Could heart rate variability predict outcome in patients with severe head injury? A pilot study

A Systematic Review of the Relationship Between Traumatic Brain Injury and Disruptions in Heart Rate Variability

Autonomic nervous system dysfunction is increasingly recognized as a common sequela of traumatic brain injury (TBI). Heart rate variability (HRV) is a specific measure of autonomic nervous system functioning that can be used to measure beat-to-beat changes in heart rate following TBI. The objective of this systematic review was to determine the state of the literature on HRV dysfunction following TBI, assess the level of support for HRV dysfunction following TBI, and determine if HRV dysfunction predicts mortality and the severity and subsequent recovery of TBI symptoms. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two raters coded each article and provided quality ratings with discrepancies resolved by consensus. Eighty-nine papers met the inclusion criteria. Findings indicated that TBI of any severity is associated with decreased (i.e., worse) HRV; the severity of TBI appears to moderate the relationship between HRV and recovery; decreased HRV following TBI predicts mortality beyond age; HRV disturbances may persist beyond return-to-play and symptom resolution following mild TBI. Overall, current literature suggests HRV is decreased following TBI and may be a good indicator of physiological change and predictor of important outcomes including mortality and symptom improvement following TBI.

Cardiovascular responses as predictors of mortality in children with acute brain injury

BACKGROUND

Investigate the utility of cardiovascular responses such as heart rate (HR), blood pressure (BP), and heart rate variability (HRV) in the prognosis of children with acute acquired brain injury (ABI).

METHODS

Children under 18 years with severe acute acquired brain injury (ABI) who survived at least 12 h after PICU admission were included in a prospective observational cohort in a tertiary academic PICU. Physiological variables, neurological data, laboratory tests (chemistry and hematology), and medications were recorded within 12 h of admission. Linear and nonlinear HRV indices, CT scans, PICU scores, and survival rates were evaluated.

RESULTS

Seventy-two children, median age 10.7 years (IQR 4.1-13.6), were eligible for the study; 28 (38.9%) were diagnosed with brain death (BD). Tachycardia, SBP and MBP < 5th percentile, and MBP and DBP> 99th percentile were significantly associated with mortality. Poincaré SD1/SD2 was significantly associated with mortality after adjusting for age, sex and ongoing medication.

CONCLUSION

Tachycardia, systolic hypotension and median hypo and hypertension were associated to mortality in children with severe ABI. While further validation through larger, multicenter studies is necessary, the Poincaré SD1/SD2 ratio has shown promise as a prognostic tool for predicting mortality in children with severe ABI.

IMPACT STATEMENT

This study explores cardiovascular changes, including heart rate and blood pressure, and linear/nonlinear HRV measures using ECG at 1000 Hz, and compare them with other prognostic factors like brain tomography and PICU scores. Tachycardia, hypo/hypertension in the early hours after admission are linked to early mortality in children with severe traumatic and non-traumatic brain injury. Linear/non-linear measures of HRV were also related to survival. Higher HRV values indicating better survival chances. We identified Poincaré SD1/SD2 ratio as a promising tool for predicting mortality in children with severe ABI.

Heart rate variability (HRV) after traumatic brain injury (TBI): a scoping review

BACKGROUND

Heart rate variability (HRV), defined as the variability between successive heart beats, is a noninvasive measure of autonomic nervous system (ANS) function, which may be altered following traumatic brain injury (TBI). This scoping review summarizes the existing literature regarding changes in HRV after TBI as well as the association between measures of HRV and outcomes following TBI.

METHODS

A literature search for articles assessing 'heart rate variability' and 'brain injury' or 'concussion' was completed. Articles were included if HRV was measured in human subjects with TBI or concussion. Review articles, protocol papers, and studies including non-traumatic injuries were excluded.

RESULTS

Sixty-three articles were included in this review. Varied methods were used to measure HRV in the different studies. Forty articles included information about differences in HRV measures after TBI and/or longitudinal changes after TBI. Fifteen studies assessed HRV and symptoms following TBI, and 15 studies assessed HRV and either functional or cognitive outcomes after TBI.

CONCLUSIONS

HRV has been studied in the context of mortality, clinical symptoms, and medical, functional, or cognitive outcomes following TBI. Methods used to measure HRV have varied amongst the different studies, which may impact findings, standardized protocols are needed for future research.

Central autonomic network and early prognosis in patients with disorders of consciousness

The central autonomic network (CAN) plays a crucial role in modulating the autonomic nervous system. Heart rate variability (HRV) is a valuable marker for assessing CAN function in disorders of consciousness (DOC) patients. We used HRV analysis for early prognosis in 58 DOC patients enrolled within ten days of hospitalization. They underwent a five-minute electrocardiogram during baseline and acoustic/visual stimulation. The coma recovery scale-revised (CRS-R) was used to define the patient's consciousness level and categorize the good/bad outcome at three months. The high-frequency Power Spectrum Density and the standard deviation of normal-to-normal peaks in baseline, the sample entropy during the stimulation, and the time from injury features were used in the support vector machine analysis (SVM) for outcome prediction. The SVM predicted the patients' outcome with an accuracy of 96% in the training test and 100% in the validation test, underscoring its potential to provide crucial clinical information about prognosis.

HEART RATE VARIABILITY PARAMETERS WERE NOT ASSOCIATED WITH 30-DAY ALL-CAUSE MORTALITY IN INTENSIVE CARE UNIT PATIENTS WITH OR WITHOUT ATRIAL FIBRILLATION: A RETROSPECTIVE STUDY OF THE MIMIC-IV DATABASE

ABSTRACT

Objective: Our study aims to evaluate the association between heart rate variability (HRV) and short- and long-term prognosis in patients admitted to intensive care unit (ICU). Methods and Results: Adult patients continuously monitored for over 24 h in ICUs from the the American Medical Information Mart for Intensive Care (MIMIC)-IV Waveform Database were recruited in our study. Twenty HRV-related variables (8 time domain, 6 frequency domain, and 6 nonlinear variables) were calculated based on RR intervals. The association between HRV and all-cause mortality was assessed. Ninety-three patients met the inclusion criteria and were classified into atrial fibrillation (AF) and sinus rhythm (SR) groups, which were further divided into 30-day survivor group and nonsurvivor\groups based on their survival status. The 30-day all-cause mortality rates in AF and SR groups were 36.3% and 14.6%, respectively. All the time domain, frequency domain, and nonlinear HRV parameters did not differ significantly between survivors and nonsurvivors with or without AF (all P > 0.05). Presence of renal failure, malignancy, and elevated blood urea nitrogen level were associated with increased 30-day all-cause mortality in SR patients, while presence of sepsis, infection, higher platelet count, and magnesium level were associated with increased 30-day all-cause mortality in AF patients. Conclusions: Heart rate variability variables were not associated with increased 30-day all-cause mortality in ICU patients with or without AF.

Normative values of resting heart rate variability in young male contact sport athletes: Reference values for the assessment and treatment of concussion

Objective

The objective of this study was to identify the main determinants of heart rate variability (HRV) in male athletes aged 14 to 21 years who practice competitive contact sports and to integrate these determinants with the aim of defining normative values of short-term HRV in the time and frequency domains.

Methods

Participants (n = 369) were aged 14 to 21 years and included 221 football players and 148 ice hockey players. HRV was measured for 5 min at rest, and standard HRV parameters in the time and frequency domains were calculated. Heart rate (HR), age, body mass index (BMI), number of sports weekly practices (WSP) and concussion history (mTBI) were considered determinants potentially able to influence HRV.

Results

Multiple regression analysis revealed that HR was the primary determinant of standard HRV parameters. The models accounted for 13% to 55% of the total variance of HRV and the contribution of HR to this model was the strongest (β ranged from -0.34 to -0.75). HR was the only determinant that significantly contributes to all HRV parameters. To counteract this dependence, we calculated HRV corrected by the mean RR interval (RRm). Such corrections do not remove any physiological differences in HRV; they simply remove the mathematical bias. HRV parameters were therefore normalized, and their normative limits were developed relative to the mean heart rate. After correction, the correlation coefficients between HR and all corrected HRV parameters were not statistically significant and ranged from -0.001 to 0.045 (p > 0.40 for all). The automatically corrected HRV calculator, which recalculates standard HRV parameters and converts them into corrected parameters in addition to determining whether a given value is within normal limits, facilitates clinical interpretation.

Conclusion

This study provides for the first time corrected normative values of short-term and resting state HRV parameters in competitive contact sport athletes aged 14 to 21 years. These values were developed independently of the major determinants of HRV. The baseline values for HRV parameters given here could be used in clinical practice when assessing and monitoring cerebral concussions. They may assist in decision making for a safe return to play.

Does the Heart Fall Asleep?-Diurnal Variations in Heart Rate Variability in Patients with Disorders of Consciousness

The current study investigated heart rate (HR) and heart rate variability (HRV) across day and night in patients with disorders of consciousness (DOC). We recorded 24-h electrocardiography in 26 patients with DOC (i.e., unresponsive wakefulness syndrome (UWS; n = 16) and (exit) minimally conscious state ((E)MCS; n = 10)). To examine diurnal variations, HR and HRV indices in the time, frequency, and entropy domains were computed for periods of clear day- (forenoon: 8 a.m.-2 p.m.; afternoon: 2 p.m.-8 p.m.) and nighttime (11 p.m.-5 a.m.). The results indicate that patients' interbeat intervals (IBIs) were larger during the night than during the day, indicating HR slowing. The patients in UWS showed larger IBIs compared to the patients in (E)MCS, and the patients with non-traumatic brain injury showed lower HRV entropy than the patients with traumatic brain injury. Additionally, higher HRV entropy was associated with higher EEG entropy during the night. Thus, cardiac activity varies with a diurnal pattern in patients with DOC and can differentiate between patients' diagnoses and etiologies. Moreover, the interaction of heart and brain appears to follow a diurnal rhythm. Thus, HR and HRV seem to mirror the integrity of brain functioning and, consequently, might serve as supplementary measures for improving the validity of assessments in patients with DOC.

Machine Learning Approaches-Driven for Mortality Prediction for Patients Undergoing Craniotomy in ICU

OBJECTIVES

We aimed to predict the mortality of patients with craniotomy in ICU by using predictive models to extract the high-risk factors leading to the death of patients from a retrospective a study.

METHODS

Five machine-learning (ML) algorithms were applied for training on mortality predictive models with the data from a surgical intensive care unit (ICU) database of the Fujian Provincial Hospital in China. The accuracy, precision, recall, f1 score and the area under the receiver operator characteristic curve (AUC) were used to evaluate the performance of different models, and the calibration of the model was evaluated by brier score.

RESULTS

We demonstrated that eXtreme Gradient Boosting (XGBoost) was more suitable for the task, demonstrating a AUC of 0.84. We analyzed the feature importance with the Local Interpretable Model-agnostic Explanations (LIME) analysis and further identified the high-risk factors of mortality in ICU through this study.

CONCLUSIONS

This study established the mortality predictive model of patients who had undergone craniotomy in ICU. Identification of the factors that had great influence on mortality has the potential to provide auxiliary decision support for clinical medical staff on their practices.

Heart rate variability as a biomarker of functional outcomes in persons with acquired brain injury: Systematic review and meta-analysis

This review aimed to quantify correlations between heart rate variability (HRV) and functional outcomes after acquired brain injury (ABI). We conducted a literature search from inception to January 2020 via electronic databases, using search terms with HRV, ABI, and functional outcomes. Meta-analyses included 16 studies with 906 persons with ABI. Results demonstrated significant associations: Low frequency (LF) (r = -0.28) and SDNN (r = -0.33) with neurological function; LF (r = -0.33), High frequency (HF) (r = -0.22), SDNN (r = -0.22), and RMSSD (r = -0.23) with emotional function; and LF (r = 0.34), HF (r = 0.41 to 0.43), SDNN (r = 0.43 to 0.51), and RMSSD (r = 0.46) with behavioral function. Results indicate that higher HRV is related to better neurological, emotional, and behavioral functions after ABI. In addition, persons with stroke showed lower HF (SMD = -0.50) and SDNN (SMD = -0.75) than healthy controls. The findings support the use of HRV as a biomarker to facilitate precise monitoring of post-ABI functions.

Heart rate variability as possible marker of brain damage in neonates with hypoxic ischemic encephalopathy: a systematic review

Heart rate variability (HRV) is currently considered the most valuable non-invasive test to investigate the autonomic nervous system function, based on the fact that fast fluctuations might specifically reflect changes of sympathetic and vagal activity. An association between abnormal values of HRV and brain impairment has been reported in the perinatal period, although data are still fragmentary. Considering such association, HRV has been suggested as a possible marker of brain damage also in case of hypoxic-ischemic encephalopathy following perinatal asphyxia. The aim of the present manuscript was to review systematically the current knowledge about the use of HRV as marker of cerebral injury in neonates suffering from hypoxic-ischemic encephalopathy. Findings reported in this paper were based on qualitative analysis of the reviewed data. Conclusion: A growing body of research supports the use of HRV as non-invasive, bedside tool for the monitoring of hypoxic-ischemic encephalopathy. The currently available data about the role of HRV as prognostic tool in case of hypoxic ischemic encephalopathy are promising but require further validation by future studies. What is Known: • Heart rate variability (HRV) is a non-invasive monitoring technique to assess the autonomic nervous system activity. • A correlation between abnormal HRV and cerebral injury has been reported in the perinatal period, and HRV has been suggested as possible marker of brain damage in case of hypoxic-ischemic encephalopathy. What is New: • HRV might provide precocious information about the entity of brain injury in asphyxiated neonates and be of help to design early, specific, and personalized treatments according to severity. • Further investigations are required to confirm these preliminary data.

Continuous heart rate variability and electroencephalography monitoring in severe acute brain injury: a preliminary study

Background

Decreases in heart rate variability have been shown to be associated with poor outcomes in severe acute brain injury. However, it is unknown whether the changes in heart rate variability precede neurological deterioration in such patients. We explored the changes in heart rate variability measured by electrocardiography in patients who had neurological deterioration following severe acute brain injury, and examined the relationship between heart rate variability and electroencephalography parameters.

Methods

Retrospective analysis of 25 patients who manifested neurological deterioration after severe acute brain injury and underwent simultaneous electroencephalography plus electrocardiography monitoring.

Results

Eighteen electroencephalography channels and one simultaneously recorded electrocardiography channel were segmented into epochs of 120-second duration and processed to compute 10 heart rate variability parameters and three quantitative electroencephalography parameters. Raw electroencephalography of the epochs was also assessed by standardized visual interpretation and categorized based on their background abnormalities and ictalinterictal continuum patterns. The heart rate variability and electroencephalography parameters showed consistent changes in the 2-day period before neurological deterioration commenced. Remarkably, the suppression ratio and background abnormality of the electroencephalography parameters had significant reverse correlations with all heart rate variability parameters.

Conclusions

We observed a significantly progressive decline in heart rate variability from the day before the neurological deterioration events in patients with severe acute brain injury were first observed.

Functional plasticity of cardiac efferent neurons contributes to traumatic brain injury-induced cardiac autonomic dysfunction

Traumatic brain injury (TBI) frequently causes cardiac autonomic dysfunction (CAD), irrespective of its severity, which is associated with an increased morbidity and mortality in patients. Despite the significance of probing the cellular mechanism underlying TBI-induced CAD, animal studies on this mechanism are lacking. In the current study, we tested whether TBI-induced CAD is associated with functional plasticity in cardiac efferent neurons. In this regard, TBI was induced by a controlled cortical impact in rats. Assessment of heart rate variability and baroreflex sensitivity indicated that CAD was developed in the sub-acute period after moderate and severe TBI. The cell excitability was increased in the stellate ganglion (SG) neurons and decreased in the intracardiac ganglion (ICG) neurons in TBI rats, compared with the sham-operated rats. The transient A-type K+ (KA) currents, but not the delayed rectifying K+ currents were significantly decreased in SG neurons in TBI rats, compared with sham-operated rats. Consistent with these electrophysiological data, the transcripts encoding the Kv4 α subunits were significantly downregulated in SG neurons in TBI rats, compared with sham-operated rats. TBI causes downregulation and upregulation of M-type K+ (KM) currents and the KCNQ2 mRNA transcripts, which may contribute to the hyperexcitability of the SG neurons and the hypoexcitability of the ICG neurons, respectively. In conclusion, the key cellular mechanism underlying the TBI-induced CAD may be the functional plasticity of the cardiac efferent neurons, which is caused by the regulation of the KA and/or KM currents.

Heart Rate Variability as a Predictor of Mortality in Traumatic Brain Injury: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically review the medical literature to determine the utility of heart rate variability in predicting mortality for moderate to severe traumatic brain injury.

METHODS

A search for randomized controlled trials, nonrandomized trials, and prospective and retrospective cohort studies was carried out using PubMed, SCOPUS, Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE. Reference lists of included studies were also searched to identify potentially eligible studies.

RESULTS

Five articles comprising 542 patients met inclusion criteria. Heart rate variability as low-frequency/high-frequency ratio (area under the curve [AUC] receiver operating characteristic [ROC]) for predicting mortality was found to be statistically significant (AUC ROC 0.810, P < 0.001) with high heterogeneity (I² = 61.98%, P = 0.032). Meta-analysis of low-frequency/high-frequency ratio, High frequency peak, and total power were statistically significant for predicting mortality. Odd's ratio for predicting mortality for LF/HF ratio, HF peak, and TP were 16.17, 19.09, 22.59 respectively. High-frequency peak in predicting mortality showed an AUC ROC of 0.986 (P ≤ 0.001) with a low level of heterogeneity. Total power (TP) showed an AUC ROC of 0.93 (P < 0.001) in predicting mortality with a high level of heterogeneity (I² = 83.16%, P = 0.002). Funnel plot analysis to assess the presence of publication bias for TP showed a high level of heterogeneity and asymmetry among studies.

CONCLUSIONS

This meta-analysis predicted high mortality based on odds ratio for variables low-frequency/high-frequency ratio, high-frequency peak, and TP. However, the statistical analysis was weakened owing to the high level of heterogeneity in the included studies. Further research is needed to generate high-quality recommendations regarding heart rate variability as a predictor of mortality after traumatic brain injury.

Measures of CNS-Autonomic Interaction and Responsiveness in Disorder of Consciousness

Neuroimaging studies have demonstrated functional interactions between autonomic (ANS) and brain (CNS) structures involved in higher brain functions, including attention and conscious processes. These interactions have been described by the Central Autonomic Network (CAN), a concept model based on the brain-heart two-way integrated interaction. Heart rate variability (HRV) measures proved reliable as non-invasive descriptors of the ANS-CNS function setup and are thought to reflect higher brain functions. Autonomic function, ANS-mediated responsiveness and the ANS-CNS interaction qualify as possible independent indicators for clinical functional assessment and prognosis in Disorders of Consciousness (DoC). HRV has proved helpful to investigate residual responsiveness in DoC and predict clinical recovery. Variability due to internal (e.g., homeostatic and circadian processes) and environmental factors remains a key independent variable and systematic research with this regard is warranted. The interest in bidirectional ANS-CNS interactions in a variety of physiopathological conditions is growing, however, these interactions have not been extensively investigated in DoC. In this brief review we illustrate the potentiality of brain-heart investigation by means of HRV analysis in assessing patients with DoC. The authors' opinion is that this easy, inexpensive and non-invasive approach may provide useful information in the clinical assessment of this challenging patient population.

Autonomic nervous system monitoring in intensive care as a prognostic tool. Systematic review

Objective

To present a systematic review of the use of autonomic nervous system monitoring as a prognostic tool in intensive care units by assessing heart rate variability.

Methods

Literature review of studies published until July 2016 listed in PubMed/Medline and conducted in intensive care units, on autonomic nervous system monitoring, via analysis of heart rate variability as a prognostic tool (mortality study). The following English terms were entered in the search field: ("autonomic nervous system" OR "heart rate variability") AND ("intensive care" OR "critical care" OR "emergency care" OR "ICU") AND ("prognosis" OR "prognoses" OR "mortality").

Results

There was an increased likelihood of death in patients who had a decrease in heart rate variability as analyzed via heart rate variance, cardiac uncoupling, heart rate volatility, integer heart rate variability, standard deviation of NN intervals, root mean square of successive differences, total power, low frequency, very low frequency, low frequency/high frequency ratio, ratio of short-term to long-term fractal exponents, Shannon entropy, multiscale entropy and approximate entropy.

Conclusion

In patients admitted to intensive care units, regardless of the pathology, heart rate variability varies inversely with clinical severity and prognosis.

Heart rate variability after endovascular coiling is associated with short-term outcomes in patients with subarachnoid hemorrhage

OBJECTIVE

to evaluate whether postoperative heart rate variability (HRV) predicts short-term outcomes in patients undergoing coil embolization of ruptured aneurysms.

METHODS

Consecutive patients receiving endovascular coiling to treat aneurysmal subarachnoid hemorrhage (SAH) were retrospectively reviewed between November 2011 and December 2014 in the authors' institution. Heart rate (HR) and blood pressure (BP) recorded in the initial 24 h after endovascular treatment were extracted along with other clinical data. HR variability (HRV) and BP variability (BPV) were determined as standard deviation (SD) and successive variation (SV) of every 2-h HR and BP. The correlation between HRV and clinical outcomes as assessed by Glasgow Outcome Scale (GOS) scores at discharge were analyzed statistically.

RESULTS

Compared to the 310 patients with favorable outcomes (GOS 4-5), the 35 with unfavorable outcomes (GOS 1-3) had significantly higher HR, HRV, and BPV in the first postoperative day. Furthermore, HRV-SD remained to be an independent predictor of unfavorable recovery in multivariate logistic analysis (OR = 1.14; 95% CI, 1.02-1.29; P = 0.026) after adjusting for age, postoperative fever, and Glasgow Coma Scale scores on admission, which have been identified as predictors of poor prognosis. The area under the receiver operating characteristic curves for HRV-SD and BPV-SV were found to be 0.745 (95% CI, 0.658-0.833) and 0.633 (95% CI, 0.524-0.741), respectively (P < 0.05).

CONCLUSIONS

Higher HRV in the first day after coil embolization was associated with unfavorable outcomes in patients with SAH. Early detection and appropriate treatment of the overactive sympathetic activity might promote functional recovery after SAH. Abbreviation: BP: Blood pressure; CI: Confidence interval; DBP: Diastolic blood pressure; GCS: Glasgow coma scale; GOS: Glasgow outcome scale; HR: Heart rate; HRV: Heart rate variability; OR: Odds ratio; ROC: Receiver operating characteristics; SD: Standard deviation; SAH: Subarachnoid hemorrhage; SV: Successive variation; SBP: Systolic blood pressure.

Pituitary adenylate cyclase-activating polypeptide drives cardiorespiratory responses to heat stress in neonatal mice

The neuropeptide pituitary adenylate cyclase-activating polypeptide (PACAP) has emerged as a principal and rate-limiting regulator of physiological stress responses in adult rodents and has been implicated in sudden infant death syndrome (SIDS). Recent studies show that PACAP plays a role in neonatal cardiorespiratory responses to hypoxia, hypercapnia, and hypothermia, but not hyperthermia, which is often associated with SIDS. Here we tested the hypothesis that, consistent with a role in SIDS, PACAP is involved in regulating the neonatal cardiorespiratory responses to severe heat. To address this, we used head-out plethysmography and surface ECG electrodes to study the cardiorespiratory physiology of conscious neonatal PACAP-null and wild-type mice at ambient temperatures of 32°C (baseline) and 40°C (heat stress). We also assessed body surface temperature as an indicator of cutaneous heat loss. Our results show that wild-type neonatal mice respond to heat stress by increasing ventilation ( P = 0.007) and associated expired CO2 ( P = 0.041), heart rate ( P < 0.001), and cutaneous heat loss ( P < 0.001). In PACAP-null neonates, this heat response is impaired, as indicated by a decrease in ventilation ( P = 0.04) and associated expired CO2 ( P = 0.006) and a blunted increase in heart rate ( P = 0.001) and cutaneous heat loss ( P = 0.0002). In addition, heart rate variability at baseline was lower in PACAP-null neonates than wild-type controls ( P < 0.01). These results suggest that, during heat stress, PACAP is important for neonatal cardiorespiratory responses that help regulate body temperature. Abnormal PACAP regulation could, therefore, contribute to neonatal disorders in which the autonomic response to stress is impaired, such as SIDS.

Heart Rate Variability of Athletes Across Concussion Recovery Milestones: A Preliminary Study

OBJECTIVE

To assess heart rate variability (HRV) in athletes with concussion across three phases of recovery.

DESIGN

A prospective matched control group design included the collection of HRV and symptoms measured by the Rivermead Post-Concussion Questionnaire. These measures were taken at 3 phases of recovery [(1) symptomatic; (2). asymptomatic; and (3) one-week after return-to-play (RTP)]. The same protocol was completed by noninjured athletes.

SETTING

Interuniversity sports teams at a single institution.

PARTICIPANTS

11 athletes, across 7 sports, diagnosed with concussion, and 11 matched-athlete controls volunteered for the study.

INTERVENTION

Physician diagnosed concussion and a sitting to standing protocol for HRV monitoring.

MAIN OUTCOME MEASURES

The frequency, time, and nonlinear domains of HRV were assessed along with the absolute difference between sitting and standing for each.

RESULTS

A 2 x 3 (group x phase) repeated-measures analysis of variance revealed significant interactions for sitting High Frequency (HF) norm, sitting Low Frequency (LF) norm, the difference between sitting and standing HF norm, and difference between sitting and standing LF norm. Acutely, athletes with concussion displayed increased LF norm and decreased HF norm while sitting and a decreased change in their HF and LF norm measures between sitting and standing. A significant group effect for sample entropy when standing was detected, with the concussed group displaying decreased values compared with the matched controls.

CONCLUSIONS

Athletes with concussion displayed autonomic dysfunction in some measures of HRV that persisted beyond RTP and were related to a previous history of concussion.

Respiratory induced heart rate variability during slow mechanical ventilation : Marker to exclude brain death patients

BACKGROUND

Respiratory induced heart rate variability (rHRV) was analysed in mechanically ventilated patients during two levels of sedation and brain death. Our aim was to determine whether rHRV can distinguish between different levels of sedation and especially between brain death and sedated patients.

METHODS

In this study 30 critically ill and 23 brain death patients were included and four respiratory rates of 15, 12, 8 and 6 breaths per minute, each lasting 5 min were used. Two sedation levels, basal and deep, were performed in the critically ill patients. Heart rate and blood pressure changes induced by ventilation were subsequently detected and analysed.

RESULTS

Significant differences were found in rHRV and rHRV adjusted for tidal volume (rHRV/VT) between critically ill and brain death patients during slow breathing at 6 or 8 breaths per minute. The rHRV at 6 breaths per minute was below 15 ms in all brain death subjects except one. The rHRV/VT was lower than 25 ms/l at both 6 and 8 breaths per minute in all brain death patients and simultaneously at 75% of non-brain death patients was higher (specificity 1, sensitivity 0.24). Differences in rHRV and rHRV/VTs between basal and deep sedation were not significant.

CONCLUSIONS

The main clinical benefit of the study is the finding that rHRV and rHRV/VT during 6 and 8 breaths per minute can differentiate between critically ill and brain death patients. An rHRV/VT exceeding 25 ms/l reliably excludes brain death.

How Can Music Influence the Autonomic Nervous System Response in Patients with Severe Disorder of Consciousness?

Activations to pleasant and unpleasant musical stimuli were observed within an extensive neuronal network and different brain structures, as well as in the processing of the syntactic and semantic aspects of the music. Previous studies evidenced a correlation between autonomic activity and emotion evoked by music listening in patients with Disorders of Consciousness (DoC). In this study, we analyzed retrospectively the autonomic response to musical stimuli by mean of normalized units of Low Frequency (nuLF) and Sample Entropy (SampEn) of Heart Rate Variability (HRV) parameters, and their possible correlation to the different complexity of four musical samples (i.e., Mussorgsky, Tchaikovsky, Grieg, and Boccherini) in Healthy subjects and Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS) patients. The complexity of musical sample was based on Formal Complexity and General Dynamics parameters defined by Imberty's semiology studies. The results showed a significant difference between the two groups for SampEn during the listening of Mussorgsky's music and for nuLF during the listening of Boccherini and Mussorgsky's music. Moreover, the VS/UWS group showed a reduction of nuLF as well as SampEn comparing music of increasing Formal Complexity and General Dynamics. These results put in evidence how the internal structure of the music can change the autonomic response in patients with DoC. Further investigations are required to better comprehend how musical stimulation can modify the autonomic response in DoC patients, in order to administer the stimuli in a more effective way.

Residual vasomotor activity assessed by heart rate variability in a brain-dead case

A patient assessed by heart rate variability (HRV) methodology, beginning just after the completion of brain death (BD) diagnosis, showed remaining very low frequency (VLF) waves for approximately 10 min. A time-varying spectral analysis showed that during the first 550 s, a significant power spectral density remained in the high-frequency (HF), low-frequency (LF) and VLF bands. From 550 to 675 s, the HF oscillations totally vanished, and a marked progressive decay of the LF and VLF power density occurred. After 700 s the VLF undulations stopped and remaining small amplitude oscillations at 0.2 Hz coincided with the ventilator frequency. The VLF oscillations recorded in our case might be related to residual sympathetic vasomotor activity that progressively disappeared due to the extension of necrosis affecting the nervous centres of the lower part of the medulla and the first 2-3 cervical spine segments.

Heart rate variability analysis during central hypovolemia using wavelet transformation

Detection of hypovolemia prior to overt hemodynamic decompensation remains an elusive goal in the treatment of critically injured patients in both civilian and combat settings. Monitoring of heart rate variability has been advocated as a potential means to monitor the rapid changes in the physiological state of hemorrhaging patients, with the most popular methods involving calculation of the R-R interval signal's power spectral density (PSD) or use of fractal dimensions (FD). However, the latter method poses technical challenges, while the former is best suited to stationary signals rather than the non-stationary R-R interval. Both approaches are also limited by high inter- and intra-individual variability, a serious issue when applying these indices to the clinical setting. We propose an approach which applies the discrete wavelet transform (DWT) to the R-R interval signal to extract information at both 500 and 125 Hz sampling rates. The utility of machine learning models based on these features were tested in assessing electrocardiogram signals from volunteers subjected to lower body negative pressure induced central hypovolemia as a surrogate of hemorrhage. These machine learning models based on DWT features were compared against those based on the traditional PSD and FD, at both sampling rates and their performance was evaluated based on leave-one-subject-out fold cross-validation. Results demonstrate that the proposed DWT-based model outperforms individual PSD and FD methods as well as the combination of these two traditional methods at both sample rates of 500 Hz (p value <0.0001) and 125 Hz (p value <0.0001) in detecting the degree of hypovolemia. These findings indicate the potential of the proposed DWT approach in monitoring the physiological changes caused by hemorrhage. The speed and relatively low computational costs in deriving these features may make it particularly suited for implementation in portable devices for remote monitoring.

Heart rate variability in neonates with hypoxic ischemic encephalopathy

OBJECTIVE

To evaluate the changes in heart rate variability (HRV) in newborns with hypoxic-ischemic encephalopathy (HIE).

METHODS

Twenty-two newborns (14 boys, 8 girls) with moderate or severe HIE and 24 term neonates with similar gestational and postnatal age for control were included in this study. Normalized low and high frequency components of HRV and their ratio were evaluated for 24-h in newborns with HIE and control subjects.

RESULTS

The newborns with hypoxic-ischemic encephalopathy had significantly lower normalized low frequency (LFn) and low frequency (LF) / high frequency (HF) values and higher normalized high frequency (HFn) values when compared with the control babies. In addition, when the cases with severe HIE are compared with those of moderate HIE, decreased LFn, LF/HF values and also increased HFn values were present in the severe cases.

CONCLUSIONS

HIE is associated with reduced sympathetic nervous system activity, and increased parasympathetic nervous system activity and these activities also correlate with the severity of the disease.

Heart rate variability is an independent predictor of morbidity and mortality in hemodynamically stable trauma patients

BACKGROUND

Reduced heart rate variability (HRV) reflects autonomic dysfunction and can triage patients better than routine trauma criteria or vital signs. However, there is questionable specificity and no consensus measurement technique. The purpose of this study was to analyze whether factors that alter autonomic function affect the specificity of HRV for assessing traumatic injury.

METHODS

We evaluated 216 hemodynamically stable adults (3:1 M:F; 97:3 blunt:penetrating; age 49 years ± 1 year, mean ± standard error) undergoing computed axial tomography (CT) scan to rule out traumatic brain injury (TBI). All were prospectively instrumented with a Mars Holter system (GE Healthcare, Milwaukee, WI). HRV was determined offline using time domain (standard deviation of normal-normal intervals, root-mean-square successive difference) and frequency domain (very low frequency [VLF], LF, wideband frequency, high frequency [HF], low to HF index ratio) calculations from 15-minute electrocardiogram and correlated with routine vital signs, mortality, TBI, morbidity, length of stay (LOS), and comorbidities. Significance (p ≤ 0.05) was determined using nonparametric analysis, Student's t test, analysis of variance, or multiple logistic regression.

RESULTS

VLF alone predicted survival, severity of TBI, intensive care unit LOS, and hospital LOS (all p < 0.05). Beta-blockers or diabetes had no effect, whereas age, sedation, mechanical ventilation, spinal cord injury, and intoxication influenced one or more of the variables with age being the most powerful confounder (all p < 0.05). Except for the Glasgow Coma Scale, no other routine trauma or hemodynamic criteria correlated with any of these outcomes.

CONCLUSIONS

Decreased VLF is an independent predictor of mortality and morbidity in hemodynamically stable trauma patients. Other time and other frequency domain variables correlated with some, but not all, outcomes. All were heavily influenced by factors that alter autonomic function, especially patient age.

Depressed sympathovagal balance predicts mortality in patients with subarachnoid hemorrhage

OBJECTIVES

The objective of this study is to investigate the role of sympathovagal balance in predicting inhospital mortality by assessing power spectral analysis of heart rate variability (HRV) among patients with nontraumatic subarachnoid hemorrhage (SAH) in an emergency department (ED).

METHODS

A cohort of 132 adult patients with spontaneous SAH in an ED was prospectively enrolled. A continuous 10-minute electrocardiography for off-line power spectral analysis of the HRV was recorded. Using the inhospital mortality, the patients were classified into 2 groups: nonsurvivors (n=38) and survivors (n=94). The HRV measures were compared between these 2 groups of patients.

RESULTS

Having compared the various measurements, the very low-frequency component, low-frequency component, normalized low-frequency component (LF%), and low-/high-frequency component ratio (LF/HF) were significantly lower, whereas the normalized high-frequency component was significantly higher among the nonsurvivors than among the survivors. A multiple logistic regression model identified LF/HF (odds ratio, 2.16; 95% confidence interval [CI], 1.18-3.97; P=.013) and LF% (odds ratio, 0.78; 95% CI, 0.69-0.88; P<.001) as independent variables that were able to predict inhospital mortality for patients with SAH in an ED. The receiver operating characteristic area for LF/HF in predicting inhospital mortality was 0.957 (95% CI, 0.914-1.000; P<.001), and the best cutoff points was 0.8 (sensitivity, 92.1%; specificity, 90.4%).

CONCLUSIONS

Power spectral analysis of the HRV is able to predict inhospital mortality for patients after SAH in an ED. A tilt in the sympathovagal balance toward depressed sympathovagal balance, as indicated by HRV analysis, might contribute to the poor outcome among these patients.

Clinical applications of heart rate variability in the triage and assessment of traumatically injured patients

Heart rate variability (HRV) is a method of physiologic assessment which uses fluctuations in the RR intervals to evaluate modulation of the heart rate by the autonomic nervous system (ANS). Decreased variability has been studied as a marker of increased pathology and a predictor of morbidity and mortality in multiple medical disciplines. HRV is potentially useful in trauma as a tool for prehospital triage, initial patient assessment, and continuous monitoring of critically injured patients. However, several technical limitations and a lack of standardized values have inhibited its clinical implementation in trauma. The purpose of this paper is to describe the three analytical methods (time domain, frequency domain, and entropy) and specific clinical populations that have been evaluated in trauma patients and to identify key issues regarding HRV that must be explored if it is to be widely adopted for the assessment of trauma patients.

Heart rate variability as a triage tool in patients with trauma during prehospital helicopter transport

BACKGROUND

Prehospital triage of patients with trauma is routinely challenging, but more so in mass casualty situations and military operations. The purpose of this study was to prospectively test whether heart rate variability (HRV) could be used as a triage tool during helicopter transport of civilian patients with trauma.

METHODS

After institutional review board approval and waiver of informed consent, 75 patients with trauma requiring prehospital helicopter transport to our level I center (from December 2007 to November 2008) were prospectively instrumented with a 2-Channel SEER Light recorder (GE Healthcare, Milwaukee, WI). HRV was analyzed with a Mars Holter monitor system and proprietary software. SDNN (standard deviation [SD] of the normal-to-normal R-R interval), as an index of HRV, was correlated with prehospital trauma triage criteria, base deficit, seriousness of injury, operative interventions, outcome, and other data extracted from the patients' medical records. There were no interventions or medical decisions based on HRV. Data were excluded only if there was measurement artifact or technical problems with the recordings.

RESULTS

The demographics were mean age 47 years, 63% men, 88% blunt, 25% traumatic brain injury, 9% mortality. Prehospital SDNN predicted patients with base excess < or = -6, those defined as seriously injured and benefiting from trauma center care, as well as patients requiring a life-saving procedure in the operating room. No other available data, including prehospital en-route vital signs, predicted any of these. The sensitivity, specificity, positive predictive value, and negative predictive value were 80%, 75%, 33%, 96%, respectively, with and an overall accuracy of 76% for predicting a life-saving intervention in the operating room.

CONCLUSIONS

This is the first demonstration that prehospital HRV (specifically SDNN) predicts base excess and operating room life-saving opportunities. HRV triages and discriminates severely injured patients better than routine trauma criteria or en-route prehospital vital signs. HRV may be a useful civilian or military triage tool to avoid unnecessary helicopter evacuation for minimally injured patients. A prospective, randomized trial in a larger patient population is indicated.

Dysautonomia and heart rate variability following severe traumatic brain injury

PRIMARY OBJECTIVE

To investigate disconnection theories postulated as the cause of dysautonomia following severe traumatic brain injury (TBI) through analysis of heart rate variability (HRV).

METHODS AND PROCEDURES

Data were collected on age-matched subjects with and without dysautonomia (eight subjects in each group) and 16 non-injured controls. Data included injury details, continuous electrocardiograph recordings and rehabilitation outcome.

MAIN OUTCOMES AND RESULTS

The TBI group revealed significant differences in HRV parameters both compared to controls and between dysautonomic and non-dysautonomic subjects. Additionally, HRV parameters for dysautonomic subjects showed evidence of an uncoupling of the normal relationship between heart rate and sympathetic/parasympathetic balance. HRV changes persisted for the dysautonomia group for a mean of 14 months post-injury.

CONCLUSIONS

Dysautonomic subjects revealed prolonged uncoupling of heart rate and HRV parameters compared to non-dysautonomic subjects and controls. These findings represent direct pathophysiological evidence supporting the disconnection theory postulated to produce dysautonomia following TBI.

Early loss of heart rate complexity predicts mortality regardless of mechanism, anatomic location, or severity of injury in 2178 trauma patients

BACKGROUND

Reduced heart rate (HR) complexity (e.g., a lack of randomness or unpatterned variability) is an established predictor of trauma patient mortality. However, this finding has not been validated across the diverse spectrum of traumatic injury, and underlying mechanisms of this relationship are poorly understood.

MATERIALS AND METHODS

Two thousand one hundred seventy-eight trauma patients were admitted directly to the intensive care unit (ICU), and had sufficient (>6h) continuous integer heart rate data within the first d. Patients were stratified by location of isolated severe injury (head, torso, both, or neither), primary mechanism (blunt or penetrating), and probability of survival, an accepted scoring system based on age, admission vital signs, and injury type and severity. HR multiscale entropy (MSE) was calculated (sum of scales, Costa's algorithm, physionet.org, m=2, r=0.15) to estimate complexity. Univariate analysis was performed by comparing MSE between survivors and nonsurvivors in each subgroup. Multivariate analysis incorporated logistic regression to characterize the relationship between MSE and risk of death, controlling for probability of survival. The MSE odds ratios (OR) and area under the receiver operator curve (AUC) were calculated.

RESULTS

Reduced MSE was significantly associated with increasing mortality, and was independent of probability of survival in all multivariate analyses (OR 0.87-0.94). This range of odds ratios implies that a patient with an MSE of 15 has roughly a 2- to 6-fold increase in odds of death versus a patient with an MSE of 25. The relationship between MSE and death was moderately stronger in patients with isolated severe head injury versus torso injury, and significantly stronger in patients with penetrating versus blunt mechanism of injury. MSE measured early in the hospital stay remained a robust predictor of mortality in all subgroups, even stratified by narrow ranges of probability of survival.

CONCLUSIONS

Early reduction of heart rate complexity is an important risk factor across diverse injury etiology. This suggests common underlying physiologic mechanisms linking the loss of biologic complexity to death.

Asymmetric insular function predicts positional blood pressure in nondemented elderly

Forty percent of nondemented octogenarians have Braak stages consistent with insular involvement, and may be at risk for "age-related" autonomic dysfunction. The authors examined the association between insular resting cerebral blood flow (rCBF) and cardiovascular functions in 29 nondemented elderly subjects who were highly screened to exclude comorbid cardiovascular disease. Mean insular rCBF was significantly higher on the right than left. However, 35.4% of participants had left dominant rCBF (a high-risk group). Right insular rCBF was significantly lower in the high-risk group. This subset had significantly increased positional drops in systolic blood pressure. While these data cannot address Alzheimer's disease as the specific cause, this possibility is being investigated in other cohorts.

Beta-blocker exposure in patients with severe traumatic brain injury (TBI) and cardiac uncoupling

BACKGROUND

Cardiac uncoupling and reduced heart rate (HR) variability are associated with increased mortality after severe traumatic brain injury (TBI). Recent data has shown beta-blocker (betaB) exposure is associated with improved survival in this patient population. The purpose of the present study was to evaluate the effect of betaB exposure on the mortality risk of patients with severe TBI and early cardiac uncoupling.

METHODS

From December 2000 to October 2005, 4,116 patients were admitted to the trauma intensive care unit. Four hundred forty-six patients (12%) had head Abbreviated Injury Scale score >/= 5 without neck injury and had continuous HR data for the first 24 hours. One hundred forty-one patients (29%) received betaB. Cardiac uncoupling was calculated as the percent of time that 5-minute HR standard deviation was between 0.3 bpm and 0.6 bpm on postinjury day 1.

RESULTS

A relationship between betaB and survival was observed when the population was considered irrespective of length of stay or betaB start time (p < 0.001). Cardiac uncoupling appears to stratify patients into groups who might receive additional benefit from betaB, and identifies patients with increasing mortality. However, the association of betaB with survival was attenuated when analyses accounted for selection bias in betaB administration.

CONCLUSIONS

betaB exposure was associated with reduced mortality among patients with severe TBI. Though loss of HR variability has previously been associated with an increase in mortality, betaB exposure appears to be associated with increased survival across all stratifications of cardiac uncoupling.

Low frequency pressure waves of possible autonomic origin in severely head-injured children

BACKGROUND

Useful information (both clinical and pathophysiological) which may be extracted from intracranial pressure (ICP) recordings include: (1) the mean level of ICP (and CPP), (2) cerebrovascular autoregulation status, (3) the intracranial pulse pressure (the pulse wave index, ICPpp/ICPm) or the pressure-volume compensatory reserve index (RAP) and (4) the presence of any abnormal ICP waveform. This paper describes a slow frequency ICP waveform in children with TBI and postulates the pathophysiological basis and whether it contains clinically useful detail.

METHODS

Children admitted to the Regional Head Injury Service in Edinburgh with TBI have continuously monitored ICP, MAP, CPP, and other physiological data (stored at a 1-min resolution). Slow frequency waveforms were noted, prompting a review of the stored monitoring from all cases over a 10 year period.

FINDINGS

Episodic slow pressure waves were detected in 11 of 122 severely head-injured (HI) children. The waveforms were detected in children of all ages (1.6-15 years) in the ICP signal, which were in phase with similar fluctuations in the MAP, CPP, and HR signals. Their mean periodicity was 1 per 7 min (range 1 per 5-10 min), with a mean ICP pulse wave amplitude of 5.45 mmHg (range 4-7.5), and mean MAP pulse wave amplitude (pulse pressure) of 10.4 mmHg (range 4-15 mmHg). The duration was variable (range approx 2 h to 4.5 days). They were detected in the preterminal phase after serious HI, as well as in those children who made an independent recovery (GOS 4/5). The waves were not related to the mean levels of ICP, CPP, MAP, temperature or the state of cerebrovascular autoregulation.

CONCLUSIONS

We postulate that these previously unreported slow waveforms may reflect the very low frequency (VLF) and ultra low frequency (ULF; < or = 1 per 5 min) components of heart rate and arterial blood pressure variability.

Heart rate variability index in trauma patients

BACKGROUND

Heart rate variability (HRV) changes often reflect autonomic dysfunction with high sensitivity, but the specificity is also low. There are several different methods for measuring HRV, but interpretation is often complex, and the units are not interchangeable. For these reasons, HRV monitoring is not routinely used in many clinical situations. We hypothesized that the specificity of HRV as a screening tool for trauma patients could be improved by controlling some of the confounding influences using multiple logistic regression.

METHODS

A prospective observational trial with waiver of consent was performed in 243 healthy student volunteers and 257 trauma patients, in the resuscitation bay and intensive care units of a Level I trauma center, who received computed axial tomography (CT) scans of the head as part of the initial work up. Electrocardiogram results were recorded for 5 minutes. HRV was defined by SD of normal R-R intervals (SDNN5) and by root mean square of successive differences of R-R intervals (RMSSD5). A head CT scan was considered positive (+) if there were abnormalities in the parenchyma (diffuse axonal injury or contusion), vasculature (intraparenchymal, subdural, or epidural hemorrhage), and/or structural or bony components (fractures of the face or cranium).

RESULTS

In volunteers, SDNN5 was 73 +/- 15 (M +/- SD) milliseconds, compared with 42 +/- 22, 31 +/- 19, 28 +/- 17, and 12 +/- 8 milliseconds in, CT(-) patients with no sedation (n = 82), CT(-) with sedation (n = 60), CT(+) with no sedation (n = 55), and CT(+) with sedation (n = 60), respectively. The differences between trauma, sedation, and CT categories were significant (all p < 0.001). RMSSD5 differences were similar and also highly significant (all p < 0.001). For both SDNN5 and RMSSD5, in each category, there was wide overlap in the range of values, and strong inverse correlations with heart rate (all p < 0.001). Using multiple logistic regression in a subset with no missing data (n = 194), an index was derived from ln(SDNN5) adjusted for six confounding factors. With a negative predictive value held constant at 0.90, compared with ln(SDNN5) alone, the stepwise addition of heart rate, sedation, age, gender, and blood pressure progressively improved the specificity of the HRV index from 0.56 to 0.77, positive predictive value from 0.55 to 0.68, and efficiency from 0.68 to 0.80. This index was then normalized (0-100 scale) for ease of interpretation.

CONCLUSIONS

(1) Several factors alter HRV in patients; (2) when HRV was indexed for some of these factors, its specificity and efficiency were improved for predicting a discrete pathologic state in trauma patients, i.e. (+) or (-) cranial CT scans; (3) the algorithm can incorporate other factors to further refine the diagnostic and/or prognostic ability of HRV as a noninvasive clinical tool; (4) this concept should be applicable to any other HRV measurement technique or outcome.

Adrenal insufficiency, heart rate variability, and complex biologic systems: a study of 1,871 critically ill trauma patients

BACKGROUND

Reduction in integer heart rate variability (HRVi), one potential measurement of complex biologic systems, is common in ICU patients and is strongly associated with hospital mortality. Adrenal insufficiency (AI) and reduced HRVi are associated with autonomic dysfunction. Failure of the autonomic nervous system can be associated with loss of biologic complexity. We hypothesize decreased HRVi is associated with AI, and HRVi improves after treatment of AI, suggesting "recomplexification" (resumption of normal stress response to injury).

STUDY DESIGN

Of 4,116 trauma ICU admissions from December 2000 to November 2005, 1,871 patients had sufficient physiologic, laboratory, pharmacy, and demographic data for analysis. Seventy-five patients failing cosyntropin-stimulation testing were defined as AI; the remaining 1,796 were defined as no AI. HRVi was calculated as integer heart rate standard deviation over 5-minute intervals. HRVi 10th, 50th (median), and 90th percentiles were calculated over the 72 hours pre-, or poststeroid, or both administration (AI). HRVi percentiles in non-AI patients were evaluated at the same interval and compared with AI using Wilcoxon's rank-sum test. In patients with AI, daily HRVi was computed 3 days before and after steroid administration, and compared between survivors and nonsurvivors.

RESULTS

There were 2.9 million heart-rate intervals measured. HRVi stratified patients with AI (cosyntropin failure), and without AI. HRVi was similar in AI survivors and nonsurvivors before steroid treatment, but differed after treatment. HRVi increased substantially in survivors after steroid administration, yet did not change in nonsurvivors. HRVi does not increase in patients who are unresponsive to steroids and die.

CONCLUSIONS

Reduced heart-rate variability, a potential measurement of complex biologic systems, is associated with cosyntropin-confirmed AI; improved in patients responding to steroid therapy; and is a noninvasive, real-time biomarker suggesting AI.

Cognitive predictors of mortality in elderly retirees: results from the Freedom House study

OBJECTIVE

The objective of this longitudinal cohort study was to study the cognitive domains associated with five-year longitudinal survival among healthy, well-educated, noninstitutionalized elderly.

METHODS

Survival curves were generated as a function of cross-sectional baseline cognitive test performance.

RESULTS

Nonverbal tests were significantly associated with survival. This finding was markedly consistent. Several nonverbal tasks were each significantly associated with survival independently of age, gender, baseline level of care, and healthcare utilization. In a multivariate model, copying a clock made the strongest, independent contribution to survival.

CONCLUSIONS

Right hemisphere integrity in general and nonverbal drawing tasks in particular have been associated with survival in conditions as diverse as Alzheimer disease, stroke, and epilepsy. This study extends this association to "normal" aging. The mechanism by which nonverbal cognitive function is related to mortality remains unclear but may be mediated by changes in right hemisphere cortical control of autonomic function. Nondemented older persons may be at risk. Clock drawing may provide a simple means of identifying them.

Insular Alzheimer's disease pathology as a cause of "age-related" autonomic dysfunction and mortality in the non-demented elderly

Only a few brain structures have been implicated in the autonomic control of blood pressure and heart rate. Among them are heteromodal association areas in the cortex, especially the insular cortex. Ischemic insular lesions have been associated with both cardiac arrhythmias and mortality. However, stroke may not be the only insular pathology with the potential to disrupt autonomic function. Alzheimer's disease (AD) is associated with both insular pathology and autonomic dysfunction. Alzheimer's dementia is merely the final stage of a pathological process that spans decades. Recent studies have demonstrated a hierarchichal sequence of AD pathology that includes the insular cortex. This may explain why AD has effects on BP and central autonomic cardio-regulatory functions. However, AD reaches the insular cortex at a "preclinical" stage in its development (i.e., before "dementia" can be diagnosed). Thus, AD pathology should also be considered as a possible explanation for autonomic morbidity and mortality in non-demented elderly persons. We hypothesize that autonomic dyscontrol, commonly seen in non-demented well elderly persons without significant cardiovascular disease (CVD), reflects subclinical stages of AD pathology affecting the insular cortex. If true, then preclinical AD pathology should be considered as a possible explanation for arrhythmia/fall related morbidity and mortality in non-demented elderly persons.

Reduced Heart Rate Variability: An Indicator of Cardiac Uncoupling and Diminished Physiologic Reserve in 1,425 Trauma Patients

BACKGROUND

Measurements of a patient's physiologic reserve (age, injury severity, admission lactic acidosis, transfusion requirements, and coagulopathy) reflect robustness of response to surgical insult. We have previously shown that cardiac uncoupling (reduced heart rate variability, HRV) in the first 24 hours after injury correlates with mortality and autonomic nervous system failure. We hypothesized: Deteriorating physiologic reserve correlates with reduced HRV and cardiac uncoupling.

METHODS

There were 1,425 trauma ICU patients that satisfied the inclusion criteria. Differences in mortality across categorical measurements of the domains of physiologic reserve were assessed using the chi test. The relationship of cardiac uncoupling and physiologic reserve was examined using multivariate logistic regression models for various levels of cardiac uncoupling (>0 through 28% reduced HRV in the first 24 hours).

RESULTS

Of these, 797 (55.9%) patients exhibited cardiac uncoupling. Deteriorating measures of physiologic reserve reflected increased risk of death. Measures of acidosis (admission lactate, time to lactate normalization, and lactate deterioration over the first 24 hours), coagulopathy, age, and injury severity contributed significantly to the risk of cardiac uncoupling (area under receiver operator curve, ROC=0.73). The association between deteriorating reserve and cardiac uncoupling increases with the threshold for uncoupling (ROC=0.78).

CONCLUSIONS

Reduced heart rate variability is a new biomarker reflecting the loss of command and control of the heart (cardiac uncoupling). Risk of cardiac uncoupling increases significantly as a patient's physiologic reserve deteriorates and physiologic exhaustion approaches. Cardiac uncoupling provides a noninvasive, overall measure of a patient's clinical trajectory over the first 24 hours of ICU stay.

Effects of concentrated ambient particles on heart rate variability in spontaneously hypertensive rats

In the present study, the cardiovascular toxicity of PM(2.5) was determined in spontaneously hypertensive (SH) rats using the standard deviation of normal-to-normal intervals (SDNN) and root mean square of successive differences of adjacent normal-to-normal intervals (RMSSD) as outcome measurements. Four SH rats implanted with radiotelemetry transmitters were repeatedly exposed to concentrated PM(2.5) in nose-only exposure chambers. Gravimetric analysis revealed the mean post-concentrating mass concentration of particles during the 5 h of exposure was 202 mug/m(3). Using each animal as its own control and linear mixed-effects model, to adjust for circadian nature and individual differences, we found that SDNN decreased by 15% initially then gradually decreased to 60% of the initial value at the end of exposure. Our results indicate that concentrated PM(2.5) may decrease SDNN on SH rats during PM exposure. The study also showed that SDNN is more sensitive to PM induced effects than RMSSD.

Heart rate variability and outcome in acute severe stroke: role of power spectral analysis

INTRODUCTION

Heart rate variability (HRV) is a predictor of outcome in acute myocardial infarction and head trauma. Its efficacy in predicting outcome in stroke has not been well documented.

MATERIALS AND METHODS

Twenty-five patients (mean age 39 years) with acute stroke treated in a stroke intensive care unit were studied. Continuous echocardiogram recorded for a 1-hour period was digitized and stored for off-line analysis. Time and frequency domain HRV measures were derived for the filtered and rectified ECG data for each patient. Clinical and HRV profiles were compared among patients who died or survived.

RESULTS

At admission, 16 patients were comatose (Glasgow Coma score<9 at admission), 16 had focal weakness, and all had abnormal brain computed tomography. Of the 25 patients,11 died, 10 had a poor outcome, and 4 had good outcome. Two variables low-frequency (LF) spectral power and very low-frequency (VLF) spectral power correlated with mortality. After adjustment for mechanical ventilation and vasopressor administration, LF, VLF, and Triangular index of RR interval (TINN) correlated with mortality. On multiple regression analysis weighed for mechanical ventilation and vasopressor administration, the eye-opening score on Glasgow Coma Scale and LF spectral power were factors that were independently predictive of mortality.

CONCLUSION

HRV measurements are independent predictors of outcome in acute severe stroke.