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(Circulation. 2003;108:1221.)
© 2003 American Heart Association, Inc.

Clinical Investigation and Reports

Risk Stratification After Acute Myocardial Infarction by Heart Rate Turbulence

Petra Barthel, MD; Raphael Schneider, Dipl Ing; Axel Bauer, MD; Kurt Ulm, PhD; Claus Schmitt, MD; Albert Schömig, MD; Georg Schmidt, MD

From 1 Medizinische Klinik and Institut für Medizinische Statistik und Epidemiologie der Technischen Universität München (K.U.), Germany.

Correspondence to Dr Georg Schmidt, 1 Medizinische Klinik der Technischen Universität München, Ismaninger Straße 22, 81675 München, Germany. E-mail gschmidt{at}med1.med.tum.de

Received April 28, 2003; revision received June 12, 2003; accepted June 13, 2003.

Background— Retrospective postinfarction studies revealed that decreased heart rate turbulence (HRT) indicates increased risk for subsequent death. This is the first prospective study to validate HRT in a large cohort of the reperfusion era.

Methods and Results— One thousand four hundred fifty-five survivors of an acute myocardial infarction (age <76 years) in sinus rhythm were enrolled. HRT onset (TO) and slope (TS) were calculated from Holter records. Patients were classified into the following HRT categories: category 0 if both TO and TS were normal, category 1 if either TO or TS was abnormal, or category 2 if both TO and TS were abnormal. The primary end point was all-cause mortality. During a follow-up of 22 months, 70 patients died. Multivariately, HRT category 2 was the strongest predictor of death (hazard ratio, 5.9; 95% CI, 2.9 to 12.2), followed by left ventricular ejection fraction (LVEF) 30% (4.5; 2.6 to 7.8), diabetes mellitus (2.5; 1.6 to 4.1), age 65 years (2.4; 1.5 to 3.9), and HRT category 1 (2.4; 1.2 to 4.9). LVEF 30% had a sensitivity of 27% at a positive predictive accuracy level of 23%. The combined criteria of LVEF 30%, HRT category 2 or LVEF >30%, age 65 years, diabetes mellitus, and HRT category 2 had a sensitivity of 24% at a positive predictive accuracy level of 37%. The combined criteria of LVEF 30% or LVEF >30%, age 65 years, diabetes mellitus, and HRT category 1 or 2 had a sensitivity of 44% at a positive predictive accuracy level of 23%.

Conclusions— HRT is a strong predictor of subsequent death in postinfarction patients of the reperfusion era.

Key Words: arrhythmia • heart rate • mortality • myocardial infarction • nervous system, autonomic

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