Heart rate variability in patients with chest pain at the ED

284 Correspondence / American Journal of Emergency Medicine 32 (2014) 277285


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    Heart rate variability in patients with chest pain at the ED?

    To the Editor,

    We read the article “heart rate variability risk score for prediction of acute cardiac complications in the emergency department (ED) patients with chest pain” by Ong et al with

    ? There is no conflict of interests.

    interest [1]. They aimed develop a risk score incorporating HRV and traditional vital signs for the prediction of early mortality and complications in patients during the initial presentation to the ED with chest pain. They concluded that heart rate variability and vital signs performed well in predicting mortality and other complications within 72 hours after arrival at ED in patients with chest pain. Thanks to the authors for their contribution.

    Neural stimulation of the cardiovascular system is under the control of the autonomic nervous system (ANS) [2]. There is a significant relationship between impared ANS and cardiovascular mortality and morbidity. Some noninvasine methods can be used to assess cardiac autonomic functions. Evaluation of global HRV in the Holter recordings yields an useful index of cardiac ANS imbalance [3].

    Analysis of HRV has been used to assess autonomic function in different pathological conditions. These include hypertension, diabetes mellitus, ischemic heart disease, particularly myocardial infarction, cardiomyopathy, valvular heart disease, congestive heart failure stroke, Multiple sclerosis, and end-stage renal disease. Furthermore, the HRV index was significantly impaired in patients with various inflammatory diseases, including Behcet disease, familial Mediterranean fever and systemic lupus erythematosus [6]. Additionally, respiratory disease such as chronic obstructive pulmonary disease is associated with cardiac autonomic dysfunc- tion. Chronic obstructive pulmonary disease patients with moder- ate and severe disease had an abnormal cardiac autonomic modulation which is related to both systemic inflammation and lung function. Several authors have reported that HRV analysis is a more sensitive indicator of Autonomic dysfunction in alcoholic and in smoker subjects than conventional autonomic tests. Finally, physical fitness and activity levels are known to change HRV parameters. HRV analysis has also been used to investigate the autonomic effects of drugs, including ?-blockers, calcium blockers, antiarrhythmics, psychotropic agents, and cardiac glycosides. Drug effects on HRV can be established with relatively small numbers of study participants because HRV measurements are quite stable over the short- and long-term [4,5]. It might be useful if the authors gave information about these factors.

    As a conclusion, HRV and vital signs performed well in predicting

    mortality and other complications within 72 hours after arrival at ED in patients with chest pain as presented in the current study. However, HRV may be affected by many factors and the pivotal roles of those risk factors deserve further large-scale prospective randomized clinical trials.

    Sevket Balta, MD Department of Cardiology Eskisehir Military hospital Eskisehir, 26020, Turkey

    E-mail address: [email protected]

    Sait Demirkol, MD

    Department of Cardiology Gulhane Medical Academy Ankara, Turkey

    Cengiz Ozturk, MD Department of Cardiology Eskisehir Military Hospital Eskisehir, 26020, Turkey

    Mustafa Demir, MD Atila Iyisoy, MD Department of Cardiology

    Gulhane Medical Academy Ankara, Turkey

    Correspondence / American Journal of Emergency Medicine 32 (2014) 277285 285


    Ong MEH, Goh K, Fook-Chong S, Haaland B, Wai KL, Koh ZX, et al. Heart rate variability risk score for prediction of acute cardiac complications in ED patients with chest pain. Am J Emerg Med 2013;31(8):1201-7.

  28. Malik M. Heart rate variability. Standards of measurement, physiological interpretation, and clinical use. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Eur Heart J 1996;17(3):354-81.
  29. Sosnowski M, Clark E, Latif S, Macfarlane PW, Tendera M. Heart rate variability fraction-a new reportable measure of 24-hour R-R interval variation. Ann Noninvasive Electrocardiol 2005;10(1):7-15.
  30. Kleiger RE, Stein PK, Bigger JT. Heart rate variability: measurement and clinical utility. Ann Noninvasive Electrocardiol 2005;10(1):88-101.
  31. Ozgur S, Ceylan O, Senocak F, Orun UA, Dogan V, Yilmaz O, et al. An evaluation of heart rate variability and its modifying factors in children with type 1 diabetes. Cardiol Young 2013;9:1-8.
  32. Ardic I, Kaya MG, Yarlioglues M, Dogdu O, Celikbilek M, Akpek M, et al. Assessment of heart rate recovery index in patients with familial Mediterranean fever. Rheumatol Int 2011;31(1):121-5.

    Regarding “Heart rate variability in patients with chest pain at the ED”

    To the Editor,

    In “Heart rate variability in patients with chest pain at the ED”, the authors mentioned that Heart rate variability has been used to assess autonomic function in different pathological conditions and to investigate the autonomic effects of drugs, etc. HRV has also been reported as a sensitive indicator of autonomic dysfunction in alcoholics and in smokers. These are interesting points that indicate the potential utility of HRV and its association with various diseases.

    Also mentioned in this letter are factors that have impact on HRV. These factors may include length of recording of electrocardiogram (ECG), noise level in ECG signals, demographic variation, and many others. Current commercially available HRV tools can only interpret sinus rhythms, and they might not handle well ECG recordings with sustained arrhythmias or large segments of artifacts. Unfortunately, patients with non-sinus rhythms are usually at high risk for acute cardiac complications.

    The authors also raise the issue of the effect of comorbid diseases and medications on HRV analysis. All these questions represent challenges as well as opportunities for further research in this field. Further analysis of data from large-scale Observational cohort studies will be useful in this respect.

    Marcus Eng Hock Ong, MBBS

    Nan Liu, PhD Department of Emergency Medicine Singapore General Hospital

    169608 Singapore E-mail addresses: [email protected]

    [email protected]

    Role of procalcitonin in the diagnosis of Infective endocarditis

    To the Editor,

    We have read with interest the recently published article titled “Role of procalcitonin in the diagnosis of infective endocarditis (IE): a meta-analysis” by Yu et al [1]. They aimed to evaluate the diagnostic value of PCT in describing IE. They only included 6 studies in their meta- analysis. They found different and heterogeneous results in every study included in their analysis: there were variable results with respect to PCT sensitivity, specificity, positive likelihood ratios, and negative likelihood ratios.

    First, the 6 studies in the meta-analysis differ in terms of median age. Stucker et al [2] reported that the diagnostic level of PCT for infection could vary according to age. Therefore, one challenge is the need for more research to describe the relationship between infection and IE. Another challenge is that 3 different methods were used in the 6 studies, each with different cutoff values for PCT.

    Second, PCT can have false-negative values in subacute IE cases. Subacute forms of IE or prosthetic valve IE may have different presentations because of biofilm and low-level inflammatory re- sponses [3]. It would have been better if the authors had mentioned these conditions as limitations of this meta-analysis.

    Lastly, PCT is affected by a variety of infectious agents. In comparisons of gram-negative agents with gram positives, PCT levels are found to be higher in gram negatives [4]. A previous study by Kocazeybek et al [5] concluded that the median values of serum PCT were found to be higher in cases with IE and non-IE related to gram- negative bacteria than in those related to Gram-positive bacteria. However, most of bacteria included in these studies were gram positive. This can bias the diagnostic value of PCT in IE. Therefore, it would have been more accurate if the authors had compared PCT levels according to infectious agents in this meta-analysis.

    In conclusion, further studies are required to determine the relationship between PCT and IE. It is important that PCT be considered along with other independent variables (eg, age, bacterial agents, subacute IE, and acute IE) to provide the required information.

    Mustafa Hatipoglu, MD

    Asim Ulcay, MD Ergenekon Karagoz, MD Vedat Turhan, MD

    Department of Infectious Diseases and Clinical Microbiology

    GATA Haydarpasa Training Hospital

    Istanbul, Turkey E-mail address: [email protected]


    Yu CW, Juan LI, Hsu SC, Chen CK, Wu CW, Lee CC, et al. Role of procalcitonin in the diagnosis of infective endocarditis: a meta-analysis. Am J Emerg Med 2013;31(6):935-41.

  33. Stucker F, Herrmann F, Graf JD, Michel JP, Krause KH, Gavazzi G. Procalcitonin and infection in elderly patients. J Am Geriatr Soc 2005;53(8):1392-5.
  34. Schuetz P, Albrich W, Mueller B. Procalcitonin for diagnosis of infection and guide to antibiotic decisions: past, present and future. BMC Med 2011;9:107.
  35. Charles PE, Ladoire S, Aho S, Quenot JP, Doise JM, Prin S, et al. Serum procalcitonin elevation in critically ill patients at the onset of bacteremia caused by either gram negative or gram positive bacteria. BMC Infect Dis 2008;8:38.
  36. Kocazeybek B, Kucukoglu S, Oner YA. Procalcitonin and C-reactive protein in infective endocarditis: correlation with etiology and prognosis. Chemotherapy 2003;49(1-2):76-84.

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