Identification and management of the hypertensive patient with elevated heart rate: statement of a European Society of Hypertension Consensus Meeting

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IntroductionAlthough the association between elevated resting heart rate and cardiovascular morbidity and mortality has been demonstrated in a large number of epidemiologic studies, elevated heart rate is not yet considered to be a risk factor for cardiovascular disease. This is mainly due to the lack of studies demonstrating that reduction of high heart rate in non-cardiac patients can improve prognosis. Other reasons for this concern are the lack of standard methods for assessing resting heart rate and defining high heart rate by a reasonable, agreed cut-off. To fill this gap, these and other issues were reviewed and discussed by stakeholders in a consensus meeting in Padova, Italy, sponsored by the European Society of Hypertension, on 23 June 2005. The consensus panel reviewed and evaluated the available evidence to make recommendations for further studies. Specific objectives of the consensus panel were to develop methodological standards for the assessment of resting heart rate and to give an answer to a number of open questions on the clinical significance of resting heart rate. An extensive literature review, a consistent part of which is cited here, was used to provide scientific evidence supporting the panel's consensus statements. The final preparation and modifications of the consensus study were made by electronic communication. The final recommendations were approved by unanimous consensus of the panel.Are data on prognostic importance of heart rate consistent?The first study to report an association between fast heart rate and cardiovascular disease was published in the USA in the 1940s [1]. Thereafter, a relationship between heart rate and coronary heart disease was shown in the 1970s in a study by Medalie et al. [2] in male government employees and in the Glostrup County study [3]. In the 1980s, large epidemiologic studies (the Chicago and the Framingham studies) found a significant association between heart rate and cardiovascular or total mortality [4–6]. More recently, in 1993, further Framingham study data showed that, in hypertensive subjects, heart rate was independently associated with all-cause mortality, cardiovascular mortality, or coronary heart disease mortality [7]. A noticeable increase in the awareness of the association between tachycardia and cardiovascular mortality took place in the late 1990s, when a number of studies in general populations confirmed those previous observations showing a positive relationship between resting heart rate and either all-cause or cardiovascular mortality [8–19]. In several studies, the role of heart rate on cardiovascular mortality persisted after excluding deaths occurring during the first years of follow-up, ruling out the hypothesis that heart rate was just an indicator of underlying chronic disease [7,15]. A thorough review of the literature showed that 43 articles, encompassing the results of 39 studies, had been published on the prognostic significance of elevated heart rate for cardiovascular and/or all-cause mortality [4–46]. For men, all but two papers reported a significant association between all-cause mortality and fast heart rate. One of these two studies was performed in a small sample of elderly subjects and reported negative data in men also for cardiovascular mortality. However, in that study, the heart rate–mortality relationship was significant among women [30]. After adjustment for confounders, three other studies failed to reach the level of statistical significance for cardiovascular mortality [6,9,18]. In most studies of resting heart rate, subjects were divided according to quartiles [33,39] or quintiles [5,6,18,25,32,35,40,44] of heart rate and fast heart rate was identified from the lower limit of the top heart rate fractile. This limit ranged from 75 to 89 in non-elderly populations [5,6,18,25,32,35,39,40,44] and from 74 to 84 in elderly persons [15,22,23,30,33].

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