Annals of Internal Medicine 5 September 2000 Volume 133 Number 5 Cardiac Sympathetic Denervation in Parkinson Disease David S. Goldstein, MD, PhD; Courtney Holmes, CMT; Sheng-Ting Li, MD; Simon Bruce, MD; Leo Verhagen Metman, MD; and Richard O. Cannon, MD Ann Intern Med. 2000;133:338-347. Orthostatic hypotension is common in Parkinson disease (1). Although earlier studies implicated L-dopa treatment as the cause (2), more recent studies have shown that orthostatic hypotension may result from deficient cardiovascular reflexes that depend on release of the sympathetic neurotransmitter norepinephrine in the heart and blood vessels (3-5). We call this phenomenon "sympathetic neurocirculatory failure." Several recent studies have reported decreased myocardial concentrations of radioactivity after injection of the sympathoneural imaging agent123 I-metaiodobenzylguanidine (123 I-MIBG) in patients with Parkinson disease (6-13). This finding is consistent with but does not prove cardiac sympathetic denervation. In addition, studies have not specifically considered the possible association between cardiac sympathetic denervation and sympathetic neurocirculatory failure in Parkinson disease. Measures of autonomic function have included blood pressure during tilt-table testing (abnormalities of which can have several causes), heart rate responses to the Valsalva maneuver (which are determined mainly by changes in parasympathetic cholinergic outflow to the heart), or skin conductance or sweating responses (which are determined mainly by alterations in sympathetic cholinergic outflow to the skin). These measures may not allow assessment of sympathetic noradrenergic function. One way to detect sympathetic neurocirculatory failure in a patient with orthostatic hypotension is by analyzing beat-to-beat blood pressure associated with performance of the Valsalva maneuver (Figure 1 ). In patients with sympathetic neurocirculatory failure, blood pressure decreases progressively during phase II of the maneuver, whereas normally blood pressure plateaus or increases at the end of phase II (phase II-L). In patients with sympathetic neurocirculatory failure, phase IV blood pressure increases slowly back to baseline after release of the maneuver, whereas normally blood pressure "overshoots." These abnormalities are a direct result of deficient cardiovascular reflexes that depend on sympathetically mediated release of norepinephrine. In our study, we defined sympathetic neurocirculatory failure as chronic, reproducible orthostatic hypotension associated with abnormal blood pressure responses in both phase II-L and phase IV of the Valsalva maneuver. Previous studies also have not independently confirmed that a low myocardial concentration of123 I-MIBG-derived radioactivity actually reflects cardiac sympathetic denervation in Parkinson disease. Neurochemical findings indicating decreased norepinephrine release, neuronal uptake, turnover, and synthesis in the heart could provide such confirmation. In humans, 6-[18 F]fluorodopamine can be used to visualize cardiac sympathetic innervation by positron emission tomographic (PET) scanning (14), which provides excellent spatial and temporal resolution. Since 6-[18 F]fluorodopamine is a catecholamine handled in the heart in a manner similar to the way in which norepinephrine is handled (15), PET scanning may allow functional and anatomic assessments of sympathetic cardiac innervation (16). We used PET scanning after injection of 6-[18 F]fluorodopamine and neurochemical measurements during cardiac catheterization to answer the following questions: 1) What proportions of patients with Parkinson disease, with or without sympathetic neurocirculatory failure, have decreased myocardial 6-[18 F]fluorodopamine-derived radioactivity? 2) Does decreased myocardial 6-[18 F]fluorodopamine-derived radioactivity in Parkinson disease actually reflect cardiac sympathetic denervation, as identified by indices of cardiac norepinephrine release, neuronal uptake, turnover, and synthesis? 3) Does the frequency of cardiac sympathetic denervation differ between groups of patients with Parkinson disease who have sympathetic neurocirculatory failure and those who do not? 4) Does cardiac sympathetic denervation also occur in patients with multiple-system atrophy, a progressive neurodegenerative disease of adults that features autonomic dysfunction and has parkinsonian, cerebellar, or mixed forms (17) ? (The diagnosis of multiple-system atrophy is clinical and, except for a typically poor response to L-dopa treatment, can be difficult to distinguish from Parkinson disease.) 5) Is cardiac sympathetic denervation in patients with Parkinson disease related to L-dopa treatment or to disease duration or severity? Methods The Intramural Research Board of the National Institute of Neurological Disorders and Stroke approved the study protocol. All participants provided written informed consent. Participants We included patients with Parkinson disease or multiple-system atrophy who were studied at the National Institutes of Health Clinical Center in Bethesda, Maryland. Twenty-nine patients had Parkinson disease, including 10 who were not receiving or had never received L-dopa. Twenty-four patients had multiple-system atrophy, including 8 who were taking L-dopa at the time of evaluation. For comparison, we used 6-[18 F]fluorodopamine PET scan data and, in most cases, cardiac neurochemical data from 7 patients with pure autonomic failure (5 men, 2 women [mean age SE, 60 6 years]) and 33 controls. Of these 33 controls, 22 had a history of neurocardiogenic syncope (4 men, 18 women [mean age, 35 3 years]) and 11 had a history of postural tachycardia syndrome (1 man, 10 women [mean age, 42 4 years]). 6-[18 F]fluorodopamine PET scan data were also obtained from 19 normal volunteers. All patients with Parkinson disease were referred by neurologists or movement disorder clinics and fulfilled accepted clinical criteria (18). Parkinson disease was staged by using the Hoehn-Yahr classification. All affected patients had bradykinesia, "cogwheel" rigidity, and one or more additional parkinsonian features ("pill-roll tremor," stooped posture, festinating gait, difficulty initiating movement, masklike face, micrographia, or marked improvement in motor function during treatment with L-dopa). Patients with multiple-system atrophy had at least two parkinsonian features but were not classified in terms of cerebellar, parkinsonian, or mixed subtypes (17). All had gradually progressive parasympathetic failure (manifested by impotence in men, urinary retention or incontinence, constipation, or constant pulse rate) and had one or more additional features of multiple-system atrophy (heat or cold intolerance and decreased sweating, intention tremor or other evidence of cerebellar dysfunction, slurred speech or a history of aspiration, or no or only slight improvement during an adequate trial of L-dopa treatment). Sympathetic neurocirculatory failure was defined as reproducible, chronic orthostatic hypotension (decrease in diastolic pressure of at least 10 mm Hg and in systolic pressure of at least 20 mm of Hg after 3 to 5 minutes of standing), coupled with abnormal responses of beat-to-beat blood pressure associated with the Valsalva maneuver (19). As noted previously, patients with sympathetic neurocirculatory failure usually exhibit a progressive decrease in blood pressure in phase II-L of the maneuver and an absence of a pressure "overshoot" in phase IV after release of the maneuver. Valsalva Maneuver For the Valsalva maneuver, the patient lay supine with his or her head on a pillow and blew into a plastic or rubber tube connected to a sphygmomanometer, keeping a pressure of 30 mm Hg for 10 to 12 seconds. The response of beat-to-beat blood pressure during phase II-L of the Valsalva maneuver was considered to be normal if the diastolic and mean arterial pressure increased before the end of the straining and abnormal if they decreased. The response during phase IV was considered to be normal if the systolic blood pressure increased progressively to a value exceeding the baseline (measured just before the patient inhaled and then began straining) and abnormal if the systolic pressure did not exceed the baseline. Sympathetic Neuroimaging Patients were positioned in a GE Advance scanner (General Electric, Milwaukee, Wisconsin), with their thoraxes in the gantry. 6-[18 F]fluorodopamine (specific activity, 7.4 to 37 MBq/mmol; dose in most cases, 0.037 MBq) was dissolved in approximately 10 mL of normal saline and infused intravenously at a constant rate for 3 minutes. Thoracic PET scanning was performed for up to 3 hours. The tomographic data were divided into intervals of 5 to 30 minutes. Data acquisition was not gated to the electrocardiogram. In most patients, PET scanning was also used to delineate the left ventricular myocardium and assess myocardial perfusion after administration of the perfusion imaging agent13 N-ammonia. Intravenously injected13 N-ammonia exits the bloodstream rapidly and enters cells nonspecifically. A few minutes after the injection, the concentration of13 N-ammonia-derived radioactivity in the left ventricular myocardium exceeds that in the left ventricular chamber, enabling visualization of the myocardium. Myocardial tissue concentrations of13 N-ammonia-derived radioactivity depend on local perfusion (20). Neurochemical Testing Patients underwent right-heart catheterization for measurements of norepinephrine spillover into coronary sinus plasma and of venous-arterial differences in plasma levels of dihydroxyphenylglycol (DHPG) and L-dopa. After placement of arm and right internal jugular venous catheters (the latter advanced into the coronary sinus), a tracer amount of [3 H]norepinephrine (levo- [2,5,6] [3 H]norepinephrine, New England Nuclear, Boston, Massachusetts) was infused intravenously. Coronary sinus blood flow was measured by thermodilution, and arterial and great cardiac venous or coronary sinus blood was sampled after at least 20 minutes. Arterial and cardiac venous plasma samples were assayed simultaneously for total and [3 H]-labeled norepinephrine, DHPG, and L-dopa (21). Statistical Analysis Cardiac images were analyzed as described elsewhere (22). Circular regions of interest (diameters about half the width of the ventricular wall) were created by using time-averaged images of single slices. Septal myocardial concentrations of 6-[18 F]fluorodopamine-derived radioactivity were used because the left ventricular free wall could not be identified with certainty due to markedly decreased 6-[18 F]fluorodopamine-derived radioactivity in many patients with sympathetic neurocirculatory failure. During infusion of 6-[18 F]fluorodopamine, the concentration of 6-[18 F]fluorodopamine-derived radioactivity in the ventricular chambers exceeds that in the interventricular septum, allowing identification of the septum by negative contrast and placement of a septal region of interest. Radioactivity concentrations, expressed in units of Bq/mL per MBq/kg of injected 6-[18 F]fluorodopamine were measured for the scanning interval between 5 and 10 minutes after initiation of the 3-minute infusion of 6-[18 F]fluorodopamine. Mean values for 6-[18 F]fluorodopamine-derived radioactivity, cardiac norepinephrine spillover, and venous-arterial differences in plasma levels of DHPG and L-dopa in the patient groups were compared by analyses of variance or (if two compared groups) by independent-means t-tests. Relationships between 6-[18 F]fluorodopamine-derived radioactivity and neurochemical measures were assessed by linear and curvilinear (logarithmic) regression. A P value less than 0.05 was considered statistically significant. Results We found no relationship between sympathetic neurocirculatory failure and treatment with L-dopa (Table 1 ). Patients with Parkinson disease and sympathetic neurocirculatory failure did not differ from patients with Parkinson disease and no sympathetic neurocirculatory failure in mean duration of Parkinson disease (6.2 2.1 years vs. 6.5 0.9 years, respectively) or in stage of Parkinson disease, as indicated by Hoehn-Yahr classification (2.4 0.5 vs. 1.9 0.2, respectively). Patients with Parkinson disease and sympathetic neurocirculatory failure tended to be older than patients with Parkinson disease and no sympathetic neurocirculatory failure (70 3 years vs. 61 2 years, respectively) (t = 1.76; P = 0.09). The mean age of patients with multiple-system atrophy and sympathetic neurocirculatory failure (59 2 years) did not differ from that of patients with multiple-system atrophy and no sympathetic neurocirculatory failure (62 3 years). Valsalva Maneuver By definition, all 26 patients with sympathetic neurocirculatory failure (9 with Parkinson disease and 17 with multiple-system atrophy) had abnormal beat-to-beat blood pressure responses to the Valsalva maneuver (Table 2 ). The same qualitative abnormalities occurred in both patient groups. Twenty patients with Parkinson disease did not have sympathetic neurocirculatory failure (because they did not have orthostatic hypotension) and performed a technically adequate Valsalva maneuver. Of these, 12 had an abnormal response of beat-to-beat blood pressure during phase II-L or phase IV and 2 had an abnormal response during both phases (Table 2 ). All volunteers had normal blood pressure responses to the Valsalva maneuver, as did all patients with multiple-system atrophy who did not have sympathetic neurocirculatory failure and were able to perform a technically adequate Valsalva maneuver. Patients with Parkinson disease and sympathetic neurocirculatory failure tended to have smaller heart rate responses during phase II of the Valsalva maneuver (5.6 1.6 beats/min) (Figure 1 ) than patients with Parkinson disease who did not have sympathetic neurocirculatory failure (9.7 1.3 beats/min) (t = 1.8; P = 0.09). Heart rate responses during the Valsalva maneuver did not distinguish patients with Parkinson disease and sympathetic neurocirculatory failure from patients with multiple-system atrophy and sympathetic neurocirculatory failure (data not shown). Sympathetic Neuroimaging Myocardial concentrations of 6-[18 F]fluorodopamine-derived radioactivity varied highly significantly as a function of patient group (F = 26.3; P < 0.001). All 9 patients with Parkinson disease and sympathetic neurocirculatory failure had markedly decreased septal myocardial concentrations of 6-[18 F]fluorodopamine-derived radioactivity (2753 414 Bq/mL per MBq/kg) (Figure 2 ) compared with normal volunteers (9118 483 Bq/mL per MBq/kg) (t = 8.2; P < 0.001). Values among these patients were similar to those in patients with pure autonomic failure (3814 778 Bq/mL per MBq/kg). In contrast, all 24 patients with multiple-system atrophy had normal myocardial concentrations of 6-[18 F]fluorodopamine-derived radioactivity, regardless of the occurrence of sympathetic neurocirculatory failure. The values were similar to those in patients with episodic or persistent orthostatic intolerance. The difference in mean 6-[18 F]fluorodopamine-derived radioactivity between patients with Parkinson disease and sympathetic neurocirculatory failure and patients with multiple-system atrophy and sympathetic neurocirculatory failure (10 227 354 Bq/mL per MBq/kg) was also highly statistically significant (t = 13.0; P < 0.001). Among the 20 patients with Parkinson disease who did not have sympathetic neurocirculatory failure, 11 had markedly decreased septal myocardial concentrations of 6-[18 F]fluorodopamine-derived radioactivity (Figure 2 ). The mean myocardial concentration of 6-[18 F]fluorodopamine-derived radioactivity (5217 525 Bq/mL per MBq/kg) was less than that in patients with multiple-system atrophy who did not have sympathetic neurocirculatory failure (8724 653 Bq/mL per MBq/kg) (t = 3.6; P = 0.0013) and less than normal (t = 5.5; P < 0.001). The mean septal myocardial concentration of 6-[18 F]fluorodopamine-derived radioactivity was significantly higher in patients with Parkinson disease who did not have sympathetic neurocirculatory failure than in those who did (t = 2.9; P = 0.007). The mean age of patients with Parkinson disease and diffusely decreased myocardial concentration of 6-[18 F]fluorodopamine-derived radioactivity (66 2 years) was significantly greater than that of the patients with localized decreases in 6-[18 F]fluorodopamine-derived radioactivity (57 3 years) (t = 2.8; P = 0.01). Five of these 20 patients had decreased 6-[18 F]fluorodopamine-derived radioactivity that was localized to the left ventricular apex or free wall, as judged from visual inspection of PET scans. Therefore, only 4 patients with Parkinson disease had completely normal 6-[18 F]fluorodopamine-derived radioactivity in all parts of the left ventricular myocardium. Cardiac Catheterization All six patients with Parkinson disease and low myocardial concentrations of 6-[18 F]fluorodopamine-derived radioactivity who underwent right-heart catheterization had markedly decreased cardiac extraction of [3 H]norepinephrine, norepinephrine spillover, and cardiac venous-arterial increments in plasma levels of DHPG and L-dopa compared with patients who had chronic orthostatic intolerance or multiple-system atrophy. The values in patients with Parkinson disease and sympathetic neurocirculatory failure were similar to those in patients with pure autonomic failure (Figures 3 and 4 ). Among all patients, the concentration of 6-[18 F]fluorodopamine-derived radioactivity had a linearly positive correlation with the extraction fraction of [3 H]norepinephrine (r = 0.74; P < 0.001) (Figure 3 ), a curvilinearly positive correlation with cardiac norepinephrine spillover (r = 0.59 for the relationship with the logarithm of norepinephrine spillover; P < 0.001), and a curvilinearly positive correlation with the cardiac venous-arterial differences in plasma levels of DHPG and L-dopa (Figure 4 ). We found a linearly positive correlation between the venous-arterial differences in plasma levels of DHPG and L-dopa (r = 0.80; P < 0.001). Mean total-body norepinephrine spillover (that is, the appearance rate of norepinephrine in arterial plasma) in patients with Parkinson disease and sympathetic neurocirculatory failure (4.61 1.56 nmol/min) did not differ significantly from that in patients with multiple-system atrophy and sympathetic neurocirculatory failure (2.95 0.34 nmol/min) and tended to exceed that in patients with pure autonomic failure (0.87 0.24 nmol/min) (t = 2.1; P = 0.06). Discussion In our study, patients with Parkinson disease who had sympathetic neurocirculatory failure, as detected by chronic orthostatic hypotension and abnormal beat-to-beat blood pressure responses to the Valsalva maneuver, all had markedly decreased 6-[18 F]fluorodopamine-derived radioactivity. In addition, half of patients who did not have sympathetic neurocirculatory failure had diffusely decreased concentrations of 6-[18 F]fluorodopamine-derived radioactivity in the left ventricular myocardium. Therefore, a low myocardial concentration of 6-[18 F]fluorodopamine-derived radioactivity was typical in most patients with Parkinson disease and in all patients with Parkinson disease who had sympathetic neurocirculatory failure. The neurochemical findings from right-heart catheterization indicated that in patients with Parkinson disease, low myocardial concentrations of 6-[18 F]fluorodopamine-derived radioactivity reflect loss of functional sympathetic nerve terminals. All patients with Parkinson disease who had low myocardial concentrations of 6-[18 F]fluorodopamine-derived radioactivity and underwent right-heart catheterization had markedly decreased cardiac extraction of circulating [3 H]norepinephrine. This extraction depends mainly on neuronal uptake by way of the membrane norepinephrine transporter (23). All of these patients had a markedly decreased estimated rate of entry of endogenous norepinephrine into the cardiac venous plasma (cardiac norepinephrine spillover). Cardiac norepinephrine spillover depends on release of norepinephrine from local sympathetic nerves (24). All of these patients had virtual absence of a venous-arterial increment in plasma levels of DHPG. Under resting conditions, this increment mainly reflects turnover of norepinephrine stored in vesicles in sympathetic nerves (25). Finally, all of these patients had virtual absence of a venous-arterial increment in plasma levels of endogenous L-dopa. This increment mainly reflects biosynthesis of norepinephrine in sympathetic nerves (26, 27). We believe that these results, which indicated decreased neuronal uptake, release, turnover, and synthesis of norepinephrine, can be explained only by loss of functional cardiac sympathetic nerve terminals. Four patients with Parkinson disease had discontinued L-dopa treatment at the time of evaluation, and 6 had never taken L-dopa. Moreover, all 8 patients with multiple-system atrophy who were taking L-dopa at the time of evaluation had normal myocardial 6-[18 F]fluorodopamine-derived radioactivity. These findings exclude L-dopa treatment as an explanation for cardiac sympathetic denervation in Parkinson disease. Because the mean duration and clinical stage of Parkinson disease in patients with sympathetic neurocirculatory failure did not differ from those in patients without sympathetic neurocirculatory failure, cardiac sympathetic denervation in Parkinson disease does not seem to be restricted to severe cases or to occur as a late consequence of the disease. In our study, several patients first came to clinical attention for symptoms and signs of autonomic failure; symptoms and signs of Parkinson disease became evident only years later. Nevertheless, because this was a cross-sectional and not a longitudinal study, our results do not exclude the possibility that patients with cardiac sympathetic denervation but without orthostatic hypotension eventually develop clinically overt sympathetic neurocirculatory failure. In our study, all patients with Parkinson disease and sympathetic neurocirculatory failure had markedly decreased septal myocardial 6-[18 F]fluorodopamine-derived radioactivity, and approximately 50% of patients with Parkinson disease who did not have sympathetic neurocirculatory failure nevertheless had decreased septal radioactivity. Decreased myocardial 6-[18 F]fluorodopamine-derived radioactivity may therefore be a more sensitive test for loss of sympathetic terminal innervation in Parkinson disease than clinical physiologic changes. Although studies using123 I-MIBG have shown a remarkably high frequency of decreased myocardial123 I-MIBG-derived radioactivity in patients with Parkinson disease, the studies have disagreed about associations of decreased123 I-MIBG-derived radioactivity with the duration or severity of Parkinson disease or with coexistent autonomic failure. For example, Takatsu and colleagues (13) noted decreased123 I-MIBG-derived radioactivity independent of Hoehn-Yahr classification, disease duration, or orthostatic hypotension. Orimo and coworkers (9) found that decreased myocardial123 I-MIBG-derived radioactivity tended to worsen as Parkinson disease progressed: Only approximately 50% of patients with stage I disease had decreased123 I-MIBG-derived radioactivity, and all patients with autonomic dysfunction were in stages III, IV, or V. Braune and colleagues (28) noted decreased myocardial123 I-MIBG-derived radioactivity independent of the duration or severity of autonomic or parkinsonian symptoms. Yoshita (6) reported decreased myocardial123 I-MIBG-derived radioactivity independent of disease severity or L-dopa treatment. In our study, we found that decreased 6-[18 F]fluorodopamine-derived radioactivity was not associated with disease severity or duration or with L-dopa treatment but was associated with sympathetic neurocirculatory failure. Patients with sympathetic neurocirculatory failure in the setting of Parkinson disease, pure autonomic failure, or multiple-system atrophy shared the same abnormal beat-to-beat blood pressure responses to the Valsalva maneuver; however, only the first two groups had evidence of cardiac sympathetic denervation. Therefore, the occurrence of sympathetic neurocirculatory failure does not imply cardiac sympathetic denervation. Conversely, because patients with evidence of diffuse cardiac sympathetic denervation did not always have abnormal blood pressure responses to the Valsalva maneuver, the occurrence of cardiac sympathetic denervation does not imply sympathetic neurocirculatory failure. In our study, all patients with Parkinson disease and sympathetic neurocirculatory failure had evidence of cardiac sympathetic denervation, and all patients with multiple-system atrophy and sympathetic neurocirculatory failure had evidence of normal cardiac sympathetic innervation. These findings suggest that sympathetic neurocirculatory failure in patients with Parkinson disease may result from a process that involves loss of sympathetic terminal innervation. In contrast, sympathetic neurocirculatory failure in patients who have multiple-system atrophy may result from a process that involves abnormal reflexive regulation of sympathetic neuronal outflows to intact terminals. Total-body norepinephrine spillover in patients with Parkinson disease and sympathetic neurocirculatory failure exceeded that in patients with pure autonomic failure. Both groups, however, had low myocardial 6-[18 F]fluorodopamine-derived radioactivity. Because pure autonomic failure is thought to be associated with diffuse loss of sympathetic terminal innervation, our findings suggest that sympathetic denervation may be cardioselective in Parkinson disease. Sympathetic denervation, at least in the heart, seems to be characteristic of most patients with Parkinson disease. Therefore, the disease may reflect an abnormality of catecholamine function not only in the brain but also in the periphery. Many reports have supported the notion that in Parkinson disease, loss of nigrostriatal dopamine cells results in some way from oxidative or neurotoxic injury (29-36). The high rate of oxidative deamination of norepinephrine that takes place in cardiac sympathetic nerves (25) may help to explain cardioselectivity of sympathetic denervation in Parkinson disease. For further consideration of this hypothesis, such cardioselectivity must be verified by neurochemical and neuroimaging approaches applied in different body organs. In addition, clinical methods must be developed to detect and quantify injury from oxidative deamination of catecholamines. Our results suggest that only Parkinson disease, not multiple-system atrophy, is associated with loss of sympathetic terminal innervation. This possible etiopathologic distinction might prove clinically useful in the differential diagnosis of these conditions. Author and Article Information <SNIP> Copyright ©2000 American College of Physicians – American Society of Internal Medicine