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J Am Coll Cardiol, 2001; 38:1980-1987
© 2001 by the American College of Cardiology Foundation
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CLINICAL STUDY: STRESS TESTING

Heart rate recovery: validation and methodologic issues

Katerina Shetler, MDa, Rachel Marcus, MDa, Victor F. Froelicher, MDa,*, Shefali Vora, MDa, Damayanthi Kalisetti, MDa, Manish Prakash, MDa, Dat Do, MDa and Jon Myers, PhDa

a Division of Cardiovascular Medicine, Stanford University Medical Center and the Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA

Manuscript received March 22, 2001; revised manuscript received August 15, 2001, accepted August 29, 2001.

* Reprint requests and correspondence: Dr. Victor Froelicher, Cardiology Division (111C), Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, California 94304 USA.
vicmd{at}aol.com

OBJECTIVES: The goal of this study was to validate the prognostic value of the drop in heart rate (HR) after exercise, compare it to other test responses, evaluate its diagnostic value and clarify some of the methodologic issues surrounding its use.

BACKGROUND: Studies have highlighted the value of a new prognostic feature of the treadmill test—rate of recovery of HR after exercise. These studies have had differing as well as controversial results and did not consider diagnostic test characteristics.

METHODS: All patients were referred for evaluation of chest pain at two university-affiliated Veterans Affairs Medical Centers who underwent treadmill tests and coronary angiography between 1987 and 1999 as predicted after a mean seven years of follow-up. All-cause mortality was the end point for follow-up, and coronary angiography was the diagnostic gold standard.

RESULTS: There were 2,193 male patients who had treadmill tests and coronary angiography. Heart rate recovery at 2 min after exercise outperformed other time points in prediction of death; a decrease of <22 beats/min had a hazard ratio of 2.6 (2.4 to 2.8 95% confidence interval). This new measurement was ranked similarly to traditional variables including age and metabolic equivalents but failed to have diagnostic power for discriminating those who had angiographic disease.

CONCLUSIONS: Heart rate at 1 or 2 min of recovery has been validated as a prognostic measurement and should be recorded as part of all treadmill tests. This new measurement does not replace, but is supplemental to, established scores.

Abbreviations and Acronyms
  CABG
  coronary artery bypass grafting
  CAD
  coronary artery disease
  HR
  heart rate
  METS
  metabolic equivalents
  MI
  myocardial infarction
  PTCA
  percutaneous transluminal coronary angioplasty
  RAS
  renin-angiotensin-sympathetic nervous system
  ROC
  receiver operating characteristic




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