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The relationship of autonomic imbalance, heart rate variability and cardiovascular disease risk factors

  • Julian F. Thayer
    Correspondence
    Corresponding author. The Ohio State University, Department of Psychology, 1835 Neil Avenue, Columbus, Ohio 43210, USA. Tel.: +1 614 688 3450; fax: +1 614 688 8261.
    Affiliations
    The Ohio State University, Department of Psychology, 1835 Neil Avenue, Columbus, Ohio 43210, USA

    Mannheim Institute of Public Health, Social and Preventive Medicine, Mannheim Medical Faculty, Heidelberg University, Ludolf-Krehl-Str. 7-11, D-68167, Mannheim, Germany
    Search for articles by this author
  • Shelby S. Yamamoto
    Affiliations
    Mannheim Institute of Public Health, Social and Preventive Medicine, Mannheim Medical Faculty, Heidelberg University, Ludolf-Krehl-Str. 7-11, D-68167, Mannheim, Germany
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  • Jos F. Brosschot
    Affiliations
    Leiden University, Division of Clinical and Health Psychology, Department of Psychology, Leiden University, P.O. Box 9555; 2300 RB Leiden, The Netherlands
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Published:November 13, 2009DOI:https://doi.org/10.1016/j.ijcard.2009.09.543

      Abstract

      Cardiovascular disease (CVD) is the leading cause of death and disability worldwide. The understanding of the risk factors for CVD may yield important insights into the prevention, etiology, course, and treatment of this major public health concern. Autonomic imbalance, characterized by a hyperactive sympathetic system and a hypoactive parasympathetic system, is associated with various pathological conditions. Over time, excessive energy demands on the system can lead to premature aging and diseases. Therefore, autonomic imbalance may be a final common pathway to increased morbidity and mortality from a host of conditions and diseases, including cardiovascular disease. Heart rate variability (HRV) may be used to assess autonomic imbalances, diseases and mortality. Parasympathetic activity and HRV have been associated with a wide range of conditions including CVD. Here we review the evidence linking HRV to established and emerging modifiable and non-modifiable CVD risk factors such as hypertension, obesity, family history and work stress. Substantial evidence exists to support the notion that decreased HRV precedes the development of a number of risk factors and that lowering risk profiles is associated with increased HRV. We close with a suggestion that a model of autonomic imbalance may provide a unifying framework within which to investigate the impact of risk factors, including psychosocial factors and work stress, on cardiovascular disease.

      Keywords

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      References

        • Friedman B.H.
        • Thayer J.F.
        Autonomic balance revisited: panic anxiety and heart rate variability.
        J Psychosom Res. 1998; 44: 133-151
        • Kang M.G.
        • Koh S.B.
        • Cha B.S.
        • Park J.K.
        • Woo J.M.
        • Chang S.J.
        Association between job stress on heart rate variability and metabolic syndrome in shipyard male workers.
        Yonsei Med J. 2004; 45: 838-846
        • Kiecolt-Glaser J.K.
        • McGuire L.
        • Robles T.F.
        • Glaser R.
        Emotions, morbidity, and mortality: new perspectives from psychoneuroimmunology.
        Annu Rev Psychol. 2002; 53: 83-107
        • Krantz D.S.
        • McCeney M.K.
        Effects of psychological and social factors on organic disease: a critical assessment of research on coronary heart disease.
        Annu Rev Psychol. 2002; 53: 341-369
        • Musselman D.L.
        • Evans D.L.
        • Nemeroff C.B.
        The relationship of depression to cardiovascular disease: epidemiology, biology, and treatment.
        Arch Gen Psychiatry. 1998; 55: 580-592
        • Rozanski A.
        • Blumenthal J.A.
        • Kaplan J.
        Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy.
        Circulation. 1999; 99: 2192-2217
        • Verrier R.L.
        • Mittleman M.A.
        The impact of emotions on the heart.
        Prog Brain Res. 2000; 122: 369-380
        • Duijts S.F.
        • Kant I.
        • Swaen G.M.
        • van den Brandt P.A.
        • Zeegers M.P.
        A meta-analysis of observational studies identifies predictors of sickness absence.
        J Clin Epidemiol. 2007; 60: 1105-1115
        • Harter J.K.
        • Schmidt F.L.
        • Hayes T.L.
        Business-unit-level relationship between employee satisfaction, employee engagement, and business outcomes: a meta-analysis.
        J Appl Psychol. 2002; 87: 268-279
        • Rosengren A.
        • Hawken S.
        • Ounpuu S.
        • et al.
        Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): case-control study.
        Lancet. 2004; 364: 953-962
        • Chandola T.
        • Britton A.
        • Brunner E.
        • et al.
        Work stress and coronary heart disease: what are the mechanisms?.
        Eur Heart J. 2008; 29: 640-648
        • Murray C.J.L.
        • Lopez A.D
        The global burden of disease: a comprehensive assessment of mortality and disability from disease injuries and risk factors in 1990 and projected to 2002.
        Harvard School of Public Health, Boston, MA1996
        • Yusuf S.
        • Reddy S.
        • Ounpuu S.
        • Anand S.
        Global burden of cardiovascular diseases: part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization.
        Circulation. 2001; 104: 2746-2753
        • Darwin C.
        The expression of emotion in man and animals.
        Oxford University Press, New York1998
        • Friedman B.H.
        • Thayer J.F.
        Anxiety and autonomic flexibility: a cardiovascular approach.
        Biol Psychol. 1998; 49: 303-323
        • Thayer JF
        • Friedman B.H.
        The heart of anxiety: a dynamical systems approach.
        Springer Verlag, Amsterdam1997
        • Thayer J.F.
        • Lane R.D.
        A model of neurovisceral integration in emotion regulation and dysregulation.
        J Affect Disord. 2000; 61: 201-216
        • Malliani A
        • Pagani M.
        • Lombardi F.
        Methods for assessment of sympatho-vagal balance: power spectral analysis.
        Futura, Armonk, New York1994
        • Ershler W.B.
        • Keller E.T.
        Age-associated increased interleukin-6 gene expression, late-life diseases, and frailty.
        Annu Rev Med. 2000; 51: 245-270
        • Electrophysiology TFotESoCatNASoP
        Heart rate variability: standards of measurement physiological interpretation and clinical use.
        Circulation. 1996; 93: 1043-1065
        • Kleiger R.E.
        • Miller J.P.
        • Bigger Jr., J.T.
        • Moss A.J.
        Decreased heart rate variability and its association with increased mortality after acute myocardial infarction.
        Am J Cardiol. 1987; 59: 256-262
        • Tsuji H.
        • Venditti Jr., F.J.
        • Manders E.S.
        • et al.
        Reduced heart rate variability and mortality risk in an elderly cohort. The Framingham Heart Study.
        Circulation. 1994; 90: 878-883
        • Gerritsen J.
        • Dekker J.M.
        • TenVoorde B.J.
        • et al.
        Impaired autonomic function is associated with increased mortality, especially in subjects with diabetes, hypertension, or a history of cardiovascular disease: the Hoorn Study.
        Diabetes Care. 2001; 24: 1793-1798
        • Liao D.
        • Carnethon M.
        • Evans G.W.
        • Cascio W.E.
        • Heiss G.
        Lower heart rate variability is associated with the development of coronary heart disease in individuals with diabetes: the atherosclerosis risk in communities (ARIC) study.
        Diabetes. 2002; 51: 3524-3531
        • La Rovere M.T.
        • Bigger Jr., J.T.
        • Marcus F.I.
        • Mortara A.
        • Schwartz P.J.
        Baroreflex sensitivity and heart-rate variability in prediction of total cardiac mortality after myocardial infarction. ATRAMI (autonomic tone and reflexes after myocardial infarction) investigators.
        Lancet. 1998; 351: 478-484
        • Camm A.J.
        • Pratt C.M.
        • Schwartz P.J.
        • et al.
        Mortality in patients after a recent myocardial infarction: a randomized, placebo-controlled trial of azimilide using heart rate variability for risk stratification.
        Circulation. 2004; 109: 990-996
        • Liao D.
        • Cai J.
        • Barnes R.W.
        • et al.
        Association of cardiac autonomic function and the development of hypertension: the ARIC study.
        Am J Hypertens. 1996; 9: 1147-1156
        • Singh J.P.
        • Larson M.G.
        • Tsuji H.
        • Evans J.C.
        • O'Donnell C.J.
        • Levy D.
        Reduced heart rate variability and new-onset hypertension: insights into pathogenesis of hypertension: the Framingham Heart Study.
        Hypertension. 1998; 32: 293-297
        • Schroeder E.B.
        • Liao D.
        • Chambless L.E.
        • Prineas R.J.
        • Evans G.W.
        • Heiss G.
        Hypertension, blood pressure, and heart rate variability: the Atherosclerosis Risk in Communities (ARIC) study.
        Hypertension. 2003; 42: 1106-1111
        • Liao D.
        • Cai J.
        • Brancati F.L.
        • et al.
        Association of vagal tone with serum insulin, glucose, and diabetes mellitus—the ARIC Study.
        Diabetes Res Clin Pract. 1995; 30: 211-221
        • Singh J.P.
        • Larson M.G.
        • O'Donnell C.J.
        • et al.
        Association of hyperglycemia with reduced heart rate variability (The Framingham Heart Study).
        Am J Cardiol. 2000; 86: 309-312
        • Carnethon M.R.
        • Fortmann S.P.
        • Palaniappan L.
        • Duncan B.B.
        • Schmidt M.I.
        • Chambless L.E.
        Risk factors for progression to incident hyperinsulinemia: the Atherosclerosis Risk in Communities Study, 1987–1998.
        Am J Epidemiol. 2003; 158: 1058-1067
        • Christensen J.H.
        • Toft E.
        • Christensen M.S.
        • Schmidt E.B.
        Heart rate variability and plasma lipids in men with and without ischaemic heart disease.
        Atherosclerosis. 1999; 145: 181-186
        • Kupari M.
        • Virolainen J.
        • Koskinen P.
        • Tikkanen M.J.
        Short-term heart rate variability and factors modifying the risk of coronary artery disease in a population sample.
        Am J Cardiol. 1993; 72: 897-903
        • Ingjaldsson J.T.
        • Laberg J.C.
        • Thayer J.F.
        Reduced heart rate variability in chronic alcohol abuse: relationship with negative mood, chronic thought suppression, and compulsive drinking.
        Biol Psychiatry. 2003; 54: 1427-1436
        • Reed S.F.
        • Porges S.W.
        • Newlin D.B.
        Effect of alcohol on vagal regulation of cardiovascular function: contributions of the polyvagal theory to the psychophysiology of alcohol.
        Exp Clin Psychopharmacol. 1999; 7: 484-492
        • Rossy L.A.
        • Thayer J.F.
        Fitness and gender-related differences in heart period variability.
        Psychosom Med. 1998; 60: 773-781
        • Weise F.
        • Krell D.
        • Brinkhoff N.
        Acute alcohol ingestion reduces heart rate variability.
        Drug Alcohol Depend. 1986; 17: 89-91
        • Hayano J.
        • Yamada M.
        • Sakakibara Y.
        • et al.
        Short- and long-term effects of cigarette smoking on heart rate variability.
        Am J Cardiol. 1990; 65: 84-88
        • Kobayashi F.
        • Watanabe T.
        • Akamatsu Y.
        • et al.
        Acute effects of cigarette smoking on the heart rate variability of taxi drivers during work.
        Scand J Work Environ Health. 2005; 31: 360-366
        • Fifer W.P.
        • Fingers S.T.
        • Youngman M.
        • Gomez-Gribben E.
        • Myers M.M.
        Effects of alcohol and smoking during pregnancy on infant autonomic control.
        Dev Psychobiol. 2009; 51: 234-242
        • Minami J.
        • Ishimitsu T.
        • Matsuoka H.
        Effects of smoking cessation on blood pressure and heart rate variability in habitual smokers.
        Hypertension. 1999; 33: 586-590
        • Yotsukura M.
        • Koide Y.
        • Fujii K.
        • et al.
        Heart rate variability during the first month of smoking cessation.
        Am Heart J. 1998; 135: 1004-1009
        • Carter J.B.
        • Banister E.W.
        • Blaber A.P.
        Effect of endurance exercise on autonomic control of heart rate.
        Sports Med. 2003; 33: 33-46
        • Rennie K.L.
        • Hemingway H.
        • Kumari M.
        • Brunner E.
        • Malik M.
        • Marmot M.
        Effects of moderate and vigorous physical activity on heart rate variability in a British study of civil servants.
        Am J Epidemiol. 2003; 158: 135-143
        • Sloan R.P.
        • Shapiro P.A.
        • DeMeersman R.E.
        • et al.
        The effect of aerobic training and cardiac autonomic regulation in young adults.
        Am J Public Health. 2009; 99: 921-928
        • Petretta M.
        • Bonaduce D.
        • de Filippo E.
        • et al.
        Assessment of cardiac autonomic control by heart period variability in patients with early-onset familial obesity.
        Eur J Clin Invest. 1995; 25: 826-832
        • Karason K.
        • Molgaard H.
        • Wikstrand J.
        • Sjostrom L.
        Heart rate variability in obesity and the effect of weight loss.
        Am J Cardiol. 1999; 83: 1242-1247
        • Riva P.
        • Martini G.
        • Rabbia F.
        • et al.
        Obesity and autonomic function in adolescence.
        Clin Exp Hypertens. 2001; 23: 57-67
        • Nagai N.
        • Matsumoto T.
        • Kita H.
        • Moritani T.
        Autonomic nervous system activity and the state and development of obesity in Japanese school children.
        Obes Res. 2003; 11: 25-32
        • Rabbia F.
        • Silke B.
        • Conterno A.
        • et al.
        Assessment of cardiac autonomic modulation during adolescent obesity.
        Obes Res. 2003; 11: 541-548
        • Antelmi I.
        • de Paula R.S.
        • Shinzato A.R.
        • Peres C.A.
        • Mansur A.J.
        • Grupi C.J.
        Influence of age, gender, body mass index, and functional capacity on heart rate variability in a cohort of subjects without heart disease.
        Am J Cardiol. 2004; 93: 381-385
        • Reinhardt F.
        • Drexler H.
        • Bickel A.
        • et al.
        Electrophysiological investigation of central, peripheral and autonomic nerve function in workers with long-term low-level exposure to carbon disulphide in the viscose industry.
        Int Arch Occup Environ Health. 1997; 70: 249-256
        • Pitzalis M.V.
        • Iacoviello M.
        • Massari F.
        • et al.
        Influence of gender and family history of hypertension on autonomic control of heart rate, diastolic function and brain natriuretic peptide.
        J Hypertens. 2001; 19: 143-148
        • Piccirillo G.
        • Viola E.
        • Nocco M.
        • Durante M.
        • Tarantini S.
        • Marigliano V.
        Autonomic modulation of heart rate and blood pressure in normotensive offspring of hypertensive subjects.
        J Lab Clin Med. 2000; 135: 145-152
        • Maver J.
        • Strucl M.
        • Accetto R.
        Autonomic nervous system and microvascular alterations in normotensives with a family history of hypertension.
        Blood Press. 2004; 13: 95-100
        • De Angelis C.
        • Perelli P.
        • Trezza R.
        • et al.
        Modified autonomic balance in offsprings of diabetics detected by spectral analysis of heart rate variability.
        Metabolism. 2001; 50: 1270-1274
        • Lindmark S.
        • Wiklund U.
        • Bjerle P.
        • Eriksson J.W.
        Does the autonomic nervous system play a role in the development of insulin resistance? A study on heart rate variability in first-degree relatives of Type 2 diabetes patients and control subjects.
        Diabet Med. 2003; 20: 399-405
        • Huikuri H.V.
        • Jokinen V.
        • Syvanne M.
        • et al.
        Heart rate variability and progression of coronary atherosclerosis.
        Arterioscler Thromb Vasc Biol. 1999; 19: 1979-1985
        • Kennedy H.L.
        Beta blockade, ventricular arrhythmias, and sudden cardiac death.
        Am J Cardiol. 1997; 80: 29J-34J
        • Lampert R
        • Bremner JD
        • Su S
        • et al.
        Decreased heart rate variability is associated with higher levels of inflammation in middle-aged men.
        Am Heart J. 2008; 156: 759.e1-759.e7
        • Stein P.K.
        • Barzilay J.I.
        • Chaves P.H.
        • et al.
        Higher levels of inflammation factors and greater insulin resistance are independently associated with higher heart rate and lower heart rate variability in normoglycemic older individuals: the Cardiovascular Health Study.
        J Am Geriatr Soc. 2008; 56: 315-321
        • Barth J.
        • Schumacher M.
        • Herrmann-Lingen C.
        Depression as a risk factor for mortality in patients with coronary heart disease: a meta-analysis.
        Psychosom Med. 2004; 66: 802-813
        • Kubzansky L.D.
        • Kawachi I.
        Going to the heart of the matter: do negative emotions cause coronary heart disease?.
        J Psychosom Res. 2000; 48: 323-337
        • van Melle J.P.
        • de Jonge P.
        • Spijkerman T.A.
        • et al.
        Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: a meta-analysis.
        Psychosom Med. 2004; 66: 814-822
        • Sheps DS
        • Sheffield D
        Depression, anxiety, and the cardiovascular system: the cardiologist's perspective.
        J Clin Psychiatry. 2001; 62 (discussion 7–8): 12-16
        • Ward H.E.
        Depression and cardiovascular disease.
        Curr Opin Psychiatry. 2003; 16: 221-225
        • Yan L.L.
        • Liu K.
        • Matthews K.A.
        • Daviglus M.L.
        • Ferguson T.F.
        • Kiefe C.I.
        Psychosocial factors and risk of hypertension: the Coronary Artery Risk Development in Young Adults (CARDIA) study.
        JAMA. 2003; 290: 2138-2148
        • Yusuf S.
        • Hawken S.
        • Ounpuu S.
        • et al.
        Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.
        Lancet. 2004; 364: 937-952
        • Everson-Rose S.A.
        • House J.S.
        • Mero R.P.
        Depressive symptoms and mortality risk in a national sample: confounding effects of health status.
        Psychosom Med. 2004; 66: 823-830
        • Macleod J.
        • Davey Smith G.
        • Heslop P.
        • Metcalfe C.
        • Carroll D.
        • Hart C.
        Psychological stress and cardiovascular disease: empirical demonstration of bias in a prospective observational study of Scottish men.
        BMJ. 2002; 324: 1247-1251
        • Thayer J.F.
        • Friedman B.H.
        • Borkovec T.D.
        Autonomic characteristics of generalized anxiety disorder and worry.
        Biol Psychiatry. 1996; 39: 255-266
        • Carney R.M.
        • Freedland K.E.
        • Miller G.E.
        • Jaffe A.S.
        Depression as a risk factor for cardiac mortality and morbidity: a review of potential mechanisms.
        J Psychosom Res. 2002; 53: 897-902
        • Cohen H.
        • Matar M.A.
        • Kaplan Z.
        • Kotler M.
        Power spectral analysis of heart rate variability in psychiatry.
        Psychother Psychosom. 1999; 68: 59-66
        • Thayer JF
        • Friedman B.H.
        A neurovisceral integration model of health disparities in aging.
        The National Academies Press, Washington, D.C2004
        • Riese H.
        • Van Doornen L.J.
        • Houtman I.L.
        • De Geus E.J.
        Job strain in relation to ambulatory blood pressure, heart rate, and heart rate variability among female nurses.
        Scand J Work Environ Health. 2004; 30: 477-485
        • Tsaneva L.
        • Dukov R.
        Correlations between certain hearing changes and vegetative balance in miners.
        Cent Eur J Public Health. 2004; 12: 49-52
        • Hintsanen M.
        • Elovainio M.
        • Puttonen S.
        • et al.
        Effort-reward imbalance, heart rate, and heart rate variability: the Cardiovascular Risk in Young Finns Study.
        Int J Behav Med. 2007; 14: 202-212
        • Vrijkotte T.G.
        • van Doornen L.J.
        • de Geus E.J.
        Effects of work stress on ambulatory blood pressure, heart rate, and heart rate variability.
        Hypertension. 2000; 35: 880-886
        • van Amelsvoort L.G.
        • Schouten E.G.
        • Maan A.C.
        • Swenne C.A.
        • Kok F.J.
        Occupational determinants of heart rate variability.
        Int Arch Occup Environ Health. 2000; 73: 255-262
        • Aboa-Eboule C.
        • Brisson C.
        • Maunsell E.
        • et al.
        Job strain and risk of acute recurrent coronary heart disease events.
        JAMA. 2007; 298: 1652-1660
        • Belkic K.L.
        • Landsbergis P.A.
        • Schnall P.L.
        • Baker D.
        Is job strain a major source of cardiovascular disease risk?.
        Scand J Work Environ Health. 2004; 30: 85-128
        • Brosschot J.F.
        • Van Dijk E.
        • Thayer J.F.
        Daily worry is related to low heart rate variability during waking and the subsequent nocturnal sleep period.
        Int J Psychophysiol. 2007; 63: 39-47
        • Pieper S.
        • Brosschot J.F.
        • van der Leeden R.
        • Thayer J.F.
        Cardiac effects of momentary assessed worry episodes and stressful events.
        Psychosom Med. 2007; 69: 901-909
        • Mozaffarian D.
        • Stein P.K.
        • Prineas R.J.
        • Siscovick D.S.
        Dietary fish and omega-3 fatty acid consumption and heart rate variability in US adults.
        Circulation. 2008; 117: 1130-1137
        • Park S.K.
        • Tucker K.L.
        • O'Neill M.S.
        • et al.
        Fruit, vegetable, and fish consumption and heart rate variability: the Veterans Administration Normative Aging Study.
        Am J Clin Nutr. 2009; 89: 778-786
        • Brosschot J.F.
        • Gerin W.
        • Thayer J.F.
        The perseverative cognition hypothesis: a review of worry, prolonged stress-related physiological activation, and health.
        J Psychosom Res. 2006; 60: 113-124
        • Tiller W.A.
        • McCraty R.
        • Atkinson M.
        Cardiac coherence: a new, noninvasive measure of autonomic nervous system order.
        Altern Ther Health Med. 1996; 2: 52-65
        • Thayer J.F.
        • Fischer J.E.
        Heart rate variability, overnight urinary norepinephrine and C-reactive protein: evidence for the cholinergic anti-inflammatory pathway in healthy human adults.
        J Intern Med. 2009; 265: 439-447
        • Coats AJ
        Ethical authorship and publishing.
        Int J Cardiol. 2009; 131: 149-150