Prolonged Elevated Heart Rate is a Risk Factor for Adverse Cardiac Events and Poor Outcome after Subarachnoid Hemorrhage

Abstract

Introduction Sympathetic nervous system hyperactivity is common after subarachnoid hemorrhage (SAH). We sought to determine whether uncontrolled prolonged heart rate elevation is a risk factor for adverse cardiopulmonary events and poor outcome after SAH. Methods We prospectively studied 447 SAH patients between March 2006 and April 2012. Prior studies define prolonged elevated heart rate (PEHR) as heart rate >95 beats/min for >12 hours. Major adverse cardiopulmonary events were documented according to predefined criteria. Global outcome at 3 months was assessed with the modified Rankin Scale (mRS). Results 175 (39%) patients experienced PEHR. Nonwhite race/ethnicity, admission Hunt-Hess grade ≥4, elevated APACHE-2 physiological subscore, and modified Fisher score were significant admission predictors of PEHR, whereas documented pre-hospital beta-blocker use was protective. After controlling for admission Hunt-Hess grade, Cox regression using time-lagged covariates revealed that PEHR onset in the previous 48 hours was associated with an increased hazard for delayed cerebral ischemia, myocardial injury and pulmonary edema. PEHR was associated with 3-month poor outcome (mRS 4-6) after controlling for known predictors. Conclusions PEHR is associated with major adverse cardiopulmonary events and poor outcome after SAH. Further study is warranted to determine if early sympatholytic therapy targeted at sustained heart rate control can improve outcome after SAH.

Tachycardia burden in stroke unit is associated with functional outcome after ischemic stroke

“…(13) Moreover, prolonged elevated heart rate is significantly associated with poor functional outcome and major cardiopulmonary events in patients with subarachnoid hemorrhage (SAH). (14) However, it is not clear whether tachycardia is associated with functional outcome in patients with acute ischemic stroke. In this study, we sought to investigate the association of tachycardia burden during stroke unit stay and 3-month functional outcome after ischemic stroke.…”

What Do We Mean by Poor-Grade Aneurysmal Subarachnoid Hemorrhage and What Can We Do?

“…A few very interesting randomized trials are currently investigating neurocritical care measures beyond neurosurgery in or including SAH: EARLYDRAIN on early lumbar drainage combined with EVD [9], SETPOINT2 on early tracheostomy [10], NEWTON on slow-release nimodipine via EVD [11], ULTRA on early tranexamic acid [12], and HIMALAIA on induced hypertension [13]. However, there are so many other NCCU aspects to be addressed prospectively: level of sedation, modes of ventilation [14,15], cardiopulmonary stability [16,17], monitoring-based circulatory strategies [18], temperature control [19][20][21], delirium management, the nursing factor and mobilization, policies of do-not-resuscitate orders and withdrawal of care [22,23], and many other day-to-day care decisions that may substantially impact outcome. Particularly, the poor-grade SAH patient, prone to so many cerebral and systemic complications, may benefit from aggressive surveillance, superb nursing care, and close clinical monitoring.…”

Baroreflex Impairment After Subarachnoid Hemorrhage Is Associated With Unfavorable Outcome

“…They are also in line with the results of Schmidt et al (30) who, assessed HR variability in the frequency domain in subarachnoid haemorrhage and identified an association between the LF/HF ratio (a ratio between the low frequency power and the high frequency power in RR intervals time series), which is an indicator of the sympathetic activity, and the occurrence of an infection or of a delayed ischemic deficit. In another study, Schmidt et al highlighted an association between a HR increase above 95 /minute lasting more than 12 hours and the 3-month functional outcome (31). Their results did not include the baroreceptor sensitivity assessment.…”