Heart Rate as a Risk Factor for Cardiovascular Disease

doi:10.1016/j.pcad.2009.05.003

Progress in Cardiovascular Diseases

Volume 52, Issue 1, July–August 2009, Pages 6-10

https://doi.org/10.1016/j.pcad.2009.05.003 Get rights and content

Abstract

Almost all the epidemiological studies that aimed to answer the question of the relationship between heart rate and all-cause or cardiovascular morbidity and mortality reported that a high heart rate was associated with a higher risk of all-cause mortality and cardiovascular events. This relationship has been found to be generally stronger in men than among women. The increase in the cardiovascular risk, associated with the acceleration of heart rate, was comparable to the increase in risk observed with high blood pressure. It has been shown that an increase in heart rate by 10 beats per minute was associated with an increase in the risk of cardiac death by at least 20%, and this increase in the risk is similar to the one observed with an increase in systolic blood pressure by 10 mm Hg. It has also been shown that heart rate recorded in elderly men has a strong predictive value in survival to a very old age. Taken together, these results indicate that the risk associated with accelerated heart rate is not only statistical significant but also clinically relevant and that it should be taken into account in the evaluation of the patients. Although the association between elevated heart rate and cardiovascular morbidity and mortality has been demonstrated in a large number of epidemiological studies, tachycardia has remained a neglected cardiovascular risk factor until very recently. For the first time, the recent guidelines of the European Society of Cardiology and the European Society of Hypertension indicate than an accelerated heart rate is considered as an independent risk factor and potentially as a target for pharmacologic therapies, especially in high-risk patients.

Section snippets

Evidence that accelerated heart rate increases the risk of mortality

One of the very first large studies to examine this question was in 1980, the Chicago People Gas Company Study, which showed that there was an association between the levels of resting heart rate and coronary mortality.¹

During the 1990s, studies such as the Paris Prospective study² and the Investigations Préventives et Cliniques (IPC)-Paris study,³ the Italian Cardiovascular Study in the Elderly (CASTEL) study,⁴ and the Cardiovascular Occupational Risk factor détermination in Israeli industry

Mechanisms of the association between heart rate and cardiovascular complications

Several mechanisms can explain the association between high heart rate, atherosclerosis, and cardiovascular events. Tachycardia may reflect an altered balance of the autonomic nervous system tone. However, although high sympathetic activity alone could explain the precipitation of a cardiovascular event in a subject with tachycardia, a direct link between high heart rate and both the formation of the atherosclerotic lesion and the occurrence of the cardiovascular event has also been proven.8, 9

Threshold of tachycardia

So far, the levels of heart rate in the evaluation of the cardiovascular risk are almost ignored with the exception of very high heart rate values (>110-120 bpm). In the CORDIS study,⁵ the risk for cardiovascular death was more than doubled in subjects with heart rate of more than 90 bpm as compared to subjects with heart rate of less than 90 bpm. In the studies conducted by our group, a clinically significant increase in the cardiovascular risk has been observed in subjects with a heart rate

Does heart rate remain a significant risk factor in elderly adults?

Given the ageing of the population in industrialized countries and the consequent increase of preventive medicine in older subjects, several questions are raised. It has been suggested that the role of risk factors can be modified with age. We, along with others,3, 4, 5 have demonstrated that the association between heart rate and total or cardiovascular mortality remains significant in both younger and older subjects. However, limited information is available on the predictive value of heart

Association between heart rate and blood pressure levels

Several epidemiological studies3, 15, 16 have shown that hypertension, either borderline or sustained, is regularly associated with a slight, yet significant, increase in heart rate. The association between heart rate and blood pressure was significant even after taking into account several confounding factors such as body mass index, age, and metabolic parameters. This association has been found in different age groups and in both sexes. In one large French population, we confirmed the

Combined effects of heart rate and blood pressure on the cardiovascular risk

Accelerated heart rate is often associated with higher blood pressure levels, and these 2 factors seem to have additive effects on cardiovascular risk. This has been shown in several epidemiological studies that the increase in the cardiovascular risk related to the accelerated heart rate persists after adjustment for blood pressure levels. Also, at least 2 studies3, 23 have shown that the increase in cardiovascular disease risk in subjects with increased heart rate could be even more important

Association between elevated heart rate, sympathetic activity, and the metabolic syndrome

Numerous studies have shown that high heart rate was associated not only with high blood pressure but also with several other risk factors, especially metabolic disturbances such as increased glycemia, triglycerides, body mass index, and total cholesterol. This finding is not particularly surprising because increased heart rate may be considered as a sign of increased sympathetic tone, which in turn affects all the other metabolic disorders. In short, it is widely accepted that enhanced

Heart rate as a major cardiovascular risk factor: the present and the future

In their latest 2007 Guidelines for the Management of Hypertension,³⁴ the European Society of Cardiology and the European Society of Hypertension stated that “There may be reasons to include an elevated heart rate as a risk factor because of a growing body of evidence that elevated heart rate values relate to the risk of cardiovascular morbidity and mortality as well as all cause mortality.” Thus, for the first time, heart rate was considered as an independent risk factor and potentially as a

Perspectives and conclusions

For the first time, an accelerated heart rate is considered by official international guidelines as an independent risk factor and potentially as a target for pharmacologic therapies, especially in high-risk patients, which opens new possibilities in the cardiovascular prevention.

The recent results of interventional studies showing benefits from heart rate reduction in coronary artery patients consolidates the concept that heart rate is not only a valid marker but probably also an independent

Statement of Conflict of Interest

All authors declare that there are no conflicts of interest.

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Citation Excerpt :
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: Statement of Conflict of Interest: see page 9.

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Heart Rate as a Risk Factor for Cardiovascular Disease

Abstract

Section snippets

Evidence that accelerated heart rate increases the risk of mortality

Mechanisms of the association between heart rate and cardiovascular complications

Threshold of tachycardia

Does heart rate remain a significant risk factor in elderly adults?

Association between heart rate and blood pressure levels

Combined effects of heart rate and blood pressure on the cardiovascular risk

Association between elevated heart rate, sympathetic activity, and the metabolic syndrome

Heart rate as a major cardiovascular risk factor: the present and the future

Perspectives and conclusions

Statement of Conflict of Interest

Am J Hypertens

J Vasc Surg

Metabolism

Diabetes Metab

Heart rate as a prognostic factor for coronary heart disease and mortality findings in three Chicago Epidemiological studies

Am J Epidemiol

Predicting sudden death in the population: the Paris Prospective Study 1

Circulation

Influence of heart rate on mortality in a French population: role of age, gender and blood pressure

Hypertension

High heart rate: a risk factor for cardiovascular death in elderly men

Arch Intern Med

The association of resting heart rate with cardiovascular, cancer and all-cause mortality. Eight year follow-up of 3527 male Israeli employees (the CORDIS Study)

Eur Heart J

Impact of increased heart rate on clinical outcomes in hypertension: implications for antihypertensive drug Therapy

Drugs

Retarding effect of lowered heart rate on coronary atherosclerosis

Science

Effect of chronic heart rate reduction with ivabradine on carotid and aortic structure and function in normotensive and hypertensive rats

J Vasc Res

Heart rate dependent stiffening of large arteries in intact and sympathectomized rats

Hypertension

Ivabradine for patients with stable coronary artery disease and left-ventricular systolic dysfunction (BEAUTIFUL): a randomised, double-blind, placebo-controlled trial

Lancet

Heart rate and the cardiovascular risk

J Hypertens

Resting heart rate in the elderly: a predictor of survival to 85 years of age

J Am Ger Soc

Associations between heart rate and other risk factors in a large French population

J Hypertens