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CLINICAL STUDY: MYOCARDIAL ISCHEMIA

Changes in heart rate and heart rate variability before ambulatory ischemic events¹

Willem J. Kop, PhD^* , Ralph J. Verdino, MD, FACC , John S. Gottdiener, MD, FACC, Shaun T. O’Leary, MD, PhD^||, C. Noel Bairey Merz, MD, FACC^¶ and David S. Krantz, PhD^*

^* Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences Bethesda, Bethesda, Maryland, USA
Division of Cardiology, Department of Medicine, Georgetown University Medical Center Washington, DC, USA
Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
Noninvasive Cardiology, Saint Francis Hospital, Roslyn, New York, USA
^|| Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
^¶ Division of Cardiology, Department of Medicine, Cedar Sinai Research Institute, Los Angeles, California, USA

Manuscript received May 19, 2000; revised manuscript received May 7, 2001, accepted June 1, 2001.

Reprint requests and correspondence: Dr. Willem J. Kop, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814
wjkop{at}mxb.usuhs.mil

OBJECTIVES

The aim of this study was to determine the time course of autonomic nervous system activity preceding ambulatory ischemic events.

BACKGROUND

Vagal withdrawal can produce myocardial ischemia and may be involved in the genesis of ambulatory ischemic events. We analyzed trajectories of heart rate variability (HRV) 1 h before and after ischemic events, and we examined the role of exercise and mental stress in preischemic autonomic changes.

METHODS

Male patients with stable coronary artery disease (n = 19; 62.1 ± 9.3 years) underwent 48-h ambulatory electrocardiographic monitoring. Frequency domain HRV measures were assessed for 60 min before and after each of 68 ischemic events and during nonischemic heart rate-matched control periods.

RESULTS

High-frequency HRV decreased from –60, –20 to –10 min before ischemic events (4.8 ± 1.3; 4.6 ± 1.3; 4.4 ± 1.2 ln [ms²], respectively; p = 0.04) and further from –4, –2 min, until ischemia (4.4 ± 1.3; 4.1 ± 1.3; 3.7 ± 1.2 ln [ms²]; p’s < 0.01). Low frequency HRV decreases started at –4 min (p < 0.05). Ischemic events occurring at high mental activities were preceded by depressed high frequency HRV levels compared with events at low mental activity (p = 0.038 at –4 min, p = 0.045 at –2 min), whereas the effects of mental activities were not observed during nonischemic control periods. Heart rate variability measures remained significantly decreased for 20 min after recovery of ST-segment depression when events were triggered by high activity levels.

CONCLUSIONS

Autonomic changes consistent with vagal withdrawal can act as a precipitating factor for daily life ischemia, particularly in episodes triggered by mental activities.

Abbreviations and Acronyms   ANOVA = analysis of variance   ECG = electrocardiogram   HRV = heart rate variability

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