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J Am Coll Cardiol, 2003; 42:831-838, doi:10.1016/S0735-1097(03)00833-7 © 2003 by the American College of Cardiology Foundation |
* Departments of Cardiovascular Medicine, Cleveland, Ohio, USA
Cardiothoracic Surgery, Cleveland, Ohio, USA
Epidemiology and Biostatistics, Cleveland Clinic Foundation, Cleveland, Ohio, USA
Manuscript received October 9, 2002; revised manuscript received January 1, 2003, accepted January 11, 2003.
* Reprint requests and correspondence: Dr. Michael S. Lauer, Desk F25, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA.
Lauerm{at}ccf.org
OBJECTIVES: We sought to determine whether abnormal heart rate recovery predicts mortality independent of the angiographic severity of coronary disease.
BACKGROUND: An attenuated decrease in heart rate after exercise, or heart rate recovery (HRR), has been shown to predict mortality. There are few data on its prognostic significance once the angiographic severity of coronary artery disease (CAD) is ascertained.
METHODS: For six years we followed 2,935 consecutive patients who underwent symptom-limited exercise testing for suspected CAD and then had a coronary angiogram within 90 days. The HRR was abnormal if 
12 beats/min during the first minute after exercise, except among patients undergoing stress echocardiography, in whom the cutoff was 18 beats/min. Angiographic CAD was considered severe if the Duke CAD Prognostic Severity Index was 
42 (on a scale of 0 to 100), which corresponds to a level of CAD where revascularization is associated with better long-term survival.
RESULTS: Severe CAD was present in 421 patients (14%), whereas abnormal HRR was noted in 838 patients (29%). There were 336 deaths (11%). Mortality was predicted by abnormal HRR (hazard ratio [HR] 2.5, 95% confidence interval [CI] 2.0 to 3.1; p < 0.0001) and by severe CAD (HR 2.0, 95% CI 1.6 to 2.6; p < 0.0001); both variables provided additive prognostic information. After adjusting for age, gender, standard risk factors, medications, exercise capacity, and left ventricular function, abnormal HRR remained predictive of death (adjusted HR 1.6, 95% CI 1.2 to 2.0; p < 0.0001); severe CAD was also predictive (adjusted HR 1.4, 95% CI 1.1 to 1.9; p = 0.008).
CONCLUSIONS: Even after taking into account the angiographic severity of CAD, left ventricular function, and exercise capacity, HRR is independently predictive of mortality.
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