Characteristics of heart beat intervals and prediction of death

Alfred P. Hallstrom, Phyllis K. Stein, Raphael Schneider, Morrison Hodges, Georg Schmidt, Kurt Ulm

Research output: Contribution to journalArticlepeer-review

28 Scopus citations


Objective: To assess the value for improving risk stratification of measures, unadjusted and adjusted for heart rate, of heart rate variability (HRV) and heart rate turbulence (HRT) based on 2- to 24-h ambulatory electrocardiographic recordings; and to relate this to the decision to use an implantable cardiac defibrillator (ICD) and the attendant consequences on effectiveness and cost-effectiveness. Background: Risk stratification for high risk or low risk of lethal ventricular arrhythmic events, and hence for a decision about defibrillator implant, most commonly utilizes the left ventricular ejection fraction (LVEF). Electrocardiographic (ECG) approaches include 24-h ambulatory ECG recordings, with counts of ventricular premature contractions (VPCs), measures of heart rate variability (HRV), and heart rate turbulence (HRT). HRT has two components: turbulence onset (TO) and turbulence slope (TS). Methods and results: We evaluated the qualifying ambulatory ECG recordings from 744 patients in the active treatment arms of the Cardiac Arrhythmia Suppression Trial (CAST). Beat characteristics, VPC counts, normal-to-normal beat intervals, and time-domain measures of HRV and HRT were calculated. Tachograms were rescaled to a heart rate of 75 and the resulting "normalized" measures evaluated as risk predictors for death, compared to unnormalized measures. Measures based on 2-h ECGs were also evaluated as risk predictors. The most powerful univariate predictor of survival was the normalized turbulence slope. The best multivariate prediction model had six components: history of angina, hypertension, diabetes, and absence of post-myocardial infarction revascularization, the log of LVEF, normalized TS, HR, and an interaction term of HR and normalized TS. Gains in effectiveness from use of this model cost between $0 and $4000 per year of life saved. Conclusions: Turbulence slope substantially exceeded other ECG-based measures in improving prediction of subsequent death in models which included LVEF, and other clinical parameters. Use of this model would improve the effectiveness and cost-effectiveness of the ICD.

Original languageEnglish (US)
Pages (from-to)37-45
Number of pages9
JournalInternational Journal of Cardiology
Issue number1
StatePublished - Apr 8 2005
Externally publishedYes

Bibliographical note

Funding Information:
This study was supported by NHLBI RO-3 Grant #HL53776, NHLBI RO-3 Grant HL 53776, and by a grant from Bristol-Myers Squibb.


  • Ambulatory electrocardiography
  • Coronary heart disease
  • Implanted cardiac defibrillator
  • Myocardial infarction
  • Risk stratification
  • Sudden cardiac death


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