Persistently elevated heart rate accelerates the progression of arterial stiffness

Changes in Heart Rate Associated with Exenatide Once Weekly: Pooled Analysis of Clinical Data in Patients with Type 2 Diabetes

INTRODUCTION

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) improve glycemia in patients with type 2 diabetes, but heart rate increases have been observed.

METHODS

A pooled post hoc analysis of 11 randomized clinical trials (N = 4595) of 10-30 weeks' duration from the exenatide once-weekly (QW) development program evaluated heart rate with exenatide QW (intervention group) and exenatide twice daily (BID), liraglutide, and non-GLP-1RAs (insulin, metformin, pioglitazone, and sitagliptin) (comparison groups). The time course and size of heart rate changes from baseline and the relationship of heart rate change with baseline heart rate were studied. A multivariate analysis (9 studies; N = 3903) examined associations between patient characteristics or treatments and heart rate increases.

RESULTS

Mean baseline heart rate ± standard deviation was 75.0 ± 8.5 beats per minute (bpm) with exenatide QW (n = 2096), 75.8 ± 8.7 bpm with exenatide BID (n = 606), 75.2 ± 8.9 bpm with liraglutide (n = 450), and 74.5 ± 8.6 bpm with non-GLP-1RAs (n = 1443). Least-squares mean ± standard error changes from baseline to final heart rate were + 2.7 ± 0.2, + 1.0 ± 0.3, and + 3.0 ± 0.4 bpm with exenatide QW, exenatide BID, and liraglutide, respectively, and - 0.8 ± 0.2 bpm with non-GLP-1RAs. The size and direction of heart rate changes in individual patients varied within each treatment group at all time points. At posttreatment follow-up, heart rate reverted to the baseline level after GLP-1RA discontinuation. Heart rate changes correlated negatively with baseline heart rate for all therapies (r = - 0.3 to - 0.4). Baseline heart rate was the strongest predictor of increased heart rate.

CONCLUSIONS

Small increases in heart rate were associated with exenatide QW, exenatide BID, and liraglutide treatments but reverted to baseline after discontinuation. Increases were more likely in patients with a low baseline heart rate. The clinical relevance of these heart rate increases is unknown but will be clarified by several ongoing and recently completed cardiovascular outcome studies.

Hyperinsulinemia and obese phenotype differently influence blood pressure in young normotensive patients with polycystic ovary syndrome

To differentiate the impact of insulin levels/resistance per se from that of excess weight on blood pressure (BP) daily changes, we evaluated, using 24-h ambulatory blood pressure monitoring (ABPM), systolic blood pressure (SBP) and diastolic blood pressure (DBP) in a cohort of young normotensive patients affected by polycystic ovary syndrome (PCOS). A cross-sectional study was performed. Fifty-four patients were studied according to (a) insulinemic state: 32 hyperinsulinemic and/or insulin-resistant (h-INS) and 22 normoinsulinemic (n-INS) patients; and (b) body mass index (BMI): 22 obese (BMI > 30) and 32 lean (18.0 < BMI < 24.9) patients. Each subject's SBP and DBP and heart rate (HR) were measured by ABPM. Supine and upright plasma renin activity (PRA), and aldosterone levels were also assayed. Patients in the h-INS group showed higher 24-h, daytime, and nighttime diastolic blood pressure (DBP), higher nighttime systolic blood pressure (SBP) levels, as well as an increased 24-h, daytime and nighttime HR, compared to both obese and lean patients in the n-INS group. In relation to BMI, only 24-h, daytime, and nighttime DBP were higher in obese than in lean patients. At variance, when both h-INS and obesity were considered, 24-h SBP and DBP were higher in h-INS obese subjects than in the other groups. In multivariate analysis, insulin (max peak), area under the curve of insulin and insulin sensitivity index was independently associated with SBP. (1) Within a normotensive range, hyperinsulinemia and/or insulin resistance influence daily BP variation more than obesity does, suggesting a pivotal role of insulin on BP control in PCOS; (2) altered insulinemic state and ABPM-derived higher nighttime BP and HR may represent early markers to identify PCOS subjects prone to high cardiovascular risk.

Management of the hypertensive patient with elevated heart rate: Statement of the Second Consensus Conference endorsed by the European Society of Hypertension

In June 2015, a panel of experts gathered in a consensus conference to plan updating recommendations on the management of the hypertensive patient with elevated heart rate (HR), previously released in 2006. The issues examined during that meeting and further discussed by the participants during the following months involved the assessment of HR, the relevance of HR as a cardiovascular risk factor, the definition of tachycardia and the treatment of the hypertensive patient with high HR. For the measurement of resting HR the panel experts recommended that scientific investigations focusing on HR should report information on length of resting period before measurement, information about temperature and environment, method of measurement, duration of measurement, number of readings, time interval between measurements, body position and type of observer. According to the panellists there is convincing evidence that HR is an important risk factor for cardiovascular disease and they suggest to routinely include HR measurement in the assessment of the hypertensive patient. Regarding the definition of tachycardia, the panellists acknowledged that in the absence of convincing data any threshold used to define tachycardia is arbitrary. Similarly, as there are no outcome studies of HR lowering in tachycardia hypertension, the panellists could not make practical therapeutic suggestions for the management of such patients. However, the experts remarked that absence of evidence does not mean evidence against the importance of tachycardia as a risk factor for cardiovascular disease and that long-term exposure to a potentially important risk factor may impair the patient's prognosis. The main aims of the present document are to alert researchers and physicians about the importance of measuring HR in hypertensive patients, and to stimulate research to clarify unresolved issues.

Resting Heart Rate Trajectory Pattern Predicts Arterial Stiffness in a Community-Based Chinese Cohort

OBJECTIVE

To examine whether the long-term resting heart rate (RHR) pattern can predict the risk of having arterial stiffness in a large ongoing cohort.

APPROACH AND RESULTS

This community-based cohort included 12 554 participants in the Kailun study, who were free of myocardial infarction, stroke, arrhythmia, and cancer. We used latent mixture modeling to identify RHR trajectories in 2006, 2008, and 2010. We used multivariate linear regression model to examine the association between RHR trajectory patterns and the risk of having arterial stiffness, which was assessed by brachial-ankle pulse wave velocity in 2010 to 2016. We adjusted for possible confounding factors, including socioeconomic status, lifestyle factors, use of medications, comorbidities, and serum concentrations of lipids, glucose, and high-sensitivity C-reactive proteins. We identified 5 distinct RHR trajectory patterns based on their 2006 status and on the pattern of change during 2006 to 2010 (low-stable, moderate-stable, moderate-increasing, elevated-decreasing, and elevated-stable). We found that individuals with elevated-stable RHR trajectory pattern had the highest brachial-ankle pulse wave velocity value and individuals with the low-stable RHR trajectory pattern had the lowest value (adjusted mean difference=157 cm/s; P<0.001). Adjusted odds ratio for risk of having arterial stiffness (brachial-ankle pulse wave velocity ≥1400 cm/s) was 4.14 (95% confidence interval, 2.61-6.57) relative to these 2 extreme categories. Consistently, a higher average RHR, a higher annual RHR increase rate, and a higher RHR variability were all associated with a higher risk of having arterial stiffness.

CONCLUSIONS

Long-term RHR pattern is a strong predictor of having arterial stiffness.

Resting Heart Rate and Aortic Stiffness in Normotensive Adults

Background and Objectives

Large-artery stiffness is an independent predictor of cardiovascular disease (CVD), and carotid-femoral pulse wave velocity (cfPWV) is considered the gold standard measure of arterial stiffness. A resting heart rate is an easily measured vital sign that is also associated with CVD morbidity and mortality. Previous studies have reported the significant relationship of a resting heart rate with arterial stiffness as measured by cfPWV only in hypertensive subjects; their relationship in nonhypertensive subjects remains unknown. The present study, therefore, examined their relationship in normotensive subjects.

Subjects and Methods

In 102 healthy Korean Americans between ages 20 and 60 years, their resting heart rate was measured by an automated blood pressure measuring device after a 10 minute rest in the supine position. Arterial stiffness was measured by cfPWV using the SphygmoCor device.

Results

The mean resting heart rate of participants (mean age, 39.64 years; 59% women) was 61.91 bpm (standard deviation [SD], 9.62 bpm) and mean the cfPWV was 6.99 (SD, 1.14) m/s. A multiple regression analysis showed that a resting heart rate is a significant predictor of cfPWV after controlling for age, body mass index, and mean arterial pressure. For one bpm increase of resting heart rate, cfPWV increased approximately 0.02 m/s.

Conclusion

Our results suggest that a higher resting heart rate is independently associated with increased arterial stiffness as measured by cfPWV in normotensive adults. Arterial stiffness may explain the prognostic role of an individual's heart rate in cardiovascular morbidity and mortality.

Prevalence of abnormal systemic hemodynamics in veterans with and without spinal cord injury

OBJECTIVE

Increased prevalence of heart rate and blood pressure abnormalities are evident in persons with spinal cord injury (SCI), but age, comorbid medical conditions, and prescription medication use may contribute. To determine differences in the prevalence of cardiac acceleration (heart rate ≥80 beats per minute), hypotension (blood pressure ≤110/70mmHg), orthostatic hypotension (OH) (-20/-10mmHg with upright positioning), and hypertension (HTN) (blood pressure ≥140/90mmHg) in veterans with and without SCI.

DESIGN

Observational trial.

SETTING

Medical center.

PARTICIPANTS

Subjects included veterans with SCI (n=62; cervical: tetraplegia, C3-8; high thoracic, T1-5; low thoracic, T7-L2) and veterans without SCI (n=160).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

We assessed medical history, prescription medication use, and heart rate and blood pressure during a routine clinical visit. Prevalence rates of cardiac acceleration, hypotension, OH, and HTN were calculated using binary logistic regression analysis with 95% confidence intervals. The influence of SCI status, age, smoking status, cardiovascular diagnoses, and use of prescribed antihypertensive medications on the prevalence of abnormal heart rate and blood pressure recordings was determined.

RESULTS

The diagnosis of HTN was reduced in the high thoracic and tetraplegia groups compared with the non-SCI and low thoracic groups. Use of antihypertensive medications was increased in the low thoracic group compared with the other 3 groups and was increased in the non-SCI group compared with the tetraplegia group. The prevalence of cardiac acceleration was reduced, and the prevalence of systolic hypotension was increased in the tetraplegia group. The prevalence of diastolic hypotension was increased in all SCI groups compared with the non-SCI group. For all analyses, increased prevalence of abnormal heart rate and blood pressure recordings was not further explained by the covariates, with the exception of age, cardiovascular diagnoses, and antihypertensive medications in the cardiac acceleration model; however, SCI status remained significant and was the dominant predictor variable.

CONCLUSIONS

Our data suggest that SCI status contributes to the prevalence of cardiac acceleration and systolic and diastolic hypotension regardless of cardiovascular medical conditions or prescription antihypertensive medication use.

The product of resting heart rate times blood pressure is associated with high brachial-ankle pulse wave velocity

OBJECTIVE

To investigate potential associations between resting heart rate, blood pressure and the product of both, and the brachial-ankle pulse wave velocity (baPWV) as a maker of arterial stiffness.

METHODS

The community-based "Asymptomatic Polyvascular Abnormalities in Community (APAC) Study" examined asymptomatic polyvascular abnormalities in a general Chinese population and included participants with an age of 40+ years without history of stroke and coronary heart disease. Arterial stiffness was defined as baPWV≥1400 cm/s. We measured and calculated the product of resting heart rate and systolic blood pressure (RHR-SBP) and the product of resting heart rate and mean arterial pressure (RHR-MAP).

RESULTS

The study included 5153 participants with a mean age of 55.1 ± 11.8 years. Mean baPWV was 1586 ± 400 cm/s. Significant (P<0.0001) linear relationships were found between higher baPWV and higher resting heart rate or higher arterial blood pressure, with the highest baPWV observed in individuals from the highest quartiles of resting heart rate and blood pressure. After adjusting for confounding parameters such as age, sex, educational level, body mass index, fasting blood concentrations of glucose, blood lipids and high-sensitive C-reactive protein, smoking status and alcohol consumption, prevalence of arterial stiffness increased significantly (P<0.0001) with increasing RHR-SBP quartile (Odds Ratio (OR): 2.72;95%Confidence interval (CI):1.46,5.08) and increasing RHR-MAP (OR:2.10;95%CI:1.18,3.72). Similar results were obtained in multivariate linear regression analyses with baPWV as continuous variable.

CONCLUSIONS

Higher baPWV as a marker of arterial stiffness was associated with a higher product of RHR-SBP and RHR-MAP in multivariate analysis. In addition to other vascular risk factors, higher resting heart rate in combination with higher blood pressure are risk factors for arterial stiffness.

Exploring the associations between arterial stiffness and spinal cord impairment: A cross-sectional study

BACKGROUND/OBJECTIVE

Elevated aortic arterial stiffness (aortic pulse wave velocity: aPWV) is an independent coronary artery disease predictor among the general population. The purpose of this study was to: (1) report aPWV values in a representative cohort of patients with spinal cord injury (SCI); (2) to compare aPWV values in people with SCI based on neurological level of injury; and (3) to contrast the reported aPWV values with available normal values for the general population.

METHODS

Adults with chronic SCI (n = 87) were divided into two groups (TETRA group, n = 37 and PARA group, n = 50). aPWV and potential confounders of aPWV were assessed. Analysis of covariance was used for comparisons between groups and adjusted for the confounders. Subjects' aPWV values were contrasted with reference values for general population determined by "The Reference value for arterial stiffness' collaboration" and prevalence of abnormal aPWV defined as greater than or equal to the age-specific 90th percentile was reported.

RESULTS

Prevalence of abnormal aPWV in the cohort was 25.3%. After adjusting for covariates, the mean aPWV values were significantly different between two groups (TETRA: 8.0 (95% confidence interval (CI): 7.5-8.6) m/second, PARA: 9.0 (95% CI: 8.5-9.4) m/second, P = 0.010). The prevalence of abnormal aPWV was significantly higher in the PARA group (36%) compared to the TETRA group (11%) (P = 0.012).

CONCLUSIONS

One-quarter of the total cohort had an abnormal aPWV. Subjects with paraplegia had higher aPWV values and a higher frequency of abnormal aPWV than subjects with tetraplegia. Elevated aPWV in people with SCI, particularly those with paraplegia, may impart significant adverse cardiovascular consequences.

A retrospective chart review of heart rate and blood pressure abnormalities in veterans with spinal cord injury

OBJECTIVE

Autonomic impairment may lead to increased prevalence of heart rate (HR) and blood pressure (BP) abnormalities in veterans with spinal cord injury (SCI). In addition, comorbid medical conditions and prescription medication use may influence these abnormalities, including bradycardia, and tachycardia, hypotension, hypertension as well as autonomic dysreflexia (AD), and orthostatic hypotension (OH).

DESIGN

A retrospective review of clinical and administrative datasets in veterans with SCI and compared the prevalence rates between clinical values and ICD-9 diagnostic codes in individuals with tetraplegia (T: C1-C8), high paraplegia (HP: T1-T6), and low paraplegia (LP: T7 and below).

RESULTS

The prevalence of clinical values indicative of a HR ≥ 80 beats per minute was higher in the HP compared to the LP and T groups. A systolic BP (SBP) ≤ 110 mmHg was more common in the T compared to the HP and LP groups, whereas the prevalence of a SBP ≥ 140 mmHg was increased in the LP compared to the HP and T groups. Diagnosis of hypertension was 39-60% whereas the diagnosis of hypotension was less than 1%. Diagnosis of AD and OH was highest in the T group, but remained below 10%, regardless of categorical lesion level. Antihypertensive medications were commonly prescribed (55%), and patients on these medications were less likely to have high BP. The odds ratio of higher SBP and DBP increased with age and body mass index (BMI).

CONCLUSION

In veterans with SCI, the prevalence of HR and BP abnormalities varied depending on level of lesion, age, BMI, and prescription medication use.

A prospective report on the prevalence of heart rate and blood pressure abnormalities in veterans with spinal cord injuries

OBJECTIVE

Decentralized autonomic cardiovascular regulation may lead to increased prevalence of heart rate (HR) and blood pressure (BP) abnormalities in veterans with SCI. In addition, comorbid medical conditions and prescription medication use may increase HR and BP abnormalities. These abnormalities include bradycardia, and tachycardia, hypotension, hypertension as well as autonomic dysreflexia and orthostatic hypotension; the prevalence of which is unknown.

DESIGN

HR and BP data were measured during a routine annual physical examination in 64 veterans with SCI. Measurements of HR and BP were recorded in the seated and supine positions to document the influence of body position and to document intra-subject variability in these assessments.

RESULTS

All subjects were chronically injured (20 ± 14 years), 33 subjects were tetraplegic (T: C3-C8), nine had high paraplegia (HP: T1-T6), and 22 had low paraplegia (LP: T7-L2). Regardless of position, the prevalence of bradycardia was increased in the T group, whereas prevalence of tachycardia was increased in the HP and LP groups. Systolic hypotension was more common in the T and HP groups than the LP group and positional effects were most evident in the T group. Systolic hypertension was comparable in the T and HP groups but was twice as prevalent in the LP group. Increased prevalence of individuals with three or more medical conditions and prescribed three or more medications which might influence HR and BP was observed.

CONCLUSION

Decentralized autonomic regulation, comorbid medical conditions, and prescription medication use in veterans with SCI result in HR and BP abnormalities; our data suggest that these abnormalities vary depending on the level of injury and orthostatic positioning.

Decentralized cardiovascular autonomic control and cognitive deficits in persons with spinal cord injury

Spinal cord injury (SCI) results in motor and sensory impairments that can be identified with the American Spinal Injury Association (ASIA) Impairment Scale (AIS). Although, SCI may disrupt autonomic neural transmission, less is understood regarding the clinical impact of decentralized autonomic control. Cardiovascular regulation may be altered following SCI and the degree of impairment may or may not relate to the level of AIS injury classification. In general, persons with lesions above T1 present with bradycardia, hypotension, and orthostatic hypotension; functional changes which may interfere with rehabilitation efforts. Although many individuals with SCI above T1 remain overtly asymptomatic to hypotension, we have documented deficits in memory and attention processing speed in hypotensive individuals with SCI compared to a normotensive SCI cohort. Reduced resting cerebral blood flow (CBF) and diminished CBF responses to cognitive testing relate to test performance in hypotensive non-SCI, and preliminary evidence suggests a similar association in individuals with SCI. Persons with paraplegia below T7 generally present with a normal cardiovascular profile; however, our group and others have documented persistently elevated heart rate and increased arterial stiffness. In the non-SCI literature there is evidence supporting a link between increased arterial stiffness and cognitive deficits. Preliminary evidence suggests increased incidence of cognitive impairment in individuals with paraplegia, which we believe may relate to adverse cardiovascular changes. This report reviews relevant literature and discusses findings related to the possible association between decentralized cardiovascular autonomic control and cognitive dysfunction in persons with SCI.

Comparison of 24-hour cardiovascular and autonomic function in paraplegia, tetraplegia, and control groups: implications for cardiovascular risk

BACKGROUND

Fluctuations in 24-hour cardiovascular hemodynamics, specifically heart rate (HR) and blood pressure (BP), are thought to reflect autonomic nervous system (ANS) activity. Persons with spinal cord injury (SCI) represent a model of ANS dysfunction, which may affect 24-hour hemodynamics and predispose these individuals to increased cardiovascular disease risk.

OBJECTIVE

To determine 24-hour cardiovascular and ANS function among individuals with tetraplegia (n=20; TETRA: C4-C8), high paraplegia (n=10; HP: T2-T5), low paraplegia (n=9; LP: T7-T12), and non-SCI controls (n=10). Twenty-four-hour ANS function was assessed by time domain parameters of heart rate variability (HRV); the standard deviation of the 5-minute average R-R intervals (SDANN; milliseconds/ms), and the root-mean square of the standard deviation of the R-R intervals (rMSSD; ms). Subjects wore 24-hour ambulatory monitors to record HR, HRV, and BP. Mixed analysis of variance (ANOVA) revealed significantly lower 24-hour BP in the tetraplegic group; however, BP did not differ between the HP, LP, and control groups. Mixed ANOVA suggested significantly elevated 24-hour HR in the HP and LP groups compared to the TETRA and control groups (P<0.05); daytime HR was higher in both paraplegic groups compared to the TETRA and control groups (P<0.01) and nighttime HR was significantly elevated in the LP group compared to the TETRA and control groups (P<0.01). Twenty-four-hour SDANN was significantly increased in the HP group compared to the LP and TETRA groups (P<0.05) and rMSSD was significantly lower in the LP compared to the other three groups (P<0.05). Elevated 24-hour HR in persons with paraplegia, in concert with altered HRV dynamics, may impart significant adverse cardiovascular consequences, which are currently unappreciated.