Proceedings of the 2nd International Conference on Inventive Communication and Computational Technologies (ICICCT 2018)

IEEE Xplore Compliant - Part Number: CFP18BAC-ART; ISBN:978-1-5386-1974-2

Heart Rate Variability Analysis: Application Overview

Aboli N. Londhe Mithilesh Atulkar*

Department of Computer Applications Department of Computer Applications
National Institute of Technology Raipur National Institute of Technology Raipur
Raipur, Chhattisgarh, INDIA Raipur, Chhattisgarh, INDIA
[email protected] [email protected]

Abstract—Heart rate variability (HRV) is very well known dilation [2]. Its abnormality associated with the several
and highly practiced bio-marker for cardiac and related systems cardiological and non-cardiological diseases. Moreover, HRV
disease diagnosis. The cardiac alterations in the time interval has achieved a prognostic value due to rising evolution in
between two consecutive heart beats is HRV and also referred as computing machines, signal processing and statistical methods
the fluctuations in the inter beat intervals (IBIs). A healthy heart and is therefore very important in risk stratification.
is rhythmic and has complex and oscillating nature which
provides the sudden and rapid adjustments in physiological The PNS and SNS which are the branches of an ANS
changes to hemostasis. This paper briefly reviews current controls and regulates the bodily functions such as the heart
application perspectives of this biomarker in various disease rate, respiratory rate, digestion, urination, pupillary response,
diagnoses along with its usefulness, strategies and challenges. and sexual arousal unconsciously [3]. An imbalance of an
autonomic function reflects on the HRV in terms of change in
Keywords- Heart rate variability, Cardiological disorders, non- heart rate (HR) and rhythms and it identification can be visible
cardiological disorders, tertiary medicine, HRV metrics, HRV in its rhythmic variation while acquiring electrocardiogram
norms. (ECG). Therefore, it could be the most momentous and
simplest but useful non-invasive technique to examine the
I. INTRODUCTION influences of various physiological activities on autonomic
Heart rate is the physiological phenomenon which is nervous system (ANS).
defined as the number of heartbeats per minute. It is the The organization of the paper is as follows: section II and
variation in the time intervals between two consecutive section II deals with the enormous overview on HRV analysis
heartbeats [1]. Basically, HRV is an outcome of heart-brain and applications in cardiovascular and non-cardiovascular
interactions and also referred as a neuro-cardiac function which disorders respectively. Moreover, the influence of the tertiary
is controlled by the parasympathetic nervous system (PNS) and medications such Ayurveda and yoga on HRV is presented in
sympathetic nervous system’s (SNS), two sub-sections of an section IV. Lastly, the important time-domain, frequency-
autonomic nervous system (ANS) as shown in figure 1 below. domain and non-linear metrics as well as the Ultra-Short-Term
(UST) measurement, Short-term (ST) measurement and
twenty-four-hour (24h) measurement norms are discussed in
section V. Further, the paper is concluded in the last section.

II. CARDIOLOGICAL DISORDERS

A. Blood Pressure
Nowadays, highest number of deaths worldwide occurs
due cardiological diseases such as Coronary heart disease
(CHD) and cerebrovascular disease (CVD). A high blood
pressure which is commonly recognized as hypertension, is
one of the most important cause of CHD and CVD, which also
create a key monetary burden in various countries across the
world [4]. The increment in sympathetic and decrement in
parasympathetic activities is commonly caused due to a
hypertension which reduces the HRV in adulthood [5].
Recently, reduction in HRV was reported in men consuming
Fig.1. The schematic representation of the Autonomous control of HRV. salt on regular basis [6], and negatively associated with the
elongated QT interval in patients with elementary vital
HRV is said to a promising cardiac bio-marker and is hypertension [7]. However, relation between childhood
significantly used due to its ease of derivation which reflects hypertension and HRV is found unclear and not stable as
the regulation of gas exchange, blood pressure (BP), heart, gut, adults. Moreover, the difference in autonomic functioning due
and vascular tone, which is related to the degree of the to difference in the physiological parameter in younger
constriction of diameter of the blood vessel in its maximum children makes it difficult to generalize the reliability of
*
Corresponding author findings with adults [8]. Nevertheless, Xie at al. has also

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 Proceedings of the 2nd International Conference on Inventive Communication and Computational Technologies (ICICCT 2018)
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reported that ANS dysfunction is a perilous attribute in disturbance of the complexity of the HRV indicating temporal
hypertensive and pre-hypertensive children. breakdown of the fractal organization of the heartbeat
regulating system induced by smoking [17]. Moreover, the
B. Diabetes termination of the smoking significantly improves HRV in
The second important common cause of CVD is Diabetes, chronic male smokers, indicating improved autonomic
which is ascertained with the decreased HRV in [9]. There are modulation of the heart [18]. Therefore, this may be primarily
chances of presence of 20-40% of other diabetic complications regarded as being caused by nicotine discontinuation rather
frequently coexists with Diabetic autonomic neuropathy which than tobacco smoke discontinuation alone.
is a cause of increased morbidity as well as mortality.
Moreover, the ANS may get affected by the one of the III. NON-CARDIOLOGICAL DISORDERS
common non-communicable disease called Diabetes mellitus Not only cardiovascular disorders affect HRV but also non-
[10]. HRV can be improves in Diabetes-II by physical exercise cardiological parameters will have effect on the HRV. The
[11]. While, in case of diabetes-I patients, the physical capacity various studies such as physical state i.e. drowsiness and an
is being determined using HRV [12]. The time domain analysis
emotional state i.e. stress, sad, happy, angry etc. [19] as well
of the parasympathetic and sympathetic control in elders with
as polycystic ovary syndrome (PCOS) [20] problem in women
and without diabetes mellitus was reported using HRV by
Rebeiro et al. [13] which suggested that parasympathetic affects on HRV. Moreover, the HRV can be associated with
control may get worsen in elders with diabetes mellitus. the ANS. Recently, HRV analysis was used as a surrogate
measure to assess importance of the cardiac autonomic
C. Physical Inactivity or Obesity functions in Chronic Traumatic Spinal Cord [21]. Similarly,
the study associated with ANS reported that the improvement
The effects of physical activeness or exercise on in HRV while performing mild cognitive task following
cardiovascular function have been presented in many
injuries [22]. Moreover, numerous studies reported recently
transverse as well as physical training studies. The one of the
has revealed that ischemic stroke which indicates autonomic
most reflective effect of aerobic training is it reduces the
resting HR. However, there are divisive disputes on the dysfunction due measured impaired HRV and other important
changes in nature of ANS that accompany consistent bodily risk factors. Moreover, the recent study has presented that the
exercise in numerous studies which have indicated increasing HRV measures will also get affected by short-time exposure
vagal tone as the wholesome effect of exercise [14]. Further, a of particulate matter (PM) in polluted air. [23].
transverse study reported that people who habitual for
moderate and vigorous physical exercise has greater levels of
vagally mediated HRV [14]. Later on, the HRV analysis IV. INTEGRATIVE/TERTIARY MEDICINE
between adults after the 12-week period of aerobic training A. Ayurveda
have been studied [15]. It was found that the high frequency Ayurveda is an ancient medication system helps in natural
(HF) power, frequency domain metric of HRV increases in healing which has origins in Vedic Culture of India. It has
men but it was constant in women and also it again retained to promising application in the management of the major
its base level after deconditioning [15]. Based on the summary depression disorders (MDD). However, it was lacking in
of the aforementioned reported studies it has been clear that the research till past decades. In 2014 [24], the influence of
physical activity has a very crucial role in increasing vagal tone Ayurvedic medication on HRV was studied by the group of
whereas, physical inactiveness is shows decreased vagal tone. researchers. The study presented the significant effect of
The next risk factor for CVD is obesity. Obesity increases Ayurvedic treatments i.e. Panchakarma and Ayushman-15 on
with increased body mass index (BMI) which may be the one HRV after a duration of two months. In last year [25], the
of the cause of mortality. Although, there are rigorous and study on a comparison of the data of spectral analysis of heart
consistent studies of rising cases of CVDs in patients with rate variability with clinical evaluation of pathological state of
obesity and still the reason associated, is unclear. However, doshas is reported.
reduction in autonomic functions which leads to fat imbalance
in the body which may be the one of the negative risk factor for B. Yoga
increasing the chances of CVD in obesity. In a normal healthy Yoga is an ancient Indian holistic art of living meant to quieten
body, the increase in the percentage of the fat contents than its the mind and achieve its union with the divine intelligence of
upper limit will increases the risk of diseases. Therefore, it is
the universe [26]. Defined by Sage Patanjali as “Yogah Chitta
needful to setup cut-off values of body fat content based upon
vritti nirodhah” and Sage Vasishta as “manah prashamana
its association with disease for a risk stratification purpose.
upayah yogah,” Yoga offers asanas, kriyas, mudras, bandhas,
and conscious physical relaxation for the body; concentration
D. Smoking
and meditation for the mind and Pranayama techniques to
According to studies, hemodynamic changes in the absorb “prana,” the life energy of the universe for the
cardiovascular system occurs due to increase in adrenergic sustenance of the being (Chandogya Upanishad).
activities in the persons who are acute cigarette smokers. The Therefore, several research groups have been studying the
change in HRV parameters immediate after smoking has
importance of the Yoga for preventing the cardiovascular
reported during short-time HRV analysis [16]. Whereas, study
diseases with the help of various studies such as effect of
on long-term smokers or habitual revealed a noticeable

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 Proceedings of the 2nd International Conference on Inventive Communication and Computational Technologies (ICICCT 2018)
IEEE Xplore Compliant - Part Number: CFP18BAC-ART; ISBN:978-1-5386-1974-2

Yoga for early prevention of CVD in Postmenopausal studied for HRV analysis as it is relatively easy for recording
Women, effect of yoga on cardiovascular parameters during [34]. However, ST values are only suitable when the subject
pregnancy [26] [27], influence of the right and left nostril breathe at normal rates (~11–20 bpm). During resonance
yogic breathing on the HRV in young adults [27], effect of frequency biofeedback, the only relevant metrics are LF ms 2
yogic techniques on HRV [28], and very recently, study of or peak frequency since breathing from 4.5 to 7.5 bpm
change in HRV during Bhramari Pranayama has been reported concentrates HR oscillations around 0.1 Hz in the LF band.
[29]. The details of ST norms are given in Table II.
V. HRV METRICS AND NORMS 3) Twenty-Four Hour (24h) Measurement Norms
Generally, ambulatory HRV monitoring is the only possible
A. HRV Metrics way to obtain the Twenty-four-hour (24h) norms. Nowadays,
Mainly, HRV metrics are categorized in linear and non- there is rapid advancement in the technology for recording and
linear metrics. The basic linear metrics are of two domains i.e. interpreting long-term “naturalistic” HR adjustments [53]. The
time domain and frequency domain. These metrics are used to risk of mortality in moderately depressed and highly-
measure HRV over long time i.e. 24 h, short-term (~5 min), depressed HRV was studied in the task force report [34] on
and ultra-short-term (< 5 min). Generally, 24h measure is 144 subjects. The authors reported 24h time-domain measures
preferable for HRV due to it generated in natural stimuli and of SDNN, SDANN, RMSSD, and the HRV HTI, and supine
workload conditions for longer period which are not get 5 min frequency-domain measures for LF power (LF ms2 and
interchange by other short and ultra-short-term values. The nu), HF power (HF ms2 and nu), LF/HF power, and total
variability of the inter beat intervals in time domain was power (ms2). The details of 24h norms are given in Table II.
calculated in natural logarithm of an original unit to achieve
better normal distribution [30]. Also, the absolute distribution
into four frequency bands viz. ultra-low-frequency (ULF), VI. CONCLUSION
very-low-frequency (VLF), low-frequency (LF), and high- HRV is said to a promising cardiac bio-marker and is
frequency (HF) bands are estimated in frequency- domain significantly used due to its ease of derivation of time-domain,
measures [31]. The details of HRV metrics are presented in frequency-domain and non-linear measures which reflects the
Table I. regulation of, gas exchange, blood pressure (BP), heart, gut,
and vascular tone, which is related to the degree of the
C. HRV Norms constriction of diameter of the blood vessel in its maximum
dilation. It's abnormality associated with the several
HRV norms for long term (24 h), short term and ultra-short- cardiological and non-cardiological diseases. Moreover, HRV
term (UST) measurements have been summarized in Table II. has achieved a prognostic value due to rising evolution in
computing machines, signal processing and statistical methods
1) Ultra-Short-Term (UST) Measurement Norms and is therefore very important in risk stratification.
HRV measurements of duration less than 5min of data are
reported under UST. Although, the efficiency of UST
recording in both clinical and research settings make it REFERENCES
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Calvano, and Ioannis, “On heart rate variability and autonomic activity
validity criterion for acceptance (e.g., r = 0.9). As there is no in homeostasis and in systemic inflammation”. Math Biosci. vol. 252,
promising correlation between measurements, investigators 2014, pp.36–44. doi: 10.1016/j.mbs.2014.03.010.
utilize the more rigorous Bland-Altman Limits of Agreement [4] P. M. Kearney, M. Whelton, K. Reynolds, P. Muntner, P. K. Whelton,
(LoA) method like Munoz et al. [50] which evaluated two and J. He, “Global burden of hypertension: analysis of worldwide data,”
Article in press. Vol 365 January 15, 2005.
methods of measurement and shown 95% agreement between
[5] J.P. Singh, M. G. Larson, H. Tsuji, C. J. Evans, C. J. O’Donnell, and D.
them over repeated measures. According to the emerging Levy. "Reduced heart rate variability and new-onset hypertension:
overview we can say that the UST measures has significant insights into pathogenesis of hypertension: the Framingham Heart
greater influence than the long-term measures in terms of the Study." Hypertension, vol. 32, no. 2, 1998, pp. 293-297.
contextual factors such as recording method (BVP vs. ECG), [6] C. S. Weber et al., “Salt-sensitive men show reduced heart rate
age, health, measurement condition, artifacting procedures, variability, lower norepinephrine and enhanced cortisol during mental
stress,” J. of Human Hypertension, vol. 22, 2008 pp. 423–431.
and the concurrent-validity criteria. The details of HRV norms
for UST are presented in Table II.

2) Short-Term (ST) Measurement Norms

HRV measurement are based on ~5 min of HRV data are ST
measurements. Although, ST measurements are widely

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Proceedings of the 2nd International Conference on Inventive Communication and Computational Technologies (ICICCT 2018)
IEEE Xplore Compliant - Part Number: CFP18BAC-ART; ISBN:978-1-5386-1974-2

Table I. HRV Metrics

Metrics Parameters units Description
Standard deviation of NN intervals: - it is a “gold standard" for medical stratification of
SDNN ms cardiac risk when recorded over a 24 h period. It used to predict both morbidity and
mortality.
Standard deviation of RR intervals: - measures the CVS’s response to more diverse
SDRR ms environmental stimuli and workloads. Abnormal beats may reflect cardiac dysfunction or
noise that pretenses as HRV
Standard deviation of the average NN intervals for each 5 min segment of a 24 h HRV
SDANN ms
recording
Time-
SDNN index Mean of the standard deviations of all the NN intervals for each 5 min segment of a 24 h
domain ms
(SDNNI) HRV recording
pNN50 % Percentage of successive RR intervals that differ by more than 50 ms
Average difference between the highest and lowest heart rates during each respiratory
HR Max − HR Min bpm
cycle
RMSSD ms Root mean square of successive RR interval differences
HRV triangular Integral of the density of the RR interval histogram divided by its height. HTI and
index (HTI) RMSSD can jointly distinguish between normal heart rhythms and arrhythmias.
TINN ms Baseline width of the RR interval histogram
Absolute power of the ultra-low-frequency band (≤0.003 Hz).: - correlated with the
ULF power SDANN time-domain index. Primary driver-24-hour rhythms [34]. Correlation with
ms2
other functions: -Core body temperature, metabolism, and the renin–angiotensin system
operates over a long-time period [33]
Absolute power of the very-low-frequency band (0.0033–0.04 Hz): - associated with
arrhythmic death and PTSD [37]. Generated by: - physical activity [38],
VLF power ms2
thermoregulatory, renin–angiotensin, and endothelial influences on the heart [39,40].
PNS activity [41].
LF peak Hz Peak frequency of the low-frequency band (0.04–0.15 Hz),
Absolute power of the low-frequency band (0.04–0.15 Hz): - produced by both the PNS
LF power ms2 and SNS, and BP regulation via baroreceptors [34,39,42-43], primarily by the PNS [44],
Frequency- or by baroreflex activity alone [45]
domain
LF power nu Relative power of the low-frequency band (0.04–0.15 Hz) in normal units
LF power % Relative power of the low-frequency band (0.04–0.15 Hz)
Peak frequency of the high-frequency band (0.15–0.4 Hz).: - correlated with the pNN50
HF peak Hz and RMSSD time-domain measures [32]. It increases at night and decreases during the
day [30]. It also correlated with stress, panic, anxiety, or worry.
HF power ms2 Absolute power of the high-frequency band (0.15–0.4 Hz)
HF power nu Relative power of the high-frequency band (0.15–0.4 Hz) in normal units
HF power % Relative power of the high-frequency band (0.15–0.4 Hz)
Ratio of LF-to-HF power: - low LF/HF ratio reflects parasympathetic dominance (tend-
LF/HF % and-befriend behaviors) and a high LF/HF ratio indicates sympathetic dominance (fight-
or-flight behaviors or parasympathetic withdrawal).
S ms Area of the ellipse which represents total HRV
SD1 ms Poincaré plot standard deviation perpendicular the line of identity
SD2 ms Poincaré plot standard deviation along the line of identity
SD1/SD2 % Ratio of SD1-to-SD2
Non-linear ApEn Approximate entropy, which measures the regularity and complexity of a time series
measures SampEn Sample entropy, which measures the regularity and complexity of a time series
DFA α1 Detrended fluctuation analysis, which describes short-term fluctuations
DFA α2 Detrended fluctuation analysis, which describes long-term fluctuations
Correlation dimension, which estimates the minimum number of variables required to
D2
construct a model of system dynamics

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TABLE II. HRV NORMS

Norms Studies Subjects Description
Salahuddin HRV monitors-ECG, Metrics: - HR and RMSSD-10 s; pNN50, HF (ms2 and nu),
24 healthy Students
et al. [35] LF/HF, and LF nu-20 s; LF ms2 and VLF ms2 - 50 s; SDNN and the coefficient of
Age 22–31
variation-60 s; HTI and TINN-90 s to estimate 150 s values
70 healthy HRV monitors-ECG, metrics: - 10 s and 1 min resting RMSSD values correlated
Nussinovitch
volunteers with 5 min RMSSD values, but 10 s and 1 min resting SDNN did not correlate with
et al. [48]
Age 42.5 ± 16.1 5 min SDNN values.
467 healthy HRV monitors-PPG, Metrics: - HR-10 s; HF ms2 -20 s; RMSSD-30 s; pNN50-
Ultra-Short- Baek
volunteers 60s; LF (ms2and nu) and HF nu-90 s; SDNN-240 s; VLF ms2-270 s to estimate 5
Term (UST) et al. [36]
Age 8–69 min values. Minimum values differed by age group
Measurement
3,387 adults HRV monitors-PPG, Metrics: - Portapres® Near-perfect agreement of 120 s
Norms
Munoz (1,727 W and RMSSD and SDNN values with 240–300 s values. UST RMSSD values achieved
et al. [50] 1,660 M) stronger agreement with 240–300 s values than UST SDNN for all record lengths
Mean age 53 and agreement metrics (Pearson r, Bland-Altman, and Cohen’s d)
HRV monitors-ECG, Metrics: - HR-10 s; NN50, and pNN50 - 60 s; TINN, LF
Shaffer 38 healthy students ms2, SD1, and SD2-90 s; HTI and DFA ɑ1-120 s; LF nu, HF ms2, HF nu, LF/HF,
et al. [49] Age 18–23 SampEn, DFA ɑ2, and DET-180 s; ShanEn-240 s; VLF ms2 -270 s to estimate 5
min values. No epoch estimated CD
145 elite athletes
Berkoff et al. HRV monitors-ECG, Metrics: - SDNN, RMSSD, pNN50, LF (ms2 and nu), HF
(87 M and 58 W)
[51] (power and nu), LF/HF (% and nu), and total power
age 18–33
21,438 healthy
adults (12,960 M HRV monitors-ECG, Metrics: - RR, SDNN, RMSSD, LF (ms2 and nu), HF (ms2
Nunan et al.
Short-Term and 8,474 W) age and nu), and LF/HF
Measurement ≥40
Norms 189 healthy adults
Abhishekh et HRV monitors-ECG, Metrics: - SDNN, RMSSD, LF (ms2 and nu), HF (ms2 and
(114 M and 75 W)
al. nu), LF/HF, and total power (ms2)
age 16–60
465 prepubertal HRV monitors-ECG, Metrics: -RR, HR, SDNN, RMSSD, pNN50, HTI, TINN,
Seppälä et al.
children (239 B) LF (peak, ms2, %), HF (peak, ms2 , %), LF/HF, SD1, SD2, SD1/SD2, SampEn,
[52]
and 226 G age 6–8 D2, DFA (α1 and α2) for 5th, 25th, 50th, 75th, and 95th percentiles
274 healthy subjects
Task Force SDNN, SDANN, RMSSD, HTI and 5 min supine LF power (ms2 and nu), HF
(202 M and 72 F),
Report [34] power (HF ms2 and HF nu), LF/HF power, and total power
age 40–69 24 h
260 healthy subjects
Umetani et
(122 M and 148 W), SDNN, SDANN, SDNNI, RMSSD, pNN50, and HR by decade
al.
age 10–99
276 healthy subjects
Beckers et SDNN, RMSSD, and pNN50, total power, LF (ms2 and %), HF (ms2 and %), and
(141 M and 135 W),
al. [31] LF/HF ratio, and nonlinear measures, 1/f, FD, DFA α1 and α2, CD, S, and LE
24 h HRV age 18–71
norms 166 healthy subjects
Bonnemeier
(85 M and 81 W), RMSSD, SDNN, SDNNI, SDANN, NN50, and HTI
et al. [53]
age 20–70
2,079 subjects (972
Aeschbacher
M and 1,107 W), HR, SDNN, LF ms2 and HF ms2
et al. [54]
age 25–41
1,743 subjects (616
Almeida-
M and 1,127 W), SDNN, SDANN, SDNNI, RMSSD, and pNN50
Santos et al.
age 40–100

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