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Cited by 167Heart Rate Variability and Autonomic ControlSepsis Diagnosis and TreatmentHemodynamic Monitoring and Therapy

Heart Rate Variability in Emergency Department Patients with Sepsis

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Barnaby, Douglas, Ferrick, Kevin, Kaplan, Daniel T., Shah, Sachin, Bijur, Polly, Gallagher, E. John·2002·Academic Emergency Medicine
DOI 10.1197/aemj.9.7.661
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Abstract

Objective: To test the hypothesis that heart rate variability (HRV) can provide an early indication of illness severity among patients presenting to the emergency department (ED) with sepsis. Methods: The authors enrolled a convenience sample of 15 ED patients meeting the American College of Chest Physicians/Society of Critical Care Medicine criteria for sepsis. Each patient had continuous Holter monitoring performed in the ED. Acute Physiology and Chronic Health II (APACHE II) and Sequential Organ Failure (SOFA) scores were calculated for the day of presentation. Holter tapes obtained in the ED were analyzed off‐line to calculate HRV variables for the 5‐minute segment with the least artifact and non‐sinus beats. These variables were correlated with APACHE II and SOFA scores. Results: LFnu (normalized low‐frequency power), an assessment of the relative sympathetic contribution to overall HRV, was correlated with increased illness severity as calculated using APACHE II (r = ‐0.67, r 2= 0.43) and SOFA (r = ‐0.80, r 2= 0.64) scores. LF/HF ratio (low‐frequency/high‐frequency ratio), a measure of sympathovagal balance, was correlated with the SOFA score [r = ‐0.54 (95% CI = ‐0.83 to ‐0.01), r 2= 0.29]. All five patients who required critical care monitoring or ventilatory support or who died during the first 5 days of their hospitalization had LFnu values below 0.5 and LF/HF ratios less than 1.0. None of the patients with measurements greater than these threshold values died or required these interventions during the five days following admission. Conclusions: A single variable, LFnu, which reflects sympathetic modulation of heart rate, accounted for 40‐60% of the variance in illness severity scores among patients presenting to the ED with sepsis. HRV, as reflected in LFnu and the LF/HF ratio and measured with a single brief (5‐minute) period of monitoring while in the ED, may provide the emergency physician with a readily available, noninvasive, early marker of illness severity. The threshold effect of LFnu and LF/HF in the prediction of early clinical deterioration was an unexpected finding and should be regarded as hypothesis‐generating, pending further study.

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  • Patients with sepsis and organ failure have depressed vagus nerve activity.

    “Cholinergic and anticholinergic drugs are also widely used in intensive care units, where patients with sepsis and organ failure have increased cytokine levels and depressed vagus nerve activity (55,56,(81)(82)(83).”

    From Physiology and immunology of the cholinergic antiinflammatory pathway (2007) · cites this paper as [55]

  • Patients with sepsis and organ failure have increased cytokine levels.

    “Cholinergic and anticholinergic drugs are also widely used in intensive care units, where patients with sepsis and organ failure have increased cytokine levels and depressed vagus nerve activity (55,56,(81)(82)(83).”

    From Physiology and immunology of the cholinergic antiinflammatory pathway (2007) · cites this paper as [55]

  • Depressed vagus nerve activity is significantly correlated with increased morbidity and mortality in sepsis, rheumatoid arthritis, lupus, sarcoidosis, inflammatory bowel diseases, other diseases, and trauma.

    “Clinical research implicates a significant correlation between depressed vagus nerve activity and increased morbidity and mortality in sepsis, rheumatoid arthritis, lupus, sarcoidosis, inflammatory bowel diseases, other diseases, and trauma (55)(56)(57)(58)(59)(60)(61)(62)(63).”

    From Physiology and immunology of the cholinergic antiinflammatory pathway (2007) · cites this paper as [55]

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Research works printed but not linked: 8

  1. Centers for Disease Control and Prevention. National Vi- tal Statistics Reports. 1999; 47(19):33.
  2. Centers for Disease Control and Prevention. Increase in national hospital discharge survey rates for septicemia- United States, 1979-1987. MMWR. 1990; 39(2):31-4.
  3. Moore RB, Shapiro NI, Wolfe RE, Smith ES, Bermudez S, Bates D. The value of SIRS criteria in ED patients with presumed infection in predicting mortality [abstract]. Acad Emerg Med. 2001; 8:477.
  4. Rivers EP, Nguyen HB, Havstad S, et al. Early goal-di- rected therapy in the treatment of the systemic inflam- matory response syndrome (SIRS): an outcome evalua- tion of emergency department intervention [abstract]. Acad Emerg Med. 2000; 7:427.
  5. Godin PJ, Buchman TG. Uncoupling of biological oscilla- tors: a complementary hypothesis concerning the patho- genesis of multiple organ dysfunction syndrome [see comments]. Crit Care Med. 1996; 24:1107-16.
  6. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985; 13:818-29.
  7. Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis- related Organ Failure Assessment) score to describe or- gan dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Soci- ety of Intensive Care Medicine. Intensive Care Med. 1996; 22:707-10.
  8. ⅷ 15532712, 2002, 7, · DOI

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Authors
Barnaby, D., Ferrick, K., Kaplan, D. T., Shah, S., Bijur, P., & Gallagher, E. J.
Affiliations
  • Icahn School of Medicine at Mount Sinai (US)
  • Albert Einstein College of Medicine (US)
  • Macalester College (US)
ORCID
Venue
Academic Emergency Medicine
Publisher
Wiley
Published
2002-07
Volume
9
Issue
7
Pages
661-670
ISSN
  • 1069-6563 (ISSN-L)
  • 1553-2712
DOI
10.1197/aemj.9.7.661
OpenAlex
W2038569109
Cited by
167
References
38
Citations by year
2026: 6 · 2025: 4 · 2024: 7 · 2023: 8 · 2022: 4 · 2021: 5 · 2020: 9 · 2019: 7 · 2018: 6 · 2017: 14 · 2016: 7 · 2015: 5 · 2014: 13 · 2013: 9 · 2012: 13
FWCI
1.96
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor, 2189 d)
Locations
  • Academic Emergency Medicine (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
  • Health Sciences › Medicine › Epidemiology › Sepsis Diagnosis and Treatment
  • Health Sciences › Medicine › Surgery › Hemodynamic Monitoring and Therapy
Keywords
heart rate variability, sepsis, disease severity, APACHE II score, SOFA score, sympathetic nervous system, sympathovagal balance, LF/HF ratio, Holter monitoring, early warning indicators, clinical deterioration prediction, emergency department patients
MeSH terms
Adult, Aged, Aged, 80 and over, Emergency Service, Hospital, Female, Heart Rate, Humans, Male, Middle Aged, Prospective Studies, Severity of Illness Index, Electrocardiography, Ambulatory, Sepsis, APACHE

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