Abstract
Hypertension is a common clinical problem and a major risk factor for cardiovascular disease and stroke. Elevated heart rate is associated with elevated blood pressure, increased risk for hypertension, and, among hypertensives, increased risk for cardiovascular disease. Despite these important relationships, heart rate is generally not a major consideration in choosing antihypertensive medications. In part, this is due to a lack of evidence supporting heart rate lowering as a therapeutic strategy in hypertension. Additionally, while there is a positive correlation between heart rate and peripheral blood pressure, there is an inverse relationship between heart rate and central blood pressure. The use of antihypertensive medications, specifically medications that affect heart rate, may not reliably reduce central blood pressure to a similar extent as observed peripherally. We review the relationship between heart rate and peripheral and central blood pressure, with a focus on the implications for chronotropic therapy in hypertension.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Guo F, He D, Zhang W, Walton RG. Trends in prevalence, awareness, management, and control of hypertension among United States adults, 1999 to 2010. J Am Coll Cardiol. 2012;60(7):599–606.
Heidenreich PA, Trogdon JG, Khavjou OA, et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011;123(8):933–44.
Klag MJ, Whelton PK, Randall BL, et al. Blood pressure and end-stage renal disease in men. N Engl J Med. 1996;334(1):13–8.
Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360(9349):1903–13.
Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206–52.
Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001;345(12):861–9.
Lewis EJ, Hunsicker LG, Clarke WR, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med. 2001;345(12):851–60.
Dulin BR, Haas SJ, Abraham WT, Krum H. Do elderly systolic heart failure patients benefit from beta blockers to the same extent as the non-elderly? Meta-analysis of > 12,000 patients in large-scale clinical trials. Am J Cardiol. 2005;95(7):896–8.
•• Palatini P. Role of elevated heart rate in the development of cardiovascular disease in hypertension. Hypertension. 2011;58(5):745–50. This article provides a comprehensive review of the current literature regarding heart rate as a risk factor for cardiovascular disease in patients with hypertension.
Palatini P, Dorigatti F, Zaetta V, et al. Heart rate as a predictor of development of sustained hypertension in subjects screened for stage 1 hypertension: the HARVEST Study. J Hypertens. 2006;24(9):1873–80.
Morcet JF, Safar M, Thomas F, Guize L, Benetos A. Associations between heart rate and other risk factors in a large French population. J Hypertens. 1999;17(12 Pt 1):1671–6.
Carnethon MR, Golden SH, Folsom AR, Haskell W, Liao D. Prospective investigation of autonomic nervous system function and the development of type 2 diabetes: the atherosclerosis risk in communities study, 1987–1998. Circulation. 2003;107(17):2190–5.
• Julius S, Palatini P, Kjeldsen SE, et al. Usefulness of heart rate to predict cardiac events in treated patients with high-risk systemic hypertension. Am J Cardiol. 2012;109:685–92. A secondary analysis of the VALUE trial indicates that baseline and in-trial heart rate are risk factors for cardiovascular events and all-cause mortality. The findings are consistent in subjects with controlled and uncontrolled blood pressure.
King DE, Everett CJ, Mainous 3rd AG, Liszka HA. Long-term prognostic value of resting heart rate in subjects with prehypertension. Am J Hypertens. 2006;19(8):796–800.
Kavanagh-Gray D. Comparison of central aortic and peripheral artery pressure curves. Can Med Assoc J. 1964;90:1468–71.
Laurent S, Cockcroft J, Van Bortel L, et al. Expert consensus document on arterial stiffness: methodological issues and clinical applications. Eur Heart J. 2006;27(21):2588–605.
•• Townsend RR, Wimmer NJ, Chirinos JA, et al. Aortic PWV in chronic kidney disease: a CRIC ancillary study. Am J Hypertens. 2010;23(3):282–9. In 2564 subjects in CRIC, increased aortic PWV was found to be associated with older age, elevated blood pressure, and lower eGFR.
Laurent S, Boutouyrie P, Asmar R, et al. Aortic stiffness is an independent predictor of all-cause and cardiovascular mortality in hypertensive patients. Hypertension. 2001;37(5):1236–41.
Taal MW, Sigrist MK, Fakis A, Fluck RJ, McIntyre CW. Markers of arterial stiffness are risk factors for progression to end-stage renal disease among patients with chronic kidney disease stages 4 and 5. Nephron Clin Pract. 2007;107(4):c177–81.
Miyashita H. Clinical assessment of central blood pressure. Curr Hypertens Rev. 2012;8(2):80–90.
Cohen DL, Townsend RR. Central blood pressure and chronic kidney disease progression. Int J Nephrol. 2011;2011:407801.
London G, Guerin A, Pannier B, et al. Increased systolic pressure in chronic uremia. Role of arterial wave reflections. Hypertension. 1992;20(1):10–9.
Papaioannou TG, Vlachopoulos CV, Alexopoulos NA, et al. The effect of heart rate on wave reflections may be determined by the level of aortic stiffness: clinical and technical implications. Am J Hypertens. 2008;21(3):334–40.
Protogerou AD, Safar ME. Dissociation between central augmentation index and carotid-femoral pulse-wave velocity: when and why? Am J Hypertens. 2007;20(6):648–9.
Vlachopoulos C, Aznaouridis K, O’Rourke MF, et al. Prediction of cardiovascular events and all-cause mortality with central haemodynamics: a systematic review and meta-analysis. Eur Heart J. 2010;31(15):1865–71.
Roman MJ, Devereux RB, Kizer JR, et al. Central pressure more strongly relates to vascular disease and outcome than does brachial pressure: the Strong Heart Study. Hypertension. 2007;50(1):197–203.
Yasmin, Brown MJ. Similarities and differences between augmentation index and pulse wave velocity in the assessment of arterial stiffness. QJM. 1999;92(10):595–600.
Wilkinson IB, Mohammad NH, Tyrrell S, et al. Heart rate dependency of pulse pressure amplification and arterial stiffness. Am J Hypertens. 2002;15(1 Pt 1):24–30.
Wilkinson IB, MacCallum H, Flint L, et al. The influence of heart rate on augmentation index and central arterial pressure in humans. J Physiol. 2000;525(Pt 1):263–70.
Lemogoum D, Flores G, Van den Abeele W, et al. Validity of pulse pressure and augmentation index as surrogate measures of arterial stiffness during beta-adrenergic stimulation. J Hypertens. 2004;22(3):511–7.
Chen CH, Ting CT, Lin SJ, et al. Different effects of fosinopril and atenolol on wave reflections in hypertensive patients. Hypertension. 1995;25(5):1034–41.
Morgan T, Lauri J, Bertram D, Anderson A. Effect of different antihypertensive drug classes on central aortic pressure. Am J Hypertens. 2004;17(2):118–23.
•• Boutouyrie P, Achouba A, Trunet P, Laurent S. Amlodipine-valsartan combination decreases central systolic blood pressure more effectively than the amlodipine-atenolol combination: the EXPLOR study. Hypertension. 2010;55(6):1314–22. Among patients already on amlodipine, a larger decrease in aortic systolic blood pressure, central pulse pressure, and augmentation index was observed with the addition of valsartan compared to atenolol. Brachial blood pressure reduction was similar in both arms.
Bangalore S, Wild D, Parkar S, et al. Beta-blockers for primary prevention of heart failure in patients with hypertension. Insights from a meta-analysis. J Am Coll Cardiol. 2008;52:1062–72.
• Shah NK, Smith SM, Nichols WW, et al. Carvedilol reduces aortic wave reflection and improves left ventricular/vascular coupling: a comparison with atenolol (CENTRAL Study). J Clin Hypertens (Greenwich). 2011;13(12):917–24. The authors demonstrated an increase in augmentation pressure and augmentation index in atenolol treated patients compared to those treated with carvedilol after 4 weeks of therapy. Reductions in central blood pressure and brachial pressures were similar in both groups.
•• Kampus P, Serg M, Kals J, et al. Differential effects of nebivolol and metoprolol on central aortic pressure and left ventricular wall thickness. Hypertension. 2011;57(6):1122–8. Randomized controlled trial of 80 patients comparing the vasodilating beta-blocker nebivolol to metoprolol. Both agents similarly reduced brachial blood pressure and heart rate; however reductions in central blood pressure and pulse pressure were seen in the nebivolol arm.
Mahmud A, Feely J. Beta-blockers reduce aortic stiffness in hypertension but nebivolol, not atenolol, reduces wave reflection. Am J Hypertens. 2008;21(6):663–7.
Pepine CJ, Handberg EM, Cooper-DeHoff RM, et al. A calcium antagonist vs a non-calcium antagonist hypertension treatment strategy for patients with coronary artery disease. The International Verapamil-Trandolapril Study (INVEST): a randomized controlled trial. JAMA. 2003;290(21):2805–16.
Hansson L, Hedner T, Lund-Johansen P, et al. Randomised trial of effects of calcium antagonists compared with diuretics and beta-blockers on cardiovascular morbidity and mortality in hypertension: the Nordic Diltiazem (NORDIL) study. Lancet. 2000;356(9227):359–65.
Dahlof B, Devereux RB, Kjeldsen SE, et al. Cardiovascular morbidity and mortality in the Losartan intervention for endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet. 2002;359(9311):995–1003.
Medical Research Council trial of treatment of hypertension in older adults: principal results. MRC Working Party. BMJ. 1992;304(6824):405–12.
• Poulter NR, Dobson JE, Sever PS, et al. Baseline heart rate, antihypertensive treatment, and prevention of cardiovascular outcomes in ASCOT (Anglo-Scandinavian Cardiac Outcomes Trial). J Am Coll Cardiol. 2009;54(13):1154–61. This large sub-study of the ASCOT trial analyzed the effect of heart rate in hypertensive patients without CVD. The authors compared amlodipine-based antihypertensive regimens to atenolol-based antihypertensive regimens and demonstrated a reduction in cardiovascular events in the amlodipine arms at all levels of heart rate.
Bangalore S, Sawhney S, Messerli FH. Relation of beta-blocker-induced heart rate lowering and cardioprotection in hypertension. J Am Coll Cardiol. 2008;52(18):1482–9.
Kalaitzidis R, Bakris G. Should nephrologists use beta-blockers? A perspective. Nephrol Dial Transplant. 2009;24(3):701–2.
Williams B, Lacy PS, Thom SM, et al. Differential impact of blood pressure-lowering drugs on central aortic pressure and clinical outcomes: principal results of the Conduit Artery Function Evaluation (CAFE) study. Circulation. 2006;113(9):1213–25.
• Williams B, Lacy PS. Impact of heart rate on central aortic pressures and hemodynamics: analysis from the CAFE (Conduit Artery Function Evaluation) study: CAFE-Heart Rate. J Am Coll Cardiol. 2009;54(8):705–13. Results of this study demonstrate an inverse relationship between heart rate and central aortic pressures, whereas lowering heart rate with treatment for hypertension resulted in elevated central aortic pressure.
Beddhu S, Nigwekar SU, Ma X, Greene T. Associations of resting heart rate with insulin resistance, cardiovascular events and mortality in chronic kidney disease. Nephrol Dial Transplant. 2009;24(8):2482–8.
Muntner P, Anderson A, Charleston J, et al. Hypertension awareness, treatment, and control in adults with CKD: results from the Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis. 2010;55(3):441–51.
Rahman M, Pressel S, Davis BR, et al. Cardiovascular outcomes in high-risk hypertensive patients stratified by baseline glomerular filtration rate. Ann Intern Med. 2006;144(3):172–80.
Townsend RR, Chirinos JA, Parsa A, et al. Central pulse pressure in chronic kidney disease: a chronic renal insufficiency cohort ancillary study. Hypertension. 2010;56(3):518–24.
Wright Jr JT, Bakris G, Greene T, et al. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA. 2002;288(19):2421–31.
Heart rate variability: standards of measurement, physiological interpretation and clinical use. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Circulation. 1996;93(5):1043–65.
Brotman DJ, Bash LD, Qayyum R, et al. Heart rate variability predicts ESRD and CKD-related hospitalization. J Am Soc Nephrol. 2010;21(9):1560–70.
Burger AJ, D’Elia JA, Weinrauch LA, Lerman I, Gaur A. Marked abnormalities in heart rate variability are associated with progressive deterioration of renal function in type I diabetic patients with overt nephropathy. Int J Cardiol. 2002;86(2–3):281–7.
Dekker JM, Crow RS, Folsom AR, et al. Low heart rate variability in a 2-minute rhythm strip predicts risk of coronary heart disease and mortality from several causes: the ARIC Study. Atherosclerosis Risk In Communities. Circulation. 2000;102(11):1239–44.
Deligiannis A, Kouidi E, Tourkantonis A. Effects of physical training on heart rate variability in patients on hemodialysis. Am J Cardiol. 1999;84(2):197–202.
Malfatto G, Facchini M, Sala L, et al. Effects of cardiac rehabilitation and beta-blocker therapy on heart rate variability after first acute myocardial infarction. Am J Cardiol. 1998;81(7):834–40.
Lanza GA, Pitocco D, Navarese EP, et al. Association between cardiac autonomic dysfunction and inflammation in type 1 diabetic patients: effect of beta-blockade. Eur Heart J. 2007;28(7):814–20.
Fodor GJ, Kotrec M, Bacskai K, et al. Is interview a reliable method to verify the compliance with antihypertensive therapy? An international central-European study. J Hypertens. 2005;23(6):1261–6.
Disclosure
No potential conflicts of interest relevant to this article were reported.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Reule, S., Drawz, P.E. Heart Rate and Blood Pressure: Any Possible Implications for Management of Hypertension?. Curr Hypertens Rep 14, 478–484 (2012). https://doi.org/10.1007/s11906-012-0306-3
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11906-012-0306-3