu, Z. Wang, S. Wang, L. Zhou, H. Jiang, S. Zhou, The right side or left side of noninvasive transcutaneous vagus nerve stimulation: based on conventional wisdom or scientific evidence? Int. J. Cardiol. 187 (2015) 44–45.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Unilateral low-level transcutaneous electrical vagus nerve stimulation: A novel noninvasive treatment for myocardial infarction Zhuo Wang a,1, Xiaoya Zhou a,1, Xia Sheng b, Lilei Yu a,⁎, Hong Jiang a,⁎⁎ a b
Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China Department of Cardiology, Sir Run Run Shaw Hospital Affiliated to Medical College of Zhejiang University, Hangzhou, China
a r t i c l e
i n f o
Article history: Received 8 April 2015 Accepted 12 April 2015 Available online 14 April 2015 Keywords: Unilateral transcutaneous vagus nerve stimulation Myocardial infarction Remodeling
Cardiac dysfunction caused by interstitial fibrosis after myocardial infarction (MI) is referred to post-MI remodeling [1]. Following MI, the activity of sympathetic nerve system was heightened and the extent of interstitial fibrosis, which was influenced by the enhancing sympathetic nerve activity, determined the prognosis [2]. Some studies found that the vagus nerve stimulation (VNS) could regulate the imbalance of autonomic nervous system by enhancing vagal nerve activity to ameliorate post-MI remodeling [3]. The low-level VNS could suppress sympathetic nerve over-activity and some cytokine such as nitric oxide, transforming growth factor β and matrix metalloproteinases were involved in the low-level VNS-mediated attenuation of cardiac remodeling [4,5]. The right- or left-sided vagus nerve stimulation had previously been shown to be cardio-protective via the amelioration of LV remodeling in animal models [6] and had both improved cardiac function in patients with heart failure [7]. There is a cardiac neuronal hierarchy between the extrinsic and intrinsic cardiac autonomic nerve system in which the activity of the intrinsic nerve system may be under the control of the extrinsic nerve system. The VNS treatment was applied on the extrinsic vagal nerve to activate the afferent and efferent vagus nerve system. The central nerve system was modulated by the afferent nerve stimulation and the major intrinsic nerve system – ganglionated plexus and left stellate ganglion – was regulated by efferent vagus nerve stimulation [2]. All ⁎ Corresponding author. ⁎⁎ Correspondence to: H. Jiang, Department of Cardiology, Renmin Hospital of Wuhan University, No. 99 Zhangzhi Dong Road, Wuchang District, Wuhan City, Hubei Province 430060, China. E-mail addresses: [email protected] (L. Yu), [email protected] (H. Jiang). 1 Dr. Wang and Zhou contributed equally to this work.
http://dx.doi.org/10.1016/j.ijcard.2015.04.087 0167-5273/© 2015 Published by Elsevier Ireland Ltd.
cardio-protective effects caused by low-level VNS could be achieved by right-sided low-level transcutaneous VNS, which could not only stimulate the afferent vagus nerve to activate the nucleus tractus solitarius neurons that is an important neural substrate in the regulation of cardiovascular functions [3], but also simulate efferent vagus nerve to inhibit the activity of the major atrial ganglionated plexus [8]. The right low-level transcutaneous electrical stimulation of the auricular branch of vagus nerve could be substituted for VNS to regulate the imbalance of the autonomic nerve activity. Our previous researches found that bilateral low-level transcutaneous VNS improved cardiac function and prevents cardiac remodeling in beagle dog post-MI model [5], rightsided low-level transcutaneous VNS could reverse rapid atrial pacing induced atrial remodeling [9] and left-sided transcutaneous VNS against cardiac diseases with cardiac autonomic dysfunction will be as equally safe and efficacious as the right-sided [10]. Therefore, we think that unilateral low-level transcutaneous electrical vagus nerve stimulation could be a noninvasive approach to attenuate LV post-MI remodeling and a novel noninvasive treatment for myocardial infarction. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. Acknowledgment This work was supported by the grants from the National Natural Science Foundation of China No. 81270339 and No. 81300182, grant from the Natural Science Foundation of Hubei Province No. 2013CFB302, grant from the Natural Science Foundation of Zhejiang Province No. LY13H020003, and grants from the Fundamental Research Funds for the Central Universities No. 2042014kf0110 and No. 2042015kf0187. References [1] N. Ohmichi, N. Iwai, K. Maeda, H. Shimoike, Y. Nakamura, M. Izumi, Y. Sugimoto, M. Kinoshita, Genetic basis of left ventricular remodeling after myocardial infarction, Int. J. Cardiol. 53 (1996) 265–272. [2] M. Ogawa, S. Zhou, A.Y. Tan, J. Song, G. Gholmieh, M.C. Fishbein, H. Luo, R.J. Siegel, H.S. Karagueuzian, L.S. Chen, S.F. Lin, P.S. Chen, Left stellate ganglion and vagal nerve activity and cardiac arrhythmias in ambulatory dogs with pacing-induced congestive heart failure, J. Am. Coll. Cardiol. 50 (2007) 335–343.
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Z. Wang et al. / International Journal of Cardiology 190 (2015) 9–10
[3] Z. Wang, L. Yu, M. Chen, S. Wang, H. Jiang, Transcutaneous electrical stimulation of auricular branch of vagus nerve: A noninvasive therapeutic approach for postischemic heart failure, Int. J. Cardiol. 177 (2014) 676–677. [4] K.E. Brack, V.H. Patel, R. Mantravardi, J.H. Coote, G.A. Ng, Direct evidence of nitric oxide release from neuronal nitric oxide synthase activation in the left ventricle as a result of cervical vagus nerve stimulation, J. Physiol. 587 (2009) 3045–3054. [5] Z. Wang, L. Yu, S. Wang, B. Huang, K. Liao, G. Saren, T. Tan, H. Jiang, Chronic intermittent low-level transcutaneous electrical stimulation of auricular branch of vagus nerve improves left ventricular remodeling in conscious dogs with healed myocardial infarction, Circ. Heart Fail. 7 (2014) 1014–1021. [6] Z. Wang, L. Yu, B. Huang, S. Wang, K. Liao, G. Saren, X. Zhou, H. Jiang, Low-level transcutaneous electrical stimulation of the auricular branch of vagus nerve ameliorates left ventricular remodeling and dysfunction by downregulation of matrix metalloproteinase 9 and transforming growth factor beta1, J. Cardiovasc. Pharmacol. 65 (2015) 342–348.
[7] H.C. Patel, S.D. Rosen, A. Lindsay, C. Hayward, A.R. Lyon, C. di Mario, Targeting the autonomic nervous system: measuring autonomic function and novel devices for heart failure management, Int. J. Cardiol. 170 (2013) 107–117. [8] S. Stavrakis, M.B. Humphrey, B.J. Scherlag, Y. Hu, W.M. Jackman, H. Nakagawa, D. Lockwood, R. Lazzara, S.S. Po, Low-level transcutaneous electrical vagus nerve stimulation suppresses atrial fibrillation, J. Am. Coll. Cardiol. 65 (2015) 867–875. [9] L. Yu, B.J. Scherlag, S. Li, Y. Fan, J. Dyer, S. Male, V. Varma, Y. Sha, S. Stavrakis, S.S. Po, Low-level transcutaneous electrical stimulation of the auricular branch of the vagus nerve: a noninvasive approach to treat the initial phase of atrial fibrillation, Heart Rhythm. 10 (2013) 428–435. [10] M. Chen, L. Yu, F. Ouyang, Q. Liu, Z. Wang, S. Wang, L. Zhou, H. Jiang, S. Zhou, The right side or left side of noninvasive transcutaneous vagus nerve stimulation: based on conventional wisdom or scientific evidence? Int. J. Cardiol. 187 (2015) 44–45.
