神经介导性晕厥患者硝酸甘油激发倾斜试验中的内源性阿片类物质和肾上腺素

Takase Bonpei, Matsushima Yoshihiro, Umeda Eiichiro, Satomura Kimio, Katsushika Shuichi, Ohsuzu Fumitaka, Sato Tetsuo, Kurita Akira

Intensive Care Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan.

Jpn Heart J. 2003 Jul;44(4):493-503. doi: 10.1536/jhj.44.493.

Endogenous opioids and catecholamines are involved in autonomic activity. Nitroglycerin provocation tilt is a useful modality for evaluating neurally mediated syncope. Endogenous opioids and epinephrine might play an important role in nitroglycerin provocation tilt. To investigate whether or not opioids and catecholamines are involved in the pathogenesis of nitroglycerin provocation tilt, we measured the temporal changes of the plasma levels of beta endorphin, norepinephrine, and epinephrine in 64 patients with syncope of unknown etiology, and compared the findings with those of 16 patients who underwent isoproterenol provocation tilt (1-3 microg/min) test with a positive response. We performed a 20 minute control tilt (80 degrees) followed by a nitroglycerin provocation tilt of 20 minutes with the intravenous infusion of nitroglycerin. Nitroglycerin infusion was started at 250 microg/h, and was increased by 250 microg/h every 3 minutes up to 1500 microg/h during the tilt test. Beta-endorphin, norepinephrine, and epinephrine were measured in peripheral venous blood in the supine position 2, 10, and 20 minutes after the start of the tilt test, and also at the onset of syncope. Twenty-six patients had a positive response to the control tilt (group 1), and 22 patients had a positive response to nitroglycerin provocation tilt (group 2). The remaining 16 patients had a negative response to both control tilt and nitroglycerin provocation tilt (group 3), compared with isoproterenol provocation tilt patients (group 4). Beta-endorphin and epinephrine only significantly increased in groups 1 and 2 (beta-endorphin; from 7.3 +/- 3.3 pg/mL to 19.9 +/- 17.7 pg/mL, in group 1, P < 0.05; from 7.3 +/- 2.9 to 16.5 +/- 10.7 pg/mL, in group 2, P < 0.05; epinephrine; from 42 +/- 58 pg/mL to 157 +/- 161 pg/mL, in group 1, P < 0.05: from 33 +/- 25 to 202 +/- 252 pg/mL, in group 2, P < 0.05), but not in groups 3 and 4. Beta-endorphin and epinephrine might participate in the pathophysiology in conventional tilt-induced as well as nitroglycerin provocation tilt-induced syncope in patients with neurally mediated syncope.

内源性阿片类物质和儿茶酚胺参与自主神经活动。硝酸甘油激发倾斜试验是评估神经介导性晕厥的一种有用方法。内源性阿片类物质和肾上腺素可能在硝酸甘油激发倾斜试验中起重要作用。为了研究阿片类物质和儿茶酚胺是否参与硝酸甘油激发倾斜试验的发病机制，我们测量了64例不明原因晕厥患者血浆β-内啡肽、去甲肾上腺素和肾上腺素水平的时间变化，并将结果与16例异丙肾上腺素激发倾斜试验（1 - 3μg/min）呈阳性反应的患者进行比较。我们先进行20分钟的对照倾斜试验（80度），然后静脉输注硝酸甘油进行20分钟的硝酸甘油激发倾斜试验。硝酸甘油输注从250μg/h开始，在倾斜试验期间每3分钟增加250μg/h，直至1500μg/h。在倾斜试验开始后2分钟、10分钟和20分钟以及晕厥发作时，于外周静脉血中测量β-内啡肽、去甲肾上腺素和肾上腺素。26例患者对照倾斜试验呈阳性反应（第1组），22例患者硝酸甘油激发倾斜试验呈阳性反应（第2组）。其余16例患者对照倾斜试验和硝酸甘油激发倾斜试验均呈阴性反应（第3组），与异丙肾上腺素激发倾斜试验患者（第4组）相比。仅第1组和第2组的β-内啡肽和肾上腺素显著升高（β-内啡肽：第1组从7.3±3.3 pg/mL升至19.9±17.7 pg/mL，P<0.05；第2组从7.3±2.9升至16.5±10.7 pg/mL，P<0.05；肾上腺素：第1组从42±58 pg/mL升至157±161 pg/mL，P<0.05；第2组从33±25升至202±252 pg/mL，P<0.05），而第3组和第4组未升高。β-内啡肽和肾上腺素可能参与神经介导性晕厥患者传统倾斜诱发以及硝酸甘油激发倾斜诱发晕厥的病理生理过程。