Exercise echocardiography: abnormal heart rate recovery increased the risk of dying

Clinical bottom line (level 1b)

  1. One in thirty patients who underwent an exercise echocardiogram died within 9 years.
  2. The risk of dying was increased with abnormal heart rate recovery.
Watanabe et al: Circulation 2001; 104 : 1911-1916
Expires March 2004

The study

Prospective cohort study with objective outcomes, adjusted for confounding factors, not validated in an independent set of patients.

Setting: university hospital, USA

5438 patients (aged mean 57, 63% male) referred for exercise stress echocardiography

Excluded if
  • aged < 30
  • history of heart failure
  • valvular or congenital heart disease
  • implanted pacemaker or atrial fibrillation
  • used digoxin
  • no valid Social Security number


Factors studied:
  • age, sex, exercise capacity, left ventricular systolic function, myocardial ischaemia, cardiovascular risk factors
  • abnormal heart rate recovery difference in heart rate between peak exercise and 1 minute later 18 beats/minute or fewer


Multivariate Cox proportional regression analyses were used to adjust for confounding factors.

100% followed for 1 month to 9 years: mean 3 years

Outcomes studied:
  • death using Social Security Death Index

    The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)    		 NNF
    (95% CI)
    death 1 month to 9 years: mean 3 years 190/5438 3.5%
    (3.0% to 4.0%)    		 29
    (25 to 33)

    prognostic factor for
    death     		time to outcome adjusted RR
    (95% CI)    		 NNF+
    (95% CI)
    abnormal heart rate recovery 1 month to 9 years: mean 3 years 2.1
    (1.5 to 2.8)     		37
    (22 to 81)

      Citation

      1. Watanabe J, Thamilarasan M, Blackstone EH, et al: heart rate recovery immediately after treadmill exercise and left ventricular systolic dysfunction as predictors of mortality: the case of stress echocardiography. Circulation 2001; 104 : 1911-1916
      Search Terms: from ACP Journal Club other articles noted
      Contributor: Chris Ball, March 2002
      Reviewer:

      Clinical Question.
      Patient undergoing exercise echocardiography
      Intervention or Exposure abnormal heart rate recovery
      Outcome death