Heart Rate Recovery After Exercise Is Associated With Arrhythmic Events in Patients With Catecholaminergic Polymorphic Ventricular Tachycardia

Abstract

BACKGROUND: Risk stratification in catecholaminergic polymorphic ventricular tachycardia remains ill defined. Heart rate recovery (HRR) immediately after exercise is regulated by autonomic reflexes, particularly vagal tone, and may be associated with symptoms and ventricular arrhythmias in patients with catecholaminergic polymorphic ventricular tachycardia. Our objective was to evaluate whether HRR after maximal exercise on the exercise stress test (EST) is associated with symptoms and ventricular arrhythmias. METHODS: In this retrospective observational study, we included patients ≤65 years of age with an EST without antiarrhythmic drugs who attained at least 80% of their age-and sex-predicted maximal HR. HRR in the recovery phase was calculated as the difference in heart rate (HR) at maximal exercise and at 1 minute in the recovery phase (ΔHRR1′). RESULTS: We included 187 patients (median age, 36 years; 68 [36%] symptomatic before diagnosis). Pre-EST HR and maximal HR were equal among symptomatic and asymptomatic patients. Patients who were symptomatic before diagnosis had a greater ΔHRR1′ after maximal exercise (43 [interquartile range, 25-58] versus 25 [interquartile range, 19-34] beats/min; P<0.001). Corrected for age, sex, and relatedness, patients in the upper tertile for ΔHRR1′ had an odds ratio of 3.4 (95% CI, 1.6-7.4) of being symptomatic before diagnosis (P<0.001). In addition, ΔHRR1′ was higher in patients with complex ventricular arrhythmias at EST off antiarrhythmic drugs (33 [interquartile range, 22-48] versus 27 [interquartile range, 20-36] beats/min; P=0.01). After diagnosis, patients with a ΔHRR1′ in the upper tertile of its distribution had significantly more arrhythmic events as compared with patients in the other tertiles (P=0.045). CONCLUSIONS: Catecholaminergic polymorphic ventricular tachycardia patients with a larger HRR following exercise are more likely to be symptomatic and have complex ventricular arrhythmias during the first EST off antiarrhythmic drug. VISUAL OVERVIEW: A visual overview is available for this article.

Aberrant autonomic pattern during the post-exercise recovery phase in long QT syndrome patients

“…In our study assessing HRR in both healthy controls and LQTS patients, BB treatment status had no significant impact on HRR. These findings are in agreement with findings published by Crotti et al in post-exercise was not affected by BB treatment (Crotti et al, 2012;Lieve et al, 2020). Moreover, we did not find any difference in HRR between asymptomatic and symptomatic patients.…”

“…Therefore, this study could not verify the findings made by Crotti et al, who reported that a more rapid HRR following exercise was correlated to symptomatic LQT1, independent of BB treatment (Crotti et al, 2012). Lieve et al also identified a correlation between a more rapid HRR and symptomatic patients in a different ion channel disease, catecholaminergic polymorphic ventricular tachycardia (CPVT) (Lieve et al, 2020). When comparing these findings to our study, it should be considered that our subgroups were relatively small (25 symptomatic and 19 asymptomatic patients) and that the groups consisted of a mixture of LQTS genotypes.…”

Repeatability of ventricular arrhythmia characteristics on the exercise-stress test in RYR2-mediated catecholaminergic polymorphic ventricular tachycardia

“…The difference between these two measures, the heart rate recovery, is indicative of the parasympathetic activity of the autonomic nerve system and is associated with the occurrence of symptoms in CPVT. 12 Therefore, parasympathetic activity does not seem highly variable within a patient at subsequent ESTs and is not likely related to our observed variability in VAS.…”

“… 1 In addition, studies addressing therapeutic efficacy use EST-specific endpoints, namely the occurrence and severity of ventricular arrhythmias 9 , 10 , 11 Finally, EST heart rate measurements have been studied to develop potential new tools for risk stratification in patients with CPVT. 12 , 13 …”

Sudden Cardiac Arrest in the Paediatric Population

“…Perturbations in the parasympathetic/sympathetic systems of the ANS or autonomic conflict, defined as concomitant sympathetic and parasympathetic stimulation, have been implicated in cardiac arrhythmias, SCD, SUD in epilepsy (SUDEP) and SIDS 5,[55][56][57] . It is well known that the ANS influences inherited arrhythmia syndromes.…”