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(Circulation. 2007;115:468-474.)
© 2007 American Heart Association, Inc.

Exercise Physiology

Prognostic Value of Heart Rate Increase at Onset of Exercise Testing

Nicholas J. Leeper, MD; Frederick E. Dewey, BA; Euan A. Ashley, MRCP, DPhil; Marcus Sandri, MD; Swee Yaw Tan, MD; David Hadley, PhD; Jonathan Myers, PhD; Victor Froelicher, MD

From Stanford University Medical Center, Stanford University Medical School, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif, and Cardiac Science, Bothell, Wash.

Correspondence to Nicholas J. Leeper, MD, Falk Cardiovascular Research Center, 300 Pasteur Dr, Stanford, CA 94305–5406. E-mail nleeper{at}cvmed.stanford.edu

Received September 22, 2006; accepted November 15, 2006.

Background— The initial response of heart rate to dynamic exercise has been proposed as having prognostic value in limited studies that have used modalities other than the treadmill. Our aim was to evaluate the prognostic value of early heart rate parameters in patients referred for routine clinical treadmill testing.

Methods and Results— The heart rate rise at the onset of exercise was measured in 1959 patients referred for clinical treadmill testing at the Palo Alto (Calif) Veterans Affairs Medical Center from 1997 to 2004. Multivariable Cox survival analysis was performed for 197 all-cause and 74 cardiovascular deaths that accrued during a mean follow-up of 5.4±2.1 years. Decreased heart rate changes at all initial relative exercise workloads were associated with significantly increased all-cause mortality. The heart rate rise at one-third total exercise capacity, however, was the only early heart rate variable that significantly predicted both all-cause and cardiovascular risk after adjustment for confounders. Failing to reach 1 SD in the heart rate rise at one-third total exercise capacity was associated with a 28% increased all-cause mortality rate (hazard ratio, 0.72; 95% CI, 0.61 to 0.85; P<0.001) and a 35% cardiovascular mortality rate (hazard ratio, 0.65; 95% CI, 0.49 to 0.86; P=0.003). Of all heart rate measurements considered (initial and recovery), the heart rate increase at peak exercise was the most powerful predictor of cardiovascular prognosis after adjustment for potential confounders. The Duke treadmill score, however, was superior to all heart rate measurements in the prediction of cardiovascular mortality.

Conclusions— In the present study population, a rapid initial heart rate rise was associated with improved survival, but the heart rate increase at peak exercise and other conventional measurements such as exercise capacity and the Duke treadmill score were more powerful predictors of prognosis.

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