Chronotropic incompetence and autonomic dysfunction in patients without structural heart disease

Kawasaki, Tatsuya; Kaimoto, Satoshi; Sakatani, Takashi; Miki, Shigeyuki; Kamitani, Takeshi; Kuribayashi, Toshiro; Matsubara, Hiroaki; Sugihara, Hiroki

doi:10.1093/europace/eup433

Cited by 38 publications

(28 citation statements)

References 37 publications

(32 reference statements)

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“…27 The most often used criteria to diagnose CI is a failure to reach an arbitrary percentage (usually 80%) of the age-predicted maximal HR or a failure to attain 80% of the HR reserve from rest to peak exercise (CRI). 16,24,27 We defined CI by a strict criteria requiring both these conditions to be met.…”

Section: Discussionmentioning

confidence: 99%

Abnormal heart rate recovery and chronotropic incompetence on exercise in chronic obstructive pulmonary disease

2013

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Chronotropic incompetence (CI; failure to reach the targeted heart rate (HR) on exercise) and a delayed HR recovery (HRR; 12 beats decline within the first minute after cessation) reflect autonomic dysfunction (AD) and predict adverse cardiac prognosis. As chronic obstructive pulmonary disease (COPD) is known to be associated with AD, we hypothesized that these patients may manifest these responses on exercise. The prevalence and predictors of these responses in COPD and their association with its severity have not been evaluated. Normoxemic, stable male patients with COPD (n ¼ 39) and 11 healthy controls underwent lung function testing and incremental leg ergometry. HR responses were monitored during exercise and recovery to compute the HRR and CI. Of all the patients, 33 (84.6%) had at least one of the two exercise responses as abnormal, with the majority (23, 58.9%) having both an abnormal HRR and CI. The frequency of abnormal responses increased with increasing Global Initiative for Chronic Obstructive Lung Disease stage and body mass index, airflow obstruction, dyspnoea and exercise capacity index. After adjusting for smoking history and post-bronchodilator forced expiratory volume in 1 second, only a reduced diffusion capacity for carbon monoxide predicted abnormal HRR, though weakly. We concluded that abnormal HRR and CI are common in patients with COPD. These responses are observed with increasing frequency as the severity of disease increases.

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Section: Discussionmentioning

confidence: 99%

Abnormal heart rate recovery and chronotropic incompetence on exercise in chronic obstructive pulmonary disease

2013

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“…This ultimately results in post-synaptic desensitization [63][64][65][66]. As the HR response to exercise is determined by the extent of sympathetic drive to the heart and the ability of b-adrenergic receptors in the sinoatrial node to respond to circulating catecholamines, such desensitization could then result in a disturbed HR regulation/ response during exercise [64,67]. Thus, hyperglycaemia in T2DM patients induces CAN, leading to sympathetic predominance, ultimately contributing to development of CI by post-synaptic desensitization of the b-adrenergic receptor pathways in the sinoatrial node.…”

Section: Cardiovascular Autonomic Neuropathymentioning

confidence: 99%

Chronotropic Incompetence During Exercise in Type 2 Diabetes: Aetiology, Assessment Methodology, Prognostic Impact and Therapy

2015

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During incremental exercise tests, chronotropic incompetence (CI), which is the inability of the heart rate (HR) to rise in proportion to an increase in metabolic demand, is often observed in patients with type 2 diabetes mellitus (T2DM). Despite the fact that CI is associated with exercise intolerance and elevated risks of development of cardiovascular disease and premature death, this clinical anomaly is often ignored or overlooked by clinicians and physiologists. CI is, however, a significant clinical abnormality that deserves further attention, examination and treatment. The aetiology of CI in T2DM remains poorly understood and is complex. Certain T2DM-related co-morbidities or physiological anomalies may contribute to development of CI, such as altered blood catecholamine and/or potassium levels during exercise, structural myocardial abnormalities, ventricular and/or arterial stiffness, impaired baroreflex sensitivity and cardiovascular autonomic neuropathy. Clinicians should thus be aware of the potential presence of yet undetected anomalies or diseases in T2DM patients who experience CI during exercise testing. However, an effective treatment for CI in T2DM is yet to be developed. Exercise training programmes seem to be the only potentially effective and feasible interventions for partial restoration of the chronotropic response in T2DM, but it remains poorly understood how these interventions lead to restoration of the chronotropic response. Studies are thus warranted to elucidate the aetiology of CI and develop an effective treatment for CI in T2DM. In particular, the impact of (different) exercise interventions on CI in T2DM deserves greater attention in future studies.

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“…Phan et al [8] found that 34% of patients with HFpEF have CI during maximal exercise when defined by %Max PHR and 63% when defined by %HRR. In order to avoid age, functional capacity and resting HR biases of each individual [1,4,5,[20][21][22][23][24], for comparison analysis of patient data we have used %HRR. It is now well known that both parameters of CI were associated with adverse risk profile, whereby %HRR represents an isolated measure of chronotropy that appeared as an independent predictor of mortality.…”

Section: Discussionmentioning

confidence: 99%

“…However, the mechanisms linking smoking to CI remain unclear. There are a number of potential mechanisms including endothelial dysfunction, increased ischaemic burden, increased peripheral vascular resistance, autonomic dysfunction and/or downstream deficits in betaadrenergic stimulation [21,28,29], all mechanisms which are inevitably connected to HFpEF.…”

Section: Discussionmentioning

confidence: 99%

“…Chronotropic incompetence (CI) was defined to be a diminished heart rate (HR) response to exercise on the basis of the following two criteria [4,18,[20][21][22][23][24]: failure to achieve 85% of the maximum age-predicted heart rate (%Max PHR) where %Max PHR was calculated as 220 -age (years) [23] and percentage of HR reserve (%HRR) of ≤ 80% which was calculated using following equation: (HR at peak exercise -resting HR)/[(220 -age) -resting HR)] [4,[20][21][22][23][24]. We decided in our study to use the latter criterion because it outweighs the possible confounding effects of age, physical fitness and resting HR.…”

Section: Chronotropic Incompetencementioning

confidence: 99%

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Echocardiographic Predictors of Chronotropic Incompetence to Exercise in Patients with Heart Failure with Preserved Ejection Fraction

Projevska-Donegati

Georgievska-Ismail

2014

Prilozi

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Objective: Exercise intolerance in patients with heart failure with preserved ejection fraction (HFpEF) is most often attributed to diastolic dysfunction (DD); however, chronotropic incompetence (CI) could also play an important role. We intended to examine whether there are predictive echocardiographic parameters of DD for impaired chronotropic response to exercise. Methods and Results: Patients (n = 143) with unexplained dyspnea and/or exercise intolerance who fulfilled clinical and echocardiographic criteria of HFpEF presence underwent a symptom-limited exercise test using a treadmill (ETT) according to the Bruce protocol. CI was defined as an achieved heart rate reserve (HRR) of ≤ 80%. Comparison of the groups with (n = 98) and without CI (n = 45) did not show any statistically significant difference regarding demographic and clinical characterristics except for use of beta blockers (BB) that were more frequently present (p = 0.012) in patients with CI in comparison with those without. Patients with CI had a higher mean E-wave velocity, E/A ratio, increased E/E' septal, lateral as well as average ratio and abnormal IVRT/T E-e' index all consistent with elevated LV filling pressures. E/E' average ratio > 15 was statistically insignificantly more frequently present in patients with CI. In addition, by multivariate stepwise regression analysis value of E' septal (β = 3.697, 95%CI 0.921-6.473, p = 0.009) along with use of BB, current smoking and basal heart rate appeared as statistically significant independent predictors of lower HRR %. Conclusion: Patients with HFpEF frequently have chronotropic incompetence to graded exercise which may partly be predicted with echocardiographic parameters that are consistent with elevated LV filling pressures.

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Chronotropic incompetence and autonomic dysfunction in patients without structural heart disease

Cited by 38 publications

References 37 publications

Abnormal heart rate recovery and chronotropic incompetence on exercise in chronic obstructive pulmonary disease

Abnormal heart rate recovery and chronotropic incompetence on exercise in chronic obstructive pulmonary disease

Chronotropic Incompetence During Exercise in Type 2 Diabetes: Aetiology, Assessment Methodology, Prognostic Impact and Therapy

Echocardiographic Predictors of Chronotropic Incompetence to Exercise in Patients with Heart Failure with Preserved Ejection Fraction

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