Skip to main content
NCBI home page
Clinical Cardiology logoLink to Clinical Cardiology
. 2009 Feb 3;20(2):162–168. doi: 10.1002/clc.4960200214

Clinical relevance of heart rate variability

Josef Kautzner 1, A John Camm 1,✉
PMCID: PMC6655696  PMID: 9034646

Abstract

Heart rate variability (HRV) has recently become a popular noninvasive research tool in cardiology. Clinical assessment of HRV is frequently based on standard long‐term ambulatory electrocardiograms, whereas physiologic studies employ spectral analysis of short‐term recordings under controlled conditions. From a general point of view, HRV can be used in clinical practice to estimate (1) the integrity of cardiac autonomic innervation, (2) the physiologic status of cardiac autonomic activity, and (3) the vulnerability to various cardiac arrhythmias resulting from autonomic imbalance. Clinical relevance of HRV has been clearly demonstrated in only two clinical conditions: (1) impaired HRV can be used alone or in a combination with other factors to predict risk of arrhythmic events after acute myocardial infarction, and (2) decrease in HRV is a useful clinical marker for evolving diabetic neuropathy. Substantial advances of our knowledge are required to establish and promote clinical applications in other areas of clinical medicine. To accomplish this task, proper hypotheses should be studied and appropriate techniques selected.

Keywords: heart rate variability, autonomic nervous system, cardiac arrhythmias, myocardial infarction, neuropathy

Full Text

The Full Text of this article is available as a PDF (864.2 KB).

References

  • 1. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology : Heart rate variability: Standards of measurement, physiological interpretation, and clinical use. Circulation 1996; 93: 1043–1065 [PubMed] [Google Scholar]
  • 2. Malliani A, Pagani M, Lombardi F, Cerutti S: Cardiovascular neural regulation explored in the frequency domain. Circulation 1991; 84: 1482–1492 [DOI] [PubMed] [Google Scholar]
  • 3. Malik M, Camm AJ: Components of heart rate variability—what they really mean and what we really measure. Am J Cardiol 1993; 72: 821–822 [DOI] [PubMed] [Google Scholar]
  • 4. Hedman AE, Hartikainen JE, Tahvanainen KU, Hakumaki MO: The high frequency component of heart rate variability reflects cardiac parasympathetic modulation rather than parasympathetic tone. Acta Physiol Scand 1995; 153: 267–273 [DOI] [PubMed] [Google Scholar]
  • 5. Weeler T, Watkins PJ: Cardiac denervation in diabetes. Br Med J 1973; 4: 584–586 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6. Ewing DJ, Neilson JMM, Traus P: New method for assessing cardiac parasympathetic activity using 24‐hour electrocardiograms. Br Heart J 1984; 52: 396–402 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7. Ewing DJ, Martyn CN, Young RJ, Clarke BF: The value of cardiovascular autonomic function tests: 10 years experience in diabetics. Diabetes Care 1985; 8: 491–498 [DOI] [PubMed] [Google Scholar]
  • 8. Pagani M, Malfatto G, Pierini S, Casati R, Masu AM, Poli M, Guzzetti S, Lombardi F, Cerutti S, Malliani A: Spectral analysis of heart rate variability in the assessment of autonomic diabetic neuropathy. J Auton Nerv Syst 1988; 23: 143–153 [DOI] [PubMed] [Google Scholar]
  • 9. Bellavere F, Balzani I, De Masi G, Carraro M, Carenza P, Cobelli C, Thomaseth K: Power spectral analysis of heart rate variations improves assessment of diabetic autonomic neuropathy. Diabetes 1992; 41: 633–640 [DOI] [PubMed] [Google Scholar]
  • 10. Bernardi L, Ricordi L, Lazzari P, Soldá P, Calciati A, Ferrari MR, Vandea I, Finardi G, Frantino P: Impaired circadian modulation of sympathovagal activity in diabetes. A possible explanation for altered temporal onset of cardiovascular disease. Circulation 1992; 86: 1443–1452 [DOI] [PubMed] [Google Scholar]
  • 11. Bellavere F: Heart rate variability in patients with diabetes and other noncardiological diseases In Heart Rate Variability (Eds. Malik M, Camm AJ.), p. 507–516. Armonk: Futura Publishing Co., Inc., 1995. [Google Scholar]
  • 12. Monforte R, Estruch R, Valls‐Sole J, Nicolas J, Villalta J, Urbano‐Marquez A: Autonomic and peripheral neuropathies in patients with chronic alcoholism. A dose‐related toxic effect of alcohol. Arch Neurol 1995; 52: 45–51 [DOI] [PubMed] [Google Scholar]
  • 13. Guzzetti S, Iosa D, Pecis M, Bonura L, Prosdocini M, Malliani A: Impaired heart rate variability in patients with chronic Chagas' disease. Am Heart J 1991; 121: 1727–1734 [DOI] [PubMed] [Google Scholar]
  • 14. Sands KEF, Appel ML, Lilly LS, Schoen FJ, Mudge GH Jr, Cohen RJ: Power spectrum analysis of heart rate variability in human cardiac transplant recipients. Circulation 1989; 79: 76–82 [DOI] [PubMed] [Google Scholar]
  • 15. Bernardi L, Valle F, Leuzzi S, Rinaldi M, Marchesi E, Falcone C, Martinelli L, Vigan M, Finardi G, Radaelli A: Non‐respiratory components of heart rate variability in heart transplant recipients: Evidence of autonomic reinnervation? Clin Sci 1994; 86: 537–545 [DOI] [PubMed] [Google Scholar]
  • 16. Halpert I, Goldberg AD, Levine AB, Levine TB, Kornberg R, Kelly C, Lesh M: Reinnervation of the transplanted human heart evidenced from heart rate variability studies. Am J Cardiol 1996; 77: 180–183 [DOI] [PubMed] [Google Scholar]
  • 17. Bernardi L, Keller F, Sanders M, Reddy PS, Griffith B, Meno F, Pinsky MR: Respiratory sinus arrhythmia in the denervated human heart. J Appl Physiol 1989; 67: 1447–1455 [DOI] [PubMed] [Google Scholar]
  • 18. Hughson RL, Maillet A, Dureau G, Yamamoto Y, Gharib C: Spectral analysis of blood pressure variability in heart transplant patients. Hypertension 1995; 25 (part l): 643–650 [DOI] [PubMed] [Google Scholar]
  • 19. Mancia G: Sympathetic activation in congestive heart failure. Eur Heart J 1990; 11 (suppl A): 3–11 [DOI] [PubMed] [Google Scholar]
  • 20. Casolo GC, Balli E, Taddei T, Amuhasi J, Gori C: Decreased spontaneous heart rate variability in congestive heart failure. Am J Cardiol 1989; 64: 1162–1167 [DOI] [PubMed] [Google Scholar]
  • 21. Casolo GC, Balli E, Fazi A, Gori C, Freni A, Gensini G: Twenty‐four hour spectral analysis of heart rate variability in congestive heart failure secondary to coronary artery disease. Am J Cardiol 1991; 67: 1154–1158 [DOI] [PubMed] [Google Scholar]
  • 22. Nolan J, Flapan AD, Capewell S, MacDonald TM, Neilson JMM, Ewing DJ: Decreased cardiac parasympathetic activity in chronic heart failure and its relation to left ventricular dysfunction. Br Heart J 1992; 67: 482–485 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23. Ajiki K, Murakawa Y, Yanajisawa‐Miwa A, Usni M, Yamashita T, Oikawa N, Inoue H: Autonomic nervous system activity in idiopathic dilated cardiomyopathy and in hypertrophic cardiomyopathy. Am J Cardiol 1993; 71: 1316–1320 [DOI] [PubMed] [Google Scholar]
  • 24. Saul J, Arai Y, Berger RD, Lilly LS, Colucci WS, Cohen RJ: Assessment of autonomic regulation in chronic congestive heart failure by heart rate spectral analysis. Am J Cardiol 1988; 61: 1292–1299 [DOI] [PubMed] [Google Scholar]
  • 25. Kienzle MG, Ferguson DW, Birkett CL, Myers GA, Berg WJ, Mariano DJ: Clinical hemodynamic and sympathetic neural correlates of heart rate variability in congestive heart failure. Am J Cardiol 1992; 69: 482–485 [DOI] [PubMed] [Google Scholar]
  • 26. Stefenelli T, Bergler‐Klein J, Globits S, Pacher R, Glogar D: Heart rate behaviour at different stages of congestive heart failure. Eur Heart J 1992; 13: 902–907 [DOI] [PubMed] [Google Scholar]
  • 27. Casolo GC, Stroder P, Sulla A, Chelucci A, Freni A, Zerauschek M: Heart rate variability and functional severity of congestive heart failure secondary to coronary artery disease. Eur Heart J 1995; 16: 360–367 [DOI] [PubMed] [Google Scholar]
  • 28. Panina G, Khot UN, Nunziata E, Cody RJ: Role of spectral measures of heart rate variability as markers of disease progression in patients with chronic congestive heart failure not treated with angiotensin‐converting enzyme inhibitors. Am Heart J 1996; 131: 153–157 [DOI] [PubMed] [Google Scholar]
  • 29. Gang Y, Goldman JH, Keeling PJ, Reardon M, McKenna WJ, Malik M: Heart rate variability in idiopathic dilated cardiomyopathy: Relationship to disease severity and prognosis. Heart 1996; (in press) [DOI] [PMC free article] [PubMed]
  • 30. Stein PK, Rich MW, Rottman JN, Kleiger RE: Stability of index of heart rate variability in patients with congestive heart failure. Am Heart J 1995; 129: 975–981 [DOI] [PubMed] [Google Scholar]
  • 31. Binkley PF, Haas GJ, Starling RC, Nunziata E, Hatton PA, Leier CV: Sustained augmentation of parasympathetic tone with angiotensin‐converting enzyme inhibition in patients with congestive heart failure. J Am Coll Cardiol 1993; 21: 655–661 [DOI] [PubMed] [Google Scholar]
  • 32. Brouwer J, van Veldhuisen DJ, Veld AJM, Dunselman PHJM, Boomsma F, Haaksma J, Lie KI, For the Dutch Ibopamine Multi‐center Trial (DIMT) Study Group: Heart rate variability in patients with mild to moderate heart failure: Effects of neurohormonal modulation by digoxin and ibopamine. J Am Coll Cardiol 1995; 26: 983–990 [DOI] [PubMed] [Google Scholar]
  • 33. Stein KM, Borer JS, Hochreiter C, Okin PM, Herrold EM, Devereux RB, Kligfield P: Prognostic value and physiological correlates of heart rate variability in chronic severe mitral regurgitation. Circulation 1993; 88: 127–135 [DOI] [PubMed] [Google Scholar]
  • 34. Messerli FH, Ventura HO, Elizard DJ, Dunn FG, Frolich ED: Hypertension and sudden death: Increased ventricular ectopic activity in left ventricular hypertrophy. Am J Med 1984; 77: 18–22 [DOI] [PubMed] [Google Scholar]
  • 35. Mandawat MK, Wallbridge DR, Pringle SD, Riyami AS, Latif S, Macfarlane PW, Lorimer AR, Cobbe SM: Heart rate variability in left ventricular hypertrophy. Br Heart J 1993; 73: 139–144 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36. Airaksinen KEJ, Ikaheimo MJ, Koistinen MJ, Takkunen JT: Impaired vagal heart rate control in aortic valve stenosis. Eur Heart J 1988; 9: 1126–1130 [DOI] [PubMed] [Google Scholar]
  • 37. Coumel JS, Hermida JS, Wennerblom B, Leenhardts A, Maison‐Blanche P, Cauchemez B: Heart rate variability in left ventricular hypertrophy and heart failure, and effects of beta blockade. Eur Heart J 1991; 12: 412–422 [DOI] [PubMed] [Google Scholar]
  • 38. Ehlert FA, Goldberger JJ, Brooks R, Miller S, Kadish AH: Persistent inappropriate sinus tachycardia after radiofrequency current catheter modification of the atrioventricular node. Am J Cardiol 1992; 69: 1092–1095 [DOI] [PubMed] [Google Scholar]
  • 39. Frey B, Heinz G, Kreiner G, Schmidinger H, Weber H, Gossinger H: Increased heart rate variability after radiofrequency ablation. Am J Cardiol 1993; 71: 1460–1461 [DOI] [PubMed] [Google Scholar]
  • 40. Kocovic DZ, Harada T, Shea JB, Soroff D, Friedman PL: Alterations of heart rate and of heart rate variability after radiofrequency catheter ablation of supraventricular tachycardia. Delineation of parasympathetic pathways in the human heart. Circulation 1993; 88 (part 1): 1671–1681 [DOI] [PubMed] [Google Scholar]
  • 41. Hartikainen J, Kautzner J, Heald S, Ward D, Malik M, Camm AJ, Rowland E: Effect of radiofrequency catheter ablation of supraventricular tachycardia on autonomic regulation of the sinus node (abstr). Eur Heart J 1995; 16 (suppl): 17 8869119 [Google Scholar]
  • 42. Kleiger RE, Miller JP, Bigger JT Jr, Moss AJ, and The Multicenter Post‐Infarction Research Group : Decreased heart rate variability and its association with increased mortality after acute myocardial infarction. Am J Cardiol 1987; 59: 256–262 [DOI] [PubMed] [Google Scholar]
  • 43. GJMagid NM, Myers G, Barnett PS, Schaad JW, Wiess JS, Lesch M, Singer DH: Heart rate variability and sudden death secondary to coronary artery disease during ambulatory electrocardiographic monitoring. Am J Cardiol 1987; 60: 86–89 [DOI] [PubMed] [Google Scholar]
  • 44. Lombardi F, Sandrone G, Pernpruner S, Sala R, Garimoldi M, Cerutti S, Baselli G, Pagani M, Malliani A: Heart rate variability as an index of sympathovagal interaction after acute myocardial infarction. Am J Cardiol 1987; 60: 1239–1245 [DOI] [PubMed] [Google Scholar]
  • 45. Cripps TR, Malik M, Farrell TG, Camm AJ: Prognostic value of reduced heart rate variability after myocardial infarction: Clinical evaluation of a new analysis method. Br Heart J 1991; 65: 14–19 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46. Vybiral T, Glaeser D, Goldberger AL, Rigney DR, Hess KR, Mietus J, Skinner JF, Francis M, Pratt CM: Conventional heart rate variability analysis of ambulatory electrocardiographic recordings fails to predict imminent ventricular fibrillation. J Am Coll Cardiol 1993; 22: 557–565 [DOI] [PubMed] [Google Scholar]
  • 47. Cerquetani E, Volterrani M, Ponikowski: The very low frequency component of heart rate variability is increased in patients with chronic heart failure prior to episodes of nonsustained ventricular tachycardia (abstr). J Am Coll Cardiol 1994. ;(suppl): 66A
  • 48. Huikuri HV, Valkama JO, Airaksinen J, Seppanen T, Kessler KM, Takkunen JT, Myerburg RJ: Frequency domain measures of heart rate variability before the onset of nonsustained and sustained ventricular tachycardia in patients with coronary artery disease. Circulation 1993; 87: 1220–1228 [DOI] [PubMed] [Google Scholar]
  • 49. Skinner JE, Pratt CM, Vybiral T: A reduction in the correlation dimension of heartbeat intervals precedes imminent ventricular fibrillation in human subjects. Am Heart J 1993; 125: 731–743 [DOI] [PubMed] [Google Scholar]
  • 50. Huikuri HV, Seppanen T, Koistinen MJ, Airaksinen J, Ikaheimo MJ, Castellanos A, Myerburg RJ: Abnormalities in beat‐to‐beat dynamics of heart rate before the spontaneous onset of life‐threatening ventricular tachyarrhythmias in patients with prior myocardial infarction. Circulation 1996; 93: 1836–1844 [DOI] [PubMed] [Google Scholar]
  • 51. Lown B, Verrier RL: Neural activity and ventricular fibrillation. N Engl J Med 1976; 294: 1165–1172 [DOI] [PubMed] [Google Scholar]
  • 52. Webb SW, Adgey AAJ, Pantridge JF: Autonomic disturbance at onset of acute myocardial infarction. Br Med J 1972; 3: 89–92 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53. Schwartz PJ, Billman GE, Stone HL: Autonomic mechanisms in ventricular fibrillation induced by myocardial ischemia during exercise in dogs with a healed myocardial infarction. An experimental preparation for sudden cardiac death. Circulation 1984; 69: 790–800 [DOI] [PubMed] [Google Scholar]
  • 54. Hull SS Jr, Evans AR, Vanoli E, Adamson PB, Stamba‐Badiale M, Albert DE, Foreman RD, Schwartz PJ: Heart rate variability before and after myocardial infarction in conscious dogs at high and low risk of sudden death. J Am Coll Cardiol 1990; 16: 978–985 [DOI] [PubMed] [Google Scholar]
  • 55. Wolf MM, Varigos GA, Hunt D, Sloman JG: Sinus arrhythmia in acute myocardial infarction. Med J Aust 1978; 2: 52–53 [DOI] [PubMed] [Google Scholar]
  • 56. Odemuyiwa O, Malik M, Farrell T, Bashir Y, Poloniecki J, Camm AJ: A comparison of the predictive characteristics of heart rate variability index and left ventricular ejection fraction for all‐cause mortality, arrhythmic events and sudden death after acute myocardial infarction. Am J Cardiol 1991; 68: 434–439 [DOI] [PubMed] [Google Scholar]
  • 57. Malliani A, Recordati G, Schwartz PJ: Nervous activity of afferent cardiac sympathetic fibres with atrial and ventricular endings. J Physiol (Lond) 1973; 229: 457–469 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 58. Malliani A: Cardiovascular sympathetic afferent fibers. Rev Physiol Biochem Pharmacol 1982; 94: 11–74 [Google Scholar]
  • 59. Bigger JT Jr, Kleiger RE, Fleiss JL, Rolnitzky LM, Steinman RC, Miller JP, and The Multicenter Post‐Infarction Research Group: Components of heart rate variability measured during healing of acute myocardial infarction. Am J Cardiol 1988; 61: 208–215 [DOI] [PubMed] [Google Scholar]
  • 60. Lombardi F, Sandrone G, Mortara A, La Rovere MT, Colombo E, Guzetti S, Malliani A: Orcadian variation of spectral indices of heart rate variability after myocardial infarction. Am Heart J 1992; 123: 1521–1529 [DOI] [PubMed] [Google Scholar]
  • 61. Kautzner J: Reproducibility of heart rate variability measurement In Heart Rate Variability (Eds. Malik M, Camm AJ.), p. 165–171. Armonk: Futura Publishing Co., Inc., 1995. [Google Scholar]
  • 62. Bigger JT, Fleiss JL, Rolnitzky LM, Steinman RC: The ability of several short‐term measures of RR variability to predict mortality after myocardial infarction. Circulation 1993; 88: 927–934 [DOI] [PubMed] [Google Scholar]
  • 63. Fei L, Malik M: Short‐term and long‐term assessment of heart rate variability for postinfarction risk stratification In Heart Rate Variability (Eds. Malik M, Camm AJ.), p. 341–346. Armonk: Futura Publishing Co., Inc., 1995. [Google Scholar]
  • 64. Bigger JT Jr, Fleiss JL, Steinman RC, Rolnitzky LM, Kleiger RE, Rottman JN: Frequency domain measures of heart period variability and mortality after myocardial infarction. Circulation 1992; 85: 164–171 [DOI] [PubMed] [Google Scholar]
  • 65. Bayés‐de‐Luna A, Viñolas X, Guindo J, Bayés‐Genis A: Risk stratification after myocardial infarction: Role of electrical instability, ischemia, and left ventricular function. Cardiovasc Drugs Titer 1994; 8: 335–343 [DOI] [PubMed] [Google Scholar]
  • 66. Breithardt G, Borggrefe M, Fetsch T, Bocker D, Mäkijärvi M, Reinhardt L: Prognosis and risk stratification after myocardial infarction. Eur Heart J 1995; 16 (suppl G): 10–19 [DOI] [PubMed] [Google Scholar]
  • 67. Casadei B, Pipilis A, Sessa F, Conway J, Sleight P: Low doses of scopolamine increase cardiac vagal tone in the acute phase of myocardial infarction. Circulation 1993; 88: 353–357 [DOI] [PubMed] [Google Scholar]
  • 68. Vybiral T, Glaeser DH, Morris G, Hess KR, Yang K, Francis M, Pratt CM: Effects of low‐dose scopolamine on heart rate variabilty in acute myocardial infarction. J Am Coll Cardiol 1993; 22: 1320–1326 [DOI] [PubMed] [Google Scholar]
  • 69. De Ferrari GM, Mantica M, Vanoli E, Hull SS Jr, Schwartz PJ: Scopolamine increases vagal tone and vagal reflexes in patients after myocardial infarction. J Am Coll Cardiol 1993; 22: 1327–1334 [DOI] [PubMed] [Google Scholar]
  • 70. Hull SS Jr, Vanoli E, Adamson PB, De Ferrari GM, Foreman RD, Schwartz PJ: Do increases in markers of vagal activity imply protection from sudden death? The case of scopolamine. Circulation 1995; 91: 2516–2519 [DOI] [PubMed] [Google Scholar]
  • 71. Hull SS Jr, Vanoli E, Adamson PB, Verrier RL, Foreman RD, Schwartz PJ: Exercise training confers anticipatory protection from sudden death during acute myocardial infarction. Circulation 1994; 89: 548–552 [DOI] [PubMed] [Google Scholar]
  • 72. Kiilavuori K, Toivonen L, Näveri H, Leinonen H: Reversal of autonomic derangements by physical training in chronic heart failure assessed by heart rate variability. Eur Heart J 1995; 16: 490–495 [DOI] [PubMed] [Google Scholar]
  • 73. Zuanetti G, Latini R, Neilson JMM, Schwartz PJ, Ewing DJ: Heart rate variability in patients with ventricular arrhythmias: Effect of antiarrhythmic drugs. J Am Coll Cardiol 1991; 17: 604–612 [DOI] [PubMed] [Google Scholar]
  • 74. Bigger JT Jr, Rolnitzky LM, Steinman RC, Fleiss JL: Predicting mortality after myocardial infarction from the response of RR variability to antiarrhythmic drug therapy. J Am Coll Cardiol 1994; 23: 733–740 [DOI] [PubMed] [Google Scholar]
  • 75. Niemelä MJ, Airaksinen KEJ, Huikuri HV: Effect of beta‐blockade on heart rate variability in patients with coronary artery disease. J Am Coll Cardiol 1994; 23: 1370–1377 [DOI] [PubMed] [Google Scholar]
  • 76. Sandrone G, Mortara A, Torzillo D, La Rovere MT, Malliani A, Lombardi F: Effects of beta blockers (atenolol and metoprolol) on heart rate variability after acute myocardial infarction. Am J Cardiol 1994; 74: 340–345 [DOI] [PubMed] [Google Scholar]

Articles from Clinical Cardiology are provided here courtesy of Wiley

RESOURCES