Significance, prognostic value and management of heart rate in hypertension

Many epidemiological studies have demonstrated that resting heart rate is a risk marker but also a risk factor in patients with coronary artery disease and heart failure. In hypertensive subjects free from overt cardiac disease, the question has been less frequently addressed. A few cohort studies have shown that hypertensive patients with a high resting heart rate have an increased risk of all-cause and cardiovascular death. However, intervention trials have not demonstrated that lowering the heart rate is beneficial in hypertensive subjects. Studies with an assessment of ambulatory heart rate tend to demonstrate a better association between cardiovascular outcomes and variables, including nighttime heart rate. Clinical trials comparing beta-blockers with non-slowing antihypertensive drugs have not demonstrated the superiority of the former. Finally, an elevated resting heart rate in hypertensive subjects free from overt cardiac disease seems to be more a risk marker than a risk factor. Although these patients are at high risk, no scientific data exist to support targeting heart rate. In this review, we describe the pathophysiological effects of heart rate, including vascular cell signalling, link with sympathetic activity and influence on central blood pressure, and the prognostic value and management of HR in hypertensive patients free from overt cardiac diseases.