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Education of the Elderly Cardiac Patient

ali ahmed, Md, MPh, Section Editor University of Alabama at Birmingham, Birmingham, AL

Increased Heart Rate: An Emerging Cardiovascular Risk Factor in Older Adults


ali ahmed, Md, MPh
From the Division of Gerontology, Geriatrics and Palliative Care, Geriatric Heart Failure Clinic, and Center for Heart Failure Research, University of Alabama at Birmingham and VA Medical Center, Birmingham, AL Address for correspondence: Ali Ahmed, MD, MPH, Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, 1530 3rd Avenue South, CH-19, Suite 219, Birmingham, AL 35294-2401 E-mail: aahmed@uab.edu

n increase in heart rate (HR) may help us cope with increased demand for oxygen associated with mental or physical stress and diseases. Persistently elevated HR, however, may be a manifestation of a sedentary lifestyle or a marker of other cardiovascular (CV) disease. Like a fast running horse, a heart with elevated HR may tire easily, leading to disease and failure. Yet unlike increased blood pressure (BP) or cholesterol levels, an increased HR is not considered a reversible risk factor for CV morbidity and mortality. That attitude, however, may be changing. Athanase Benetos, MD, PhD, is a geriatric cardiologist and director of the Department of Geriatrics, University Hospital of Nancy, Nancy, France. Dr Benetos has extensively studied the topic of HR and its effect on mortality and morbidity and gave us his expert opinion in a recent conversation.

considered normal. Many believe, however, that this should be lower, especially for older adults. Recent data suggest that a HR above 80 to 85 bpm may be associated with increased mortality. Based on these data, I believe that a HR above 85 bpm should be considered high for older adults.

Q
Dr Ahmed: Is there any association between increased HR and mortality?
Dr Benetos: Yes. An increased HR may be harmful for the heart in the long run. We measured resting HR in more than 2500 men and women aged 65 to 70 years who were free from severe heart disease and followed them for about 20 years. Compared with men with a HR of <60 bpm, persons with a heart rate of >80 bpm were less likely to live to be 85 years of age. No such association between HR and longevity, however, was observed in women. We also examined this in a large French population of about 20,000 people aged 40 to 69 years. In that study, increased resting HR was a predictor of non-CV mortality in both sexes and of CV mortality in men, independent of age and the presence of hypertension.

Q
Dr Ahmed: What is a normal HR in older adults and does it change with aging?
Dr Benetos: A resting HR of 70 beats per minute (bpm) would be considered normal for most healthy adults aged 18 years and older; however, HR in younger adults varies quite a bit, between 60 to 100 bpm. While HR does not change much with aging, its variability may be reduced with aging.

Q
Dr Ahmed: Any explanation for the sex difference?
Dr Benetos: Findings from several studies including the Framingham Heart Study indicate a sex difference regarding the impact of increased HR on mortality in all age groups. This may be due in part to the fact that CV diseases are less common in women.

Q
Dr Ahmed: What is increased HR or tachycardia?
Dr Benetos: Normally, a HR below 100 bpm would be

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Education of thE EldErly cardiac PatiEnt

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thE aMErican Journal of GEriatric cardioloGy 2008 Vol. 17 no. 1

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The American Journal of Geriatric Cardiology (ISSN 1076-7460) is published bimonthly (Jan., March, May, July, Sept., Nov.) by Le Jacq, a Blackwell Publishing imprint, located at Three Enterprise Drive, Suite 401, Shelton, CT 06484. Copyright 2007 by Le Jacq. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial purposes, please contact Ben Harkinson at BHarkinson@bos.blackwellpublishing.com or 781-388-8511.

Q
Dr Ahmed: So, why might an increased HR be harmful?
Dr Benetos: It appears that an increased HR may be associated with atherosclerosis and arterial stiffness and may be due to imbalances in the autonomic nervous system tone. An increased HR may increase oxygen consumption by heart muscles. Findings from monkeys suggest that increased HR may promote cholesterol plaque formation, which is delayed by heart rate lowering. Also, increased HR may be associated with lack of physical activity, and regular physical activity may reduce HR in older adults.

under resting conditions. In clinical practice, one should respect the same conditions as those used in the measurement of BP, which includes patients being seated for at least 5 minutes before HR or pulse is estimated. Further, pulse rate should be counted for a period of at least 30 seconds.

Q
Dr Ahmed: Should we aim to decrease HR if it is >85 bpm?
Dr Benetos: There are no data to make such a recommendation for healthy, older adults. For older adults with coronary disease and heart failure, however, it may be preferable to achieve and maintain a lower HR. Their doctor may prescribe a b-blocker, which will help lower HR. More data from large clinical trials are needed to evaluate the benefits of HR reduction in other groups of high-risk patients, such as those with high BP, high cholesterol, and diabetes. Personally, I try to reduce HR in older adults with high HRs if they also have the CV risk factors mentioned above. I also recommend regular physical activity, as it can be one of the most natural approaches to obtain a reduction in HR, especially in elderly, since we know that lack of physical activity is one of the major determinants of frailty and loss of autonomy in this age group.

Q
Dr Ahmed: What is the implication of increased HR associated mortality for older adults?
Dr Benetos: Unlike high BP and high serum cholesterol levels, an increased HR is generally not considered a risk factor for heart disease, especially if the heart rate is within the normal range of 60 to 100 bpm. In June 2007, however, the European Society of Cardiology and the European Society of Hypertension guidelines for the management of hypertension stated that, There may be reasons to include an elevated heart rate as a risk factor because of a growing body of evidence that elevated heart rate values relate to the risk of cardiovascular morbidity and mortality as well as allcause mortality. Thus, for the first time, HR is being considered an independent risk factor and potentially as a target for pharmacologic therapies, especially in high-risk patients.

Q
Dr Ahmed: Any comment on predicted maximum HR in older adults?
Dr Benetos: Predicted maximum HR is generally estimated by subtracting ones age from the number 220. Therefore, the predicted maximum heart rate is generally lower for older adults. For example, the predicted maximum HR for someone 20 years of age would be 200, while that for someone 70 years of age would 150. It is often used to estimate the safe target HR for exercise and generally, healthy older adults may raise their HR safely up to 75% of their predicted maximum HRs. For example, the target HR for a 70-year-old with a predicted maximum HR of 150 bpm would be 110 to 120 bpm. Older adults with CV disease should consider consulting their doctors before starting an exercise program. Their doctor may order a graded exercise test to determine actual target HR for exercise.

Q
Dr Ahmed: How is HR estimated? Why is it essential that a person be rested before measuring HR?
Dr Benetos: HR can be estimated by auscultation of the heart or by counting pulse at the wrist. It is important to estimate the resting HR as it seems to be a better predictor of CV risk than, say, nonresting HR. Therefore, the estimation of HR should be performed

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Education of thE EldErly cardiac PatiEnt

thE aMErican Journal of GEriatric cardioloGy 2008 Vol. 17 no. 1

The American Journal of Geriatric Cardiology (ISSN 1076-7460) is published bimonthly (Jan., March, May, July, Sept., Nov.) by Le Jacq, a Blackwell Publishing imprint, located at Three Enterprise Drive, Suite 401, Shelton, CT 06484. Copyright 2007 by Le Jacq. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial purposes, please contact Ben Harkinson at BHarkinson@bos.blackwellpublishing.com or 781-388-8511.