Prediction of arrhythmic events in patients following myocardial infarction

Relationships between heart rate variability, functional capacity, and left ventricular function following myocardial infarction: an evaluation after one week and six months

BACKGROUND

Relationships between heart rate (HR) variability and different prognostic markers such as ejection fraction, functional capacity, and patency of the infarct-related artery, as well as the comparison of their time courses are not fully elucidated.

HYPOTHESIS

The aim of study was to assess prospectively the early postinfarction changes in HR variability and its evolution over a period of 6 months: the relationships between HR variability and functional capacity in exercise testing; left ventricular function in cardiac catheterization: status of the infarct-related artery; and the comparison of their time courses.

METHODS

In 42 patients with anterior myocardial infarction, a study was made of the early changes in HR variability analyzed by the complex demodulation method, its evolution over a period of 6 months. and the relationships between HR variability and (1) functional capacity in exercise testing, (2) left ventricular function in cardiac catheterization, and (3) status of the infarct-related artery.

RESULTS

At 1 week HR variability parameters correlated directly with functional capacity indicators such as METS, percent change in HR from rest to peak exercise (%deltaHR), difference between initial and peak HR (HR range), percent peak theoretical HR (% peak HR), left ventricular ejection fraction (EF), and, inversely, with end-systolic volume (ESV). Stepwise multiple regression analysis to establish HR variability parameters (recorded at 1 week) as related to functional capacity and left ventricular function at 1 week and 6 months postinfarction established the following variables: (1) At 1 week: standard deviation (SD) of the RR cycles in relation to %deltaHR (r = 0.60, p <0.0001), HR range (r = 0.43, p < 0.01), and EF (r = 0.79, p < 0.0001). (2) At 6 months, the sole accepted HR variability parameter was the SD in relation to %deltaHR (r = 0.38, p < 0.05) and HR range (r = 0.45, p < 0.01). No variability parameter was accepted in relation to METS, % peak HR, or ESV. Relationship between EF or ESV and HR variability parameters was not significant when both were evaluated at 6 months. At that time, there was a significant increase in all HR variability parameters among all surviving patients (n = 39), with the exception of the LF/HF ratio and mean RR cycle. The percent increase in HR variability between the first week and 6 months was greater among those patients with the lowest basal EF. No relation was established between HR variability and patency of the infarct-related artery.

CONCLUSION

The decrease in HR variability observed following myocardial infarction is associated with a diminished functional capacity and an increased alteration of the EF. This does not affect the recovery of HR variability, which was observed in all surviving patients.

Diminished short-term heart rate variability predicts inducible ventricular tachycardia

PURPOSE

The purpose of this study is to determine whether short-term heart rate variability (HRV) can be used successfully to predict inducible ventricular tachycardia (VT).

METHODS

A high-speed (300 mm/s) electrocardiographic recording was obtained in 32 patients in the supine position prior to programmed ventricular stimulation. Beat-to-beat RR intervals (in milliseconds) were derived from an 11-beat strip (10 RR intervals). Logistic regression was used to study the relationship between several variables and a dichotomous dependent variable (inducible, clinical, or electrocardiographic evidence of VT).

RESULTS

Of 32 patients, 12 had inducible VT (inducible VT group) and 20 had no clinical or electrocardiographic evidence of VT (control group). Mean short-term HRV values were significantly lower in those with inducible VT than in the control group in all patients (25+/-15 ms, n=12 vs 67+/-22 ms, n=20; p<0.0001) and in patients with coronary artery disease or congestive heart failure or both (22+/-13 ms, n=11 vs 63+/-23 ms, n=11; p<0.0001). For the group as a whole, short-term HRV was < or =50 ms in 11 of 12 patients (92%) with inducible VT, but was < or =50 ms in only 3 of 20 control subjects (15%; p<0.001). As a result of a stepwise selection procedure conducted within the logistic regression, only the short-term HRV was found to be predictive of inducible VT (p<0.0001).

CONCLUSION

Short-term HRV is significantly lower in subjects with inducible VT than in those without clinical or electrocardiographic evidence of VT. The probability of developing sudden death increases substantially when short-term HRV decreases below 50 ms.

Heart rate variability in workers exposed to carbon disulfide

It is assumed that the cardiovascular impairments resulting from CS2 exposure may be associated with some functional disturbances within the autonomic nervous system. We adopted the heart rate variability (HRV) analysis to investigate the sympathetic and parasympathetic functions of the autonomic nervous system in workers exposed to carbon disulfide. The studies were performed on 152 workers, aged 24-66, with the period of exposure ranging from 5-38 years and 93 age-matched, non-exposed, healthy individuals as the control group. The HRV analysis concerned time-domain (AVG R-R, SD R-R, modal, median, minimum and maximum values) and frequency-domain indices (power spectrum in the very low-VLF, low-LF and high-HF frequency bands) calculated using the fast Fourier transformation. In the exposed group, neurovegetative regulation impairments could be observed. They were expressed as increased heart rate at rest, reduced power spectrum: total (TPS) and within HF, LF and VLF frequency bands as well as the absence of the physiological dependence of HRV parameters on age. These abnormalities could be found even in the group of workers exposed to the lowest CS2 levels (0-10 mg/m3) and they concerned the VLF band. In workers under conditions of exposure to 10-18 mg/m3 the dysfunction of the autonomic control referred both to its sympathetic and parasympathetic part and was found to be more intense in workers exposed to the highest CS2 concentrations (over 18 mg/m3). In view of our findings we concluded that occupational exposure to carbon disulfide may bring about an impaired neurovegetative regulation of the cardiovascular function.

Stepwise strategy of using short- and long-term heart rate variability for risk stratification after myocardial infarction

Independent of other established risk factors, depressed heart rate variability (HRV) has been shown to be a powerful predictor of cardiac events after MI. Unfortunately, the need of 24-hour ECG recording and subsequent laborious editing of Holter data limits the clinical use of long-term HRV. In order to perform post-MI risk stratification more efficiently, we evaluated the value of short-term HRV estimates for preselection of patients who might benefit from long-term HRV assessment. Two measures were assessed from 24-hour ambulatory ECGs recorded in 729 survivors of acute MI prior to hospital discharge. In addition to a complete 24-hour HRV index, a standard deviation of normal-to-normal RR intervals (SDNN) was obtained from the first stationary and ectopic free 5-minute segment of the Holter recording. Predictive power (relation between positive predictive accuracy and sensitivity) of a complete 24-hour HRV index in identifying patients who suffered from cardiac mortality or arrhythmic events during a 2-year follow-up was compared to the predictive power of assessing the 24-hour HRV index limited to 50%, 40%, or 20% of patients with the lowest values of 5-minute SDNN. The HRV index was significantly lower in patients who died (19 +/- 11 units) or had an arrhythmic event (AE) (18 +/- 11 units) compared to those who survived without an event (28 +/- 10 resp. 27 +/- 11 units; P < 0.001). Similarly, 5-minute SDNN was significantly lower in patients who died (25 +/- 12 ms) or suffered an AE (26 +/- 13 ms) compared to survivors (40 +/- 19 ms resp. 39 +/- 19 ms; P < 0.001). When limited to patients with depressed 5-minute SDNN, assessment of the HRV index performed better than 5-minute SDNN alone in positive prediction of cardiac events. Preselected assessment of the lowest HRV index in 50% to 20% of the total population yielded a 2-year cardiac event prediction rate as high as analysis of the HRV index in all patients. Long-term HRV assessment for risk stratification after MI in patients preselected by depressed short-term SDNN is safe and efficient, and allows a practical identification of patients with the highest likelihood of cardiac events during long-term follow-up.

Heart rate variability in workers exposed to medium-frequency electromagnetic fields

This study was undertaken to evaluate the neurovegetative regulation of the heart in workers occupationally exposed to medium frequency (MF) electromagnetic (EM) fields. The subjects were 71 workers of MF broadcast stations, aged 20-68 (mean 47.1) with the duration of work under exposure ranging from 2-40 years and 22 workers of radio link stations, aged 21-65 (mean 46.9) who were not exposed to MF EM fields. The distribution of age and work tenure in both groups did not differ significantly. Heart rate variability (HRV) was analysed basing on 512 normal heart evolutions registered in resting, from the body surface, using the Medea-HRV system. The analysis concerned time-domain and frequency-domain parameters of HRV using fast fourier transformation. Power spectrum in the low (0.05-0.15 Hz) and high (0.15-0.35 Hz) frequency bands (LF and HF, respectively) was determined. Statistically insignificant differences found between exposed and non-exposed groups were found either in time- or in frequency-domain parameters of HRV. No correlation between the power spectrum and the subjects age was noted. Such a relationship, however, could be observed in the control group. In the study group a statistically significant negative correlation was found between the maximum intensity of EM fields and HF power spectrum. Thus it was concluded that occupational exposure to EM fields brings about impairments in the neurovegetative regulation of the cardiovascular function.

Short- and long-term assessment of heart rate variability for risk stratification after acute myocardial infarction

Depressed heart rate variability (HRV) has been shown to be a powerful and independent risk factor in patients following acute myocardial infarction (AMI). A detailed comparison of the predictive values between short- and long-term HRV has not been made. The predictive value of short-term HRV for 1-year total cardiac mortality was studied in 700 consecutive patients after AMI. All patients underwent 24-hour Holter monitoring before discharge from the hospital (5 to 8 days after AMI) and were followed up for 1 year. Short-term HRV was computed as the standard deviation of all normal RR intervals (SDNN) from a 5-minute stationary period selected from 24-hour Holter electrocardiographic recordings. Long-term HRV was computed as an HRV index over the entire 24 hours. There was a significant but relatively poor correlation between SDNN and HRV index (r = 0.51, p <0.001). The positive predictive accuracy of SDNN for 1-year mortality (13% to 18%) was lower than the HRV index (17% to 43%) over a range of sensitivity of 25% to 75%. Assessment of HRV index in > or = 35% of the patients preselected by the lowest SDNN was able to achieve predictive power similar to that of HRV index assessed in all the patients. These data suggest that lower predischarge short-term HRV is associated with increased 1-year total cardiac mortality in patients after AMI. Analysis of long-term HRV for postinfarction risk stratification can safely be limited to patients preselected by depressed short-term HRV measures.

Change of autonomic influence on the heart immediately before the onset of spontaneous idiopathic ventricular tachycardia

OBJECTIVES

This study aimed to assess heart rate variability immediately before the onset of episodes of spontaneous ventricular tachycardia.

BACKGROUND

It has been shown that decreased heart rate variability may be associated with a propensity to ventricular tachyarrhythmias. However, it is still disputed whether there is an abrupt change in heart rate variability immediately before the onset of these arrhythmias.

METHODS

Twenty-three patients with idiopathic ventricular tachycardia underwent two-channel 24-h Holter monitoring in a drug-free state. Spectral heart rate variability was computed as low (0.04 to 0.15 Hz) and high (0.15 to 0.40 Hz) frequency components at 2-min intervals over a 1-h period immediately before the onset of ventricular tachycardia. Average values of heart rate variability were also computed for the entire 24-h recordings. The low/high frequency component ratio was calculated as an index of the autonomic balance of the heart.

RESULTS

Seventy-one episodes of ventricular tachycardia from the 23 recordings formed this study. There was an increased low/high ratio during 6- to 8-min periods immediately before the onset of ventricular tachycardia episodes compared with the average values for the entire 24 h. This increase in the low/high ratio resulted largely from a decrease in the high frequency component value (4.70 +/- 1.15 vs. 5.10 +/- 1.06 ln[ms2] [mean +/- SD], p = 0.001) because there was no significant change in the low frequency component value (6.37 +/- 1.20 vs. 6.34 +/- 0.91 ln[ms2], p = 0.786, 95% confidence interval -0.25 to 0.19 ln[ms2], type II error < 0.0001 for change of 7.8%). In contrast, there were no significant differences in the low or high frequency components or low/high ratio between 6-min salvo-free periods 40 min before the onset of ventricular tachycardia and the average 24-h values (type II error < 0.0001, < 0.038 and < 0.1841, respectively, for change of 7.8%). The low/high ratio was also significantly higher during the 6 min immediately before the onset of ventricular tachycardia compared with that during the 6-min salvo-free periods 40 min before the onset of ventricular tachycardia. A significant increase in mean heart rate immediately before the onset of ventricular tachycardia was also noted.

CONCLUSIONS

There is a significant change in autonomic influence on the heart during the last few minutes preceding the onset of episodes of idiopathic ventricular tachycardia. This seems to result mainly from decreased vagal activity rather than enhanced sympathetic input to the heart.

Heart rate variability and its relation to ventricular arrhythmias in congestive heart failure

BACKGROUND

It has been shown that heart rate variability is decreased in patients with congestive heart failure and that depressed heart rate variability is associated with a propensity to ventricular arrhythmias. Little is known, however, about heart rate variability in patients with both congestive heart failure and ventricular arrhythmias.

METHODS

Spectral heart rate variability was analysed from 24 hour ambulatory electrocardiograms in 15 controls, 15 patients with non-sustained ventricular tachycardia associated with clinically normal hearts (NHVT group), and 40 patients with congestive heart failure (CHF group) secondary to either ischaemic heart disease (n = 15) or idiopathic dilated cardiomyopathy (n = 25). Of the 40 patients with congestive heart failure 15 had no appreciable ventricular arrhythmias (ventricular extrasystoles < 10 beats/h and no salvos) and formed the CHF-VA- group. Another 15 patients with congestive heart failure and non-sustained ventricular tachycardia formed the CHF-NSVT group.

RESULTS

Heart rate variability was significantly lower in the CHF group than in controls (mean (SD) total frequency 23 (12) v 43 (13) ms; low frequency 12 (8) v 28 (9) ms; high frequency 8 (5) v 14 (7) ms; p < 0.001). The differences in heart rate variability between controls and the NHVT group, between ischaemic heart disease and dilated cardiomyopathy, and between the CHF-VA- and CHF-NSVT groups were not significant. In the CHF group heart rate variability was significantly related to left ventricular ejection fraction but not associated with ventricular arrhythmias. The frequency of ventricular extrasystoles was significantly related to the high frequency component of heart rate variability (r = 0.54, p < 0.05) in the NHVT group. Stepwise multiple regression analysis showed that in the CHF group, heart rate variability was predominantly related to left ventricular ejection fraction (p < 0.05). There was no significant difference in heart rate variability between survivors (n = 34) and those who died suddenly (n = 6) at one year of follow up in the CHF group.

CONCLUSION

In patients with congestive heart failure, heart rate variability is significantly decreased. The depressed heart rate variability is principally related to the degree of left ventricular impairment and is independent of aetiology and the presence of ventricular arrhythmias. The data suggest that analysis of heart rate variability does not help the identification of patients with congestive heart failure at increased risk of sudden death.

Decreased heart rate variability in survivors of sudden cardiac death not associated with coronary artery disease

BACKGROUND

Although heart rate variability has already been studied in survivors of sudden cardiac death secondary to coronary artery disease, an assessment of heart rate variability in survivors of sudden cardiac death not associated with coronary artery disease has not been made.

METHODS

10 patients with aborted sudden cardiac death not associated with coronary artery disease (seven patients with primary ventricular fibrillation and three with unclassified mild cardiomyopathy) underwent two channel 24 hour Holter monitoring in a drug free state. All subjects were in sinus rhythm and had normal atrioventricular conduction and normal cardiac function. Spectral heart rate variability was analysed on a Holter analysis system and was expressed as total (0.01-1.00 Hz), low (0.04-0.15 Hz) and high (0.15-0.40 Hz) frequency components for each hour. Heart rate variability index was calculated for the 24 hour periods. 10 age and sex matched healthy subjects were taken as a control group.

RESULTS

The spectral heart rate variability over 24 hours was significantly lower in survivors of sudden cardiac death than in controls (total 38(15) v 48(14) ms; low, 25(11) v 32(13) ms; and high, 13(8) v 18(8) ms; p < 0.05 for all comparisons). The differences in the ratio of low/high (2.19(0.76) v 1.98(0.50), p = 0.132), mean heart rate (77(12) v 69(12) beats/min, p = 0.070), and heart rate variability index (38(12) v 44(16), p = 0.287) over 24 hours between survivors of sudden cardiac death and controls did not reach significance. Comparisons of the hourly heart rate variability over the 24 hour period between the two groups showed that the differences in all components of heart rate variability, low/high ratio and mean heart rate were highly significant. Furthermore, there was no significant difference in the maximum hourly heart rate variability over the 24 hour period. The minimum hourly heart rate variability was, however, significantly lower in survivors of sudden cardiac death than in controls (total, 20(8) v 28(4) ms; low, 12(6) v 17(3) ms; high, 6(2) v 8(2) ms; p < 0.05 for all comparisons).

CONCLUSIONS

These findings suggest that there is abnormal autonomic influence on the heart in patients without coronary artery disease at risk of sudden cardiac death. Hourly analysis of heart rate variability throughout the 24 hour period may provide additional information important in the identification of high risk patients.

Abnormal autonomic modulation of QT interval in patients with idiopathic ventricular tachycardia associated with clinically normal hearts

BACKGROUND

Idiopathic ventricular tachycardia (VT) occurs in a small but important subset of patients without clinically overt heart disease. The mechanism of the arrhythmogenesis remains unclear in these patients. This study examines modulation of the QT interval by the autonomic nervous system in a group of patients with idiopathic ventricular tachycardia.

METHODS

Cardiac autonomic activity and ventricular repolarisation were studied in 27 patients with VT associated with a clinically normal heart (NHVT) and in 20 normal subjects. All the patients were in sinus rhythm, had normal atrioventricular conduction, and were in a drug free state. Cardiac efferent autonomic activity was measured by spectral analysis of heart rate variability from 24 hour ambulatory electrocardiograms on a Holter analysis system (Marquette). Ventricular repolarisation was evaluated by measuring the QT intervals from the same 24 hour Holter tapes at one hour intervals.

RESULTS

There was no difference in any of the QT interval variables including the maximum, minimum, and mean of both the QT interval and its corrected value (Bazett's formula) between patients with NHVT and normal subjects. The high frequency component (0.04-0.15 Hz) of heart rate variability was significantly decreased in patients with NHVT compared with normal subjects (16 (8) v 21 (12) ms, p < 0.05). There was a significant correlation between the spectral variables of heart rate variability and the mean, maximal, and minimal QT intervals in normal subjects, whereas the relation was lost in patients with NHVT. No difference was found in mean heart rate between normal subjects and patients with NHVT (70 (9) v 72 (13) beats/min, NS).

CONCLUSIONS

The high frequency component of heart rate variability is significantly decreased and the relation of QT interval to heart rate variability is significantly altered in patients with NHVT as compared with normal subjects. These findings suggest that abnormal modulation of the QT interval by the autonomic nervous system may play an important part in the arrhythmogenesis of NHVT. This might result from impaired vagal efferent cardiac activity in these patients.