The effect of transcutaneous auricular vagus nerve stimulation on cardiovascular function in subarachnoid hemorrhage patients: a safety study

Reviewer #1 (Public Review):

The authors report the results of a randomized clinical trial of taVNS as a neuromodulation technique in SAH patients. They found that taVNS appears to be safe without inducing bradycardia or QT prolongation. taVNS also increased parasympathetic activity, as assessed by heart rate variability measures. Acute elevation in heart rate might be a biomarker to identify SAH patients who are likely to respond favorably to taVNS treatment. The latter is very important in light of the need for acute biomarkers of response to neuromodulation treatments.

Comments:

(1) Frequency domain heart rate variability measures should be analyzed and reported. Given the short duration of the ECG recording, the frequency domain may more accurately reflect autonomic tone.

(2) How was the "dose" chosen (20 minutes twice daily)?

(3) The use of an acute biomarker of response is very important. A bimodal response to taVNS has been previously shown in patients with atrial fibrillation (Kulkarni et al. JAHA 2021).

Reviewer #2 (Public Review):

Summary:

This study investigated the effects of transcutaneous auricular vagus nerve stimulation (taVNS) on cardiovascular dynamics in subarachnoid hemorrhage (SAH) patients. The researchers conducted a randomized clinical trial with 24 SAH patients, comparing taVNS treatment to a Sham treatment group (20 minutes per day twice a day during the ICU stay). They monitored electrocardiogram (ECG) readings and vital signs to assess acute as well as middle-term changes in heart rate, heart rate variability, QT interval, and blood pressure between the two groups. The results showed that repetitive taVNS did not significantly alter heart rate, corrected QT interval, blood pressure, or intracranial pressure. However, it increased overall heart rate variability and parasympathetic activity after 5-10 days of treatment compared to the sham treatment. Acute taVNS led to an increase in heart rate, blood pressure, and peripheral perfusion index without affecting corrected QT interval, intracranial pressure, or heart rate variability. The acute post-treatment elevation in heart rate was more pronounced in patients who showed clinical improvement. In conclusion, the study found that taVNS treatment did not cause adverse cardiovascular effects, suggesting it is a safe immunomodulatory treatment for SAH patients. The mild acute increase in heart rate post-treatment could potentially serve as a biomarker for identifying SAH patients who may benefit more from taVNS therapy.

Strengths:

The paper is overall well written, and the topic is of great interest. The methods are solid and the presented data are convincing.

Weaknesses:

(1) It should be clearly pointed out that the current paper is part of the NAVSaH trial (NCT04557618) and presents one of the secondary outcomes of that study while the declared first outcomes (change in the inflammatory cytokine TNF-α in plasma and cerebrospinal fluid between day 1 and day 13, rate of radiographic vasospasm, and rate of requirement for long-term CSF diversion via a ventricular shunt) are available as a pre-print and currently under review (doi: 10.1101/2024.04.29.24306598.). The authors should better stress this point as well as the potential association of the primary with the secondary outcomes.

(2) The references should be implemented particularly concerning other relevant papers (including reviews and meta-analysis) of taVNS safety, particularly from a cardiovascular standpoint, such as doi: 10.1038/s41598-022-25864-1 and doi: 10.3389/fnins.2023.1227858).

(3) The dose-response issue that affects both VNS and taVNS applications in different settings should be mentioned (doi: 10.1093/eurheartjsupp/suac036.) as well as the need for more dose-finding preclinical as well as clinical studies in different settings (the best stimulation protocol is likely to be disease-specific).

Overall, the present work has the important potential to further promote the usage of taVNS even on critically ill patients and might set the basis for future randomized studies in this setting.

Reviewer #3 (Public Review):

Summary:

The authors aimed to characterize the cardiovascular effects of acute and repetitive taVNS as an index of safety. The authors concluded that taVNS treatment did not induce adverse cardiovascular effects, such as bradycardia or QT prolongation.

Strengths:

This study has the potential to contribute important information about the clinical utility of taVNS as a safe immunomodulatory treatment approach for SAH patients.

Weaknesses:

A number of limitations were identified:

(1) A primary hypothesis should be clearly stated. Even though the authors state the design is a randomized clinical trial, several aspects of the study appear to be exploratory. The method of randomization was not stated. I am assuming it is a forced randomization given the small sample size and approximately equal numbers in each arm.

(2) The authors "first investigated whether taVNS treatment induced bradycardia or QT prolongation, both potential adverse effects of vagus nerve stimulation. This analysis showed no significant differences in heart rate calculated from 24-hour ECG recording between groups." A justification should be provided for why a difference is expected from 20 minutes of taVNS over a period of 24 hours. Acute ECG changes are a concern for increasing arrhythmic risk, for example, due to cardiac electrical restitution properties.

(3) More rigorous evaluation is necessary to support the conclusion that taVNS did not change heart rate, HRV, QTc, etc. For example, shifts in peak frequencies of the high-frequency vs. low-frequency power may be effective at distinguishing the effects of taVNS. Further, compensatory sympathetic responses due to taVNS should be explored by quantifying the changes in the trajectory of these metrics during and following taVNS.

(4) The authors do not state how the QT was corrected and at what range of heart rates. Because all forms of corrections are approximations, the actual QT data should be reported along with the corrected QT.

(5) The QT extraction method needs to be more robust. For example, in Figure 2C, the baseline voltage of the ECG is shifting while the threshold appears to be fixed. If indeed the threshold is not dynamic and does not account for baseline fluctuations (e.g., due to impedance changes from respiration), then the measures of the QT intervals were likely inaccurate.

(6) More statistical rigor is needed. For example, in Figure 2D, the change in heart rate for days 5-7, 8-10, and 11-13 is clearly a bimodal distribution and as such, should not be analyzed as a single distribution. Similarly, Figure 2E also shows a bimodal distribution. Without the QT data, it is unclear whether this is due to the application of the heart rate correction method.

(7) Figure 3A shows a number of outliers. A SDNN range of 200 msec should raise concern for a non-sinus rhythm such as arrhythmia or artifact, instead of sinus arrhythmia. Moreover, Figure 3B shows that the Sham RMSSD data distribution is substantially skewed by the presence of at least 3 outliers, resulting in lower RMSSD values compared to taVNS. What types of artifact or arrhythmia discrimination did the authors employ to ensure the reported analysis is on sinus rhythm? The overall results seem to be driven by outliers.

(8) The above concern will also affect the power analysis, which was reported by authors to have been performed based on the t-test assuming the medium effect size, but the details of sample size calculations were not reported, e.g., X% power, t-test assumed Bonferroni correction in the power analysis, etc.

(9) If the study was designed to show a cardiovascular effect, I am surprised that N=10 per group was considered to be sufficiently powered given the extensive reports in the literature on how HRV measures (except when pathologically low) vary within individuals. Moreover, HRV measures are especially susceptible to noise, artifacts, and outliers.

If the study was designed to show a lack of cardiovascular effect (as the conclusions and introduction seem to suggest), then a several-fold larger sample size is warranted.