Heart Rate Turbulence: Standards of Measurement, Physiological Interpretation, and Clinical UseInternational 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
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Figure 1 VPC Tachograms
Ventricular premature complex (VPC) tachograms showing normal (left) and abnormal (right) heart rate turbulence (HRT). HRT is composed of the transient acceleration phase of heart rate (R-R interval shortening) immediately after the compensatory pause followed by a subsequent and gradual deceleration phase (R-R interval prolongation). Orange curves show single VPC tachograms. Bold brown curves show the averaged VPC tachogram over 24 h.
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Figure 2 HRT Calculation
Calculation of the HRT parameters turbulence onset (TO) and turbulence slope (TS). Turbulence onset is the relative change of R-R intervals (red lines) from before to after the VPC. Turbulence slope is the slope of the steepest regression line fitted over the sequences of 5 consecutive sinus rhythm R-R intervals within the 15 R-R intervals after the VPC. The light blue lines are the 11 possible regression lines. The dark blue line is the steepest one used for TS calculation. Abbreviations as in Figure 1.
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Figure 3 Normal Post-Ectopic Blood Pressure and R-R Interval Changes
Averaged profiles (mean ± 95% confidence interval) of R-R intervals, systolic arterial blood pressure (SBP), stroke volume (SV), and peripheral vascular resistance (PVR) after VPCs expressed in relative numbers (with 100% corresponding to pre-VPC value) in patients with normal left ventricular function. R-R intervals numbered –1 and –2 indicate those preceding the VPC; the first 2 post-VPC sinus R-R intervals are numbered 1 and 2. Modified, with permission, from Wichterle et al. (17). Abbreviations as in Figure 1.
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Figure 4 Post-Ectopic Blood Pressure and R-R Interval Changes in LV Dysfunction
Profiles of R-R intervals, systolic arterial blood pressure (SBP), stroke volume (SV), and peripheral vascular resistance (PVR) after VPCs in patients with left ventricular (LV) dysfunction. Symbols and layout as in Figure 3. Note the post-extrasystolic potentiation of SBP after VPC with subsequent mechanical and electrical alternans. Modified, with permission, from Wichterle et al. (17). Abbreviations as in Figure 1.
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Figure 5 HRT Changes After PCI
Percentage change of turbulence slope and turbulence onset during the first 2 h after percutaneous coronary intervention (PCI) and during hours 6 to 24 after PCI in patients with complete reperfusion (Thrombolysis In Myocardial Infarction [TIMI] risk score III, green) and incomplete reperfusion (TIMI II, red) after PCI for acute myocardial infarction. **p < 0.01; ***p < 0.001. Abbreviations as in Figure 1.
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Figure 6 HRT Post-Infarction Risk Stratification
Cumulative mortality rates of patients stratified by HRT categories in the populations of MPIP (Multicenter Post-Infarction Program) (left), EMIAT (European Myocardial Infarction Amiodarone Trial) (middle), and ISAR-HRT (Innovative Stratification of Arrhythmic Risk HRT) studies (right). The numbers of patients in the individual groups involved in the analyses at 0, 6, 12, 18, and 24 months are shown under each graph. Data for the MPIP and EMIAT studies are from Schmidt et al. (1) and for the ISAR-HRT study from Barthel et al. (92). Abbreviations as in Figure 1.
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