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Need for a Revision of the Normal Limits of Resting Heart Rate

Paolo Palatini

Hypertension. 1999;33:622-625
doi: 10.1161/01.HYP.33.2.622
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Commentary

Need for a Revision of the Normal Limits of


Resting Heart Rate
Paolo Palatini, MD

T he current definition of sinus tachycardia is a heart rate


.100 beats per minute (bpm).1 This limit was set
arbitrarily when heart rate was not yet regarded as a risk
rate distribution, and an increase in the risk of coronary
events and/or cardiovascular and total mortality was found in
the subjects of the top quintile. In the Framingham study, for
factor for cardiovascular disease, probably with the main example, a 6-fold increase in the relative risk of sudden death
purpose of distinguishing between a disease state (fever, was seen in the subjects of the top heart rate quintile in
thyrotoxicosis, anemia, congestive heart failure, etc) and a comparison with those of the bottom quintile.6 In the Fra-
normal condition. mingham study, a linear relationship was found between heart
rate and mortality,6 although in other studies, a J-shaped
Tachycardia as a Cardiovascular Risk Factor
relation5 or a sigmoidal relation9 was observed. However, in
In recent years, interest has been aroused by the awareness
all studies, the excess in risk was present chiefly in the
that fast heart rate is a potent precursor of hypertension,
subjects of the highest heart rate quantile.
atherosclerosis, and their sequelae.210 In addition, many
leading epidemiological studies have shown that tachycardia
Is There a Level of Heart Rate That Separates
is associated with an increased risk of death from cardiovas- Two Populations With Normal and High
cular and noncardiovascular causes. This relationship has Heart Rate?
been found in general populations,37 in elderly individuals,9 Some years ago, Spodick et al13 attempted to redefine the
and in hypertensive cohorts.10 In all of these studies, the heart normal limits of heart rate on the basis of the results obtained
rate value above that in which a significant increase in risk in a population of subjects aged 50 to 80 years. By the
was observed was below the 100 bpm threshold (Table 1). addition of 2 SD to the mean heart rate value, Spodick et al
Only in the study by Levy et al3 was tachycardia defined as found upper normal limits of 93 bpm for resting heart rate in
a heart rate .99 bpm, but in that study the cutoff between the men and of 95 bpm in the women, which are above those
normal and high heart rate was chosen arbitrarily, and the found to be associated with an increased risk of mortality by
highest heart rate value measured during the examination was most investigators.4 10 Moreover, the Spodick approach im-
taken to define the subjects heart rate. In all the other studies, plies the existence of a normal distribution for heart rate in the
the threshold level between normal and fast heart rate was general population. Recent results obtained in our laboratory
between 79 and 90 bpm. indicate that this is not the case. In fact, in the Belgian, the
The normalcy limits of a clinical variable can be estab- HARVEST, and the Tecumseh populations we found that the
lished according to different criteria. For many parameters, heart rate distribution was significantly skewed among men
such as most biochemical indexes, the 95% confidence and women from Tecumseh.14 Similar results were obtained
interval is calculated to identify the upper normal limit of the in a recent analysis of the Mirano population,15 in which both
variable. This statistical approach does not appear suitable for men and women showed a skewed distribution of resting
those clinical variables in which the relationship with the heart rate (unpublished observations). Mixture analysis
level of risk is a continuous one. A typical example is showed that in all these populations, the distribution of heart
observed with blood pressure, in which the upper normal rate was explained by the mixture of 2 homogeneous sub-
limits were set arbitrarily.11 Blood pressure was considered populations, a larger one with normal heart rate and a
abnormal by the World Health Organization when it was smaller one with high heart rate. Mixture analysis is a
greater than the level at which the increase in risk became statistical test used in the biological sciences to investigate
considerable. This level roughly corresponded to the highest whether a mixture of normal distributions better explains the
quintile of the blood pressure distribution in the populations variation of a trait than a single distribution when overlap
of the industrialized countries.12 In most of the studies exists between the subpopulations.16 This is an entirely
reported in the Table, subjects were considered to have objective way to establish a cutoff level between normal and
tachycardia if they were in the highest quintile of the heart abnormal values, which avoids the necessity for establishing

Received October 5, 1998; first decision October 28, 1998; revision accepted November 24, 1998.
From the Department of Clinical and Experimental Medicine, University of Padova, Padova, Italy.
Correspondence to Professor Paolo Palatini, MD, Dipartimento di Medicina Clinica E Sperimentale, University of Padova, via Giustiniani, 2, 35128
Padova, Italy. E-mail palatini@ux1.unipd.it
(Hypertension. 1999;33:622-625.)
1999 American Heart Association, Inc.
Hypertension is available at http://www.hypertensionaha.org

622
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Palatini February 1999 623

Heart Rate Values Above Which a Significant Increase in Risk Was Found: Data From 9 Epidemiological Studies
HR Cutoff, bpm HR Method Used
Measurement: for Cutoff
Author (Study) Men Women Type (No.) Identification Study Outcome
Levy et al (US Army officers)
3 99 zzz Pulse (1) Arbitrary 5-y cardiovascular mortality in subjects with
HR.99 bpm far in excess compared with
subjects with HR#99 bpm
Medalie et al4 (Israeli government employees)* 90 zzz Not specified Highest tertile Age-adjusted rate/1000 of MI over 5 y: 61 in
top tertile and 40 in bottom tertile (P defined
as significant)
Dyer et al5 (Chicago-People Gas Co)* 79 zzz From ECG Highest quintile Age-adjusted 15-y all-cause mortality rate in
the HR quintiles: x2520.1, P#0.001
Dyer et al5 (Chicago-Heart Association)* 86 zzz From ECG Highest quintile Age-adjusted 5-y all-cause mortality rate in
the HR quintiles: x2520.4, P#0.001
Dyer et al5 (Chicago-Western Electric)* 89 zzz Pulse (1) Highest quintile Age-adjusted 17-y all-cause mortality rate in
the HR quintiles: x2521.05, P#0.001
Kannel et al6 (Framingham) 87 87 From ECG Highest quintile Age-adjusted 26-y sudden death mortality rate
in top HR quintile vs others: P,0.001
Gillum et al7 (NHANES) 84 84 Pulse (1) Arbitrary Odds ratios for risk-adjusted 10-y all-cause
mortality for HR.84 bpm: black men, 1.71
(1.142.56); white men, 1.81 (1.262.60);
black women, 1.95 (1.163.27); white women,
NS. Reference are subjects with HR,74 bpm.
Palatini et al9 (CASTEL) 80 84 Pulse (3) Highest quintile Odds ratios for risk-adjusted 12-y
cardiovascular mortality for HR.80 bpm: men,
1.38 (0.942.03), P50.005; women, NS.
Reference are subjects with HR from 64 to 80
bpm.
Gilman et al10 (Framingham) 84 84 From ECG Arbitrary Odds ratios for risk-adjusted 36-y all-cause
mortality for each 40-bpm increment in HR.
Men, 1.98 (1.522.59); women, 1.87
(1.372.56)
HR indicates heart rate; y, years; MI, myocardial infarction; NHANES, National Health and Nutrition Examination Survey; and CASTEL, CArdiovascular STudy in the
ELderly.
*Male population; elderly subjects; hypertensive cohort; data adjusted for age, smoking, blood pressure, cholesterol, and other confounders.

arbitrary threshold levels. With the use of this method in the benefit was clear only in patients with a heart rate .82 bpm.
above mentioned populations, we identified cutoffs varying An association between the reduction in heart rate and
from 80 to 85 bpm for resting heart rate measured by the mortality has been shown also with amiodarone, which
physician in the clinic.14 The percentage of subjects with a improved survival in patients with congestive heart failure,
high heart rate ranged from 12.3% to 29.8% in the various but only in subjects with heart rate .89 bpm.19 According to
male and female populations. These results show that 2 some investigators, the upper normal limit of a clinical
subpopulations with normal and high heart rate can be variable should be defined as the level at which the benefits
separated within a general population and that the threshold of treatment outweigh the risks or, in other words, as a
level between the 2 subpopulations is around 80 to 85 bpm. treatment threshold.20 The data obtained in subjects with
myocardial infarction or congestive heart failure suggest that
Effect of Treatment in Subjects With Tachycardia for heart rate this level should be set in the range of 80 to
If tachycardia is a strong risk factor for cardiovascular 89 bpm.
disease, antihypertensive drugs that also decrease heart rate
should be more beneficial in hypertensive subjects with fast Bradycardia
heart rate. However, no clinical trial has been implemented as Sinus bradycardia is said to exist in the adult when the sinus
yet with the specific purpose of studying the effects of cardiac node discharges at a rate ,60 bpm.1 Sinus bradycardia may
slowing on morbidity and mortality in hypertension. The only occur as a consequence of a disease such as increased
available data on the effect of heart rate reduction in humans intracranial pressure, myxedema, hypothermia, and vasovagal
stem from retrospective analyses of subjects with myocardial syncope. In epidemiological studies in general populations or
infarction or congestive heart failure. These results suggest hypertensive cohorts, no increased risk of mortality was
that b-blockers are effective in reducing mortality only in generally found for the lower extreme of heart rate. Only in
subjects with a high baseline heart rate.17 Carvedilol, for the Chicago Heart Association Study were low heart rates
example, has been reported to cause a marked reduction in (,60 bpm) related to an increase in sudden death.5 However,
mortality in subjects with congestive heart failure,18 but the in that study, subjects with bradyarrhythmias at ECG were
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624 Heart Rate Normal Limits

not excluded, and, thus, the excess in mortality could be variability and mortality from myocardial infarction and other
explained by subjects with bradycardia having important cardiovascular causes.23 Thus, not only the mean heart rate
bradyarrhythmias. In the elderly subjects of the CASTEL value but also its variability seems to be related to cardiovas-
study in which all individuals with bradyarrhythmias at cular morbidity and mortality.
standard ECG had been excluded, we found a better progno- The above mentioned heart rate limits can be of help for
sis in the subjects with heart rate lower than 64 bpm and as better defining the cardiovascular risk profile of a given
low as 50 bpm than in those with heart rates between 64 and individual, but we are still unable to say whether a reduction
80 bpm.9 This suggests that there is not an increase in risk of of heart rate below those levels could confer any benefit in
mortality for the lower extreme of heart rate, provided the terms of life expectancy, especially in hypertensive patients.
subject has been checked for possible sinoatrial dysfunction. As for the opposite extreme of the heart rate range, the data
Unlike tachycardia, sinus bradycardia does not appear to be a from the literature do not allow the identification of any
distinct clinical entity. With mixture analysis, we could not clinically meaningful limit. In fact, no increased risk of
identify a subpopulation of subjects with bradycardia at the mortality was generally found for the lowest values of sinus
lower extreme of the heart rate distribution in any of the heart rate. With the above mentioned approach, Spodick et
populations examined.14 al13 identified the level of 50 bpm as the lowest normal limit
of heart rate, but there is no indication from the literature that
Looking for a New Definition of Tachycardia a heart rate below that limit is really hazardous in the absence
Although there are no objective data that allow us to establish of sinoatrial dysfunction. It is obvious that a low heart rate,
new normal limits for resting heart rate, it seems clear that the particularly in unfit elderly subjects, may need further eval-
traditional 100 bpm value is not appropriate to define the
uation for sinoatrial node dysfunction or other diseases.
threshold below that in which heart rate can be considered
safe. The epidemiological studies listed in the Table clearly
demonstrate that the association between heart rate and the Conclusions
cardiovascular risk occurs for levels well below the 100 bpm Heart rate has been neglected for a long time as a clinical
value. Also, the results of the intervention trials in post parameter, and it is time that this variable receives the
myocardial infarction patients or in subjects with congestive consideration it deserves in clinical practice. Although offi-
heart failure suggest that the limit of normality of heart rate cial upper normal limits for resting heart rate are not yet
should be set below 100 bpm. On the basis of the data from available, the data of the literature are sound and indicate that
the literature and the results obtained with mixture analysis in these limits should be set well below 100 bpm, the threshold
our laboratory, we suggest a new consensus: for men, it currently used to define tachycardia, to probably around 85
appears reasonable to set the upper normal value of heart rate bpm. Heart rate can become a useful tool in clinical practice
at 85 bpm. Because of the higher heart rate commonly seen in and research in the future provided the criteria for measure-
women (3 to 7 bpm greater),2 a slightly higher threshold ment are strictly standardized by the scientific societies. We
should be adopted for them. Conversely, a lower limit should suggest that criteria similar to those adopted for blood
be set in the elderly. Heart rate has been reported to decline pressure assessment be used with heart rate. The clinician
slowly with age, with an average decrease of 1 bpm every 8 must consider all of the circumstances that may produce
years.2 The cutoff between normal and high heart rate found variations in heart rate and attempt to control or avoid them
in our laboratory in elderly men (80 bpm)9 was slightly lower before taking the measurement. At least 2 readings taken over
than that found in younger adults by most investigators a 30-second period should be averaged. In addition, heart rate
(Table). Hypertensive individuals,11 myocardial infarction should be checked by the use of repeated visits before a final
patients,21 and subjects with congestive heart failure18,19 diagnosis is made, because a white-coat tachycardia can
usually have higher values of heart rate than healthy controls. occur in some patients in the presence of healthcare profes-
However, this does not mean that the level of risk related to sionals. We have recently demonstrated that the day-to-day
heart rate is shifted toward higher values in these patients. A variability of clinic heart rate is 40% greater than that for
recent report in subjects with acute myocardial infarction heart rate recorded over 24 hours.24 If heart rate is measured
showed that the risk of death sharply increases for heart rate by 24-hour recording or with automatic devices, lower values
values .80 bpm.21 Another well recognized factor that should be expected.14 The evolution of our understanding of
affects heart rate is physical training.22 Tachycardia may be a the relationship between heart rate and mortality will dictate
marker for decreased physical fitness, which in turn may that different levels of heart rate are taken, which depends on
increase risk of cardiovascular death. However, high heart the method of measurement, as the upper limit of the normal
rate turned out to be a predictor of cardiovascular mortality heart rate is reached.
also in the studies that controlled for energy expenditure.7
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