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EDITORIAL

The Breakdown of Fractal Heart Rate Dynamics Predicts Prolonged Postoperative Myocardial Ischemia

Timo T. Laitio, MD^*, Heikki V. Huikuri, MD^||, Timo H. Mäkikallio, MD^||, Jouko Jalonen, MD^*, Erkki S. H. Kentala, MD^*, Hans Helenius, MSc, Olar Pullisaar, MD, Jaakko Hartiala, MD, and Harry Scheinin, MD

Departments of *Anesthesiology and Intensive Care, and Clinical Physiology, Turku University Hospital, Turku, Finland; the Departments of Biostatistics, and Pharmacology and Clinical Pharmacology, and Turku PET Centre, University of Turku, Turku, Finland; ||Division of Cardiology, Department of Medicine, Oulu University Hospital, Oulu, Finland

Address correspondence and reprint requests to Timo Laitio, MD, Department of Anesthesiology and Intensive Care, Turku University Hospital, Turku, Finland. POB 52, FIN-20521 Turku, Finland. Address email to timo.laitio{at}tyks.fi

Abstract

Patients with myocardial ischemia after noncardiac surgery have a three- to ninefold increased risk of adverse cardiac events. In this study we tested the hypothesis that altered preoperative heart rate variability (HRV) predicts postoperative prolonged myocardial ischemia (>10 min) in elderly surgical patients. Thirty-two patients, age 60 yr or older, admitted to hospital for surgical repair of a traumatic hip fracture with preoperative night and daytime Holter recordings were included. Holter monitoring was initiated at arrival at hospital and continued until the third postoperative morning. Conventional HRV measures along with analysis of short-term fractal scaling exponent (₁) of RR intervals were assessed for night (from 2 AM to 5 AM) and day (7 AM to 12 AM) periods in each patient. Preoperative ₁ was significantly lower (i.e., increased randomness in HRV) during the nighttime compared with daytime (mean ± SEM; 0.92 ± 0.08 versus 1.03 ± 0.06; P = 0.002) in patients with postoperative myocardial ischemia. Patients without ischemia had no such difference. In stepwise multivariate logistic regression analysis, increased preoperative night-day difference of ₁ was the only independent predictor of postoperative prolonged ischemia. The odds ratio for an increase of 0.16 U in night-day difference of ₁ (corresponding to interquartile range) was 7.7 (95% confidence interval, 1.9–51.4; P = 0.0018). Breakdown of fractal-like heart rate dynamics is predictive for postoperative prolonged myocardial ischemia in elderly patients having emergency surgery for traumatic hip fracture.

IMPLICATIONS: Night and daytime Holter recordings before surgical repair of traumatic hip fracture were analyzed with linear and nonlinear heart rate variability methods. Preoperatively increased randomness in heart rate variability was predictive for postoperative, silent prolonged myocardial ischemia. Prolonged myocardial ischemia increases the risk for adverse cardiac events.

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