Physicians' Academy for Cardiovascular Education

Resting heart rate has predictive value for heart failure in healthy men, but not women

Literature - Nanchen D, Leening MJ, Locatelli I et al. - Circ Heart Fail. 2013 May 1;6(3):403-10. doi: 10.1161/CIRCHEARTFAILURE.112.000171

Resting heart rate and the risk of heart failure in healthy adults: the Rotterdam study.

Nanchen D, Leening MJ, Locatelli I et al.
Circ Heart Fail. 2013 May 1;6(3):403-10. doi: 10.1161/CIRCHEARTFAILURE.112.000171


Despite improvements in health care for heart failure (HF) patients, the incidence of hospitalization  for HF is increasing in the aging Western population [1]. It is therefore important to better detect patients at risk of HF. Resting heart rate (HR) possibly has predictive value for heart failure and cardiovascular disease [2]. In patients experiencing HF, resting HR is a modifiable risk factor which can prevent rehospitalisation for HF [3]. For the general population this association is not known. This question should be addressed in a prospective manner because a subclinical decompensated state in cardiac patients might enhance a hemodynamic response that increases HR. The biological interaction between resting HR and subclinical HF prevents extrapolation of the association to healthy adults.
Therefore, this study investigated whether higher resting HR is independently associated with the development of HF in adults without pre-existing heart disease or HR -modifying medication use in the general population. This study is part of the Rotterdam Study, and included data from 4768 participants [4].

Main results

  • In men, HR was <68.5 beats per minute (BPM) for the first tertile, 69-78 BPM for the second and >79 BPM in the third tertile. In women, the tertiles were <72, 73-80 and >81 BPM, with pulse measurement at the radial artery. HR measured by ECG was generally somewhat lower than pulse measurement.
  • In a median (IQR) follow-up period of 14.6 (7.6) year, 656 participants developed incident HF.
    Crude incidence HF was higher in men with higher HR than in men with lower HR (13.7 vs. 9.9 per 1000 person-years). In women, crude incidence rates of HF did not differ between HR categories, except when HR was measured with ECG.
  • For each increment of 10 BPM, the multivariable adjusted hazard ratio in men were 1.16 (95%CI: 1.05-1.28) in a time-fixed HR model and 1.13 (95%CI: 1.02-1.25) in a time-dependent HR model (HR measured by ECG). Resting HR was not associated with a higher risk of HF in women.
  • After censoring  328 participants who developed nonfatal coronary heart disease (CHD) during follow-up, similar results were obtained.
  • When taking into account time until first prescription of common HR-lowering drugs, men with HR in the upper tertile had higher risk of HF than men in the lower tertile (adjusted hazard ratio: 1.47, 95%CI: 1.08-2.01).


Higher resting heart rate as measured with pulse palpation or ECG was independently associated with incident heart failure in healthy male adults from the general population. This association was not mediated through overt CHD. In women no such association was identified.
Thus, men at higher risk of developing HF can be identified based upon high resting HR. It remains to be determined whether these men can benefit from preventive therapy aimed at reducing HR.


1. Hunt SA, Abraham WT, Chin MH et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the
International Society for Heart and Lung Transplantation. Circulation.2009;119:e391–e479.
2. Ceconi C, Guardigli G, Rizzo P. The heart rate story. Eur Heart J Suppl. 2011;13:C4–C13.
3. Böhm M, Swedberg K, Komajda M, et al., SHIFT Investigators. Heart rate as a risk factor in chronic heart failure (SHIFT): the association between heart rate and outcomes in a randomised placebo-controlled trial. Lancet. 2010;376:886–894.
4. Hofman A, van Duijn CM, Franco OH et al. The Rotterdam Study: 2012 objectives and design update. Eur J Epidemiol. 2011;26:657–686.

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