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Heart Rate Variability in Athletes

Article in Sports Medicine · February 2003


DOI: 10.2165/00007256-200333120-00003 · Source: PubMed

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Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 1

Heart Rate Variability in Athletes

A.E. Aubert, B. Seps and F. Beckers

Laboratory of Experimental Cardiology, School of Medicine, K.U. Leuven, Leuven, Belgium

Address for corresponding author:


André E. Aubert
Laboratory of Experimental Cardiology
University Hospital Gasthuisberg O/N
Herestraat 49
3000 Leuven, Belgium
Tel: 32/16-345840
Fax: 32/16/345844
E-Mail: Andre.aubert@med.kuleuven.ac.be
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 2

Contents

Abstract

1. Introduction

2. Control of heart rate: the autonomic nervous system

3. Methodology and analysis of cardiovascular variability: heart rate variability (HRV), blood

pressure variability (BPV) and baroreflex sensitivity

3.1 Time domain

3.2 Frequency analysis.

3.2.1 FFT approach

3.2.2 Autoregressive modelling (AR)

3.2.3 Wavelet decomposition

3.3 Selection of the most relevant frequency ranges and physiologic significance

3.4 Non-linear methods

4. Exercise physiology related to HRV

4.1 General cardiovascular changes due to exercise

4.2 Exercise and the autonomic nervous system

5. Changes in HRV related to exercise training

5.1 HRV during exercise

5.2 Cross sectional: comparison of athletes and sedentary groups

5.3 Longitudinal: effect on HRV of exercise training of non-athletes

5.4 Differences due to age and gender

5.5 Over-training and the autonomic nervous system

6. Conclusions
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 3

Abstract
The present review examines the influence on heart rate variability (HRV) indices in athletes from
training status, different types of exercise training, gender and ageing, presented from both cross-
sectional and longitudinal studies. Also the predictability of HRV in over-training, athletic
condition and athletic performance is included. Finally some recommendations concerning the
application of HRV methods in athletes are made.
The cardiovascular system is mostly controlled by autonomic regulation through the activity of
sympathetic and parasympathetic pathways of the autonomic nervous system. Analysis of HRV
permits insight in this control mechanism. It can easily be determined from ECG recordings,
resulting in time series (RR-intervals) that are usually analysed in time and frequency domain. As
a first approach it can be assumed that power in different frequency bands corresponds to activity
of sympathetic (0.04-0.15 Hz) and parasympathetic nerves (0.15-0.4 Hz). However also other
mechanisms (and feedback loops) are at work, especially in the low frequency band.
During dynamic exercise it is generally assumed that heart rate increases due to both a
parasympathetic withdrawal and an augmented sympathetic activity. However, because some
authors disagree with the former statement and the fact that during exercise there is also a
technical problem related to the non-stationary signals, a critical look at interpretation of results is
needed.
It is strongly suggested that, when presenting reports on HRV studies related to exercise
physiology in general or concerned with athletes, a detailed description should be provided on
analysis methods, as well as concerning population, training schedule, intensity and duration.
Most studies concern relatively small numbers of subjects, diminishing the power of statistics.
Therefore multicentre studies would be preferable.
In order to further develop this fascinating research field, we advocate prospective, randomised,
controlled, long term studies using validated measurement methods. Finally, there is a strong need
for basic research on the nature of the control and regulating mechanism exerted by the autonomic
nervous system on cardiovascular function in athletes, preferably with a multidisciplinary
approach between cardiologists, exercise physiologists, pulmonary physiologists, coaches and
biomedical engineers.

1. Introduction stenosis or hypertension) leads to a thickening of


The manner in which the intact organism in the ventricular wall and an unchanged internal
general and the cardiovascular system more dimension. This type of adaptation is called
specific, responds to the stress of exercise has concentric left ventricular hypertrophy. An
intrigued sports physiologist for the past century. essential difference between exercise and
The cardiovascular adjustments, necessary to meet pathologic conditions is that the load on the heart
the extraordinary demands of the working is continuous in the latter case and intermittent in
musculature, which begins even before the onset of the former.
exercise, remain areas of intense investigation and Other adjustments take place in almost every organ
speculation(1-2). As well anatomical geometry as system of the body and involve all aspects of
cardiovascular function of the heart are altered cardiac and peripheral vascular control, including
after chronic physical activity(3). For example, on regulation by the autonomic nervous system
the one hand, persistent volume load such as (ANS). Neural mechanisms appear to be of great
elicited after endurance training (or its pathologic importance in mediating the initial response to
equivalent after aortic or mitral insufficiency) leads exercise, which involves very rapid changes in
to enlargement of the left ventricular internal heart rate and blood pressure. All these phenomena
diameter and a proportional increase in wall involving heart rate and blood pressure are
thickness(4-5). This type of adaptation is called described as “cardiovascular variability”. Both
eccentric left ventricular hypertrophy. On the other phenomena covered in this review, exercise
hand, a pressure load such as elicited after power training and its relation to control and regulation of
training (or its pathologic equivalent of aortic the cardiovascular function by the ANS, have also
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 4

important clinical aspects: 1. Can exercise training metabolism and circulating hormones(7). Study of
be used to retard the advance of coronary and other cardiovascular variability allows mainly access to
heart diseases? 2. Can HRV be used as a predictor the activity of the nerves and the baroreceptors.
or as a marker of the progression of cardiovascular The autonomic nervous system describes those
disease? nerves that are concerned predominantly with the
Understanding interactions between cardiovascular regulation of bodily functions. These nerves
function, activity of the autonomic nervous system generally function without consciousness or
and exercise training, remains a difficult problem. volition. Autonomic nerves comprise sympathetic
The disciplines of medicine, exercise and nerves and parasympathetic nerves (the latter often
environmental physiology, physical education and being used as synonym of vagal, because the
biomedical engineering are all closely allied to parasympathetic supply to the heart runs in the
study the effects of exercise and other stresses on vagal nerves). Both divisions contain both afferent
cardiac structure and function. and efferent nerves and both myelinated and non-
The goal of this review is to discuss how some of myelinated fibers. In general the effects of the two
the consequences of exercise training on the divisions are complementary, with activity in
cardiovascular system, can be deducted from sympathetic nerves exciting the heart (increasing
measured basic experimental data of heart rate heart rate), constricting blood vessels, decreasing
variability (HRV), aortic blood pressure variability gastrointestinal motility and constricting
(BPV) and baroreflex sensitivity (BRS). sphincters, and parasympathetic nerves inducing
More specific, time and frequency analysis of heart the opposite response. The autonomic system
rate will be described as a valuable tool to supplies both afferent and efferent nerves to the
investigate the reflex mechanisms of heart, with sympathetic nerve endings all over the
cardiovascular regulation in active athletes in a myocardium and parasympathetic on the sino-atrial
fully non-invasive way. node, on the atrial myocardium and the atrio-
The parameters of HRV, BPV and BRS can simply ventricular node. These nerves not only control
be obtained from the measurement of the ECG heart rate and force, but both sympathetic and
(and heart rate) and (non-invasive) blood pressure parasympathetic nerves supply important
as will be shown further. Indices from HRV and reflexogenic areas in various parts of the heart
BPV can be studied in time (statistical studies) and which, when excited by either mechanical or
frequency domain (power spectrum). These indices chemical stimuli, give rise to reflexes which
can be a valuable non-invasive tool to investigate influence both the heart itself and the state of
the reflex mechanisms of cardiovascular regulation constriction of blood vessels(8). These neural
during and after exercising, for de-training and pathways are also closely linked to baroreceptor
over-training, gender differences and the effects of reflex activity, with changes in blood pressure
ageing. playing a key role in either increasing or
This review will discuss consecutively: 1. control decreasing activity of one or the other pathway.
mechanisms of heart rate and blood pressure and Analysis of cardiovascular variability permitted
the role of the ANS; 2. how to measure insight into the neural control mechanism of the
experimentally HRV and BPV, starting from the heart, leading to a new discipline:
ECG and (non-invasive) blood pressure signals and “Neurocardiology”(9-10-11). This area combines the
how to analyse; 3. correlation between HRV and disciplines of neurosciences and cardiovascular
physical and physiological parameters, 4. HRV physiology on the research side and of neurology
data obtained from studies on athletes and related and cardiology on the clinical side.
to training, training overload and age and gender The normal heartbeat and blood pressure vary
differences. secondary to respiration (respiratory sinus
arrhythmia), in response to physical,
2. Control of heart rate: the autonomic nervous environmental, mental and multiple other factors
system and is characterized by a circadian variation. Both
The cardiovascular system, the heart and the the basic heart rate and its modulation are
circulation, are mostly controlled by higher brain primarily determined by alterations in autonomic
centres (central command) and cardiovascular activity. Increased parasympathetic nervous
control areas in the brain stem through the activity activity slows the heart rate and increased
of sympathetic and parasympathetic nerves(6). sympathetic activity increases the heart rate
Control is also affected by baroreceptors, (Figure 1a)(12). In reality however the situation is
chemoreceptors, muscle afferent, local tissue much more complex and figure 1b depicts a more
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 5

evolved working model that, starting from central Therefore, cardiovascular control, as expressed by
cardiovascular control as a black box, identifies the the time-dependence of haemodynamic variables,
output of the ANS to blood pressure and heart rate is a direct reflection of autonomic activity. It may
and describes the feedback loop via the be a useful tool to examine autonomic fluctuations
baroreceptors(13). In a healthy individual, the role under different physiological circumstances(14) or
of the autonomic nervous system in the beat-to- to study external influences such as the effect of
beat adjustment of haemodynamic parameters is training.
essential to adequate cardiovascular functioning. Autonomic nerves thus have a pivotal role in the
regulation of the cardiovascular system both in
a. ensuring optimal function during various activities
B ra in in health under varying physical conditions, even
+
_ during weightlessness(15), and also in mediating
several of the manifestations of cardiac diseases.
S y m p a t h e t ic P a r a s y m p a t h e t ic
3. Methodology and analysis of cardiovascular
variability: heart rate variability (HRV), blood
pressure variability (BPV) and baroreflex
+ sensitivity (BRS).
The first step for the analysis of HRV and BPV
H eart
HR, BP signals are obtaining high quality ECG and
SV
(non)invasive blood pressure tracings under
stationary conditions (Figure 2). As the analysis of
the ECG and blood pressure are very similar, only
b. the ECG will be discussed further. Duration of
recordings can extend from a minimum of 10 min
to 24 h in Holter recordings. The duration has to be
sufficiently long and stationary during that period,
allowing a good frequency resolution. For
frequency domain measurements it is
recommended that the duration of the recording is
at least two times the wavelength of the lowest
frequency component. Accordingly the minimum
duration for the assessment of the high frequency
component (0.15 Hz) would be 13.3 s and for the
Figure 1 a. A very simple model illustrating the low frequency component (0.04Hz) 50 s. However,
influence of the sympathetic (increase heart it is generally recommended to have minimum
rate) and parasympathetic nervous activity duration recordings of 5 minutes or even better 10
(decrease heart rate) on heart rate, so called minutes. For the study of circadian variations
“balance model”. 1. b. Block diagram of a more Holter recordings (24 hour) covering a full
elaborated working model of cardiovascular day/night cycle are needed. Also, as will be shown
control mechanisms of heart rate and blood later, many HRV indices depend upon the duration
pressure and feedback mechanism from of the recording. Thus, it is inappropriate to
baroreflex. The diagram illustrates independent compare HRV indices obtained from recordings of
actions of the vagal, alpha-sympathetic and different duration with each other.
beta-sympathetic systems. Their action can be While laboratory conditions may be closely
assessed by measuring HRV, BPV and controlled, artifacts are present in almost all Holter
baroreflex mechanism. The parasympathetic recordings or telemetry recordings as obtained in
activity is responsible for the bradycardia the field. These signals are analog/digital
accompanying baroreceptor stimulation and for converted for computer processing. In order to
the tachycardia accompanying baroreceptor have a good time resolution and event definition, a
deactivation, with the sympathetic nervous sampling rate of at least 250 Hz and up to 1000 Hz
system also playing a minor role. TPR: total (giving a time resolution of 1 ms) is recommended.
peripheral resistance, CO: cardiac output, SV: The second step is the recognition of the QRS
stroke volume. complex. Peak detection is often performed with
commercially available software included in the
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 6

c d

Figure 2. Analysis of HRV: calculation of consecutive RR intervals (a) on the ECG, results in the
tachogram (b) which can be analysed in the frequency domain (c) and the time domain (d). Spectral
analysis and histogram are results from a 24 h Holter recording. Therefore the histogram shows two
peaks: around 1100 ms, corresponding to mean heart rate at night and around 750 ms,
corresponding to mean heart rate during day time.

Holter analysis systems. An algorithm was algorithms have been proposed to achieve
developed in house for threshold detection(16). This equidistant sampling(19-20-18).
algorithm functions as well on the ECG as on the Non-invasive blood pressure can be measured
blood pressure recordings. The result is a discrete, using finger cuffs(21-22) or a pulse displacement
unevenly spaced time event series: the tachogram, device(23). Both methods allow continuous
obtained from the ECG. It is crucial that before recording of blood pressure and can be calibrated
processing, these signals are corrected for ectopic with a conventional arm cuff device. The analysis
and missed beats(11-17). This is performed with of blood pressure signals is very similar.
filtering (elimination of spurious peaks) and Therefore, a separate description will not be given.
interpolation algorithms (i.e. replacing beats to be The only supplementary differences are: 1.
corrected by the mean of a combination of maxima (systolic blood pressure values) and
preceding and following beats)(18). After this step a minima (diastolic blood pressure values) should be
normal-to-normal interval (NN) is obtained. detected as well and 2. on the contrary to the QRS
A final step is needed before spectral analysis can peak where only the timing of its occurrence has to
be performed. Computation of the spectral be recorded, here both coordinates: amplitude (in
components of the tachogram requires a signal mmHg) and timing (s) have to be recorded. The
sampled at regular intervals, which is not the case variations in systolic blood pressure lead to the
for the tachogram, sampled by each (variable) systogram and the variations in diastolic blood
heartbeat. A regular signal is obtained by pressure to the diastogram.
modifying the tachogram. An interpolation is Data analysis on all these graphs can be
performed and, on this last signal, equidistant approached from different viewpoints,
points are sampled every 0.5 s. Different accentuating different underlying physiological
mechanisms. Traditionally time and frequency
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 7

domain have been considered, recently also non- standing position. Also rMSSD and pNN50 are
linear dynamics methods have been added. significantly larger (p<0.05) in supine compared to
standing position. This corresponds to a larger high
3.1 Time domain: frequency modulation in supine position compared
Parameters in the time domain are easily computed to standing (more vagal modulation) as will be
with simple statistical methods, even from short discussed later (see also Figure 4).
time windows. Their main limitation is the lack of Another possibility to process RR intervals in the
discrimination between the activity of the different time domain is the use of geometrical methods(27).
autonomic branches. The simplest one is the sample histogram (Figure
Recommendations for a standardization of valid 2d), of which parameters related to the distribution
parameters have been published(24). The most can be calculated: mode (value that occurs most
frequently used time domain parameters include often), skewness (a measure of symmetry) and
SD and SDANN, which represent global kurtosis (a measure of peakedness). Lorenz or
variability, and rMSSD and pNN50, which are Poincaré maps plot the duration of each RR
highly correlated to high frequency power in the interval against the duration of the immediately
frequency domain and represent markers for vagal preceding RR interval. The practical use of the
modulation(25), (as will be explained later). The geometrical methods seems to be rather limited
definition of the different indices is as follows: and up to now, not so often used in the literature.
SDNN (or SD), (ms): standard deviation of the
normal to normal (NN) interval (result from Table 1. HRV parameters in time domain
corrected signals for ectopic and missed beats by obtained from 10 control (sedentary) subjects
filtering and interpolation algorithms) over the and 10 aerobic trained athletes. Values are
recorded time interval. Theoretically heart rate mean±SD. *p<0.05 (Modified from[143] )
variance, equal to (SDNN)2 and total power are Mean NN (ms) SDNN (ms) rMSSD (ms) pNN50 (%)
mathematically identical. In practical terms Supine
Control 880.7±263.8 69.7±37 45.5±26.8 21.8±19.7
however, correspondence between SDNN and the 1100.3±158.5* 97.9±15.7* 73.5±23.7* 40.1±16.6*
Aerobic
total spectral power depends on data processing: Standing
treatment of ectopic beats, interpolation, definition Control 749.7±165.6 65.4±38.9 30.6±16.9 10.5±12.4
of total power, etc(26). It depends largely on the Aerobic 947.7±108.8* 92.9±30.9 47.2±11.1* 22.4±8.9*
duration of the recording; therefore, SDNN values
from recordings of different duration should not be 3.2 Frequency analysis
compared. By definition, spectral analysis decomposes any
SDANN (ms): standard deviation of the 5-minute steady, stationary, fluctuating time dependent
mean NN interval over the entire recording. As signal into its sinusoidal components. It allows
SDANN values are obtained from successive short plotting the power of each such component as a
5-minute periods, it can only estimate changes in function of its frequency and the computation of
heart rate caused by cycles shorter than 5 minutes. the power in defined frequency regions. Power
Previous indices can be obtained from statistical spectral analysis has been performed by Fast
methods such as shown in the histogram in figure Fourier Transform (FFT)(28), by autoregressive
2d. It provides mean values, standard deviation, modelling(29) and by wavelet decomposition(30).
coefficient of variation and related parameters.
rMSSD (ms): the square root of the mean squared
successive differences between adjacent RR 3.2.1 FFT approach
intervals over the entire recording. The FFT method is an objective method because
pNN50 (%): the percentage of successive interval no information is lost: the tachogram can be shown
differences larger than 50 ms computed over the in the frequency domain after FFT and the latter
entire recording. signal can be backward transformed to retrieve the
Some typical values of previously mentioned original tachogram. Units of the spectral
parameters are shown in Table 1. It gives values components are: ms2/Hz for HRV and mmHg2/Hz
for Mean NN, SD, rMSSD and pNN50, obtained for BPV. The advantage of the classical FFT
from 10 control subjects and 10 aerobic trained approach consists mainly in its computational
athletes(143), in supine and standing position. efficiency and its simple implementation (Figure
Aerobic trained athletes show a higher NN (lower 2c). However these advantages are
heart rate) compared to the control group and counterbalanced by some limitations. These are
higher rMSSD and pNN50 as well in supine as in mainly related to the limited frequency
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 8

resolution(18), which is directly related to the tachogram, are mostly non-stationary. The
duration of the recording period (which also information obtained by the wavelet
determines the lower limit of the spectrum, the decomposition can, be used to compare differences
latter equals the inverse of the recording length) in power or standard deviations at each of the
which is affected by the windowing process as wavelet levels analysed.
well. The upper frequency limit (1 Hz in humans)
is imposed by the Nyquist criterion: it equals half
the sampling rate, which in case of resampling the
signal every 0.5 s corresponds to 2 Hz. Therefore
the upper frequency limit is at 1 Hz.
The main reason why FFT analysis is so popular in
the scientific community is that is relatively simple
to apply, gives a nice graphical representation and
is readily available for application on computers, it
is even used for analysis of running velocity(31).

3.2.2. Autoregressive modelling


This approach considers the time series as a
difference equation, such that the signal at every
time step is expressed as a linear function of its
values at J previous time steps. Therefore the
autoregressive model (AR) requires an a priori a.
choice of the value of J (the order of the parametric
model) to provide the best fit to the data set that is
being processed. Visually the autoregressive
spectrum presents smoother spectral components,
which can be distinguished independently of pre-
selected frequency bands(29). The power content in
these peaks can be calculated without the need for
predefined spectral bands.
The limitations of this method are linked with the
adequacy of the choice of the order J, which may
affect the accuracy of the determination of the time
series and the power spectra. The model order J,
even if selected objectively by information theory
criteria, importantly determines both centre
frequency and the magnitude of the spectral
components(32).

3.2.3 Wavelet decomposition.


Wavelet transform(30-33), a relative recent
development, provides a general signal processing b.
technique that can be used in numerous biomedical Figure 3a. Comparison of spectral analysis
applications. Its development was originally methods: upper panel FFT, lower panel:
motivated by the desire to overcome the drawbacks autoregressive modelling (order is 24). Peaks
of traditional Fourier analysis (e.g. fast Fourier (due to respiration at fixed rate) are at the same
transform FFT), simultaneously providing time and frequency, but the autoregressive signal is
frequency information of the signal. The wavelet smoother than the FFT signal.
transform (WT) indicates which frequencies occur 3b. Comparison of power bands as obtained
at what time, showing good time resolution at high from FFT (top) and wavelet transform (WT)
frequencies and good frequency resolution at low (bottom). Control measurements from 10
frequencies. This multiresolution joint time- (sedentary) control subjects and aerobic: from
frequency analysis is therefore suited for the 10 aerobic trained athletes. Recordings were
examination of non-stationary signals. Real obtained in supine position (modified from
signals, like an electrocardiogram (ECG) or a [30]).
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 9

Wavelet transform offers superior time resolution components are not fixed but may vary in relation
and time localisation compared to FFT or to changes in autonomic modulation of heart rate
autoregressive models. Wavelet transform analysis and blood pressure(17). In man, the spectral
also is not restricted to stationary signals. The components are usually integrated over two
advantage of WT over AR is that no assumptions frequency regions defined as LF (0.04-0.15 Hz,
have to be made about model parameters. It offers with a central frequency around 0.1 Hz) and HF
rapid frequency decomposition with time (0.15-0.4 Hz, with a central frequency at the
resolution, useful when one is interested in a respiratory rate around 0.25 Hz). The LF and HF
particular power spectral band over time and a bands are indicated in figure 2c. In other mammals
potential use to assess fractal characteristics. these regions are differently chosen according to
A limitation of the method consists in the choice of the heart rate of the specific species(18).
the basic wavelet function (the mother wavelet), Which neural mechanisms are underlying these
which has to possess some specific properties. spectral bands fluctuations? Parasympathetic
Furthermore the wavelet transform results in efferent activity was considered responsible for
coefficients, which have to be related to power in HF, i.e. respiration linked oscillation of HRV. This
specific frequency bands. statement was made in conclusion after
The previously mentioned frequency analysis experiments with vagotomy performed in
methods are compared in Figure 3. Both FFT and experiments on decerebrate cats(34), or after
AR methods provide very comparable results, with muscarinic receptor blockade in conscious dogs(35)
AR providing a smoother spectral shape. It also and in humans(36). Both parasympathetic and
allows decomposition of the spectrum (division of sympathetic outflows were considered to
the spectrum in its root components) without the determine LF, together with other regulatory
need for predefined spectral bands. mechanisms such as the renin-angiotensin system
In the same figure (Figure 3b), power bands and baroreflex(37-36).
obtained from FFT and from WT are compared The LF/HF ratio can assess the fractional
between the same two groups (control subjects and distribution of power(38), although like any ratio, it
aerobic trained athletes) as described in Table 1. can emphasize the opposite changes.
Two conclusions can be drawn from this figure: 1. Below the LF frequency range (referred to as
FFT and WT provide very comparable results; 2. VLF), there is often a continuous increase in
aerobic trained athletes, with a low resting heart power. In part, this is the expression of very slow
rate, have indications of increased power in all frequency oscillations, probably related to
frequency bands compared to the control thermoregulation, but also non-harmonic DC noise
(sedentary) group. This implies an increased and the windowing process. These rhythms cannot
modulation of heart rate by the ANS, especially of be satisfactorily resolved and quantified by the
the parasympathetic component. traditional spectral analysis methods that are
performed on short recordings (of the order of
3.3 Selection of the most relevant frequency minutes). Different techniques and specific
ranges and physiologic significance methodologies have to be applied for a correct
The power spectrum of the HRV signal, as understanding and quantification of these complex
obtained from spectral analysis (FFT, and not yet fully clarified mechanisms. Spectral
autoregressive modelling or wavelet transform), analysis of 24-h traces provides information down
was proposed to be used as a quantitative probe to to 10-5 Hz and shows a circadian pattern. The long-
assess cardiovascular control mechanisms(14) term power spectrum of heart rate(39) (40-33-41)seems
In a typical heart rate power spectral density (PSD) to display a 1/f shaped frequency dependence (with
(which is the integral of the amplitude-frequency a slope around –1 in humans), raising the question
curve and is expressed in ms2 for HRV and in whether the cardiovascular control mechanism is
mmHg2 for BPV) three main frequency bands can of fractal nature.
be observed: very low frequency (VLF), low
frequency (LF) and high frequency (HF) A simple autonomic provocation consists in an
components (Figure 2c). Power in the LF and HF active change of posture from supine (Figure 4
bands can also be expressed in normalised units: left) to standing (Figure 4 right) (see also Table 1).
LFnu and HFnu, these are the values of LF and HF This results in a shift of blood away from the chest
divided by the total power minus VLF and to the venous system below the diaphragm, usually
multiplied by 100 (in %). The distribution of the referred to as venous pooling. Almost invariably in
power and the central frequency of these all normal subjects an increase in heart rate is the
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 10

Figure 4. Tachogram and corresponding power spectral density (PSD) of a standing subject (left)
and a supine subject (right). From supine to standing heart rare rises (RR intervals become shorter)
and high frequency power (parasympathetic) is depressed compared to supine, whereas low
frequency power (partially sympathetic) increases.

result (from mean value of 85 beats/min supine to related to chaos theory are used to describe the
120 beats/min standing on figure 4). While non-linear properties of heart rate fluctuations
standing, the regulatory system increases heart (attractors, 1/f behaviour of the power spectrum,
rate, cardiac contractility and vascular tone by a fractal-(49-50) and correlation dimension(51),
decrease in parasympathetic outflow and an Poincaré- and higher order moment plots,
increase in sympathetic outflow. The latter approximate entropy(52), pointwise correlation
increase is reflected in the LF content of the PSD dimension, detrended fluctuation analysis(47),
(Figure 4 left) and the former decrease in the HF Lyapunov exponents(53)).
content. While being supine, there is a The use of the new methods from non-linear
parasympathetic predominance, which switches to dynamics for HRV analysis may provide a more
sympathetic predominance on standing. sensitive way to characterise function or
dysfunction of the control mechanism of the
3.4 Non-linear methods cardiovascular system. These tools are promising
Chaotic behaviour exhibits a number of with regard to the understanding of the latter
characteristics that distinguish it from periodic and mechanism, but are still under development and
random behaviour(42-43) i.e. HRV spectra show a evaluation. Moreover these methods require more
broad band noise-like variability over a large powerful computing and are less visual attractive
frequency span(44-45).. This seems to be due to non- compared to frequency analysis.
linearity in the cardiovascular control network. The
long-term regulation of heart rate contains both 3.5 Baroreflex sensitivity
short-time periodic (e.g. respiratory) modulations Evaluation of RR interval changes corresponding
and entirely non-periodic fluctuations. There are to aorta blood pressure variations, allow to assess
indications that a reduction in complexity comes the activity of the baroreceptive mechanism(54).
along with a decrease in parasympathetic activity, Results from combined HRV and BPV signal
suggesting that a considerable amount of non- analysis lead to different methods that relate to the
linear behaviour be provided by this branch of the baroreflex mechanism. The enormous complexity
ANS. Methods of non-linear dynamics define of baroreflex interactions has been extensively
parameters that quantify complicated interactions reviewed recently(55).
of independent and interrelated components, which Several methods have been described to study
can be described as ‘complexity measure’(46-47-48). arterial baroreflex activity. The majority of the
Non-linear dynamical methods have made their methods depend on pharmacological or
appearance in the analysis of HRV only recently physiologic maneuvers that produce an abrupt
and methods have still to be established. Methods increase or decrease in blood pressure(56).
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 11

Subsequently, quantification of the (linear) relation testing(87-88), sudden infant death syndrome(89),
between blood pressure and corresponding heart influence of gravity(90-91), exercise training in
rate changes is performed by calculation of the patients after coronary artery disease(92) or heart
slope of the fitted linear curve(57). With standing or transplantation(93-94).
passive tilt transient hypotension occurs that results
in a reflex increase in heart rate, whereas the post- All the HRV and BPV analysis methods as
Valsalva increase in blood pressure causes reflex described above, have been implemented in
slowing(58). Maneuvers like neck suction or neck appropriate algorithms in our laboratory and
pressure that alter the transmural pressure or accordingly software was developed in-house. All
stretch in the carotid sinus also can be used in programs were implemented in LabVIEW, (which
humans to activate (load) or deactivate (unload) is a graphical language) and variability parameters
arterial baroreceptor reflexes(59). Drugs such as α- determined according to the standards provided in
adrenergic agents (phenylephrine or PE) or the Task Force on HRV(24) and extensively tested
angiotensin II that increase blood pressure produce and validated(16-18-26-47-52-67).
reflex slowing of the heart rate, whereas drugs like
nitrates or sodium nitroprusside that lower blood 4. Exercise physiology aspects as related to
pressure directly by relaxing vascular smooth HRV
muscle augment sympathetic efferent nerve The cardiovascular adjustments in exercise
activity and cause tachycardia and an increase in represent a combination and integration of neural
cardiac contractility. A high slope of the regression and local chemical factors. The neural factors
line is interpreted as indicating the presence of consist of: 1. central command, 2. reflexes
strong vagal reflexes while a relatively flat slope originating in the contracting muscle, and 3. the
indicates the presence of weak vagal reflexes, baroreflex. Central command is the cerebrocortical
possibly associated with high reflex sympathetic activation of the sympathetic nervous system that
activity(60). produces cardiac acceleration, increased
The usefulness and constraints of traditionally used myocardial contractile force and peripheral
methods have been reviewed elsewhere(61). Some vasoconstriction. When exercise stops, an abrupt
investigators have even viewed the traditional decrease in heart rate and cardiac output occurs
drug-induced baroreflex as misleading(62). and the sympathetic drive to the heart is essentially
Recently, several methods have been developed to removed. Blood pressure will be stabilised by the
quantify spontaneous BRS or spBRS. Some are baroreflex and parasympathetic activity will be
based on the use of the spectral analysis of both enhanced.
RR and BPV variabilities (α-index)(63), on the
analysis of sequences of concurrent alterations in 4.1 General cardiovascular changes due to
BP and HR (sequence method)(64), or on the exercise
method of statistical dependence(65-66-67). The Physical activity is associated with hemodynamic
spontaneous BRS has a number of important changes and alters the loading conditions of the
advantages: is does not require the use of i.v. drugs heart(95). Cardiovascular responses to physical
or a neck chamber apparatus and it measures BRS activity depend on the type and intensity of
in the normal physiological range over a period of exercise. The main difference, at heart level is the
time rather than brief and extreme perturbations as increased volume load during endurance exercise
induced by other methods. In this respect, it in contrast to pressure load during strength
represents a true steady-state assessment of the exercises(96). These differences in loading will
cardiac baroreflex under stationary conditions. cause various cardiovascular responses to physical
activity. After long term athletic training left
It is out of the scope of this review, but suffice it to ventricular diastolic cavity dimensions, wall
mention that HRV methods have many thickness and mass will increase(4-5). These
physiological and clinical applications studying the changes are described as the "athlete's heart".
influence of: ageing and gender studies(68-69), However in comparison to men, female athletes
anxiety, stress(70) and depression(71-72) , smoking(73- show smaller left ventricular mass(97). This gender
74)
, caffeine(75-76) and alcohol consumption(77-78), difference has been associated with a lower
risk assessment after myocardial infarction(79) or systolic blood pressure during 24-h Holter
predictor of mortality(80-81), hemodialysis(82), recordings and during exercise in female
congestive heart failure(83)and heart transplant athletes(98).
patients(84), diabetes(85), hypertension(86), drug
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 12

The volume load during endurance training results cardiovascular sympathetic afferent fibres produce
in adaptive changes in many aspects of cardiovascular reflexes that operate through a
cardiovascular function(2). The heart improves its positive feedback mechanism and thus may be
ability to pump blood, mainly by increasing its particularly responsible for the increased
stroke volume, which occurs because of an sympatho-adrenal activity of exercise(2). This is
increase in end-diastolic volume and a small opposed to reflex responses initiated by
increase in left ventricular mass. In contrast, baroreceptor or parasympathetic innervated
strength training results in larger increases in left cardiopulmonary receptors that operate through
ventricular mass. There is little or no change in negative feedback mechanisms(7).
ventricular volume. Endurance exercise also Thus both the sympathetic and parasympathetic
decreases the metabolic load on the heart at rest arms of the ANS play a pivotal role during
and at any submaximal exercise intensity. It does exercising. Therefore it can be expected to find
so by increasing stroke volume and decreasing changes in HRV indices according to the degree
heart rate. The result is a more efficient pressure- and duration of training and/or the kind of
time relationship. training(104).
A short overview of the major cardiovascular Long term physical training influences cardiac
changes will be given. rhythm: sinus bradycardia in resting conditions and
Heart rate is the predominant mechanism by which a slower increase in heart rate at any degree of
cardiac output rises during exercise under submaximal oxygen uptake due to a shift of the
physiological circumstances(99). Tachycardia can sympathovagal balance(105) towards
occur either by neural stimulation or by an parasympathetic dominance(106). Although the
elevation in circulating catecholamines(100). latter point has been questioned recently(107-108) and
Increased heart volume and contractility will lead a direct involvement of the sinus node was
to higher values of stroke volume, as well during suggested. This point will be dealt with later on.
rest as during submaximal and maximal exercise. Heart rate during exercise is regulated by increased
Also, the lower heart rate will increase stroke sympathetic modulation and withdrawal of
volume because of longer periods of diastole. The parasympathetic activity(8). It varies within an
heart ejects the extra blood due to the Frank- individual according to heredity (size of the left
Starling mechanism(2). Another factor inducing ventricle: predisposition for certain sport
higher stroke volume is the larger blood volume in activities), fitness level, exercise mode (endurance
athletes(101). or static training) and skill (economy of exercise).
Endurance training reduces resting and Body posture (supine, sitting, standing(109)),
submaximal exercise systolic, diastolic and mean environmental variables (temperature(110),
arterial blood pressures(102). The mechanism of humidity, altitude ), state of mood(112) and
(111)

reduced blood pressure at rest is not known. hormonal status(113) also alter heart rate response.
Endurance training will also influence the release Heart rate and HRV as well are also affected by
of catecholamines. Norepinephrine is released by drugs, stimulants(76) and eating habits.
the sympathetic nerve processes. An endurance Reflex adjustments initiated by the stimulation of
training programme will result in less afferent nerve fibres from the exercising muscles
catecholamine response to submaximal exercise are also likely to play a role in the cardiovascular
but not to maximal exercise(103). response to exercise(114). There is evidence that
reflex cardiovascular adjustments originating in the
contracting muscles are not mediated by muscle
4.2 Exercise and the autonomic nervous system spindle afferents but rather by small myelinated
Heart rate is generally regulated predominantly by and unmyelinated afferent fibres(115).
the ANS(7). The two major efferent mechanisms by Since exercise is accompanied by major
which tachycardia occurs are either through a cardiovascular alterations, including marked
decrease in parasympathetic or through an increase tachycardia, increases in cardiac output and in
in sympathetic stimulation(6). The latter can occur arterial and atrial pressures and a reduction in total
either by neural stimulation or by an elevation in peripheral resistance, it could be expected that a
circulating catecholamines. The mechanism of the cardiovascular regulating mechanism as important
(exercise induced) tachycardia appears to involve as the arterial baroreceptor reflex would play a
parasympathetic and spinal sympathetic reflex significant role in mediating and modifying the
circuits (Brainbridge reflex). The latter mechanism exercise response(116). Investigations into the role
is important to mention, since stimulation of of the arterial baroreflex in the control of the
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 13

Table 2. HRV during exercise.


Author N Age Sympathetic Parasympathetic Remarks
(years)
Arai(126) 43 25-65 no change withdrawal FFT
Maciel(129) 23 25-35 no change withdrawal pharmacologic
increase at higher blockade
activity level
Brenner(130) increase at onset withdrawal FFT
later on attenuated review
increase due to
higher temperature
Perini(125) 7 23.7±0.5 no change at no change at AR
low intensity low intewnsity
decrease at higher
Kamath(133) 19 20-32 decrease AR
Shin(135-136) 5 17-21 decrease decrease AR
8 21-40 decrease decrease Non-athletes
N : Number of subjects, FFT : fast Fourier transform, AR : autoregressive method

cardiovascular system during exercise have yielded vagal nerve impulses to the heart and increases
conflicting conclusions as to their importance(117). sympathetic discharge(123-124). The concerted
At first it was suggested that the baroreflex is just inhibition of parasympathetic control areas and
as active during exercise as at rest. On the other activation of sympathetic control areas in the
hand, if the baroreflex was also important during medulla oblongata elicit an increase in heart rate
exercise, than the occurrence of tachycardia and myocardial contractility.
associated with an elevated pressure is opposite to Technically a problem arises for heart rate
the predicted response, since the baroreceptor measurements during exercise: as it is increasing
should act to restrain heart rate in the face of an according to the intensity of exercising, no steady
elevated pressure(118). state is obtained, which is necessary for spectral
There is now a large body of evidence suggesting analysis. Two approaches are usually proposed in
the lack of importance of the baroreflex during the literature to solve this problem: 1. perform
exercise(119-120) (also similar response to moderate measurements at a fixed intensity level(125), 2.
exercise in intact dogs and arterial baroreceptor subtract a background trend to decrease the
denervation(121)). contribution of the continuous increase in heart
In reality, cardiovascular control mechanisms are rate with increasing exercise intensity(126). The
much more complex as shown in figure 1 as was latter method is based on the fact that the linear
recently shown in a review by Malpas(122). Stroke trend (first order) represents the largest non-
volume and end-diastolic volume also contribute(13) stationarity of heart rate during and after exercise.
in an intricate feedback system . Normally one is also only interested in resolving
Taking all these considerations together spectral components in the range where baroreflex
concerning HRV and its relationship to training, and respiratory inputs are the dominant effectors of
some questions still remain unanswered: 1. Are heart rate fluctuations (higher then 0.03 Hz).
differences in ANS control of the cardiovascular During exercise sometimes an exponential trend is
system between trained athletes and a sedentary subtracted.
population due to a training effect or are other ECG and/or blood pressure recordings before or
factors involved? 2. Can cardiovascular variability after exercise cause no particular problems. Best
(HRV and BPV) parameters be used as a predictive practice is to perform these measurements in a quit
factor for athletic achievements, or in other words, surrounding, at comparable timings for all subjects
can HRV and BPV be used to predict optimal in order to avoid circadian variations among
training and athletic performance? subjects. Usually, ECG is recorded as in clinical
practice, sometimes only RR-intervals are stored
5. Changes in HRV related to exercise training with a wrist watch. For particular studies, requiring
Highly trained athletes have a lower resting heart day/night resolution or circadian variations, 24 h
rate(3). Anticipation of physical activity inhibits the Holter recordings are used.
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 14

5.1 HRV during exercise As well Warren et al.(131) and Cottin et al.(132)
It has since long been shown that during dynamic concluded that HRV is a valid technique for non-
exercise heart rate increases due to both a invasive measurement of parasympathetic activity
parasympathetic withdrawal and an augmented during exercise, but its validity as a measure of
sympathetic activity(127-128). The relative role of the sympathetic activity during exercise is equivocal.
two drives depends on the exercise intensity(120-125). The former concluded this from measurements
Arai et al.(126) were the first to test this hypothesis during exercise (progressive cycling tests at 40, 60
with the aid of Fourier spectrum analysis of heart anf 80% of each subject’sheart rate reserve) with
rate time series in 43 normal subjects (range 25-69 infusion of saline, esmolol (beta-1 blocker),
years of age), who exercised until peak level. Their glycopyrrolate (muscarinic blocker), or both drugs.
data (Table 2) support a progressive withdrawal of HF power decreased exponentially with workload
parasympathetic activity during exercise but no and was attenuated by glycopyrrolate and
changes in normalized values of LF and HF with combined treatments. The latter group showed
respect to rest and no correlation between LF spectral analysis to confirm withdrawal of
power and sympathetic activity have been parasympathetic control during graded exercise
observed during muscular exercise. load (25, 50 and 75% of VO2max), as the power
Maciel et al.(129) came to similar conclusions. They spectral density of the HF band significantly
performed bicycle ergometer test in a group of 23 decreased with exercise loads. However also the
untrained subjects, at 3 levels (25W, 50W and LF power decreased with exercise load, suggesting
100W), before and after blockade with atropine or that LF and LF/HF is not a good indicator of
propranolol. Their results showed that tachycardia cardiovascular modulation during exercise.
induced by dynamic exercise is mediated by a Kamath et al.(133) in his study compared orthostatic
biphasic mechanism initially depending on rapid stress (10 min supine followed by 10 min standing)
vagal release and an increased sympathetic and exercising on a cycle ergometer (at 50% of
activity, especially at higher levels of exercising. their maximum predicted power output) in a group
In a recent review article Brenner et al.(130) also of 19 healthy untrained subjects (16 male, 3
supports this hypothesis: at the onset of exercise, females; 20-32 years of age). They found the same
heart rate is increased by a reduction in significant decrease in the LF component due to
parasympathetic activity and a temporally increase exercise, but an enhanced during orthostatic stress.
in sympathetic tone. A continuation of physical Therefore they concluded that humoral factors,
activity is associated with a continued withdrawal such as circulating catecholamines, probably play a
of vagal activity and an attenuation of sympathetic more dominant role in maintaining the tachycardia
nervous system tone. during exercise instead of neurogenic control
In contrast to Arai et al.(126) and other previously which takes place during orthostatic stress. The
mentioned authors, Perini et al.(125) performed existence of a non-neural mechanism in the
power spectral analysis (with an autoregressive reduction of the HF component was also supported
modelling) during steady-state exercise at different by a study from Casadei et al.(134).
intensities (3 levels: low at 50W, medium at 100W Shin et al.(135-136) submitted 5 runners (18±2 years)
and high at 150W) and during the corresponding and 8 sedentary subjects (27±7 years) to a bicycle
recovery periods in seven sedentary young males ergometer exercise to the point of exhaustion. The
(age: 23.7±0.9 years). They found only at low found that as well in athletes as in non-athletes LF
exercise intensities no changes in the relative and HF gradually decreased with exercise
power of the three components with respect to rest. intensity. They suggested two possible reasons: a
Above 30% VO2max, a marked decrease in LF marked absence of vagal modulation may have led
normalized power coupled to an increase in VLF% to reductions in LF accompanied by an influence
was found. Their hypothesis was that above this on the baroreflex (restored at higher operating
threshold additional mechanisms were involved in point or turned off), or hormonal factors. Possible
cardiovascular adjustment and that a not negligible limitations of this study are: 1. the choice of order
portion of the power of HRV was in the VLF band for the AR analysis, which influences power
and that this component might reflect, at least in distribution over different bands, 2. the small
part, the sympathetic activity. However, they also number of athletes (N=4), rather young and
mentioned a technical problem with the VLF compared to 3. an older non-athletes(137)
detection after trend removal. Therefore population.
conclusions about this component are maybe not
entirely justified.
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 15

Table 3. Cross-sectional: athletes versus sedentary population


Author N Age Spectral Remarks
analysis
(years)
Tonkins(142) 39 21.2±3 No change 24 h Holter
39 time domain
Aubert(211) 10 18-34 HF (increase) FFT
10 19-31
Verlinde(30) 10 18-34 HF (increase) Wavelet
10 19-31
Dixon(146) 10 22-33 HF (increase) AR
14 23-33
Goldsmith(147) 8 24-38 HF (increase) 24 h Holter, FFT
8 24-38 sleeping and
awake
Furlan(151) 21 16±0.6 LF (increase) trained
15 16±0.5 HF (increase) detrained
29 16±0.4
Jansen(152) 18 19-32 LF (decrease) supine
11 23-33
N: number of subjects, LF: low frequency power, HF: high frequency power,
FFT: fast Fourier transform, AR: autoregressive method.
Last row for each author: sedentary comparison group

Yamamoto et al.(138) found an increase of LF subjects (13 females, 9 males; 20-40 years of age)
component with increasing exercise intensity. In on a cycle ergometer with a ramp load until
their study 6 healthy male volunteers performed exhaustion. The authors were only interested in the
incremental exercise test on an electrically braked HF component. Therefore the tachogram was high-
cycle ergometer, consisting of a 5 min warm up pass filtered with a low frequency cut-off at 0.15
period at 50W, followed by work rate increment in Hz. As ramp loading leads to non-stationary time
a ramp fashion until exhaustion. But these authors series, Fourier analysis was not applicable. To
used 0.0 Hz to 0.15 Hz as limits for the low obtain the instantaneous frequency of the HF
frequency bands. Therefore we cannot interpret component of the HRV, the analytic signal
these data compared to previous ones, because approach was used. This method consists in
their LF component involves also the VLF constructing a complex function (the analytic
component as proposed by the Task Force(24). function) where the real part is the time series and
Parasympathetic activity of heart rate during the complex part is the Hilbert transform of
exercise was investigated with a time series previous time series. From this complex function
analysis by way of geometrical methods (Poincaré the amplitude and phase of the time series can be
plot) in a study in 31 subjects by Tulppo et al.(139). obtained, and finally the instantaneous frequency is
They showed that during recovery parasympathetic the derivative of the instantaneous phase. They
activity decreased progressively until the concluded that the instantaneous frequency
ventilatory threshold level was reached, when component of the HF power of HRV and of the
sympathetic activation was reflected from changes respiratory signal developed in parallel during a
in the Poincaré plot. They concluded that poor ramp load test. Both signals were closely linked,
physical fitness is associated with an impairment showing a strong correlation between respiration
of cardiac parasympathetic function during and heart rate. Due to this correlation, the HF
exercise and that their data support the concept that component of HRV was modified during ramp
good aerobic fitness may exert cardioprotective load and in most cases can be used for the
effects by enhancing the cardiac parasympathetic detection of the ventilatory anaerobic threshold,
function during exercise. because the shift in instantaneous frequency of the
A totally different technique to analyse heart rate HF component occurred during the transition from
variability during exercise is proposed by Anosov aerobic to anaerobic work. The modulation of
et al.(140). They examined a group of 22 untrained HRV in terms of its frequency is strong, even at
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 16

high physical activity levels, whereas the absolute young endurance trained athletes (mean age lower
power of HRV is clearly reduced at high work than 30 year; disciplines: cycling, canoeing,
loads. athletics, roller-skating, volleyball)(145-146-147-148-149-
Gonzalez-Camarena(141) compared heart rate and 150)
. These studies concluded that endurance
blood pressure variabilities during static and training results in the enhanced vagal tone in
dynamic (cycling at 30% and 60% of VO2max)) athletes, which may contribute in part to the lower
exercise in 10 subjects. They found a resting heart rate. Goldsmith(147), who performed a
parasympathetic withdrawal and sympathetic Holter study in 8 endurance trained athletes and
augmentation during dynamic exercise and an compared with 8 age matched untrained men,
overall increase in HRV indices during static suggests that aerobic exercise training may be a
exercise, suggesting an increased activity of both useful adjunct or alternative to drug therapy in
autonomic branches. lessening the derangements of autonomic balance
HRV analysis during exercise remains a problem. in many cardiovascular diseases.
There are not so many studies and almost all of In a combined RR-interval blood pressure study,
them mention the technical problem of not dealing Macor et al.(149) concluded that competitive cycling
with stationary time series. There is also a problem causes an enhanced parasympathetic drive to the
related to the interpretation due to the sinus node, whereas the neural control of blood
methodology. There are nearly as many protocols pressure is not affected. Furlan et al.(151) examined
proposed as there are papers written on this topic. two groups of endurance athletes: one group in rest
Methodology differs widely especially concerning period (detrained athletes, 15 in total: 6 male, 9
training intensity and/or exercise intensity, even in female) and one group during peak season (21
some papers they are only vaguely mentioned. swimmers, 14 male, 7 female). The latter had, in
Therefore it is strongly recommended to establish a contrast with the former group, elevated
protocol, one for performing studies in sedentary sympathetic activity and higher parasympathetic
populations and another for athletes, while using activity compared to a control group. They
appropriate blockade mechanisms and different concluded that the enhanced athletic performance
analysis methods: time domain (and geometric resulting from long-term training might depend on
methods), spectral analysis and its variations an increase of both parasympathetic and
(Hilbert transform) and non-linear methods as sympathetic modulation. Janssen et al.(152)
well. compared athletes (18 cyclists, 19-32 years of age)
with 11 sedentary subjects (23-33 years of age) in
Changes in HRV after exercise training both supine and standing position. Spectral
5.2 Cross –sectional studies: comparison of analysis was performed with autoregressive
athletic and sedentary groups methods. Their measurements would suggest that
In this section, the differences between a sedentary in the supine position, the sympathovagal balance
group and one or more groups of athletes (Table 3) of the athletes differed from the control values,
will be discussed as described in the literature. caused by lowered sympathetic and/or increased
Tonkins(142) reports a positive effect of time parasympathetic tone. This is mostly due to a
domain parameters, as obtained from Holter persistent sympathetic activation after exercise,
recordings in 39 trained athletes but did not find a lasting up to 24 h, which is also studied in the same
difference between aerobic trained and anaerobic work. They concluded that the differences in
trained athletes. This is in contrast with results of autonomic control between the athletes and the
Aubert et al.(143). They found significant higher controls, were reflected in the quality (balance
values of rMMSD and pNN50 between aerobic between slow and fast heart rate fluctuations)
trained athletes and anaerobic trained athletes or rather than in the quantity of heart rate variability.
rugby players, the latter are involved in combined De Meersman et al.(153) performed a cross-sectional
aerobic and anaerobic training. These differences study for all age groups in 72 runners (15-83 years
were also found in the frequency spectrum: larger of age) and in 72 sedentary controls matched for
high frequency component in aerobic trained age, body weight, blood pressure and social status.
athletes as well with FFT as with wavelet HRV however was not determined from spectral
analysis(30). In an earlier study(144) they came to the analysis but defined as % change of heart rate with
same conclusion: significantly higher rMSSD in 14 breathing (imposed breathing at 6/min). Although
middle aged athletes, compared to a sedentary age no correlations with spectral component were
matched population (N=14, 35-55 years of age). made, it can be assumed that this parameter is
Many other studies confirm these findings for related to the HF component of HRV. The
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 17

physically active group had significantly higher modulation. Most studies(146-148-150) mention that the
levels of % change of heart rate, when compared higher parasympathetic activity is not the only
with their sedentary counterparts. These authors factor that contributes to the bradycardia in athletes
concluded that habitual aerobic exercise augments but that it is only a part of the lower heart rate. All
some parameters of HRV and could be a beneficial these studies point to endurance training as an
modulator of heart rate variability in an ageing effector of enhanced parasympathetic activity in
population. They also suggested that this athletes, which may contribute in part to the resting
augmented HRV in physically active individuals bradycardia. Katona et al.(155) already found in
provided further support for life-long aerobic 1982 that lower resting heart rate in endurance
exercise as a possible non-pharmacological cardio- trained athletes (8 world class oarsmen) is solely
protective therapy. However this statement remains due to a reduction in intrinsic cardiac rate, and not
highly speculative, as it is not entirely supported to an increase in parasympathetic tone. They
by their data. showed it by using pharmacological blockade
All previous studies showed an increment in (propranolol and atropine) to suppress either
parasympathetic activity due to an aerobic exercise sympathetic or parasympathetic activity of the
program. Some other studies(154-155-156-157-69-158-108- autonomic nervous system. Also, Bonaduce et
105)
did not find this positive effect on the al.(161) came to the conclusion that other
autonomic nervous system. Migliaro et al.(69) found mechanisms than changes in cardiac autonomic
no differences in HRV (as determined from control could be involved in determining the
spectral analysis: LF and HF) parameters between profound bradycardia of athletes.
sedentary (N=29, 15-24 years of age) and non- Another possible reason for the controversial
sedentary young subjects (N=29, 15-24 years of results concerning ANS activity in athletes is due
age). They also did not observe training to a disturbance on the LF power caused by
bradycardia which can probably explain their respiration. This was shown in a study from Strano
observation. et al.(162) comparing controlled versus paced
A recent pharmacological blockade study by Stein breathing. A slow breathing rate, which is a
et al.(108), with atropine and propranolol, caused common feature in athletes, caused the HF and LF
parallel shifts in the sinus automaticity of athletes components to overlap, leading to a
(6 runners, 29±4 years of age and 6 non-athletes misinterpretation of the LF power. ECG was
28±5 years of age). Increased parasympathetic recorded in supine position in athletes, while they
activity would cause greater heart rate response were breathing at their spontaneous frequency and
post-atropine and a reduction in sympathetic at rates of 15, 12 and 10 to 14 (in random order)
activity would cause lesser heart rate response breaths/min (corresponding to 0.25, 0.2, 0.16 and
post-propranolol in athletes compared to non- 0.23 Hz). Uncontrolled and random breathing rates
athletes. These conclusions were obtained after significantly altered spectral sympathetic indices.
electrophysiological studies of the conduction On the other hand, 15 and 12 breaths/min
system. The authors concluded that sinus redistributed respiratory related power through the
automaticity and AV node conduction changes of HF, thus yielding correct LF power estimation.
endurance athletes were related to intrinsic The authors conclude and recommend to
electrophysiology and not to autonomic influences. standardize respiration at 0.25 Hz (15 breaths/min)
The same group suggested earlier(107) that in in athletes for assessing ANS activity.
addition to its parasympathetic effects, athletic A possible hypothesis as to the controversy about
training might induce intrinsic adaptations in the autonomic versus non-autonomic determinants of
conduction system (mostly by influencing electrophysiological adaptations in athletes could
conduction velocity), which could contribute to the be a fundamental difference between short-term
higher prevalence of atrioventricular abnormalities and long-term physical training programs (108).
observed in athletes. Short-term training, as in prospective studies,
The latter study was in agreement with the results could induce autonomic adaptations, with a
of a blockade study of Smith et al.(159) who found reduction in sympathetic activity and an increase in
greater parasympathetic influence in endurance parasympathetic activity (leading to bradycardia).
trained subjects as well as lower intrinsic heart On the other hand, long-term aerobic training,
rate, but in disagreement with all the studies as eliciting atrial and ventricular dilation, would
mentioned in the first paragraph of this chapter and induce intrinsic electrophysiological adaptations
Goldsmith(160) who indicated from their results that and enhance parasympathetic activity.
physical fitness is strongly associated with vagal
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 18

Table 4 Effect of training on a sedentary population.


Author N Age Duration repetions TP LF HF Remarks
(years) (weeks) (/week) (ms2) (ms2) (ms2)

Melanson(157) 11 25-45 16 3 234 398 before


416 798* after training
5 25-45 No training 173 331 before
169 446 after 16 weeks
Loimaala(171) 26 35-55 20 863 321 control/before
829 391 after training
26 4 to 6 1212 572 before
1300 659 jogging/walking
55%
28 4 to 6 846 317 before
1054 478 jogging 75%
Catai(154) 10 19-21 12 3 1821 818 277 Before/awake
2870 1048 429 Jogging/walking
70-85% peak HR
7 50-59 12 3 2601 687 265 before
2942 513 253 after
10 19-21 12 3 4862 1030 2589 Before/asleep

3152 930 1374 after


7 50-59 12 3 1225 357 342 before
1584 502 488 after

*: p<0.05
N: number of subjects, TP: total power, LF: low frequency power, HF: high frequency power
Melanson and Loimaala: values LF and HF transformed from log.

5.3 Longitudinal: effect on HRV of exercise Boutcher and Stein(167) found no change in HRV in
training of non-athletes. a group of 19 middle aged men (46.2±1.6 years of
Beneficial effects of physical training have been age) compared to an age-matched control group
reported in post-myocardial patients(163-164) and in (N=15). HRV was assessed after 24 exercise
heart transplant patients(165). Therefore it can sessions of moderate intensity exercise training
hypothesised that exercise training would be (during 8 weeks). The subjects exercised 3 times
effective in improving the autonomic balance in a each week at an intensity of 60% of heart rate,
general public while developing physical fitness as determined through baseline at maximal exercise
well. heart rate. The exercise session consisted of a 0.25
Melanson and Freedson showed influence of mile walking warm up, a series of stretches, an
exercise training on HRV parameters on a young aerobic exercise period (20 min for the first 3
(11 subjects, 25-40 years of age) male sessions, 15 for the next 3, and 30 min for 7 to 24),
population(166). The subjects performed moderate to a 0.25 mile cool down walk and a repeat of the
vigorous intensity stationary cycling on 3 days stretching. LF and HF components were obtained
each week for 30 min per session. In their study after band pass filtering of the tachogram and
they showed that a moderate-to-vigorous-intensity variance was determined in these bands. In the
endurance training program in adult, previously exercise group VO2max increased (12% absolute
sedentary men increased markers of cardiac value) after the training period, but without altering
parasympathetic activity after 12 weeks. This was HRV. These results show that a short duration and
proven by a significant increase in HF power after moderate intensity aerobic training in a middle-
training (Table 4) and a significant increase in time aged population, is insufficient to alter HRV
domain parameters related to parasympathetic parameters in that age group.
activity (pNN50 and rMSSD) as well. The same conclusion was reached by Perini et
al.(168) in a training program in an elderly
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 19

population of 7 men and 8 females (73.9±3.5 years among different studies. In one study it was even
of age). They reported no changes in HRV suggested that endurance should be practiced for a
parameters after an intense 8-week aerobic training prolonged period, even extending over many
program. However after a training program of 6 years(171) in a middle-aged population. On the other
months (3 aerobic training sessions a week lasting hand in a young population (20-22 years of age)
45 min) in an elderly population (51 older men and we have seen (Figure 5) some influence on HF of
women, 67±5.1 years of age), Schuit et al.(169) HRV after only 6 weeks of training (unpublished
found a general increase in HRV, after a training data). In most of the studies dynamic exercise is
program of 6 months (3 times a week aerobic performed, however in some studies also static
supervised training) in an elderly population (51 training is used(141). This again, if not taken into
men and women, 67.0±5.1 years of age). account, can lead to differing conclusions. A last
Theyshowed specifically that the very low and LF factor is usually the small number of subjects in
power bands, were significantly increased the training program. The effect working with
compared with a control group. Their conclusion: small numbers is to reduce the statistical power,
“In older subjects physical training may be an making it more difficult to detect differences due
effective means to modify positively a factor that is to the training. Therefore, whether age or other
associated with increased incidence of cardiac factors would modulate the effects of training on
events.”, however is questionable as LF power is HRV parameters is still unclear and is an area for
associated with arrhythmogenic activity and low further investigation.
LF in pre-menopausal women is
cardioprotective(170).
Again in a 5 month duration aerobic training
program in 83 middle aged (35-55 years of age)
men, Loimaala et al. (171) found no changes in HRV
parameters in both time and frequency domains
(Table 4). Subjects were trained 4-6 times a week
during 30 min in two different groups: 1. jogging
at a heart rate level corresponding to 55% of the
VO2max measured at baseline; 2. jogging at an heart
rate level corresponding to 75% of the VO2max
measured at baseline. Indices reflecting tonic
parasympathetic outflow (SDNN, pNN50 and HF
power) did not change significantly during the
intervention. They concluded: “exercise training
was not able to modify the cardiac parasympathetic
activity in sedentary, middle-aged persons.”
No consistent changes were observed in BRS,
although a significant reduction in heart rate was
found. The authors blame the short duration of the
training program and suggest that in order to obtain
any effect on HRV it should last for a period of a Figure 5. Top: Tachogram and power spectral
year at least(171). density of a recording in a young sedentary
Many factors affect the physiological significance subject before training (HF=812,3 ms2) and
of these studies. One of the most important is the bottom: the same subject after a 6 months
age factor, which contributes to the discrepant aerobic training program (HF=1878.4 ms2).
findings in the literature. It is well known that
HRV parameters are decreasing with ageing(170) Levy et al.(174) submitted an elderly (N=13, 60-82
(and a function of gender as well). Exercise years of age) and a younger population (N=11, 24-
training studies in young adults(172) generally report 32 years of age) to a 6 months aerobic training
increases in measures of HRV, whereas studies in program (walking, jogging and bicycling). The
middle-aged(167) and older adults(173) show no subjects trained as follows: 10 min warm up, 45
changes in cardiac autonomic function, as min exercise and 10 min cool down. Training
determined from HRV. began at 50 to 60% of heart rate reserve and
Duration and intensity of training, the accent of the increased to 80 to 85% by the 10th month. However
program even gender distribution, also vary widely HRV was only measured as SD (ms) of all normal
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 20

RR intervals during a 2 min acquisition. They 5.4 Differences due to age and gender
found an increase of this parameter of 68% in the Many studies with a large number of subjects
elderly and of 17% in the younger population. groups, have focused on the influence of age and
Their conclusion was that exercise training gender on cardiac autonomic tone (HRV
increases parasympathetic tone in both the healthy parameters)(176-177-68-178-179-180). The general
older and young men. However it has been conclusion of these studies was that: 1. ageing
proven(18), and it is a mathematical law (Parseval’s reduced the global measure of HRV, at rest, in
theorem), that SD corresponds to total power and general and of both its spectral components (LF
as such is a combination of sympathetic and of and HF) as well. Therefore this decline might
parasympathetic activity and as such, their reflect reduced responsiveness of autonomic
conclusion is wrong, or at least an overstatement. activity with age. 2. All HRV parameters, except
A contribution by each division of autonomic for HF power were higher in men and this gender
modulation to HRV is only possible when this difference was confined to the age categories less
variable is represented in the frequency domain as than 40-50 years. The lower sympathetic tone (LF)
a power spectral density graph. in women might provide protection against
Catai et al.(154) also trained an elderly (50-59 years arrhythmias and the development of coronary heart
of age) and a younger (19-24 years of age) disease.
population and reported HRV values obtained in A potential confounding effect of the menstrual
the frequency domain, awake and during sleep cycle can arise in studies that address gender
(Table 4). The training programs were conducted differences in HRV parameters. Effects of the
for 3 months on a field track and included menstrual cycle have been shown on cardiac
stretching for 10 min followed by walking and/or autonomic function as assessed by HRV
jogging for 40 min; 3 times a week at a prescribed methods(181-182-183) and even of hormonal
heart rate corresponding to 70-80% of peak heart replacement therapy in post-menopausal
(183)
rate. The authors found no significant changes in women . All studies agreed that regulation of
HRV associated with an increase in aerobic the autonomic tone is modified during menstrual
capacity induced by aerobic training. They cycle. The alteration in the balance of ovarian
concluded that resting bradycardia induced by hormones might be responsible for these changes
short-term aerobic training in both young and in the cardiac autonomic activity. Results suggest
middle-aged men is more related to intrinsic that parasympathetic nerve activity is predominant
alterations in the sinus node than to changes in in the follicular phase. Unfortunately in the few
efferent parasympathetic-sympathetic modulation. gender studies concerning young female athletes,
As they mentioned, however, the primary goal of no mention is made of timing within the menstrual
the experimental design was directed to evaluate cycle.
the cardiorespiratory adaptation in short-term This view is also supported in a study from
training: they only used two 1000 s epochs out of a Boutcher et al.(184) and confirmed by Davy et al.(185)
24 h Holter recording (awake and asleep). The and McCole et al.(113) who found that older women
training period was very short (12 weeks) with a athletes (postmenopausal women), who had
small number of subjects. habitually performed vigorous endurance training,
To conclude this paragraph it can be stated that had higher stroke volume and cardiac outputs
there are conflicting reports in the literature during maximal exercise, than their sedentary
concerning the effects of aerobic training in a postmenopausal peers. On the other hand in young
general population on HRV parameters under female athletes, similar results are found compared
resting conditions. While some studies have to their male counterparts. Pigozi et al.(186)
reported an increase in the magnitude of HRV in performed a 24-h Holter study (spectral analysis
the time domain(175), in the frequency domain with AR) in 26 highly trained female athletes
others have reported absence of modifications(167), (24.5±1.9 years). They were assigned to a 5-week
and an increase(151) or decrease(150) of aerobic training program during a yearly rest
sympathovagal balance in the sinus node. period. They concluded that from the relative
Therefore studies of aerobic training effects on night-time increase in LF and the decrease in the
HRV parameters on a previously not-trained day-night difference in time domain indexes,
(young and/or elderly) population still remain exercise training is able to induce an increase in
necessary, preferably under well controlled the sympathetic modulation of the sinus node,
conditions. coexisting with signs of reduced or unaffected
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 21

Table 5. HRV parameters in elderly athletes and age matched sedentary population
Author N Age LF HF Remarks
(years) (ms2) (ms2)
Holter 24 H
Yataco(191) 15 69±7 891* 575* athletes
14 537 102 sedentary
Banach(192) 9 52.9±7.2 1088* 920* athletes
9 52.9±7.2 220 294 sedentary
Jensen- 11 73.2±2.8 673±244 353±349 athletes/24 h Holter
Urstad(148)
12 74.5±2.7 492±290 209±172 sedentary
764±327 475±654 athletes/night
728±485 328±48 sedentary
587±250* 267±163* athletes/day
346±177 127±41 sedentary

*: p<0.05
N: number of subjects, LF: low frequency power, HF: high frequency power
Yataco: values LF and HF transformed from log

vagal modulation in this group of young female This is supported by the very few HRV studies
athletes. performed in senior athletes so far (Table 5).
A gender difference was obtained by Hedelin et Yataco et al.(191) determined the age-associated
al.(187) in junior athletes. They compared short-term decline in HRV with decreases in HRV by
HRV recordings (AR power spectrum) in 17 cross- comparing HRV parameters in older athletes
country skiers (9 females, 8 males, 16-19 years of (N=15, 69±7 years of age) with age-matched
age) before and after the competitive season. After sedentary persons (N=14, 69±4 years of age). They
the intensive training/competition season there was showed positive correlations between HRV
a general increase in HRV. No difference in resting parameters and aerobic fitness (as determined from
heart rate was found, pre- and post season. maximal treadmill exercise). Frequency analysis
However in females they found a higher level of was performed after Holter monitoring. Senior
parasympathetic activity than in males, reflected competitive athletes had increased HRV and
by a consistently higher HF and total variability. parasympathetic heart rate activity (Table 5) when
A difficulty comparing previous data is that 1. compared with their sedentary counterparts. This
training level is different, 2. training duration is work support the hypothesis that the age associated
different: short-term or long term effects, 3. decline in HRV parameters is due in part to
duration of ECG recording is different: 24 h Holter lifestyle and not solely to ageing. Similar results
recordings versus short duration ECG recordings. were shown in the study by Banach et al.(192):
In general the literature proposes three conclusions higher HRV parameters in middle-aged athletes
concerning ageing: 1.cardiovascular and compared to a sedentary population (Table 4),
cardiorespiratory function are higher in elderly indicating that the autonomic activity in sportsmen
athletes than in age comparable sedentary is not affected by ageing to the sixth decade of life.
groups(188), 2. the capacity for significant function Jensen-Urstad et al.(193) on the other hand showed
in endurance and power persists throughout life in that elderly athletes (N=11, 73.2±2.8 years of age)
trained individuals, 3. strength decreases more with a lifelong training history seem to have more
rapidly than endurance (189). complex arrhythmias and profound brady-
How do these findings in a general population arrhythmias than do healthy elderly controls,
relate to the ageing athlete? which may increase the risk of sudden cardiac
There are many physiological, structural and death. In contrast however, the age-related
psychological differences, which distinguish decrease in HRV seems also retarded as in
elderly athletes from younger ones and from a previous studies (Table 5). The latter has a positive
similar aged sedentary group, especially if still prognostic value and may decrease the risk of life
active. Regular exercise may be able to retard the threatening ventricular arrhythmias.
physiological decline(190). Results from the few HRV studies in elderly
athletes all point in the same direction: the decline
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 22

in HRV parameters associated with age is Hedelin et al.(203) investigated nine canoeists (6
overcome to some extend by sustained endurance men and 3 women, 18-23 years of age) before and
training into high age. However, more studies are after a training regimen corresponding to a 50%
needed, especially to show any beneficial effect of increase in normal training load applied during 6
lifelong regular training on quality of life and on days. Heart rates reduced (-5 to –8 bpm) both at
life expectancy. sub-maximal and maximal levels which could be
due to hypervolemia leading to increased stroke
5.5 Over-training and the autonomic nervous volume and maintenance of cardiac output with
system lower heart rates. Unlike these changes in heart
In athletic training, workloads are gradually rate, no significant differences were found in HRV
increased, thereby exceeding the previously parameters, neither when stressing the
employed workload. This ‘overload’ principle is an parasympathetic system (controlled breathing) nor
important component of modern training(194) and is when stressing the sympathetic system (tilt test: the
a positive stressor that can be quantified according subject starts in a supine position on a special bed
to load, repetition, rest and frequency(2). that and the subject is raised passively to an angle
Application of too great training stress and too of 60°). So, they concluded that these HRV data
frequent training sessions can result in exhaustion did not support an altered autonomic balance in
of a physiological system. ‘Over-training these athletes. A possible explanation could be that
syndrome’ or ‘staleness’ in athletes results from a 6 day training period has only a small effect on
long-term stress or exhaustion due to prolonged individual HRV parameters and also that group
imbalance between training and other external and differences will be difficult to determine in small
internal stressors and recovery(195-196-197). groups. A case study of the same authors(204) in a
It is well known that over-training causes cross-country skier, showed a relative
hormonal imbalance(198-199) in athletes. Due to these parasympathetic dominance when the athlete was
hormonal changes, over-training will lead to an over-trained.
autonomic imbalance(200-201-202). In which way the We suggest that it is impossible to find group
autonomic nervous system changes changes in HRV because of the two types of over-
(parasympathetic versus sympathetic) is still training. Individual HRV, however, can change
controversial. From a clinical standpoint, Israel(201) due to over-training. These hypotheses were
distinguished between a parasympathetic type or confirmed by Uusitalo et al.(205) who investigated
vagal type (Addison type) over-training syndrome HRV and BPV of young female athletes during 6-9
and a sympathetic type (Basedow type). The two weeks of training period. They compared a high
types of over-training were the consequence of an intensity training group (4 long distance runners, 1
imbalance between training and rest periods, but it cross country skier, 2 triathletes, 1 orienteer), with
was expected that a sympathetic type over-training a low intensity training group (1 long distance
syndrome might rather be the consequence of too runner, 3 cross country skiers, 1 triathlete, 1
much accompanying psycho-emotional stress, such orienteer). The purpose of the experimental
as too many competitions and too many non- training period was to over-train this group after a
training stress factors (social, educational, period of 6 to 9 weeks. Heavy endurance training
nutritional,…)(200). Kuipers (198) hypothesized that seemed to induce a significant (Table 6) increase in
during the early stage of the over-training LF of HRV during supine position, but not in the
syndrome, the sympathetic system was low intensity training group. In many subjects the
continuously altered, whereas during advanced changes in supine and standing heart rate
over-training the activity of the sympathetic system variability seemed to be rather contrary. Since
was inhibited, resulting in a marked dominance of there were no large uniform findings in the over-
the parasympathetic system. trained athletes the authors looked also at
The cardiac autonomic imbalance observed in individual results during a tilt-test. Increased as
over-trained athletes implies changes in HRV and well as decreased changes due to upright tilt were
therefore would suggest that heart rate variability found in the over-trained athletes compared to their
could provide useful parameters to detect over- values in the normal training state. This is a sign of
training in athletes. Despite these expectations, either increased or decreased ability to increase
little is known about changes in heart rate sympathetic discharge during standing and
variability due to over-training and only a few corresponds to the two over-training types.
studies are available (Table 6). However, the changes were not specific to over-
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 23

Table 6. Effect of over-training on HRV parameters


Author N Age TP LF HF Remarks
(years) (ms2) (ms2) (ms2)

Hedelin(204) 9 18-23 3.71±0.29 2.9±0.57 3.4±0.27 control


3.66±0.26 2.77±0.29 3.36±0.43 Over-trained

Uusitalo(205-212) 6 19-27 5100±900 800±200 2800±700 control


8600±3700 700±200 5600±3200 light training
9 20-27 5500±100 600±100 2700±600 control
5500±1200 900±200* 2900±700 Over-training
N: number of subjects, TP: total power, LF: low frequency power, HF: high frequency power
Values from Hedelin have been log transformed, mean ±SD, *: p<0.05
Values from Uusitalo: absolute values mean ±SEM

training because there also were similar changes in variability studies in athletes are still an almost
the not over-trained athletes. unexplored domain. Much work still needs to be
Portier et al.(206) tested 8 runners twice : after a done to advance in understanding of the action of
relative rest period of 3 weeks and after a 12 week the autonomic nervous system in athletes as a
intense training period for endurance and each time function of athletic discipline, age, gender,
determined HRV parameters. Although the athletes intensity and duration of training, detraining and
were not trained until over-training, they over-training effects, comparison with sedentary
concluded that spectral analysis could be a means population, and so on.
of demonstrating impairment of autonomic balance Another key issue is that almost no studies are
for the purpose of detecting a state of fatigue that available as a longitudinal section for the follow-
could result in over-training. Pichot et al.(207) came up of athletes during ageing, as well as very few
to similar conclusions. They assessed ANS activity studies about active elderly athletes.
in 7 middle distance runners (24.6±4.8 years) For further studies it is recommended to apply
during their training cycle: 3 weeks heavy training, standardized conditions: 1. selection of subjects:
followed by a relative resting week. HRV was age, gender, training or physical fitness level,
analysed using FFT and wavelet transform. Their athletic discipline and accent on aerobic or
results confirmed that heavy training shifted the anaerobic training; 2. measurements: minimal
cardiac autonomic balance of the sympathetic over number of parameters proposed: ECG, (non-
the parasympathetic drive. Night–time results of invasive) blood pressure, eventually respiration; 3.
HRV parameters proved a good tool to estimate measurements at rest with a minimum of 10
cumulated physical fatigue. Therefore they minutes supine and 10 minutes standing, to
concluded that HRV could be valuable for activate the sympatho-vagal balance, eventually
optimizing individual training profiles. breathing at different fixed frequencies, to activate
Concerning the use of HRV methods during over- primarily the parasympathetic system, 24 h Holter
training in athletes, no definite conclusions can be monitoring when day to night separation is needed
reached as only very few studies are available, for circadian pattern detection; 4. measurements
even so with conflicting results. It remains to be during exercise: either with adapted trend removal
proven that the autonomic imbalance observed in or else at constant work levels in order to have
over-trained athletes, manifests itself from HRV stationary signals.
indices. For interpretation of the data in as well time as
frequency domain the use of the guidelines(24) are
recommended in order to be able to compare
6. Conclusions different studies.
Innumerable studies have been published It is strongly suggested that, when presenting
concerning training in general (computer search on reports on HRV studies related to exercise
the keyword “training” results in 409395 hits) physiology in general or concerned with athletes, a
concerning physical and physiological condition of detailed description should be provided on analysis
athletes. However, only very few papers are methods, as well as concerning population, training
dealing with studies of HRV regarding applications schedule, intensity and duration. Only with such
in athletics (117 hits). Therefore, cardiovascular information will it be possible to understand and
Heart rate variability in athletes. AE Aubert, B Seps and F Beckers. Sports Medicine 33(12):889-919, 2003 24

evaluate conclusions drawn and compare results We thank Bart Verheyden for his suggestions and
with other studies. As until now this is not the case for carefully reading the manuscript.
in most studies on HRV in athletes as found in the
literature, it is only possible to make general References
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