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Reduced heart-rate variability and increased risk of hypertension—a prospective study of the ELSA-Brasil


Although autonomic disturbances are known to precede hypertension onset, the risks underlying different ranges of blood pressure and impaired cardiac autonomic modulation are still unknown. This study aimed to identify the risk of hypertension incidence related to low heart-rate variability profile in normotensive blood pressure subcategories: normal (<120/80 mmHg) and prehypertension (120/80–139/89 mmHg) in a 4-year follow-up. 7665 participants free of hypertension at baseline were examined. They were allocated into one of two groups (<P25 and ≥P25) based on age-specific value distributions of heart-rate variability ranges presented in the literature. The relationship between heart-rate variability parameters (SDNN, RMSSD, VLF, LF, and HF) and hypertension incidence was analyzed using Poisson regression. The reference for the independent variable in these regressions was the dataset with all HRV values ≥P25. After full adjustments for age, sex, ethnicity, educational level, body mass index, smoking status, glucose, insulin, dyslipidemia, alcohol consumption, and physical activity, low values for all heart-rate variability indices were significantly associated with an increased relative risk of developing hypertension in the overall sample. Individuals with normal BP levels presented an increased risk for low SDNN, VLF, and LF values, whereas the risk in prehypertensive participants was only verified for low VLF. In conclusion, cardio autonomic disturbances precede the incidence of clinical hypertension and are potentially involved in its pathophysiological basis and progression. Even individuals with normal blood pressure may be at an increased risk for future hypertension in the presence of reduced cardio autonomic control.

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Fig. 1: Study flowchart.
Fig. 2: Venn’s diagram of subjects distribution according to each HRV index ≥P25.
Fig. 3: Forest plot displaying relative risk (RR), 95% confidence interval, and P values from fully adjusted Poisson regression models for the association between low HRV variables (<P25) and incident hypertension at 4-year follow-up.

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  1. Kanegae H, Oikawa T, Kario K. Should pre-hypertension be treated? Curr Hypertens Rep. 2017;19:1–9.

    Article  Google Scholar 

  2. Chen Q, Yin YJ, Chen WY, Wu JN, Huang X. Assessment of the association between serum uric acid levels and the incidence of hypertension in nonmetabolic syndrome subjects. Medicine. 2018;97:e9765.

    Article  CAS  Google Scholar 

  3. Thayer JF, Yamamoto SS, Brosschot JF. The relationship of autonomic imbalance, heart rate variability and cardiovascular disease risk factors. Int J Cardiol. 2010;141:122–31.

    Article  Google Scholar 

  4. Singh JP, Larson MG, Tsuji H, Evans JC, Donnell CJO, Levy D. Reduced heart rate variability and insights into pathogenesis of hypertension: the Framingham Heart Study. Hypertension. 1998;32:293–7.

    Article  CAS  Google Scholar 

  5. Jae SY, Bunsawat K, Fadel PJ, Fernhall B, Choi YH, Park JB, et al. Attenuated heart rate recovery after exercise testing and risk of incident hypertension in men. Am J Hypertens. 2016;29:1103–8.

    Article  Google Scholar 

  6. Grassi G, Mark A, Esler M. The sympathetic nervous system alterations in human hypertension. Circ Res. 2015;116:976–90.

    Article  CAS  Google Scholar 

  7. Schroeder EB, Liao D, Chambless LE, Prineas RJ, Evans GW, Heiss G. Hypertension, blood pressure, and heart rate variability: the Atherosclerosis Risk in Communities (ARIC) Study. Hypertension. 2003;42:1106–11.

    Article  CAS  Google Scholar 

  8. Task Force of the European Society of Cardiology the North American Society of Pacing Electrophysiology. Heart rate variability: standards of measurement, physiological interpretation, and clinical use. Circulation. 1996;93:1043–65.

    Article  Google Scholar 

  9. Hoshi RA, Vanderlei L, Godoy MF, Bastos FN, Netto J Jr, Pastre CM. Temporal sequence of recovery-related events following maximal exercise assessed by heart rate variability and blood lactate concentration. Clin Physiol Funct Imaging. 2017;37:536–43.

    Article  CAS  Google Scholar 

  10. Hoshi RA, Pastre CM, Vanderlei LCM, Godoy MF. Poincaré plot indexes of heart rate variability: relationships with other nonlinear variables. Auton Neurosci Basic Clin. 2013;177.

  11. Vanderlei LCM, Pastre CM, Hoshi RA, de Carvalho TD, de Godoy MF. Basic notions of heart rate variability and its clinical applicability. Braz J Cardiovasc Surg. 2009;24:205–17.

    Article  Google Scholar 

  12. Shaffer F, McCraty R, Zerr CL. A healthy heart is not a metronome: an integrative review of the heart’s anatomy and heart rate variability. Front Psychol. 2014;5:1040.

    Article  Google Scholar 

  13. Hoshi RA, Santos IS, Dantas EM, Andreão RV, Schmidt MI, Duncan BB, et al. Decreased heart rate variability as a predictor for diabetes—a Prospective Study of the Brazilian Longitudinal Study of Adult Health. Diabetes Metab Res Rev. 2019;35:e3175.

    Article  Google Scholar 

  14. Liao D, Cai J, Barnes RW, Tyroler HA, Rautaharju P, Hohne I, et al. Association of cardiac autonomic function and the development of hypertension—the ARIC Study. Am J Hypertens. 1996;7061:1147–56.

    Article  Google Scholar 

  15. Joint National Committee. The Seventh Report of the Joint National Committee on Complete Report on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. 2004.

  16. Doğru MT, Simşek V, Sahin O, Ozer N. Differences in autonomic activity in individuals with optimal, normal, and high-normal blood pressure levels. Turk Kardiyol Dern Ars. 2010;38:182–8.

    PubMed  Google Scholar 

  17. Lucini D, Mela GS, Malliani A, Pagani M. Impairment in cardiac autonomic regulation preceding arterial hypertension in humans. Circulation. 2002;106:2673–9.

    Article  Google Scholar 

  18. Aquino EML, Barreto SM, Bensenor IM, Carvalho MS, Chor D, Duncan BB, et al. Brazilian longitudinal study of adult health (ELSA-Brasil): objectives and design. Am J Epidemiol. 2012;175:315–24.

    Article  Google Scholar 

  19. Mill JG, Pinto K, Griep RH, Goulart A, Foppa M, Lotufo P, et al. Medical assessments and measurements in ELSA-Brasil. Rev Saude Publica. 2013;47:54–62.

    Article  Google Scholar 

  20. Williams B, Mancia G, Spiering W, Agabiti RE, Azizi M, Burnier M, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J. 2018;39:3021–104.

    Article  Google Scholar 

  21. Schmidt M, Hoffmann JF, Diniz MF, Lotufo PA, Griep RH, Bensenor IM et al. High prevalence of diabetes and intermediate hyperglycemia—the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Diabetol Metab Syndr. 2014;6.

  22. Bensenor IM, Griep RH, Pinto KA, Faria CP, de, Felisbino-Mendes M, Caetano EI, et al. Routines of organization of clinical tests and interviews in the ELSA-Brasil investigation center. Rev Saude Publica. 2013;47:37–47.

    Article  Google Scholar 

  23. Tomiyama H, Kimura Y, Sakuma Y, Shiojima K, Yamamoto A, Saito I, et al. Effects of an ACE Inhibitor and a calcium channel blocker on cardiovascular autonomic nervous system and carotid distensibility in patients with mild to moderate hypertension. Am J Hypertens. 1998;11:682–9.

    Article  CAS  Google Scholar 

  24. Pinar E, García-Alberola A, Llamas C, Vicente T, López-Candel J, Rojo JL, et al. Effects of verapamil on indexes of heart rate variability after acute myocardial infarction. Am J Cardiol. 1998;81:1085–9.

    Article  CAS  Google Scholar 

  25. Brembilla-Perrot B, Jacquemin L, Beurrier D. Relationships between heart rate variability and antiarrhythmic effects of hydroquinidine. Cardiovasc drugs Ther. 1997;11.

  26. Dantas EM, Kemp AH, Andreão RV, da Silva VJD, Brunoni AR, Hoshi RA, et al. Reference values for short-term resting-state heart rate variability in healthy adults: results from the Brazilian Longitudinal Study of Adult Health-ELSA-Brasil study. Psychophysiology. 2018;55:e13052.

    Article  Google Scholar 

  27. Chor D, Luiz Pinho Ribeiro A, Sá Carvalho M, Bartholow Duncan B, Andrade Lotufo P, Araújo, Nobre A, et al. Prevalence, awareness, treatment and influence of socioeconomic variables on control of high blood pressure: results of the ELSA-Brasil Study. PLoS ONE. 2015;10:e0127382.

    Article  Google Scholar 

  28. Matsudo S, Araújo T, Matsudo V, Andrade D, Andrade E, Oliveira LC, et al. Questionário Internacional de Atividade Física (IPAQ): Estudo de validade e reprodutibilidade no Brasil. Ativ FíSci e Saúde. 2001;6:5–18.

    Google Scholar 

  29. World Health Organization. Global recommendations on physical activity for health. Geneva; World Health Organization: 2010.

  30. Verma N. Sympathetic nervous system and hypertension. Hypertens J. 2017;3:27–36.

    Article  Google Scholar 

  31. Selby J, Friedman G, Quesenberry C. Precursors of essential hypertension: pulmonary function, heart rate, uric acid, serum cholesterol, and other serum chemistries. Am J Epidemiol. 1990;131:1017–27.

    Article  CAS  Google Scholar 

  32. Palatini P, Julius S. Heart rate and the cardiovascular risk. J Hypertens. 1997;15:3–17.

    Article  CAS  Google Scholar 

  33. McCraty R, Shaffer F. Heart rate variability: new perspectives on physiological mechanisms, assessment of self-regulatory capacity, and health risk. Glob Adv Heal Med. 2015;4.

  34. Lampert R, Bremner J, Su S, Miller A, Lee F, Cheema F, et al. Decreased heart rate variability is associated with higher levels of inflammation in middle-aged men. Am Heart J. 2008;156:759.e1–7.

    Article  Google Scholar 

  35. Virtanen R, Jula A, Kuusela T, Helenius H, Voipio-Pulkki LM. Reduced heart rate variability in hypertension: Associations with lifestyle factors and plasma renin activity. J Hum Hypertens. 2003;17:171–8.

    Article  CAS  Google Scholar 

  36. Shaffer F, Ginsberg JP. An overview of heart rate variability metrics and norms. Front Public Health. 2017;5:1–17.

    Article  Google Scholar 

  37. Reyes del Paso GA, Langewitz W, Mulder LJM, van Roon A, Duschek S. The utility of low frequency heart rate variability as an index of sympathetic cardiac tone: a review with emphasis on a reanalysis of previous studies. Psychophysiology. 2013;50:477–87.

    Article  Google Scholar 

  38. Hoshi RA, Santos IS, Dantas EM, Andreão RV, Mill JG, Duncan BB, et al. Diabetes and subclinical hypothyroidism on heart rate variability. Eur J Clin Invest. 2020;50:e13349.

    Article  CAS  Google Scholar 

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We are very grateful to all the ELSA-Brasil participants and research staff.


This study was funded by the Brazilian Ministry of Health (Science and Technology Department) and Brazilian Ministry of Science and Technology (FINEP and CNPq).

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Correspondence to Rosangela A. Hoshi.

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Hoshi, R.A., Santos, I.S., Dantas, E.M. et al. Reduced heart-rate variability and increased risk of hypertension—a prospective study of the ELSA-Brasil. J Hum Hypertens 35, 1088–1097 (2021).

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