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Health & Medicine for Senior Citizens

New Risk Factor for Heart Disease Death Found in Healthy Senior Citizens

Older people not expected to die of cardiac causes found in danger by abnormal heart rate turbulence - appear healthy but they're not

Study author, Phyllis K. Stein, Ph.D

Feb. 16, 2011 - Abnormal heart rate turbulence is associated with an increased risk of heart disease death in otherwise low-risk senior citizens, finds a new study. The research indicates that an abnormal response to an early beat in the left ventricle, the heart’s main pumping chamber, can identify high-risk patients even when they have no other evidence of cardiovascular disease.

“These are people we do not expect to die of cardiac causes,” says study author Phyllis K. Stein, Ph.D., a research associate professor of medicine and director of the Heart Rate Variability Laboratory at Washington University School of Medicine in St. Louis.

 

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“They appear healthy, but they’re not. We have shown a way they’re not healthy that isn’t showing up using standard tests.”

This study, funded by the National Heart, Lung, and Blood Institute (NHLBI), part of the National Institutes of Health, appears in the Feb. 15 edition of the Journal of Cardiovascular Electrophysiology.

"These findings suggest that apparently healthy people might be at increased risk of death from cardiovascular disease, and heart rate turbulence may help us identify them," said Susan B. Shurin, M.D., acting director of the NHLBI. "It will be important to see if we can replicate this finding in other populations."

A ventricular premature beat (VPB) occurs when the ventricle gets an inappropriate signal causing it to beat before it should. VPBs are common, even in healthy people. The question is not whether VPBs occur, but how the body responds to them. The heart’s response to a VPB is called heart rate turbulence. It can be measured with a Holter monitor, a device worn for 24 hours that records a person’s electrocardiogram, the electrical signals produced by the heart.

When the ventricle beats early, the heart has not finished filling and it pumps less blood to the body than it should. To compensate, the heart rate speeds up to increase blood flow.

But an early beat also empties the heart early, leaving extra filling time afterward. So on the second beat after the VPB, the heart is extra full and pumps more blood to the body than it should. To compensate properly, the heart rate slows down.

A healthy heart will alternately speed up and slow down to compensate for the over- and under-filling that follows a VPB until the amount of blood filling the heart returns to normal.

Abnormal heart rate turbulence occurs when the heart can’t compensate in this way.

“It’s a clear test of whether the autonomic nervous system, which regulates your heart rate, can adapt to a challenge,” Stein says.

Among the nearly 1,300 senior citizen study participants, heart rate turbulence, which reflects how well the heart reacts to occasional premature contractions, was an even stronger heart disease risk factor than elevated levels of C-reactive protein. CRP is a potential heart disease biomarker that has emerged in recent years.

Study participants considered at low risk of heart disease based on traditional risk factors were on average 8 to 9 times more likely to die of heart disease during the roughly 14-year follow-up period if they had abnormal heart rate turbulence values.

Traditional risk factors include age, gender, high blood cholesterol, high blood pressure, obesity, diabetes, and smoking. Low-risk individuals with elevated CRP in their blood were about 2.5 times more likely to die than those with normal or low CRP.

This study followed 1,272 adults aged 65 and older as part of the NHLBI's Cardiovascular Health Study. Participants were categorized as healthy (no sign of heart disease risk except possibly diabetes), subclinical (some signs of heart disease) or clinical (had a cardiovascular event, such as a heart attack).

Use of Holter monitor

At the onset, participants underwent 24-hour monitoring of their hearts’ electrical activity through a small electrocardiographic, or ECG, device called a Holter monitor attached to their skin.

Abnormal heart rate turbulence and CRP levels both appeared to independently correlate with an increased likelihood of dying of heart disease in the group that was categorized as healthy, even after controlling for other risk factors. Abnormal heart rate turbulence - present in about 7 percent of the study participants - also predicted an increased likelihood of heart disease death in the subclinical and clinical groups, though these results were not as pronounced.

Heart rate turbulence refers to how smoothly the heart rate returns to normal after a premature ventricular contraction, a fairly common event in which the second portion of a heart beat is triggered too soon. Due to the improper timing between the atrial and ventricular contractions, the ventricles haven’t fully filled with blood and therefore do not push out enough blood to the body.

The brain detects this sub-optimal release of blood and instantly increases the heart rate to pump more blood. However, this overcompensation raises blood pressure, causing the brain to react again and lower the heart rate until blood pressure returns to normal.

By analyzing the heart's electrical signals, physicians can measure the magnitude of the initial heart rate jump (turbulence onset) and the speed at which heart rate returns to normal (turbulence slope), and then determine if the heart rate turbulence response is normal or abnormal.

"A heart rate turbulence measurement is insightful because it offers a sign of how well the autonomic, or subconscious, nervous system is functioning," said Stein.

"If someone's heart doesn't react well to these uncoordinated beats that might mean it's not good at reacting to other issues like sudden stress or severe arrhythmias."

Researchers don't yet know if abnormal heart rate turbulence can be treated or prevented. In the meantime, said Stein, interest might grow within the medical community in measuring heart rate turbulence in clinical practice. Currently, this type of measurement is not widely available.

"This study shows a great potential value for heart rate turbulence in diagnostic settings," said Robin Boineau, M.D., a medical officer in the NHLBI's Division of Cardiovascular Sciences.

"It appears that signs of heart rate turbulence are also generally present a year or more before clinical manifestations of heart disease, indicating that this may be an opportunity for disease prevention in addition to disease prediction."

Though the Holter monitor is a common, noninvasive device, Stein says the software needed to measure heart rate turbulence is only available for clinical use on one commercial Holter monitor. She speculates that this work and other studies showing the value of measuring heart rate turbulence may make the software more widely available.

In addition to the NHLBI, the National Institute of Neurological Disorders and Stroke also contributed funding to this study.

Information Sources: Parts of this news story came from a report by Julia Evangelou Strait
Senior Medical Sciences Writer, Washington University School of Medicine, and information provided by the National Heart, Lung, and Blood Institute (NHLBI).

More information

>> Cardiovascular Health Study (CHS): https://biolincc.nhlbi.nih.gov/studies/chs/

>> What Are Heart Disease Risk Factors?: http://www.nhlbi.nih.gov/health/dci/Diseases/hd/hd_whatare.html

>> National Institutes of Health, the National Heart, Lung, and Blood Institute (NHLBI) www.nhlbi.nih.gov.

>> National Institute of Neurological Disorders and Stroke (NINDS) www.ninds.nih.gov

>> The National Institutes of Health (NIH) www.nih.gov.

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