Heart Rate Variability after Coronary Artery Bypass Grafting
Y Suda, K Otsuka", T Ban,S Ichikawa, R Higashita, Y Takeuchi
Department of Cardiovascular Surgery, *Department of Medicine,
Tokyo Women's Medical University Daini Hospital, Tokyo, Japan
Abstract
Forty-nine C4BGpatients, aged from 38 to 77years, were
examined by 24-h ambulatory ECG monitoring before and
4 weeks after surgery. HRV spectral components were
obtained by MEM analysis and the 24-h averages of time
and frequency domain measures were obtained.
Comparison of groups was done by the paired t-test and
p<0.05 was defined as statistical significance. The
average HR for a 24-h period increased significantly after
W G CpcO.0001). K F and LF components showed a
decrease after surgery (1215.0 vs 572.3, p<O.OOOl, and
260.3 vs 125.9, p<0.002), but the HF spectral power did
not show a signifcant change (98.7 vs 125.9, XS.).
Analysis of the normalized units revealed a significant
increase of ULFITF from 0.6496 2 0.0931 to 0.7003 * (SD * 29.1 min). Angiography was performed 3 to 4
0.1338 CpcO.OOOl), and a signifcant decrease of the
KLFITF and LFITF from 0.2671 2 0.0689 to 0.2040 -C
0.0832 f'jx0.0001) and from 0.0568 f 0.0290 to 0.0429 2
0.0232 @=0.0088), respectively. There was no
signijicant alteration of HFITF. These results suggest
that CABG improves cardiovascular function in 010
patients with increased sympathetic activity. These
observations might be explained by prolonged recovery of
the myocardium after normalization of myocardial
perjhsion.
1. Introduction
Heart rate variability (HRV) is a widely used
noninvasive index for the assessment of cardiac
autonomic function. Decreased HRV is associated with
a poor prognosis in patients with coronary artery disease
(CAD). Interventional techniques, such as percutaneous
transluminal coronary angioplasty (PTCA) and coronary
artery bypass grafting (CABG), may improve the
outcome of certain patients with CAD. However, it has
not yet been determined precisely how CABG influences
HRV. Therefore, the aim of this study was to assess the
cardiovascular autonomic function of CAD patients after
CABG by HRV analysis.
0276-6547/99 $10.00 0 1999 IEEE
2. Methods
This prospective study investigated 49 patients (38
men and 11 women) with CAD documented by
angiography. The mean age of the patients was 61.4
years (SD 8.8 years), with a range of 38 to 77 years.
Twenty-two patients had previous myocardial infarction.
Left ventricular angiography was performed in the 30-
degree right anterior oblique projection and the ejection
fraction (LVEF) was calculated by the area-length
method. The average LVEF was 67.7 % (SD* 13.6 %).
Patients with atrial fibrillation and bundle branch block
were excluded.
A total of 124 bypass grafts were successfully
performed. The average number of grafts was 2.5 * 1.1
and the extracorporeal circulation time was 111.8 min
weeks after CABG to assess graft patency: three grafts
were obstructed and the patency rate was 97.2 %.
Ambulatory ECG monitoring for 24 hours was
performed 3 to 7 days before CABG and 15 to 33 days
after CABG (mean * SD; 23.6 * 4.2 days). The 24-
hour ECG was obtained using an ambulatory two-channel
Holter recorder (SM-28, Fukuda-Denshi, Tokyo) and an
analyzer (SCM-280-3, Fukuda-Denshi, Tokyo) with an
R-R interval counter and a built-in A/D converter. The
interval resolution was 8 msec. Analysis was carried
out on smoothed R-R interval data sampled at 4 Hz.
As time domain measures, CVRR, SDNN, r-MSSD,
"50, pNN50, SDANNs (5 and 30 min), SDNNIDXs (5
and 30 min), triangular indexes (TI", HRVI, TI), and
Lorenz plot indexes (9O%L, 90%W, W )were
computed. The mean cycle length of the normal-normal
RR (NN) intervals for 24 hours and the standard
deviation (SD) of the NN intervals for 24 hours were
calculated as 24-hour average NN and SDNN,
respectively. CVRR, SDA"s, SDNNIDXs and
Lorenz plot indexes were calculated as a mean of each 5-
min (or 30-min) reading over the entire 24-hour ECG
recording.
Frequency-domain measures were analyzed by the
maximum entropy method (MEM). Calculations were
607 Computers in Cardiology 1999;26:607-610.
 Fig. 1 Circadian variation of the NN interval (upper) and heart rate (lower) in a patient with CAD, and MEM
power spectra showing circadian rhythmicity.

f-
ii-
8-
3-
E-
*
I-
si-

Fig. 2 Geometrical methods of HRV assessment. Left;Triangular interpolation method,

Right; Lorenz plot.

done with the MemCalc/CHIRAM program (Suwa Trust
Co., Ltd., Tokyo Japan). A 5-min NN interval time
series was processed consecutively, and the power of the
very low frequency (VLF, 0.003-0.04 Hz), low
frequency (LF< 0.04-0.15 Hz), and high frequency (HF,
0.15-0.40 Hz) spectra as well as the LF/HF ratio were
calculated. A 180-min NN interval time series was
processed consecutively with successive 180-min spans
overlapping by 5-min, and the ultra-low frequency (ULF,
0.0001-0.003 Hz) component and the slope of llf
fluctuations of NN ((3,0.0001-0.01 Hz) were determined.
Normalization of spectral power was done by dividing
by total power (0.0001-0.50 Hz). As a representative
value of each HRV measure, the 24-hour average was
calculated for each record.
Comparison between groups was done by the paired
t-test and results were considered to be statistically
significant at p<O.O5
3. Results
An example of HRV analysis in a 56-year-old man
with CAD is as follows. Circadian variation of the
average NN and heart rate (HR) for every 5-min period
is shown in Fig.1. The MEM spectrum of these
circadian profiles shows ,251.52 hour and 25.54 hour
rhythmicity, respectively. Geometrical methods of
HRV assessment are shown in Fig. 2, including the
triangular interpolation method (left) and the Lorenz
plot (right).

608
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f il
0 UWl tom 0.81 LU aU 1 L l E1 U 1 L 4 8 s 8.1 Ll
K1 la HI

Fig. 3 MEM spectral analysis in a patient with CAD. Left; ULF component (0.0001-0.003 Hz),Middle; VLF
component (0.003-0.04 Hz), Right; LF and HF components (0.04-0.50 Hz).

:oe 10:@e-11:00 (lO:n-11:10)

10:00.,"11 (lO:Oo--ll :OO)
. .
.
=
zI
-:-
I ."""I

B 4
3, -d
sm -3
0 P
19:W 1O:lS 1P:SO 10:45 0.001 L 01

Fig. 4 The l/f fluctuations of the RR interval.

8 is the slope over the range from 0.0001 to 0.01 Hz,and is -0.96 for this time span.

Figure 3 illustrates the 3-dimentionaldisplay of MEM

spectra (left; ULF component, middle; VLF component,
and right; LF and HF components),while an example of
l/f fluctuation analysis is shown in Fig. 4. Circadian
variation of the slope of l/f fluctuations ((3) and ULF
components is shown in Fig. 5.
The effects of CABG on HRV are summarized in
Table 1. The average HR for a 24-hour period
increased significantly after CABG (p<O.OOOl), while
most of the HRV measures decreased after CABG.
Measures of long-term heart rate fluctuation, such as
SDNN, SDANNs, p, TF, and ULF also showed a
significant decrease. The VLF and LF components
decreased after surgery @<0.0001 and pc0.002), but the
HF spectral power did not show a significant change.
Alteration of the normalized units of HRV should be
noted. Our data revealed a significant increase of
U L F m (p<O.OOOl), and a significant decrease of
VLF/TF (p<O.OOOl) and LF/TF (p=O.OOSS). However,
there was no statistically significant alteration of HF/TF.
4. Discussion
Niemela et al. [l]analyzed 2-min resting ECGs in
CABG patients, and noted that the LF and HF powers
were respectively reduced to one-seventh and one-third
within one week after CABG, and that the HF power did
not recover even after 6 weeks. Several studies on the
effect of reperfusion on HRV after successful CABG in
patients with CAD, there is a lack of improvement of
HRV. Possible reasons for these findings may be
mechanical injury of the cardiac nerves induced by
surgery, with denervation of the autonomic nervous
system.
Our data suggest that the operative procedure showed
an influence on HRV measures, which reflect long-term
heart rate fluctuations. However, HRV measures
which reflect cardiovascular sympathetic activity, such
as VLF and LF, decreased after CABG. We also

609
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0
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Fig. 5 Circadian variation of (upper) and ULF (middle) in a patient with CAD,
and MEM power spectra showing its circadian rhythmicity.

Table 1. Effects of CABG surgery - . on have to take note of the fact that the normalized ULFEF
heart rate variability (HRV) increased after CABG, which may mean that a decrease
Control PosI-CABG
P value in the indexes of long-term heart rate fluctuations
Mean S.D. Mean S.D. depends on an increase of HR after CABG. We have
AverageHR 69.0 11.5 82.9 10.9 <O.OOOl already reported the possibility that CABG improves
Aver& NN 892.7 142.2 736.0 96.1 4.OOO1
CVRR 12.89 3.43 12.04 3.98 N.S.
cardiovascular parasympathetic activity [2]. Future
SDNN 106.96 28.04 76.83 30.18 <0.0.0001 work will determine whether these observations might
r-MSSD 22.67 7.53 19.06 17.93 N.S. be explained by a prolonged recovery of the
50 3340.7 3407.2 1590.0 2074.4 0.0078 myocardium after normalization of myocardia1
p50 3.806 4.185 1.508 2.078 0.0028 perfusion.
SDA 95.64 27.1 1 70.34 27.99 <O.OOOl
SDANN30 88.15 27.56 65.04 27.44 4.0001
SDNNIDX 41.96 12.68 27.68 16.22 4.OOO1
SDNNIDX30 57.33 16.12 38.62 19.74 4.OOO1 References
m 475.6 126.6 320.9 107.0 4.OOO1
HRVI 59.45 15.81 40.12 13.38 <O.OOOI [l] Niemela MJ, Airaksinen KEJ, Tahvaninen KUO et al.
TI 57.90 16.10 39.66 13.49 co.OOO1 Effect of coronary artery bypass grafting on cardiac
9O%L 491.9 131.2 351.4 125.6 <O.OOOl parasympathetic nervous function. Eur Heart J. 1992;
9O%W 50.92 19.68 41.90 51.09 N.S. 13:932-935.
UW 10.68 4.12 11.06 4.85 N.S. [2] Suda Y. Effect of coronary artery bypass grafting on
B Wf) -1.224 0.172 -1.359 0.233 0.0004
cardiac autonomic nervous function as assessed by power
TF 4443.5 2331.8 2398.1 2709.6 <O.OOol
ULF 2859.9 1527.4 1601.2 1470.3 <O.OOol
spectral analysis of heart rate variability. The
VLF 1215.0 763.3 572.3 816.5 <O.OOol Autonomic Nervous System (Tokyo) 1997; 34:442-450.
LF 260.3 221.4 125.9 228.4 0.002
HF 98.7 68.8 125.9 237.8 N.S. Dr. Yuji Suda, 2-1-10Nishioku,Arakawa, Tokyo, 116-0011,
LF
m 2.931 1.531 2.454 1.894 N.S. JAPAN
ULFm 0.6496 0.0931 0.7003 0.1338 <O.OOol
VL
Fm 0.2671 0.0689 0.2040 0.0832 <O.MMl
L
Fm 0.0568 0.0290 0.0429 0.0232 0.0088
HFm 0.0238 0.0148 0.0289 0.0247 N.S.

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