Background The increase in heart rate that accompanies exerciseis due in part to a reduction in vagal tone. Recovery of theheart rate immediately after exercise is a function of vagalreactivation. Because a generalized decrease in vagal activityis known to be a risk factor for death, we hypothesized thata delayed fall in the heart rate after exercise might be animportant prognostic marker.
Methods For six years we followed 2428 consecutive adults (mean[±SD] age, 57±12 years; 63 percent men) withouta history of heart failure or coronary revascularization andwithout pacemakers. The patients were undergoing symptom-limitedexercise testing and single-photon-emission computed tomographywith thallium scintigraphy for diagnostic purposes. The valuefor the recovery of heart rate was defined as the decrease inthe heart rate from peak exercise to one minute after the cessationof exercise. An abnormal value for the recovery of heart ratewas defined as a reduction of 12 beats per minute or less fromthe heart rate at peak exercise.
Results There were 213 deaths from all causes. A total of 639patients (26 percent) had abnormal values for heart-rate recovery.In univariate analyses, a low value for the recovery of heartrate was strongly predictive of death (relative risk, 4.0; 95percent confidence interval, 3.0 to 5.2; P<0.001). Afteradjustments were made for age, sex, the use or nonuse of medications,the presence or absence of myocardial perfusion defects on thalliumscintigraphy, standard cardiac risk factors, the resting heartrate, the change in heart rate during exercise, and workloadachieved, a low value for heart-rate recovery remained predictiveof death (adjusted relative risk, 2.0; 95 percent confidenceinterval, 1.5 to 2.7; P<0.001).
Conclusions A delayed decrease in the heart rate during thefirst minute after graded exercise, which may be a reflectionof decreased vagal activity, is a powerful predictor of overallmortality, independent of workload, the presence or absenceof myocardial perfusion defects, and changes in heart rate duringexercise.
Source Information
From the Departments of Cardiology (C.R.C., F.J.P., C.E.S., M.S.L.), Cardiothoracic Surgery (E.H.B.), and Epidemiology and Biostatistics (E.H.B.) and the George M. and Linda H. Kaufman Center for Heart Failure (M.S.L.), Cleveland Clinic Foundation, Cleveland.
Address reprint requests to Dr. Lauer at the Section of Heart Failure and Cardiac Transplantation Medicine, Department of Cardiology, Desk F25, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195, or at lauerm{at}ccf.org.
Exercise Capacity and Mortality
Palatini P., Ko D. T., Hebert P. R., Krumholz H. M., Perlo D. H., Myers J., Froelicher V., Balady G. J.
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N Engl J Med 2002;
347:288-290, Jul 25, 2002.
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