Heart Rate Turbulence: Standards of Measurement, Physiological Interpretation, and Clinical Use
Open accessAbstract
This consensus statement has been compiled on behalf of the International Society for Holter and Noninvasive Electrophysiology. It reviews the topic of heart rate turbulence (HRT) and concentrates on technologies for measurement, physiologic background and interpretation, and clinical use of HRT. It also lists suggestions for future research. The phenomenon of HRT refers to sinus rhythm cycle-length perturbations after isolated premature ventricular complexes. The physiologic pattern of HRT consists of brief heart rate acceleration (quantified by the so-called turbulence onset) followed by more gradual heart rate deceleration (quantified by the so-called turbulence slope) before the rate returns to a pre-ectopic level. Available physiologic investigations confirm that the initial heart rate acceleration is triggered by transient vagal inhibition in response to the missed baroreflex afferent input caused by hemodynamically inefficient ventricular contraction. A sympathetically mediated overshoot of arterial pressure is responsible for the subsequent heart rate deceleration through vagal recruitment. Hence, the HRT pattern is blunted in patients with reduced baroreflex. The HRT pattern is influenced by a number of factors, provocations, treatments, and pathologies reviewed in this consensus. As HRT measurement provides an indirect assessment of baroreflex, it is useful in those clinical situations that benefit from baroreflex evaluation. The HRT evaluation has thus been found appropriate in risk stratification after acute myocardial infarction, risk prediction, and monitoring of disease progression in heart failure, as well as in several other pathologies.
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Clinical and ECG covariates such as age, LVEF, NYHA class, heart rate, number of PVCs, pharmacotherapy, and invasive therapeutic strategies influence HRT results.
“Clinical and ECG covariates such as age, LVEF, NYHA class, heart rate, number of PVCs, pharmacotherapy, and invasive therapeutic strategies influence HRT results (Bauer et al., 2008;Cygankiewicz, 2013).”
From 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry (2017) · cites this paper as Bauer et al., 2008
The Physiologic Background section says increasing age is associated with decreased HRT and that LVEF significantly influences its measures. The Modifications of HRT by specific interventions section reports effects of medications, coronary reperfusion, and bypass surgery. The copy does not establish in its discussion that NYHA class or baseline heart rate changes HRT results; it discusses PVC number as a requirement for reliable measurement rather than as a demonstrated influence on HRT itself (page numbers unavailable). (LLM, conf=0.85)
Experimental — accuracy not yet measuredAbnormal HRT parameters have been documented in various subsets of patients following myocardial infarction, or patients with heart failure or other cardiac and noncardiac diseases such as diabetes, obstructive sleep apnea, or connective tissue diseases.
“Abnormal HRT parameters have been documented in various subsets of patients following myocardial infarction, or patients with heart failure or other cardiac and noncardiac diseases such as diabetes, obstructive sleep apnea, or connective tissue diseases (Barthel et al., 2003;Bauer et al., 2008;Cygankiewicz et al., 2008;Exner et al., 2007;Huikuri et al., 2009;Schmidt et al., 1999).”
From 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry (2017) · cites this paper as Bauer et al., 2008
The Clinical Use of HRT section reports abnormal HRT after myocardial infarction and in patients with heart failure and diabetes. It also reports abnormal TO and TS during obstructive sleep apnea episodes. The passages do not document abnormal HRT in connective tissue diseases, so that part of the sentence is not supported by this source. (LLM, conf=0.86)
Experimental — accuracy not yet measuredAbnormal HRT seems to be particularly useful in identifying high-risk patients among those with LVEF >30% and is frequently evaluated in risk scores that combine assessment of arrhythmogenic substrate, repolarization instability, and abnormal autonomic nervous system tone.
“Abnormal HRT seems to be particularly useful in identifying high-risk patients among those with LVEF .30%(Bauer et al., 2008;Cygankiewicz et al., 2009;La Rovere et al., 2012) and is frequently evaluated in risk scores that combine assessment of arrhythmogenic substrate (low LVEF), repolarization instability (e.g., TWA), and abnormal autonomic nervous system tone (HRV).”
From 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry (2017) · cites this paper as Bauer et al., 2008
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Experimental — accuracy not yet measuredHeart rate turbulence analyzes the baroreceptor-mediated response of the sinus node to premature ventricular beats composed of an early acceleration and subsequent deceleration and is an indicator of baroreceptor sensitivity.
“Heart rate turbulence analyzes the baroreceptor-mediated response of the sinus node to premature ventricular beats composed of an early acceleration and subsequent deceleration and is an indicator of baroreceptor sensitivity (Schmidt et al., 1999;Bauer et al., 2008).”
From 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry (2017) · cites this paper as Bauer et al., 2008
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- Authors
- Bauer, A., Malik, M., Schmidt, G., Barthel, P., Bonnemeier, H., Cygankiewicz, I., Guzik, P., Lombardi, F., Müller, A., Oto, A., Schneider, R., Watanabe, M., Wichterle, D., & Zareba, W.
- Affiliations
- Deutsches Herzzentrum München (DE)
- University of Lübeck (DE)
- University of Rochester Medicine (US)
- University of Milan (IT)
- Hacettepe University (TR)
- Saint Louis University (US)
- Charles University (CZ)
- ORCID
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2008-10
- Volume
- 52
- Issue
- 17
- Pages
- 1353-1365
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W2004025317
- Cited by
- 462
- References
- 284
- Citations by year
- 2026: 12 · 2025: 15 · 2024: 14 · 2023: 17 · 2022: 20 · 2021: 17 · 2020: 26 · 2019: 20 · 2018: 20 · 2017: 46 · 2016: 26 · 2015: 30 · 2014: 25 · 2013: 48 · 2012: 37
- FWCI
- 21.18
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- mediaTUM – the media and publications repository of the Technical University Munich (Technical University Munich) (submittedVersion)
- Hacettepe University Institutional Repository (hacettepe.edu.tr) (submittedVersion, other-oa)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
- Keywords
- heart rate turbulence, baroreflex sensitivity, premature ventricular contractions, vagal withdrawal, heart rate acceleration, heart rate deceleration, heart failure monitoring, autonomic nervous system, Holter monitoring
- MeSH terms
- Arrhythmias, Cardiac, Consensus Development Conferences as Topic, Consensus Statements as Topic, Heart Conduction System, Heart Rate, Humans, Prognosis, Vagus Nerve, Ventricular Function, Baroreflex, Risk Assessment
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
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