Long-term cardiovascular risks associated with an elevated heart rate: the Framingham Heart Study

Abstract

Background: Higher heart rate has been associated with an adverse prognosis, but most prior studies focused on individuals with known cardiovascular disease or examined a limited number of outcomes. We sought to examine the association of baseline heart rate with both fatal and nonfatal outcomes during 2 decades of follow-up.

Methods and results: Our study included 4058 Framingham Heart Study participants (mean age 55 years, 56% women). Cox models were performed with multivariable adjustment for clinical risk factors and physical activity. A total of 708 participants developed incident cardiovascular disease (303 heart failure, 343 coronary heart disease, and 216 stroke events), 48 received a permanent pacemaker, and 1186 died. Baseline heart rate was associated with incident cardiovascular disease (hazard ratio [HR] 1.15 per 1 SD [11 bpm] increase in heart rate, 95% CI 1.07 to 1.24, P=0.0002), particularly heart failure (HR 1.32, 95% CI 1.18 to 1.48, P<0.0001). Higher heart rate was also associated with higher all-cause (HR 1.17, 95% CI 1.11 to 1.24, P<0.0001) and cardiovascular mortality (HR 1.18, 95% CI 1.04 to 1.33, P=0.01). Spline analyses did not suggest a lower threshold beyond which the benefit of a lower heart rate abated or increased. In contrast, individuals with a higher heart rate had a lower risk of requiring permanent pacemaker placement (HR 0.55, 95% CI 0.38 to 0.79, P=0.001).

Conclusions: Individuals with a higher heart rate are at elevated long-term risk for cardiovascular events, in particular, heart failure, and all-cause death. On the other hand, a higher heart rate is associated with a lower risk of future permanent pacemaker implantation.

Keywords: cardiovascular disease; epidemiology; heart failure; risk factor.

Figure 1.

Heart rate quartiles and risk of long‐term cardiovascular events. Cumulative incidence of clinical events increases across sex‐specific heart rate quartiles for cardiovascular events (A), heart failure (B), and all‐cause mortality (C). Analyses for nonfatal events were adjusted for competing risk of death. Heart rate cut‐offs for men are 25th percentile=55 bpm, 50th percentile=61 bpm, 75th percentile=69 bpm; for women: 25th percentile=59 bpm, 50th percentile=65 bpm, and 75th percentile=74 bpm. CVD indicates cardiovascular disease; HF, heart failure.

Figure 2.

Restricted cubic spline plots, showing the association of heart rate and clinical outcomes for cardiovascular disease (A), heart failure (B), and all‐cause mortality (C). Three knots were placed at the 25th, 50th, and 75th percentiles of heart rate, and dashed lines represent 95% CIs.