HEART RATE

VARIABILITY
PART I
By Dr Utkarsha
2nd yr PG
Physiology deparment
OBJECTIVES
 What is HRV and it’s basics?
 Generation of HRV

 History of HRV

 About the Task Force

 Methods of Heart Rate Variability analysis

 Effect of Stress and Autonomic Nervous system

on HRV
 HRV and respiration

 HRV and Age

 Diabetes and HRV

 Cardiovascular Disease and HRV ,Myocardial

Infarction
DEFINITION OF HRV
 HRV, heart rate variability is the degree of fluctuation in the
length of the intervals between heart beats. (Malik & Camm,
1995)
 Heart rate variability (HRV) describes the variations
between consecutive inter-beat-intervals.
 It is a measurement of central autonomic drive to
the myocardium.
 It depends on the balance between sympathetic and
parasympathetic drives to myocardium.

In contrast to many conventional tests to evaluate

ANS, HRV analysis stands as a non-invasive method
of detecting an early autonomic impairment of heart.
HRV BASICS
Ability of the heart to handle the everpresent
stresses and relaxations placed on the body.
• Stresses: Physical, Psychological
• Relaxations: Recovery from these stresses
• One may conclude the greater the variability,
the better the heart can keep up with changes
and, therefore, healthier the person.
 GENERATION OF HRV
 The intrinsic HR generated by SA node in the absence of any
neutral or hormonal influence about 100 to 120 beats per minute.
 However in healthy individual resting HR would never be that
high.
 In a healthy individual , the HR is ranging between 60 and 100
bpm.
 Therefore, one should technically detect the occurrence times of
the SA-node action potentials. This is, however, practically
impossible and, thus, the heart beat is usually determined from
the ECG recording.
 After the QRS complex occurrence times have been
estimated, the HRV time series can be derived. The
inter-beat intervals or RR intervals are obtained as
differences between successive R-wave occurrence
times.
 Normal-to-normal (NN) may also be used when
referring to these intervals.
 The time series constructed from all available RR
intervals is, clearly, not equidistantly sampled, but
has to be presented as a function of time.
 In general, three different approaches have been
used.
 Calculate the spectrum directly from the RR
interval tachogram
 Another common approach, adopted in this software, is to use
interpolation methods for converting the non-equidistantly
sampled RR interval time series. After interpolation, regular
spectrum estimation methods can be applied.
 Third approach is to apply methodology, which are
designed for analysing non-equidistantly sampled
data. Such a method is for example the Lomb
periodogram, which computes the periodogram
spectrum estimate for non-equidistantly sampled
data.
HISTORY OF HRV
 18th century Albrecht von Haller noticed heat beat is
not regular
 The clinical relevance of HRV was first appreciated in
1965. HON and Lee noticed that the beat to beat
interval changes are the first alternation before fetal
distress occurs.
 1971 Sayers and others focused on rhythm imbedded
in beat to beat HR.
 1977 Wolf showed association of HR to sudden death
post MI.
 1981 Akselrod introduced Power spectral Analysis.
 Late 1980’s HRV
confirmed strong predictor
of mortality after an acute
MI.
 1996 Task Force published
Standards of Measurement
for HRV.
 At Present with the
availability of new digital ,
high frequency, 24h
multichannel electrographic
recorders, HRV has the
potential to provide
additional valuable insight
into physiological and
pathological conditions to
enhance risk stratification.
ABOUT THE TASK FORCE
 The task force was established by the Board Of
European Society Of Cardiology.
 The specific goals:

1. To standardize nomenclature and develop definitions of

terms.
2. To define physiological and pathological correlates.

3. To describe currently appropriate clinical applications

4. To identify areas for future research.

 The standards of measurement, physiological

interpretation and clinical use was the major goal of the
task force.
 Heart rate variability (HRV) an indirect indicator of
tonic autonomic interactions at the sinus node level, is
used as an indicator for neural control of the heart.
 It is mainly an efferent system that transmits impulses
from the central nervous system to the peripheral
organs. Thus, it controls heart rate, contraction
strength of the heart, contraction and dilation of
vessels, contraction and loosening of smooth muscles
in various organs and secretion from endocrine and
exocrine glands.
METHODS OF HEART RATE VARIABILITY ANALYSIS
I.TIME-DOMAIN METHODS

 The time-domain methods are the simplest to perform since they are
applied straight to the series of successive RR interval values. In this
method, the heart rate taken at any time or the interval between
successive normal complexes is determined.
 In a continuous ECG record, each QRS complex is detected, and the
normal-to-normal (NN) intervals or the instantaneous heart rate is
determined. In general, time domain methods are ideal for the analysis
of short-term recordings. These values may be expressed in original
units or as the natural logarithm (Ln) of original units to achieve a
more normal distribution.
 These methods are further divided into Statistical and Geometrical
methods.
The geometrical measures are derived from the RR interval histogram.
The sequence of NN intervals can be expressed by a geometric pattern.
There are two general approaches.

1) Basic measurement of the geometric pattern. Example: The width of

the distribution histogram at the specified level is converted into the
measure of HRV.
2) The geometric pattern is interpolated by a mathematically defined
shape. Example: Approximation of the distribution histogram by a
triangle: A triangular interpolation of the discrete distribution of RR
intervals (histogram counts) is used for the TINN [Triangular
interpolation of RR (or NN interval) histogram] measure: TINN =
B– A
##Based on a histogram of RR intervals with bin
size 1/128 sec, the HRV triangular index (HRVI) is
given by the most frequent value X (mode) with its
absolute frequency Y: HRV triangular index: =
D/Y
D/Y (Total number of all NN intervals/ Y). For
measurement a discrete scale is constructed on
the horizontal axis and named the sample density
distribution (D) which assigns the number of
equally long normal RR intervals to each value of
their lengths . Y is the maximum sample density
distrubition (D).
Geometrical methods
Statistical Methods:
a. From a series of instantaneous heart rates or cycle intervals,
particularly those recorded over longer periods (traditionally
24 hours), more complex statistical time domain measures can
be calculated.
b. These may be divided into two classes:
1) those derived from direct measurements of the NN intervals
or instantaneous heart rate.
2) those derived from the differences between NN intervals.
a. The simplest variable calculated is the standard deviation of
the NN intervals (SDNN), that is, the square root of variance.
Since variance is mathematically equal to total power of
spectral analysis, SDNN reflects all the cyclic components
responsible for variability in the period of recording.
Time Domain Statistical Methods
II. FREQUENCY DOMAIN PARAMETERS

 In the frequency-domain methods, a power spectrum density (PSD)

estimate is calculated for the RR interval series.
 From R-wave ECG intervals (Inter-Beat Interval-IBI) a
special time sequence is constructed (Interpolated IBI).
From the IIBI, an HRV power spectrum can be obtained.
Frequency Domain:

o This method distinguishes the heart rate signals according to their

frequency and intensity.

o It provides information on the amount of all changes in the heart rate

by taking advantage of periodic heart rate oscillations at various
frequencies.

o Power spectral density (PSD) analysis provides the basic information

of how power (variance) distributes as a function of frequency.
o Basically, the records are approached with short term periods
ranging from 2 to 5 minutes or 24-hour long term periods, then 4
main spectral components are calculated .

o These components are described as ultra-low frequency (ULF), very

low frequency (VLF), low frequency (LF) and high frequency (HF)
. However, ULF is not included in the standard Holter programs.
The spectral analyzes of HRV signals are considered as an
uninterrupted indicator of sympathetic and parasympathetic
activities of ANS .
From the HRV Spectrum, there are two bands of interest:– The high frequency (HF)
band (typically defined between 0.15 Hz and 0.7Hz)– The low frequency (LF) band
(typically defined between 0.04 Hz and 0.15 Hz)
 PSD estimation is generally carried out using either
Fast Fourier transform based methods or
parametric Autoregressive modeling based methods.
 FFT based methods is the simplicity of
implementation, while the AR spectrum yields
improved resolution especially for short samples.
1.Ultra Low Frequency (ULF): includes the frequency
components below 0.0033 Hz. Its characteristics are not fully
understood. It is scarcely used in clinical practice. The recording
time is long-term (entire 24 hours)

2. Very Low Frequency (VLF): It includes the frequency

components in the range of 0.0033-0.04 Hz. Although it is not
exactly known how this component has occurred, it is considered
to be originated from thermal and hormonal control along with
vasomotor activity, and not associated with ANS. The recording
time is short-term (1-5 min) and long-term (entire 24 hours)
3. Low Frequency (LF): It includes the frequency range
between 0.04 Hz and 0.15 Hz and is consisting of a
combination of sympathetic and parasympathetic effects. It is
associated with thermoregulation and peripheral vasomotor
activity. The recording time is short-term (1-5 min) and long-
term (entire 24 hours)

4. High Frequency (HF): It includes the frequency range

between 0.16 Hz and 0.4 Hz. It is considered that it is
modulated by the parasympathetic activity of ANS and that is
the major determinant of respiratory sinus arrhythmia. The
recording time is short-term (1-5 min) and long-term (entire
24 hours)
LF/HF ratio:
 The ratio of LF to HF reflects the sympathovagal balance.
 An increased LF/HF ratio indicates low vagal activation. In healthy
subjects, LF and HF have a circadian pattern with reciprocal fluctuations. In
the daytime LF increases, in the nighttime HF increases. LF increases
during 90-degree tilt, mental stress, standing, occlusion of coronary arteries,
moderate exercise, and occlusion of carotid arteries. HF increases in cases
of respiration, cold application on the face and rotational stimulation.
 Under stable conditions, time measurements should be made in 24-hour
long-term recordings and frequency measurements should be made in 5-min
recordings
 The use of four of the time measurements is always required. These include
SDNN and the triangular index reflecting overall HRV; SDANN showing
long-term components and RMSSD showing short-term components.
.
NON PARAMETRIC
(FFT)
Simplicity of algorithm is used.
Absolute power values for each
frequency band are obtained by simply
integrating the spectrum over the band
limits.
High processing speed, good
reproducibility.
Spectral component influenced by data length
PARAMETRIC
(AR)
Factorized into separate
spectral components
Distinct spectral components emerge for
each frequency band with a proper
selection of the model order and the
absolute power values are obtained
directly as the powers of these
components. Accurate estimation of
PSD.
Smoother spectral components can be
distinguished independent of preselected
frequency bands.
Easy post processing of spectrum
III NON-LINEAR METHODS
 These measurements allow us to quantify the unpredictability
of a time series and act different compared to linear systems.
They are determined by complex interactions of
hemodynamic, electrophysiological and humoral variables, as
well as by autonomic and central nervous regulations.

 Key elements to study complexity are mathematical models

and time-series analysis. Time-series tools is the most used
arguements for HRV analysis in clinical practice
 . For data representation, Lorenz plots (or Poincaré
plots), low-dimension attractor plots, singular value
decomposition, and attractor trajectories have been used.

 . The Poincaré plot is used to quantify recurrence, self-
similarity, or periodicity in a time series. It is based on
the concept of a return map, and in its simplest form
provides a means for displaying sequential pairs of
points
POINCARÉ PLOT
 Itis a graphical representation of the correlation between successive RR
intervals, i.e. plot of RRj+1 as a function of RRj.
 The shape of the plot is the essential feature.

 The Poincaré plot is a map of points in Cartesian coordinates that is

constructed from the values of the RR intervals. Each point is represented
on the x-axis by the previous normal RR interval and on the y-axis by the
following RR interval.
 An ellipse fits along the line of identity (dotted line) . SD1 is the short-
term variability and SD2 is the long-term variability. The transverse axis
(SD1) reflects beat-to-beat variation, while the longitudinal axis (SD2)
reflects the overall fluctuation. The SD1/SD2 shows the ratio between the
short- and long-term variability among the RR intervals and named
Cardiac Sympathetic Index
 The Poincaré plot therefore shows how well each
RR interval predicts the next – a greater spread of
values would mean an increased HRV, while the
closer they bunch together, the less HRV.
• Some Conditions that Cause Heart Rate Variability to Change:With
HRV method, efferent cardiac sympathetic - parasympathetic
modulation can be measured at the sinus node level.
• It has been shown in experimental studies that myocardial level effects
of efferent neural stimulation could be measured with changes in
effective refractory period. HRV analyzes provide a well-defined and
non-invasive good option for the examination of autonomic nervous
system modulation.
• The modulation of heart rate is under the control of complex regulatory
mechanisms including the nervous system, the endocrine system and the
cardiovascular system.
• The alterations in autonomic balance may be associated with the onset
of the disease and the alterations observed during cardiac autonomic
control, which are measured by heart rate variability.
 Heart rate variability (HRV), which we can describe as
cyclic alterations in the rate of sinus rhythm, is
considered as a measure of cardiac autonomic tone and
as a non-invasive indicator of the cardiorespiratory
system, since it provides information about sympathetic-
parasympathetic balance.

 Physiological increase in the variability between

heartbeats is a desirable condition, and concordantly
decrease in HRV is associated with worse cardiovascular
prognosis.
HRV AND THE AUTONOMIC NERVOUS
SYSTEM
 Although HRV manifests as a function of your heart rate, it actually
originates from your nervous system. Our autonomic nervous system,
which controls the involuntary aspects of your physiology, has two
branches, parasympathetic and sympathetic
It has been shown that:
– The HF HRV frequency band is dependent on the
Parasympathetic branch
– The LF HRV frequency band is dependent on both the
Parasympathetic and Sympathetic branches
– Ratio of LF/HF measure of ANS balance
STRESS AND HRV

 (1) The systems involved in allostasis don't shut off

when not needed or don't become active when they are
needed.
 (2) The balance between SNS and PNS can be disturbed
and either one of the SNS or PNS can predominate over
the other leading to stress related health problems.
 (3) The body doesn't return to a state of rest after an
emergency,
HRV AND RESPIRATION

 Respiratory Sinus Arrhythmia (RSA) is the phenomenon by

which heart rate is modulated by respiration.
 Respiration rate typically falls in the range of high frequency
HRV, and is the largest contributing component to variability
in this frequency range.
 HRV AND AGE

•HRV declines as people get older. The middle 50% of 20-25

year olds usually fall in the 55-105 range, while 60-65 year olds
are normally between 25-45.
DIABETES AND HRV

 T2DM was associated with an overall decrease in the HRV of

T2DM patients. Both sympathetic and parasympathetic activity
were decreased, which can be explained by the deleterious
effects of altered glucose metabolism on HRV, leading to cardiac
autonomic neuropathy.
CARDIOVASCULAR DISEASE AND HRV
MYOCARDIAL INFARCTION
Myocardial infarction:
Decrease in HRV identified after acute myocardial infarction has been reported to be a
powerful indicator in terms of mortality and arrhythmic complications in these cases.
This predictive value of HRV has been found to be independent of other post-
infarction risk factors. This characteristic of HRV cannot simply be attributed to only
hyperfunction of the sympathetic system and/or vagal withdrawal due to poor
ventricular performance. Decrease in HRV is indicative of suppressed vagal activity,
which is closely associated with the pathogenesis of ventricular arrhythmias and
sudden cardiac deaths [32]. It was first reported by Kleiger et al, that decrease in the
SDNN value observed in post-myocardial infarction period was associated with
clinical and demographic characteristics, increased mortality rate independent of
ventricular ectopic activity and left ventricular ejection fraction [33]. Similar results
were also observed in the study of ATRAMI (Autonomic Tone and Reflexes After
Myocardial Infarction). This study conducted with 1300 cases showed that decreased
HRV (SDNN<70 msec) levels are a very important and independent predictor of total
cardiac mortality [6]. The combination of decreased left ventricular ejection fraction
with decreased SDNN significantly increases the predictive value
Methods for increasing HRV include the
following:
Hydration. The better hydrated you are, the easier it is for your
blood to circulate and deliver oxygen and nutrients to your body.
Aiming to drink close to one ounce of water per pound of
bodyweight each day is a good goal.
Avoid Alcohol. One night of drinking potentially decreases HRV
for up to five days.
Steady Healthy Diet. Poor nutrition has adverse effects on HRV,
as does eating at unexpected times.
Quality Sleep. It’s not just the amount of sleep you get that
matters, but also the quality and consistency of your sleep. Going
to bed and waking up at similar times each day is beneficial.
Auto-Regulation. In general, trying to get your body on a
consistent schedule (in particular with sleep and eating to align
your circadian rhythm is helpful. Your body does things more
efficiently when it knows what’s coming.