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STATE-OF-THE-ART PAPER

Heart Rate Turbulence: Standards of Measurement, Physiological Interpretation, and Clinical Use

International Society for Holter and Noninvasive Electrophysiology Consensus

Axel Bauer, MD^_*, Marek Malik, PhD, MD, FACC^,_*, Georg Schmidt, MD^_*, Petra Barthel, MD^_*, Hendrik Bonnemeier, MD, Iwona Cygankiewicz, MD, PhD, Przemyslaw Guzik, MD, PhD^||, Federico Lombardi, MD^¶, Alexander Müller, Dipl-Ing (FH)^_*, Ali Oto, MD, FACC^#, Raphael Schneider, Dipl-Ing (FH)^_*, Mari Watanabe, MD, PhD^_**, Dan Wichterle, MD, PhD and Wojciech Zareba, MD, PhD, FACC

^_* Deutsches Herzzentrum and 1. Medizinische Klinik der Technischen Universität München, Munich, Germany
Division of Cardiac and Vascular Sciences, St. George's, University of London, London, United Kingdom
2nd Department of Internal Medicine, University of Lübeck, Lübeck, Germany
Heart Research Follow-up Program, University of Rochester, Rochester, New York
^|| University School of Medicine, Poznan, Poland
^¶ Cardiology, San Paolo Hospital, University of Milan, Milan, Italy
^# Department of Cardiology, Hacettepe University, Ankara, Turkey
^_** St. Louis University School of Medicine, St. Louis, Missouri
Institute for Clinical and Experimental Medicine and 1st Faculty of Medicine, Charles University, Prague, Czech Republic

Manuscript received May 12, 2008; revised manuscript received June 18, 2008, accepted July 10, 2008.

^_* Reprint requests and correspondence: Dr. Marek Malik, Division of Cardiac and Vascular Sciences, St. George's, University of London, Cranmer Terrace, London SW17 0RE, United Kingdom (Email: marek.malik{at}btinternet.com).

This consensus statement has been compiled on behalf of the International Society for Holter and Noninvasive Electrophysiology. It reviews the topic of heart rate turbulence (HRT) and concentrates on technologies for measurement, physiologic background and interpretation, and clinical use of HRT. It also lists suggestions for future research. The phenomenon of HRT refers to sinus rhythm cycle-length perturbations after isolated premature ventricular complexes. The physiologic pattern of HRT consists of brief heart rate acceleration (quantified by the so-called turbulence onset) followed by more gradual heart rate deceleration (quantified by the so-called turbulence slope) before the rate returns to a pre-ectopic level. Available physiologic investigations confirm that the initial heart rate acceleration is triggered by transient vagal inhibition in response to the missed baroreflex afferent input caused by hemodynamically inefficient ventricular contraction. A sympathetically mediated overshoot of arterial pressure is responsible for the subsequent heart rate deceleration through vagal recruitment. Hence, the HRT pattern is blunted in patients with reduced baroreflex. The HRT pattern is influenced by a number of factors, provocations, treatments, and pathologies reviewed in this consensus. As HRT measurement provides an indirect assessment of baroreflex, it is useful in those clinical situations that benefit from baroreflex evaluation. The HRT evaluation has thus been found appropriate in risk stratification after acute myocardial infarction, risk prediction, and monitoring of disease progression in heart failure, as well as in several other pathologies.

Key Words: heart rate turbulence • baroreflex • risk stratification • sudden death

Abbreviations and Acronyms   APC = atrial premature complex   HRT = heart rate turbulence   HRV = heart rate variability   LVEF = left ventricular ejection fraction   MI = myocardial infarction   SBP = systolic blood pressure   TO = turbulence onset   TS = turbulence slope   VPC = ventricular premature complex

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