Circulation, Vol 88, 127-135, Copyright © 1993 by American Heart Association
KM Stein, JS Borer, C Hochreiter, PM Okin, EM Herrold, RB Devereux and P Kligfield
BACKGROUND. A variety of measures of heart rate variability have been
devised to measure high-frequency (0.15-0.40 Hz), low-frequency (0.04- 0.15
Hz), or ultralow-frequency (< 0.0033 Hz) fluctuations in sinus cycle
length. Although measures of low-frequency and ultralow-frequency heart
rate variability have been shown to correlate with prognosis in several
populations with ischemic heart disease, their relevance to patients with
primary valvular heart disease remains to be determined. METHODS AND
RESULTS. Thirty-eight patients with nonischemic causes of chronic severe
mitral regurgitation who were in sinus rhythm underwent 24-hour ambulatory
electrocardiography as part of a prospective study of the natural history
of regurgitant valvular heart disease. Patients were followed for as long
as 9.2 years, and end points of mortality, progression to mitral valve
surgery, and development of chronic atrial fibrillation were tabulated.
Time- and frequency-domain measurements of high-frequency, low-frequency,
and ultralow-frequency heart rate variability were computed and compared
with resting ventricular function by radionuclide cineangiography and
outcome. The standard deviation of the 5-minute mean RR intervals (SDANN),
a measure of ultralow-frequency heart rate variability, was correlated with
left ventricular ejection fraction (r = 0.49, p = 0.002) and right
ventricular ejection fraction (r = 0.43, p = 0.007), whereas low- frequency
and high-frequency heart rate variabilities were not. Heart rate,
ultralow-frequency heart rate variability, and, to a lesser extent,
high-frequency heart rate variability exhibited significant diurnal
variation, but low-frequency heart rate variability did not. Heart rate and
ultralow-frequency, low-frequency, and combined low- and high-frequency
heart rate variability predicted mortality and total events. The most
powerful predictor of subsequent events was SDANN. Patients with reduced
SDANN were significantly more likely to develop end-point events (p <
0.001) with increased progression to mitral valve surgery (p < 0.001) as
well as increased early mortality (p = 0.02). In a multivariate
proportional hazards model, SDANN retained independent predictive power (p
= 0.001). Likewise, SDANN was the only variable that was significantly
associated with the subsequent development of atrial fibrillation (relative
risk, 3.1; p = 0.03). CONCLUSIONS. Ultralow-frequency heart rate
variability, as measured by SDANN, correlates with right and left
ventricular performance and predicts development of atrial fibrillation,
mortality, and progression to valve surgery in patients with chronic severe
mitral regurgitation.
ARTICLES
Prognostic value and physiological correlates of heart rate variability in chronic severe mitral regurgitation
Department of Medicine, New York Hospital-Cornell Medical Center, New York 10021.
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