Role of Heart Rate Recovery in Chronic Heart Failure: Results From the MyoVasc Study

Abstract

Background: Cardiac autonomic dysfunction is associated with heart failure (HF). Reduced heart rate recovery (HRR) indicates impaired parasympathetic reactivation after physical activity. Heart rate recovery 60 seconds after peak effort (HRR₆₀) is linked to autonomic dysfunction, but data on its relevance across HF phenotypes are scarce. This study aimed to identify clinical determinants of HRR₆₀ in an HF cohort and assess its relationship with clinical outcomes.

Methods: Data from the MyoVasc study (NCT04064450; N=3289) were analyzed. Participants underwent standardized clinical phenotyping including cardiopulmonary exercise testing. HRR₆₀ was defined as the heart rate decline 60 seconds after exercise termination. Clinical determinants of HRR₆₀ were evaluated using multivariate regression, whereas Cox regression analyses assessed all-cause death and worsening of HF.

Results: The analysis sample comprised 1289 individuals (median age, 66.0 [interquartile range {IQR}, 58.0-73.0] years, 30.4% women) ranging from stage B to stage C/D according to the universal definition of HF. Age, sex, smoking, obesity, peripheral artery disease, and chronic kidney disease were identified as determinants of HRR₆₀. HRR₆₀ showed a strong association with all-cause death (hazard ratio [HR]_{HRR60 [10 bpm]}, 1.56 [95% CI, 1.32-1.85]; P<0.0001) and worsening of HF (HR_{HRR60 [10 bpm]}, 1.36 [95% CI, 1.10-1.69]; P=0.0052) independent of age, sex, and clinical profile. Sensitivity analysis showed a stronger association with worsening HF in HF with preserved left ventricular ejection fraction (P_interaction=0.027).

Conclusions: HRR₆₀ was associated with clinical outcome in chronic HF. Because it showed a stronger association with outcomes in HF with preserved ejection fraction, future research should consider phenotype-specific differences.

Keywords: all‐cause death; autonomic dysfunction; heart failure; heart rate recovery; prognosis; worsening of heart failure.

Figure 1. Clinical determinants of HRR₆₀.

Multivariate linear regression model for HRR₆₀ (bpm) as dependent variable with adjustment for age, sex, CVRF, comorbidities, and medication score. Detailed definitions of cardiovascular risk factors and comorbidities can be found in the Supplemental Methods. COPD indicates chronic obstructive pulmonary disease; CVRF, cardiovascular risk factors; HRR₆₀, heart rate recovery 60 seconds after peak effort; and MI, myocardial infarction.

Figure 2. Clinical outcome by HRR₆₀ quartiles.

A, Event‐free survival by the median of HRR₆₀. Event‐free survival during a median follow‐up time of 8 years (IQR, 6.47–9.00) is displayed for stages B to C/D according to the universal definition and classification of HF. B, Worsening of HF by the median of HRR₆₀. The cumulative incidence of worsening of HF during a median follow‐up time of 4 years (IQR, 2.32–4.00) is displayed for stages B to C/D. HF indicates heart failure; HRR₆₀, heart rate recovery 60 seconds after peak effort; and IQR, interquartile range.

Figure 3. Prediction of clinical outcome by HRR₆₀ according to HF phenotypes.

Forest plot depicting clinical outcome in HF phenotypes with all‐cause mortality and worsening of HF as the dependent variables and HRR₆₀ (bpm) as the predictor in the Cox regression model with adjustment for age and sex. HFpEF was defined as individuals with stage C/D HF with an LVEF ≥50%. HFrEF was defined as stage C/D HF with LVEF <50%. HF indicates heart failure; HFpEF, HF with preserved ejection fraction; HFrEF, HF with reduced ejection fraction; HR, hazard ratio; HRR₆₀, heart rate recovery 60 seconds after peak effort; and LVEF, left ventricular ejection fraction.