Clinical Endocrinology (2008) 68, 88–93 doi: 10.1111/j.1365-2265.2007.03004.

ORIGINAL ARTICLE

Abnormal heart rate recovery after maximal cardiopulmonary

Blackwell Publishing Ltd

exercise stress testing in young overweight women with

polycystic ovary syndrome
Francesco Giallauria*, Stefano Palomba†, Francesco Manguso§, Alessandra Vitelli*, Luigi Maresca*,
Domenico Tafuri¶, Gaetano Lombardi‡, Annamaria Colao‡, Carlo Vigorito* and Francesco Orio‡,**

*Department of Clinical Medicine, Cardiovascular and Immunological Sciences, Cardiac Rehabilitation Unit, University
‘Federico II’ of Naples, Naples, †Unit of Reproductive Medicine and Surgery, ‘Magna Graecia’ University of Catanzaro,
Catanzaro, ‡Department of Molecular & Clinical Endocrinology and Oncology, and §Department of Clinical and Experimental
Medicine, Gastroenterology Unit, University ‘Federico II’ of Naples, Naples, ¶Chair of Methods and Teaching of Sportive Activity,
Faculty of Exercise Sciences and **Department of Endocrinology, Faculty of Motor Science, University ‘Parthenope’ of Naples,
Naples, Italy

Summary
Objective Heart rate recovery (HRR) is a measure derived from
exercise test, defined as the fall in heart rate during the first minute
after maximal exercise. Abnormal HRR is a measure of autonomic
dysfunction associated with an increased mortality. This study was
performed to evaluate the HRR in polycystic ovary syndrome (PCOS).
Design Prospective controlled clinical study.
Patients Seventy-five PCOS women compared to 75 healthy women
matched for age (21·7 ± 2·1 years vs. 21·9 ± 1·8 years, respectively)
and body mass index (BMI) (29·0 ± 2·6 kg/m2 vs. 29·1 ± 2·9 kg/m2,
respectively).
Measurements Subjects were studied for their hormonal and
metabolic profile, and underwent cardiopulmonary exercise test (CPX).
Results PCOS women showed a significantly reduced HRR
(12·9 ± 1·8 vs. 20·4 ± 3·1 beats/min, P < 0·001) compared to healthy
controls, an impairment in maximal oxygen consumption
(18·0 ± 2·3 ml/kg/min vs. 29·3 ± 3·9 ml/kg/min) and in oxygen
consumption at anaerobic threshold (13·6 ± 2·6 ml/kg/min vs.
24·2 ± 3·0 ml/kg/min). In PCOS women, abnormal HRR was
inversely correlated to BMI (r = −0·582, P < 0·001) and to the area
under the curve for insulin (r = −0·596, P < 0·001).
Conclusions Our data demonstrate an abnormal HRR after
maximal CPX in young overweight PCOS patients, and that HRR
should be investigated as a further potential marker of increased
cardiovascular risk in PCOS.
(Received 2 April 2007; returned for revision 22 April 2007; finally
revised 24 May 2007; accepted 22 June 2007)
Correspondence: Francesco Orio, Faculty of Exercise Sciences, University of
Naples ‘Parthenope’, Naples and Department of Molecular & Clinical
Endocrinology and Oncology, University of Naples ‘Federico II’, Via S.
Pansini 5, 80131 Naples, Italy. Tel: +39 3477676883; Fax: +39 0892574878;
E-mail: francescoorio@virgilio.it
Introduction
Polycystic ovary syndrome (PCOS) is a relatively common
endocrine-metabolic disorder predominantly characterized by
chronic anovulation, hyperandrogenism and insulin-resistance
(IR).1,2
Heart rate recovery (HRR) is an easily obtained measure derived
from exercise stress testing and is defined as the fall in heart rate
during the first minute after maximal exercise.3 HRR is a marker of
autonomic function and is directly correlated to parasympathetic
activity. Abnormal HRR is an independent cardiovascular risk
(CVR) factor4 and a powerful predictor of all-cause mortality in
patients with or without coronary artery disease.5–8
PCOS is a multifaceted syndrome associated with a wide range of
cardiovascular risk (CVR) factors including dyslipidaemia, hyper-
tension, glucose intolerance and diabetes.9 Although IR is not a key
factor to diagnose PCOS,10 it is clearly documented that subjects
affected by this syndrome are more insulin resistant than healthy
women, even taking into account body weight.2
Moreover, in a large cohort of PCOS women, we recently
documented an IR-related impairment of cardiopulmonary
functional capacity compared to age- and body mass index (BMI)-
matched healthy women.11
Even if no increased mortality for cardiovascular disease (CVD)
has yet been demonstrated in PCOS,12 several observations suggest
that subjects affected by this syndrome show a complex mixture of
risk factors that may predispose to an elevated CVR.13–15
Abnormal autonomic function as evaluated by HRR is strongly
associated with elevated fasting plasma glucose levels16 and with
diabetes.17 It has also been reported that in diabetic patients, an
abnormal HRR was independently predictive of cardiovascular and
all-cause deaths.18
To date, there are no data available regarding autonomic function
assessment in PCOS. Therefore, this study was aimed at evaluating
autonomic function as determined by end-exercise HRR in PCOS
patients compared to healthy young controls.

© 2007 The Authors

88 Journal compilation © 2007 Blackwell Publishing Ltd

Subjects and methods
Subjects
Seventy-five consecutive young nonsmoking PCOS patients were
enrolled in the study protocol. All the PCOS patients achieved the
European Society for Human Reproduction and Embryology/
American Society for Reproductive Medicine criteria for the
diagnosis of PCOS.2
Polycystic ovaries were identified by transvaginal (TV) or pelvic
ultrasonography (USG) examination and hirsutism by Ferriman-
Gallwey (FG) score > 8 and an elevated total testosterone (normal
range < 2·0 nmol/l) levels.
Exclusion criteria included pregnancy, glucose intolerance [as
screened by a 2-h oral glucose tolerance test (OGTT)] and diabetes,
hypothyroidism, hyperprolactinaemia, Cushing’s syndrome,
nonclassical congenital adrenal hyperplasia, and use of oral con-
traceptives, glucocorticoids, antiandrogens, ovulation induction
agents, and antipsychotic, antidiabetic or antiobesity drugs, or other
hormonal drugs within the previous 6 months. Subjects with
neoplastic, hepatic, respiratory and any cardiovascular disorder or
other concurrent medical illness (i.e. heart failure, lung or renal
disease) were also excluded from the study.
Another 75 healthy age- and BMI-matched women acted as controls.
Each control was defined as age- and BMI-matched with PCOS case
when the differences between the case and control was < 2 years and
< 1 kg/m2 for age and BMI, respectively. The healthy state of the
controls was determined by medical history, physical and pelvic
examination, and complete blood chemistry. Their normal ovula-
tory state was confirmed by transvaginal ultrasonography (TV-USG)
and plasma progesterone (P) assay. Both procedures were performed
during the luteal phase of the menstrual cycle (7 days before the
expected menses). The presence of fluid in the cul-de-sac at TV-USG
and a plasma P assay greater than 31·8 nmol/l (> 10 ng/ml) were
considered criteria for ovulation having occurred.19
None of the subjects (PCOS and controls) drank alcoholic
beverages.
Study protocol
A common core of assessments was performed at enrolment: blood
sampling for a hormonal assessment, lipid profile, and fasting
glucose and insulin levels (see below). During the same visit, all
subjects underwent cardiovascular and endocrinological examination,
12-lead electrocardiography, TV-USG, cardiopulmonary exercise
test (CPX), anthropometric measurements such as height, weight,
BMI (ratio between the weight and the square of the height) and
waist to hip ratio (WHR, ratio between the smallest circumference
at the torso and the widest circumference at the hip), and completed
a leisure-time physical activity (LTPA) questionnaire (No, Low,
Moderate, High).20
All clinical assessments were performed by the same physician
who was blinded to the patient condition. All study procedures were
completed under the same conditions.
The study was conducted according to the guidelines of the
Declaration of Helsinki, and the Institutional Ethical Committee of
© 2007 The Authors
Journal compilation © 2007 Blackwell Publishing Ltd, Clinical Endocrinology, 68, 88–93
Heart rate recovery in PCOS 89
the University of Naples ‘Federico II’ approved the study protocol.
The purpose of the protocol was explained to each subject, and written
informed consent was obtained from each patient before the start
of the study.
Biochemical assays
All blood samples were obtained in the morning between 08·00 h
and 09·00 h after an overnight fasting during the early follicular
phase (2nd–4th day) of progesterone (P)-induced menstrual cycle.
Blood samples were collected into tubes containing EDTA after a
30-min resting period in the supine position. All blood samples were
immediately centrifuged at 4 °C for 20 min at 1600 g and stored at
–20 °C until assayed.
Plasma LH, FSH, prolactin (PRL), oestradiol (E2), P, 17α-
hydroxyprogesterone (17-OH-P), T, androstenedione (A) and
DHEAS levels were measured by specific radioimmunoassays (RIA)
as previously described.13,14 The levels of SHBG were measured using
an immunoradiometric assay (IRMA)7,8 and the free androgen index
was calculated [T (nmol/l)/SHBG (nmol/l) × 100]. Blood insulin
and glucose levels were measured by a solid-phase chemiluminescent
enzyme immunoassay and the glucose oxidase method, respectively.13,14
The glucose and insulin area under curve (AUC), and the AUCGLU/
21
AUCINS ratio in response to the OGTT were also calculated.
Haemochrome analysis was performed according to standard
evaluation. C-reactive protein (CRP) was measured as recently
described.22
Cardiopulmonary exercise test
PCOS and healthy control women underwent a symptom-limited
CPX with Bruce treadmill protocol.23 Heart rate and blood pressure
at baseline and peak exercise, heart rate 1 min into a walking
cool-down period (1·7 mph at 0% grade), and treadmill speed and
grade at peak exercise were recorded.
HRR was calculated as the difference between heart rate at peak
exercise and heart rate after the first minute (HRR) of the cool-down
period. Abnormal HRR was defined as ≤ 18 beats/min3 for standard
exercise testing.
Both PCOS and healthy women underwent two cardiopulmonary
exercise stress tests at maximal interval of 3 days and in the same
conditions. Short-term test-retest concordance of HRR values was
assessed for individual patients. The coefficient of variation (CV)
between test-retest HRR values was less than 5%. Respiratory gas
exchange measurements were obtained breath-by-breath with use of
a computerized metabolic cart (Vmax 29C, Sensormedics, Yorba
Linda, CA) as previously described.24
Statistical analysis
2
Pearson χ -test was used for categorical data. Continuous data are
expressed as mean ± SD. The unpaired Student’s t-test was used to
compare the two groups. Bivariate correlations computing Pearson’s
coefficient with their significance levels were calculated between
HRR and other variables. In PCOS women as well as in controls,
multiple linear regression analysis (stepwise method) was performed
90 F. Giallauria et al.

Table 1. Clinical and hormonal profile in polycystic ovary syndrome (PCOS) Table 2. Anthropometrical, metabolic and cardiovascular risk profile of
women and healthy controls polycystic ovary syndrome (PCOS) women and healthy controls

PCOS Controls PCOS Controls

(N = 75) (N = 75) P-value (N = 75) (N = 75) P-value

Age (years) 21·7 ± 2·1 21·9 ± 1·8 0·503 Fasting glucose (mmol/l) 5·18 ± 0·30 5·25 ± 0·34 0·226
BMI (kg/m2) 29·0 ± 2·6 29·1 ± 2·9 0·753 Fasting insulin (mU/l) 19·8 ± 3·3 12·3 ± 2·1 < 0·001
WHR 0·87 ± 0·3 0·85 ± 0·2 0·599 AUCGLU 12 001 ± 2166 11 687 ± 1786 0·290
Ferriman-Gallwey score 13·1 ± 4·1 4·2 ± 1·3 < 0·001 AUCINS 16 661 ± 837 3748 ± 240 < 0·001
FSH (IU/l) 11·5 ± 4·9 11·0 ± 4·7 0·499 AUCGLU/AUCINS ratio 0·72 ± 0·1 3·1 ± 0·5 < 0·001
LH (IU/l) 25·8 ± 8·5 12·8 ± 10·7 < 0·001 CRP (mg/l) 1·81 ± 0·7 0·61 ± 0·3 < 0·001
PRL (mU/l) 216 ± 50 206 ± 34 0·118 Hb (g/dl) 13·3 ± 0·8 13·1 ± 1·0 0·603
E2 (pmol/l) 122·8 ± 69·7 117·9 ± 49·3 0·595
P (nmol/l) 1·4 ± 0·3 1·9 ± 0·4 < 0·001 Data expressed as mean ± standard deviation.
17-OHP (nmol/l) 1·8 ± 0·7 0·9 ± 0·5 < 0·001 AUCGLU, area under curve for glucose; AUCINS, area under curve for insulin;
T (nmol/l) 2·5 ± 1·0 0·8 ± 0·7 < 0·001 AUCGLU/AUCINS, glucose/insulin area under curve ratio; BMI, body mass
A (nmol/l) 5·7 ± 2·8 1·8 ± 0·5 < 0·001 index; CRP, C-reactive protein; Hb, haemoglobin.
DHEAS (μmol/l) 4209 ± 985 2867 ± 754 < 0·001
SHBG (nmol/l) 25·0 ± 6·8 38·7 ± 5·4 < 0·001
FAI 9·8 ± 4·8 2·3 ± 1·0 < 0·001 Table 3. Cardiopulmonary exercise test parameters in polycystic ovary
syndrome (PCOS) women and healthy controls
Data expressed as mean ± standard deviation.
A, androstenedione; BMI, body mass index; DHEAS, PCOS Controls
dehydroepiandrosterone sulphate; E2, oestradiol; FAI, free androgen index; (N = 75) (N = 75) P-value
PRL, prolactin (1 μg/l = 20 mU/l); T, testosterone; WHR, waist to hip ratio;
17-OHP, 17-hydroxyprogesterone.
VO2max (ml/kg/min) 18·0 ± 2·3 29·3 ± 3·9 < 0·001
VO2AT (ml/kg/min) 13·6 ± 2·6 24·2 ± 3·0 < 0·001
VE/VCO2slope 28·2 ± 4·7 28·6 ± 5·4 0·594
to test a relationship between HRR as dependent variable and age, RER 1·08 ± 0·04 1·09 ± 0·06 0·810
HRrest (beats/min) 77·4 ± 4·9 77·5 ± 4·3 0·872
BMI, VO2max, AUCINS, AUCGLU/AUCINS ratio as independent
HRpeak (beats/min) 146·3 ± 13·7 147·4 ± 13·8 0·582
variables. Moreover, we performed another multiple linear regression
SBPrest (mmHg) 118·9 ± 9·6 120·8 ± 8·4 0·147
analysis (stepwise method) pooling the data of PCOS and control SBPpeak (mmHg) 166·6 ± 8·2 167·5 ± 8·8 0·459
subjects using HRR as dependent variable and age, BMI, VO2max, DBPrest (mmHg) 76·1 ± 4·7 75·7 ± 4·9 0·494
AUCINS, and AUCGLU/AUCINS ratio, together with PCOS as a factorial DBPpeak (mmHg) 85·3 ± 4·1 85·8 ± 3·6 0·422
variable (Controls/PCOS coded 0/1). In assessing the suitability of HRR (beats/min) 12·9 ± 1·8 20·4 ± 3·1 < 0·001
the data for linear regression models, the collinearity diagnostics
were evaluated. All tests of significance were two-sided. A P- Data expressed as mean ± standard deviation.
value ≤ 0·05 was considered as significant. SPSS software for DBPpeak, diastolic blood pressure at peak exercise; DBPrest, diastolic blood
pressure at rest; VO2max, maximal oxygen consumption; VO2AT, oxygen
Windows (release 15·0·0, SPSS Inc, Chicago, IL) was used for
consumption at anaerobic threshold; VE, ventilation; VCO2, carbon dioxide
statistical analysis. production (l/min); RER, respiratory exchange ratio; HRrest, heart rate at rest;
HRpeak, heart rate at peak exercise; SBPrest, systolic blood pressure at rest;
SBPpeak, systolic blood pressure at peak exercise; HRR, heart rate recovery at
Results the first minute after maximal exercise.
Clinical and hormonal profiles of the study population are presented
in Table 1. The groups were closely matched for age and BMI. All
PCOS patients showed a significant difference (P < 0·001) in FG concentrations were significantly increased (P < 0·001) in PCOS
score LH, P, 17OH-P, T, A, DHEA-S, SHBG and FAI when compared women compared to the control group.
to the control group (Table 1). Baseline cardiopulmonary exercise stress test parameters are
All PCOS patients (100%) showed polycystic ovaries and summarized in Table 3.
anovulation, 66 (88%) had clinical and 51 (68%) biochemical In PCOS women, we observed a significant impairment in VO2max
hyperandrogenism. (18·0 ± 2·3 ml/kg/min vs. 29·3 ± 3·9 ml/kg/min, P < 0·001) and
Anthropometrical, metabolic and CVR profiles of PCOS and VO2AT (13·6 ± 2·6 ml/kg/min vs. 24·2 ± 3·0 ml/kg/min) and an
control groups are summarized in Table 2. No difference was abnormal HRR (12·9 ± 1·8 beats/min vs. 20·4 ± 3·1 beats/min)
detected in fasting glucose and AUCGLU whereas fasting insulin levels compared to the healthy control group. In PCOS women, abnormal
and AUCINS were significantly higher (P < 0·001) in PCOS than control HRR is inversely correlated to BMI (r = −0·582, P < 0·001) (Fig. 1)
women (Table 2). AUCGLU/AUCINS ratio was also significantly lower and to AUCINS (r = −0·596, P < 0·001) (Fig. 2). No significant difference
(P < 0·001) in PCOS women compared to the control group. CRP was observed in resting and peak exercise heart rate (HR), systolic

© 2007 The Authors

Journal compilation © 2007 Blackwell Publishing Ltd, Clinical Endocrinology, 68, 88–93

Fig. 1 Correlation between baseline values of body mass index (BMI) and
heart rate recovery (HRR) in young polycystic ovary syndrome (PCOS)
women.
Fig. 2 Correlation between baseline values of the area under the curve for
insulin (AUCINS) and heart rate recovery (HRR) in young polycystic ovary
syndrome (PCOS) women.
blood pressure (SBP) and diastolic blood pressure (DBP) between
PCOS and control group (Table 3).
In PCOS patients, multiple linear regression analysis showed a
significant inverse relationship between HRR, our dependent variable
and BMI [unstandardized coefficient (B) ± SE, –0·057 ± 0·018,
standardized coefficient (β) –0·087, P = 0·002], AUCINS (B
0·000 ± 0·000, β –0·137, P < 0·001), and a direct relationship with
VO2max (B 0·121 ± 0·051, β 0·156, P = 0·02) and AUCGLU/AUCINS
ratio (B 10·239 ± 1·052, β 0·698, P < 0·001), with a constant of 9·805.
No other parameter showed a relationship to HRR. Pooling together
data from PCOS and control subjects, multiple linear regression
analysis showed a significant inverse relationship between HRR and
AUCINS (B –0·001 ± 0·000, β –1·371, P = 0·003) and a direct relation-
ship with VO2max (B 0·162 ± 0·059, β 0·228, P = 0·007), AUCGLU/
AUCINS ratio (B 1·301 ± 0·531, β 0·359, P = 0·015) and PCOS status
(B 9·642 ± 3·907, β 1·069, P = 0·015), with a constant of 15·243.
No significant differences between PCOS patients and healthy
controls were observed in LTPA level (Table 4).
© 2007 The Authors
Journal compilation © 2007 Blackwell Publishing Ltd, Clinical Endocrinology, 68, 88–93
Heart rate recovery in PCOS 91
Table 4. Leisure time physical activity (LTPA) levels in polycystic ovary
syndrome (PCOS) women and healthy controls
PCOS Controls
(N = 75) (N = 75) P-value
LTPA, N (%) 0·979
No 26 (35) 26 (35)
Low 22 (29) 24 (32)
Moderate 20 (27) 19 (25)
High 7 (9) 6 (8)
Discussion
The rapid deceleration of heart rate immediately following exercise
is regulated by various intrinsic, neural and humoral factors.
However, autonomic nervous system responses, in particular
parasympathetic reactivation, are a major determinant of HRR.25,26
Slower HRR may therefore be indicative of decreased parasympathetic
responsiveness.27
In healthy subjects, HRR has been shown to be inversely associated
to IR and other risk factors that tend to cluster with IR, such as BMI,
abdominal obesity, low HDL-cholesterol28 and triglyceride/
HDL-cholesterol ratio.29
Although IR is not a criterion to diagnose PCOS,2 it is well
known30 that PCOS subjects are more insulin resistant than healthy
women independently of their body weight. In the present study,
an abnormal HRR is shown in PCOS patients when compared to
healthy controls and this alteration is significantly correlated to BMI
and markers of IR, suggesting a close and complex relationship
between autonomic function and glucose metabolism in young
overweight PCOS women. Furthermore, PCOS is probably only
linked to HRR via IR.
This study also highlights the cardiopulmonary impairment
observed in young PCOS women.11,24 Maximal oxygen consumption
represents a validated index for assessing cardiovascular functional
capacity31 and it is also considered a strong determinant of the
insulin sensitivity index in both men and women.32
Abnormal HRR following exercise has been linked to the Metabolic
Syndrome and to several of its components in cross-sectional
studies.16,28,29,33,34 Recently, Kizilbash et al.35 observed that abnormal
HRR does not precede development of the Metabolic Syndrome,
but appears after syndrome components are present, probably playing
a role in increasing cardiovascular diseases (CVD) morbidity and
mortality.
Our data suggest that IR leads to a reduced cardiopulmonary
functional capacity (as expressed by a reduced VO2max) and to
autonomic dysfunction (as expressed by an abnormal HRR) that
may be responsible for the increased CVR profile in PCOS women.
In women referred for cardiac rehabilitation, Kavanagh et al.36
reported that oxygen consumption was a strong independent
predictor of cardiac mortality and that each increase of 1 ml/kg/min
of initial maximal oxygen consumption was associated with a 10%
lower cardiac mortality. Although these results refer to women with
proven coronary artery disease, the study have confirmed the
92 F. Giallauria et al.
powerful prognostic significance of maximal oxygen consumption
also in subjects of both sexes without CVD.37 Therefore, we believe
that these results can be extended also to our young PCOS women
if we take into consideration their long-term risk.
Abnormal HRR also represents a powerful independent predictor
of cardiovascular and all-cause mortality in healthy adults.12–15
Therefore, it appears that the abnormal HRR after maximal exercise
could be used as an outcome tool that could help to identify patients
at increased risk for cardiovascular event.
Further studies will be necessary to extend our results to a larger
and older PCOS women population and long-term follow-up studies
are required in order to evaluate if an improvement of autonomic
function per se and/or cardiopulmonary function could represent a
protective factor for reducing CVR in PCOS women. Moreover,
adding data on visceral fat mass [i.e. dual energy X-ray absorptiometry
(DEXA) measurements] might help to explain the marked differences
in VO2max and HRR in PCOS.
In conclusion, PCOS seems to be characterized by several
alterations that could increase the risk for CVD. Among these factors,
cardiopulmonary impairment and abnormal HRR should be
considered as further markers of cardiovascular risk.
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