Cerebrovascular compliance during progressive hypotension in patients with autonomic failure

The compliant nature of cerebral blood vessels may represent an important mechanical protection for sustained cerebral perfusion during reductions in arterial blood pressure (ABP). However, whether the rise in cerebrovascular compliance (Ci) with falling ABP persists and exhibits a threshold effect remains unknown. Therefore, we analyzed Ci changes during graded head-up tilt (HUT) in individuals with autonomic failure (AF), a group that tolerates graded and progressive reductions in ABP. Finger ABP and middle cerebral artery blood velocity (MCAv) were recorded from five patients with AF (61 ± 22 yr) at supine rest and during graded HUT. Tilt gradients increased incrementally between 30, 45, and 60° every 5 min until ABP reached a critically low value. The total time in HUT was 11 ± 4 min. Every 5 s during supine and HUT, individual ABP and MCAv waveforms were assessed for Ci and cerebrovascular resistance (CVR) using a modified Windkessel model. Pulse pressure (PP) was calculated as systolic ABP - diastolic ABP. A threshold value for the increase in Ci was determined using breakpoint analysis of the linear relationship between changes in Ci and PP or ABP across tilt periods. Graded HUT resulted in reduced ABP, PP, CVR, and mean MCAv, and increased Ci (all P < 0.01). Ci began to increase progressively after PP fell by 22 ± 6 mmHg and ABP fell by 20 ± 11 mmHg. In conclusion, the increase in Ci during progressive hypotension exhibited a threshold effect and persisted as ABP continued to fall.NEW & NOTEWORTHY We identify a threshold effect for the increase in cerebrovascular compliance (Ci) during progressive hypotension (baseline vs. end-tilt: 86 ± 18 vs. 50 ± 8 mmHg) in individuals with autonomic failure, such that Ci began to increase progressively after pulse pressure fell by 22 ± 6 mmHg and arterial blood pressure fell by 20 ± 11 mmHg.