Resting heart rate and measures of effort-related cardiac autonomic dysfunction predict cardiovascular events in asymptomatic type 2 diabetes

Autonomic control of the cardiovascular system may be impaired in type 2 diabetes and is associated with increased morbidity and mortality. Parameters obtained during stress testing may reflect early stages of cardiac autonomic dysfunction and provide prognostic information in asymptomatic type 2 diabetes.

We performed maximal exercise treadmill testing in 594 patients with type 2 diabetes without known coronary heart disease. The prognostic significance of physiological parameters associated with autonomic dysfunction was assessed, including chronotropic incompetence (<80% heart rate reserve), abnormal heart rate recovery at 1 minute <18 beats/minute, and resting tachycardia >100 beats/minute. Cox proportional hazards analysis was used to determine the association of exercise parameters with a composite outcome of all-cause mortality, myocardial infarction or stroke.

Resting heart rate >100 beats/minute was observed in 18% of patients, chronotropic incompetence in 30% and heart rate recovery at 1 minute <18 beats/minute in 35%. Over 79 ± 16 months, there were 72 (12%) events. Each parameter was significantly associated with event risk in an adjusted multivariate analysis: chronotropic incompetence (hazard ratio 1.89, 95% confidence interval 1.18–3.01; P = 0.008), resting heart rate ≥100 beats/minute (hazard ratio 1.97, 95% confidence interval 1.19–3.26; P = 0.008) and heart rate recovery at 1 minute <18 beats (hazard ratio 1.77, 95% confidence interval 1.12–2.81; P = 0.015). A progressive relationship between the number of abnormal parameters and event risk was observed (log rank P < 0.001).

Chronotropic incompetence, resting tachycardia and reduced heart rate recovery are independently and additively associated with long-term mortality, myocardial infarction or stroke in type 2 diabetes without known coronary heart disease.