Prognostic Performance of Heart Rate Recovery on an Exercise Test in a Primary Prevention Population

Nóra Sydó, Tibor Sydó, Karina A Gonzalez Carta, Nasir Hussain, Shausha Farooq, Joseph G Murphy, Béla Merkely, Francisco Lopez-Jimenez, Thomas G Allison, Nóra Sydó, Tibor Sydó, Karina A Gonzalez Carta, Nasir Hussain, Shausha Farooq, Joseph G Murphy, Béla Merkely, Francisco Lopez-Jimenez, Thomas G Allison

Abstract

Background: Heart rate (HR) recovery has been investigated in specific patient cohorts, but there is less information about the role of HR recovery in general populations. We investigated whether HR recovery has long-term prognostic significance in primary prevention.

Methods and results: Exercise tests performed between 1993 and 2010 on patients aged 30 to 79 years without cardiovascular disease were included. Mortality was determined from Mayo Clinic records and Minnesota Death Index. Total, cardiovascular, and non-cardiovascular mortality was reported according to HR recovery <13 bpm using Cox regression. 19 551 patients were included, 6756 women (35%), age 51±10 years. There were 1271 deaths over follow-up of 12±5 years. HR recovery declined after age 60, and was also lower according to diabetes mellitus, hypertension, obesity, current smoking, and poor cardiorespiratory fitness but not sex or β-blockers. Adjusting for these factors, abnormal HR recovery was a significant predictor of total (hazard ratio [95% confidence interval]=1.56 [1.384-1.77]), cardiovascular (1.95 [1.57-2.42]), and non-cardiovascular death (1.41 [1.22-1.64]). Hazard ratios for cardiovascular death according to abnormal HR recovery were significant in all age groups (30-59, 60-69, 70-79), in both sexes, in patients with and without hypertension, obesity, and diabetes mellitus, but not in patients taking β-blockers, current smokers, and patients with normal cardiorespiratory fitness.

Conclusions: HR recovery is a powerful prognostic factor predicting total, cardiovascular, and non-cardiovascular death in a primary prevention cohort. It performs consistently well according to sex, age, obesity, hypertension, and diabetes mellitus but shows diminished utility in patients taking β-blockers, current smokers, and patients with normal cardiorespiratory fitness.

Keywords: exercise testing; heart rate recovery; mortality; primary prevention.

© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Figures

Figure 1
Figure 1
Hazard ratios with 95% confidence intervals for an abnormal heart rate recovery predicting death, cardiovascular death, and non‐cardiovascular death. Three models are shown for each outcome: unadjusted; adjusted for age and sex; fully adjusted for age, sex, diabetes mellitus, hypertension, obesity, current smoking, and poor cardiorespiratory fitness. Hazard ratios for cardiovascular and non‐cardiovascular death are compared by the Z‐score method.
Figure 2
Figure 2
Hazard ratios with 95% confidence intervals for an abnormal heart rate (HR) recovery predicting cardiovascular death stratified by age, sex, presence of obesity, hypertension, diabetes mellitus, current smoking, use of HR‐lowering drug, and level of cardiorespiratory fitness (CRF). Poor CRF refers to functional aerobic capacity (FAC) <80%, reduced CRF to FAC 80% to 99%, and normal CRF to FAC ≥100% predicted. All models are fully adjusted for age, sex, diabetes mellitus, hypertension, obesity, current smoking, and poor CRF. Hazard ratios for cardiovascular death are compared by the Z‐score method. Hazard ratio bars filled with striped pattern indicate nonsignificant findings.

References

    1. Kligfield P, Lauer MS. Exercise electrocardiogram testing: beyond the ST segment. Circulation. 2006;114:2070–2082.
    1. Cole CR, Blackstone EH, Pashkow FJ, Snader CE, Lauer MS. Heart‐rate recovery immediately after exercise as a predictor of mortality. N Engl J Med. 1999;341:1351–1357.
    1. Nishime EO, Cole CR, Blackstone EH, Pashkow FJ, Lauer MS. Heart rate recovery and treadmill exercise score as predictors of mortality in patients referred for exercise ECG. JAMA. 2000;284:1392–1398.
    1. Cole CR, Foody JM, Blackstone EH, Lauer MS. Heart rate recovery after submaximal exercise testing as a predictor of mortality in a cardiovascularly healthy cohort. Ann Intern Med. 2000;132:552–555.
    1. Aijaz B, Squires RW, Thomas RJ, Johnson BD, Allison TG. Predictive value of heart rate recovery and peak oxygen consumption for long‐term mortality in patients with coronary heart disease. Am J Cardiol. 2009;103:1641–1646.
    1. Maeder MT, Munzer T, Rickli H, Schoch OD, Korte W, Hurny C, Ammann P. Association between heart rate recovery and severity of obstructive sleep apnea syndrome. Sleep Med. 2008;9:753–761.
    1. Yamada T, Yoshitama T, Makino K, Lee T, Saeki F. Heart rate recovery after exercise is a predictor of silent myocardial ischemia in patients with type 2 diabetes. Diabetes Care. 2011;34:724–726.
    1. Phan TT, Shivu GN, Abozguia K, Davies C, Nassimizadeh M, Jimenez D, Weaver R, Ahmed I, Frenneaux M. Impaired heart rate recovery and chronotropic incompetence in patients with heart failure with preserved ejection fraction. Circ Heart Fail. 2010;3:29–34.
    1. Curtis JM, Horton ES, Bahnson J, Gregg EW, Jakicic JM, Regensteiner JG, Ribisl PM, Soberman JE, Stewart KJ, Espeland MA. Prevalence and predictors of abnormal cardiovascular responses to exercise testing among individuals with type 2 diabetes: the Look AHEAD (Action for Health in Diabetes) study. Diabetes Care. 2010;33:901–907.
    1. Sydo N, Sydo T, Merkely B, Carta KG, Murphy JG, Lopez‐Jimenez F, Allison TG. Impaired heart rate response to exercise in diabetes and its long‐term significance. Mayo Clin Proc. 2016;91:157–165.
    1. Khan MN, Pothier CE, Lauer MS. Chronotropic incompetence as a predictor of death among patients with normal electrograms taking beta blockers (metoprolol or atenolol). Am J Cardiol. 2005;96:1328–1333.
    1. Morise AP. Heart rate recovery: predictor of risk today and target of therapy tomorrow? Circulation. 2004;110:2778–2780.
    1. Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA. 2006;296:1593–1601.
    1. Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, Mark DB, McCallister BD, Mooss AN, O'Reilly MG, Winters WL Jr, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC Jr. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (committee to update the 1997 exercise testing guidelines). Circulation. 2002;106:1883–1892.
    1. Gibbons RJ, Balady GJ, Beasley JW, Bricker JT, Duvernoy WF, Froelicher VF, Mark DB, Marwick TH, McCallister BD, Thompson PD, Winters WL Jr, Yanowitz FG, Ritchie JL, Cheitlin MD, Eagle KA, Gardner TJ, Garson A Jr, Lewis RP, O'Rourke RA, Ryan TJ. ACC/AHA guidelines for exercise testing: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (committee on exercise testing). Circulation. 1997;96:345–354.
    1. Daida H, Allison TG, Squires RW, Miller TD, Gau GT. Peak exercise blood pressure stratified by age and gender in apparently healthy subjects. Mayo Clin Proc. 1996;71:445–452.
    1. Sydo N, Abdelmoneim SS, Mulvagh SL, Merkely B, Gulati M, Allison TG. Relationship between exercise heart rate and age in men vs women. Mayo Clin Proc. 2014;89:1664–1672.
    1. Gayda M, Bourassa MG, Tardif JC, Fortier A, Juneau M, Nigam A. Heart rate recovery after exercise and long‐term prognosis in patients with coronary artery disease. Can J Cardiol. 2012;28:201–207.
    1. Arena R, Myers J, Abella J, Peberdy MA, Bensimhon D, Chase P, Guazzi M. The prognostic value of the heart rate response during exercise and recovery in patients with heart failure: influence of beta‐blockade. Int J Cardiol. 2010;138:166–173.
    1. Kubrychtova V, Olson TP, Bailey KR, Thapa P, Allison TG, Johnson BD. Heart rate recovery and prognosis in heart failure patients. Eur J Appl Physiol. 2009;105:37–45.
    1. Cheng YJ, Lauer MS, Earnest CP, Church TS, Kampert JB, Gibbons LW, Blair SN. Heart rate recovery following maximal exercise testing as a predictor of cardiovascular disease and all‐cause mortality in men with diabetes. Diabetes Care. 2003;26:2052–2057.
    1. Lauer M, Froelicher ES, Williams M, Kligfield P. Exercise testing in asymptomatic adults: a statement for professionals from the American Heart Association Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation. 2005;112:771–776.
    1. Maddox TM, Ross C, Ho PM, Masoudi FA, Magid D, Daugherty SL, Peterson P, Rumsfeld JS. The prognostic importance of abnormal heart rate recovery and chronotropic response among exercise treadmill test patients. Am Heart J. 2008;156:736–744.
    1. Dhoble A, Lahr BD, Allison TG, Kopecky SL. Cardiopulmonary fitness and heart rate recovery as predictors of mortality in a referral population. J Am Heart Assoc. 2014;3:e000559. doi: 10.1161/JAHA.113.000559.
    1. Wandell PE, Carlsson AC, Theobald H. Effect of heart‐rate recovery on long‐term mortality among men and women. Int J Cardiol. 2010;144:276–279.
    1. Daugherty SL, Magid DJ, Kikla JR, Hokanson JE, Baxter J, Ross CA, Masoudi FA. Gender differences in the prognostic value of exercise treadmill test characteristics. Am Heart J. 2011;161:908–914.
    1. Kokkinos P, Myers J, Doumas M, Faselis C, Pittaras A, Manolis A, Kokkinos JP, Narayan P, Papademetriou V, Fletcher R. Heart rate recovery, exercise capacity, and mortality risk in male veterans. Eur J Prev Cardiol. 2012;19:177–184.
    1. Carnethon MR, Sternfeld B, Liu K, Jacobs DR Jr, Schreiner PJ, Williams OD, Lewis CE, Sidney S. Correlates of heart rate recovery over 20 years in a healthy population sample. Med Sci Sports Exerc. 2012;44:273–279.
    1. Desai MY, De la Pena‐Almaguer E, Mannting F. Abnormal heart rate recovery after exercise as a reflection of an abnormal chronotropic response. Am J Cardiol. 2001;87:1164–1169.
    1. Karnik RS, Lewis W, Miles P, Baker L. The effect of beta‐blockade on heart rate recovery following exercise stress echocardiography. Prev Cardiol. 2008;11:26–28.
    1. Myers J, Tan SY, Abella J, Aleti V, Froelicher VF. Comparison of the chronotropic response to exercise and heart rate recovery in predicting cardiovascular mortality. Eur J Cardiovasc Prev Rehabil. 2007;14:215–221.
    1. Oktay AA, Lavie CJ, Kokkinos PF, Parto P, Pandey A, Ventura HO. The interaction of cardiorespiratory fitness with obesity and the obesity paradox in cardiovascular disease. Prog Cardiovasc Dis. 2017;60:30–44.
    1. Myers J, McAuley P, Lavie CJ, Despres JP, Arena R, Kokkinos P. Physical activity and cardiorespiratory fitness as major markers of cardiovascular risk: their independent and interwoven importance to health status. Prog Cardiovasc Dis. 2015;57:306–314.
    1. Higgins JP, Higgins JA. Electrocardiographic exercise stress testing: an update beyond the ST segment. Int J Cardiol. 2007;116:285–299.

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