The Effect of Age on Heart Rate

in Subjects Free of Heart Disease

Studies By Ambulatory Electrocardiography
and Maximal Exercise Stress Test
JOHN B. KoSTIS, M.D., ABEL E. MOREYRA, M.D., MANUEL T. AMENDO, M.D.,
JOANNE Di PIETRO, ED.M., NORA COSGROVE, R.N., AND PETER T. Kuo, M.D.

SUMMARY To delineate the effects of true aging, undetected heart disease and deconditioning on heart
rate, we performed 24-hour ambulatory electrocardiography and maximal exercise stress test on 101 subjects
with normal hearts. The maximal heart rate recorded was 180 beats/min; the minimum was 35 beats/min. A
distinct diurnal pattern was observed.
With increasing age, a decrease of the maximal heart rate achieved during exercise stress test (r = 0.27,p =
0.05) or spontaneously recorded during the day (r = 0.41, p = 0.0005) or night (r = 0.24, p = 0.03) was
observed. The resting and average heart rates were not affected by age. Older subjects had lower exercise
tolerance (r = 0.41, p = 0.0001). Low exercise tolerance was associated with higher increments of heart rate
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for submaximal exercise levels (r = 0.53, p = 0.001), steeper increase of heart rate with increasing intensity of
exercise (r = 0.68, p = 0.0001) and lower maximal heart rates (r = 0.43, p = 0.008).
These changes of heart rate with age are not due to undetected cardiac disease, because the subjects included
in the study were meticulously screened by noninvasive and invasive means.

MANY STUDIES have shown that the maximal ex-
ercise heart rate declines with age.18 The intrinsic
heart rate after autonomic blockade with atropine and
propranolol also decreases with age with a slope simi-
lar to that of the maximal exercise heart rate.9
However, the average daily heart rate is not influenced
by age,'0 and contradictory or few data are available
on the effect of age on resting heart rate, on the incre-
ment of heart rate induced by standardized exercise
and on the diurnal variation of heart rate." 64, 10-18
A common problem in studying the effect of age on
the heart is the difficulty in separating the true effects
of aging from those due to deconditioning or unrecog-
nized diseases. Deconditioning due to sedentary life-
style is a common accompaniment of aging, and un-
detected significant coronary artery disease may be
present in more than one-fourth of persons older than
45 years of age.9-22
In the studies mentioned above, the effect of age
cannot be clearly distinguished from the effects of sub-
clinical coronary artery disease or deconditioning. To
further define the effect of age on the heart rate, we
performed 24-hour ambulatory electrocardiography
and maximal exercise stress testing on 101 subjects
free of detectable heart disease verified by extensive
noninvasive and invasive testing.
Materials and Methods
Population
One hundred one subjects with normal hearts were
identified among 1500 patients referred for cardiac
From the Department of Medicine, CMDNJ-Rutgers Medical
School, Piscataway, New Jersey.
Address for correspondence: John B. Kostis, M.D., Department
of Medicine, CMDNJ-Rutgers Medical School, P.O. Box 101,
Piscataway, New Jersey 08854.
Received February 5, 1981; revision accepted April 21, 1981.
Circulation 65, No. 1, 1982.
141
catheterization to the laboratories associated with
CMDNJ-Rutgers Medical School for the differential
diagnosis of chest pain. These subjects had normal
physical examination of the cardiovascular system
and normal chest x-ray, ECG, echocardiogram, max-
imal exercise stress test using a Balke protocol,28
right- and left-heart catheterization and coronary ar-
teriography. Patients with coronary artery disease
compromising the lumen of a major branch by even
5%, impaired left ventricular function manifested by
an ejection fraction smaller than 0.5, or left ventric-
ular end-diastolic pressure higher than 12 mm Hg
were excluded. Patients with mitral valve prolapse,
cardiomyopathy, asymmetric septal hypertrophy,
valvular disease, pulmonary hypertension or an abnor-
mal stress test (more than 0.075 mV of horizontal or
downsloping ST depression) were also excluded from
the study. Subjects with low exercise tolerance but
without other abnormalities during stress test were
allowed to participate. Patients with significant extra-
cardiac disease diagnosed by physical examination,
chest x-ray, complete blood count, urinalysis and bio-
chemical screen (blood sugar, BUN, creatinine,
bilirubin, total protein, albumin, uric acid, alkaline
phosphatase, SGOT, LDH, cholesterol, triglycerides,
serum calcium, sodium, potassium, chloride and car-
bon dioxide) were excluded. The sex, weight, height
and body mass index (an index of obesity derived by
dividing the weight by the square of the height) of each
subject and the use of tobacco, alcohol, coffee and tea
were noted.
There were 50 women and 51 men, average age 48.8
years (range 16-68 years). A cause for the chest pain
that prompted the coronary arteriography was found
retrospectively in 51 subjects: Esophageal disorder
was identified in 29, cervical osteoarthritis in 19, chest
wall tenderness in 13 and psychological abnormalities
were thought to account for the pain in seven sub-
 142 CIRCULATION VOL 65, No 1, JANUARY 1982

jects. A cause of chest pain was not found in 50 sub-
jects who were discharged from the hospital with the
diagnosis of chest pain of unknown etiology.
Ambulatory Electrocardiography
Twenty-four-hour ambulatory electrocardiography
was performed using portable two-channel tape
recorders to obtain two leads corresponding to
modified V1 and V6 (Avionics Model #445). The tapes
were played back on a 660A Avionics playback
system by an experienced nurse. The heart rate was
measured on an analog recording of the heart rate vs
time obtained from the playback system (trend record-
ing) and verified by obtaining ECGs at 25 mm/sec.
The following variables were measured and entered
into an IBM 370/168 computer for statistical analysis
using an SAS program24: age, sex, weight, body mass
index, serum calcium, sodium, potassium, hemo-
globin, systolic blood pressure, diastolic blood pres-
Downloaded from http://circ.ahajournals.org/ by guest on November 19, 2017
ing intensity of exercise (obtained by dividing the
heart rate increment induced by maximal exercise by
the intensity [duration] of maximal exercise).
The recovery of heart rate after exercise was calcu-
lated in three ways: the decrement of heart rate from
the maximum achieved during exercise within 2 and 4
minutes after exercise, the number of beats by which
the heart rate 2 and 4 minutes after exercise exceeded
the resting heart rate, and the percent recovery of the
heart rate obtained by dividing the decrement of heart
rate at a given time (2 and 4 minutes) after exercise by
the total exercise-induced increment in heart rate in
each subject.
Statistical analysis was performed for 97 subjects
who had satisfactory recordings of ambulatory elec-
trocardiography and exercise stress test by construct-
ing a correlation matrix of the relationship of each
variable mentioned above to all others, and when ap-
propriate, by cross tabulations and by chi-square and t

sure, number of cigarettes smoked per day, number of tests.24

ounces of alcohol consumed per week, number of cups
of caffeinated coffee and tea per day. The following
variables (developed for this study) affecting the heart
rate were also entered: the maximal, minimal and
average heart rates in each hour, the difference
between maximal and minimal heart rate in each
hour, the average maximal heart rate (the sum of the
maximal heart rates in each of the 24 hours divided by
24), the average minimal heart rate (the sum of the
minimal heart rates in each of the 24 hours divided by
24), the average average (overall average) heart rate
(the sum of the average heart rates in each of the 24
hours divided by 24), and the maximal and minimal
heart rates recorded. The same variables were ob-
tained for daytime hours (9 a.m. to I p.m.) and for
nighttime hours (I a.m. to 5 a.m.) when all subjects
were asleep. All subjects were awake and engaged in
their usual activities between 9 a.m. and 1 p.m. The
subjects had sedentary occupations and did not exer-
cise routinely.
Results
The results are presented in tables 1 and 2 and
figures 1-3.
Diurnal Variation of Heart Rate
The diurnal variation of heart rate is shown in figure
1. Maximal heart rates occurred in the late morning
and minimal rates occurred between 3 and 5 a.m.
Heart rate varied widely within each hour of the day
and night. The minimal, average, maximal and the
difference between minimal and maximal heart rates
were lower at night (t = 6.41-9.69, p < 0.0001; table
1). The maximal heart rate recorded was 180
beats/min and the minimum was 35 beats/min.
Ambulatory Electrocardiography
A significant negative correlation of age with exer-
cise tolerance (r = 0.41,p = 0.001) was observed. Age
was also associated with height (r -0.22,p 0.045)
= =

The following variables were obtained from the and systolic blood pressure (r = 0.28,p = 0.01). With
exercise stress test: exercise tolerance (the exercise increasing age, the average maximal heart rate during
performed at the end of maximal exercise test in meta- day and night declined significantly. The maximal
bolic equivalents), maximal heart rate achieved during heart rate and the difference between maximal and
exercise stress test, the heart rate at each exercise minimal heart rates declined significantly during the
level, and the rate of change of heart rate with increas- day (table 2, fig. 2).
TABLE 1. Heart Rates in Normal Subjects
Difference
between
24 Hours Day Night day and night
Mean SD Mean SD Mean SD Mean SD t p
Avg max HR 99.3 10.3 106.5 14.2 88.9 12.7 17.3 15.0 9.69 0.0001
Avg min HR 71.2 8.5 74.9 9.8 66.3 10.7 8.9 9.8 7.7 0.0001
Overall avg HR 78.9 8.8 84.2 11.5 70.0 10.0 13.6 13.0 8.57 0.0001
Max observed HR 127.2 17.4 115.9 16.7 96.5 16.5 19.3 18.2 9.51 0.0001
Min observed HR 58.8 9.6 69.6 10.3 62.4 10.8 7.2 10.0 6.41 0.0001
Avg dif between
max and miin HR 28.1 7.2 31.3 10.7 22.6 8.2 8.4 10.5 6.77 0.0001
Abbreviation: HR == heart rate (beats/min).
 EFFECT OF AGE ON HEART RATE/Kostis et al. 143

TABLE 2. Effect of Age on Heart Rates

Difference
between
24 Hours Day Night day and night
r p r p r p r p
Avg max HR -0.41 0.0005 -0.29 0.01 -0.24 0.03 -0.03 NS
Avg min HR -0.18 NS -0.16 NS -0.14 NS 0.02 NS
Overall avg HR -0.12 NS -0.03 NS -0.04 NS 0.01 NS
Max observed HR -0.31 0.004 -0.31 0.0055 -0.16 NS -0.14 NS
Min observed HR -0.10 NS -0.18 NS -0.13 NS -0.04 NS
Avg dif between
max and min HR -0.38 0.002 -0.24 0.04 -0.19 NS 0.07 NS
Abbreviation: HR heart rate. =

Significant effects of age on minimal and average heart rate during the day and night (r = 0.28, p <
heart rates and on the difference in heart rates between 0.05) and a higher maximal heart rate during the exer-
day and night were not observed. Subjects with high cise stress test (r = 0.43, p < 0.008). However, the
exercise tolerance tended to have a lower minimal average maximal heart rate recorded by ambulatory
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8PM
110

'1X4
FIGURE 1. Diurnal variation of heart rate.
Q90 MxHR = maximal heart rate in hour;
MnHR = minimal heart rate; AveHR-
average heart rate. The 95% confidence
80. limits are shown. The average heart rate
tends to remain closer to the minimal heart
rate than to the maximal heart rate.
70.-

60:: ,,,,I L
L I-- , i*- --t....... .............. .... I t ........
I, I, ,1,i..
:7 8..9 10 il 12 2 3: 4 86
7 8 -9 10 I : : 1;f;:;2
1d:X a m2 4 5:6 7
am noon. mid:h, m :;3
night

130

120

EiE 110 50
FIGURE 2. Effect of age on heart rate dur-
, loo pca02 40 ing the day. MAXIMUM = average max-
imal heart rate; MINIMUM = minimal
LU

cr- E
go90 F AVERAGE 301[ p 004 heart rate; A VERA GE = average heart
rate; DIFFERENCE = difference between
.%- 80 20[ maximal and minimal heart rates.
-r
70[ MINIMUM PC 27 lot
....d

601

<30 30-39 40-49 50-59 60+ <30 30-39 40-49 50-59 60+
AGE
 144 CIRCULATION VOL 65, No 1, JANUARY 1982

120 r p - 0.05), had lower exercise tolerance (r = 0.41, p =

0.01) and showed a steeper increase in heart rate with
110k exercise (r - 0.30, p = 0.05). Increasing age resulted
in a slower decline of heart rate after exercise (at 2
100k~
minutes r = 0.28, p = 0.05). No change in the re-
covery expressed as a percentage of the exercise-
induced increment in heart rate was noted.
k Subjects with high exercise tolerance achieved
higher maximal heart rates (r = 0.42, p = 0.008), had
E 80k lower submaximal heart rates (r - 0.52,p = 0.001 for
-

phase 1; r = 0.55, p = 0.0007 for phase 2; r = 0.72, p

a
70k
= 0.000 1 for phase 3; r = 0.65, p = 0.0006 for phase 4;
m r = 0.76, p = 0.0002 for phase 5 of the exercise pro-
uJ tocol) and had a smaller rate of change of heart rate
!- eo witn exercise (r = -O.68,p = 0.0001) (fig. 3). Subjects
with high exercise tolerance also showed a faster
50k decline of heart rate at a given time after exercise (r =
0.44, p = 0.007 at 2 minutes; r = 0.48, p = 0.003 at 4
minutes). However, these subjects had a higher heart
Downloaded from http://circ.ahajournals.org/ by guest on November 19, 2017

401
30k
20k FE OF CHANGE
10k
0 led to the catheterization did not affect the resting or
3-4 5-6 7--8 9-10
EXERCISE PHASE
FIGURE 3. Effects of exercise tolerance (EXERCISE
PHASE = exercise at the end of maximum exercise test) on
heart rate during exercise. MAXIMUM INCREMENT -
increment of heart rate induced by maximal exercise; SUB-
MAXIMUM INCREMENT = increment of heart rate in-
duced by standardized (6 mets) submaximal exercise; RA TE
OF CHANGE = rate of change of heart rate with increas-
ing exercise level computed by dividing the increment of
heart rate induced by maximal exercise by the intensity of
maximal exercise (exercise phase). Subjects with high exer-
cise tolerance achieve higher maximal heart rate but have
lower submaximal rates for any given exercise intensity.
electrocardiography was not affected by exercise tol-
erance (r 0.03, NS).
=
There were strong positive correlations between the
average maximal heart rate and the average minimal
heart rate (r 0.73, p - 0.0001), the average heart
=
rate (r - 0.67, p = 0.0001), the difference between the
average maximal and minimal heart rates (r =
0.57, p
0.0001), and the difference between maximal heart
rate during the day and night (r 0.22, p=
0.064).
Obesity (body mass index), male or female sex, smok-
ing, and the biochemical variables had no significant
effects. The use of alcohol was associated with higher
minimal (r 0.36, p 0.005) and average (r 0.26, p
= = =
=
0.03) heart rates.
Maximal Exercise Treadmill Test
During the maximal exercise test, older subjects
achieved lower maximal exercise heart rates (r = 0.27,
rate at a given time after recovery than subjects with
low exercise tolerance (r = 0.30, p =
0.007 at 2
minutes; r 0.35, p = 0.04 at 4 minutes). Therefore, a
consistent effect of exercise tolerance on the per-
centage of the exercize-induced rate increment that
recovered at a given time after exercise was not
observed. The presence or absence of esophageal dis-
order, cervical osteoarthritis, chest wall tenderness or
psychological abnormality as the cause of pain that
exercise heart rates.
Discussion
The decrease in maximal exercise heart rate with in-
creasing age in this population is in agreement with
previous studies. In addition, ambulatory electro-
cardiography revealed an age-related decrease in
spontaneously achieved maximal heart rate. This
decrease was not solely due to avoidance of strenuous
activity by older persons, for it occurred during the
day and at night, when all subjects were asleep. The
fact that age did not affect the difference in heart rate
between day and night also implies that variations in
activity were not the only reason for the decline of
maximal heart rate with age. Another cause may be a
decline in the capacity of the sinus node to increase the
heart rate. Aging is associated with changes in
pacemaker tissue, a decrease in the responsiveness of
autonomic cardiovascular reflexes, a decline in the in-
trinsic heart rate, and decreased adrenergic receptor
sensitivity.9' 25-30 Decreased responsiveness of the sinus
node to catecholamines may also explain the lower
nighttime maximal heart rate of older subjects despite
increased plasma norepinephrine levels at night and
higher levels of wakefulness and insomnia.31
The apparent contradiction between the decline of
maximal heart rate with age and the absence of an
effect of age on the average heart rate may be recon-
ciled by considering the effect of age on the heart-rate
response to exercise. In our study, the rate of change
of heart rate with increasing exercise level increased
with age. Although older subjects have a lower intrin-
sic heart rate, the increment of heart rate caused by
daily activities may be higher, resulting in an average
 EFFECT OF AGE ON HEART RATE/Kostis et al.
heart rate similar to that of younger subjects. In addi-
tion, sympathetic activity measured by plasma
norepinephrine levels during the day and night, at rest
and in response to postural changes or to static exer-
cise are higher in older subjects.3' 33
The delayed recovery of heart rate after exercise in
older subjects has been reported." '8 It could be
because for a given exercise level, older subjects use
more of their reserve and depend more upon anaerobic
metabolism than younger subjects. Bruce et al.4"
reported a decline in the chronotropic capacity with
age, which resulted in use of greater chronotropic
reserve and delayed heart rate recovery after exercise.
The decreased exercise tolerance of older subjects may
also explain the decrease in heart rate recovery after
exercise, because conditioned subjects show a larger
heart rate decrement at a given time after exercise.
Although cardiac disease was excluded by metic-
ulous screening, the patients in this study were re-
Downloaded from http://circ.ahajournals.org/ by guest on November 19, 2017
ferred to us for chest pain and do not represent a ran-
dom sample of normal subjects. Therefore, inferences
on intrinsic heart rate from other studies may not
necessarily apply to this population. However, the fact
that similar results were obtained in the presence or
absence of each cause of chest pain implies that the
data reported here pertain to normal subjects.
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 The effect of age on heart rate in subjects free of heart disease. Studies by ambulatory
electrocardiography and maximal exercise stress test.
J B Kostis, A E Moreyra, M T Amendo, J Di Pietro, N Cosgrove and P T Kuo
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Circulation. 1982;65:141-145
doi: 10.1161/01.CIR.65.1.141
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 1982 American Heart Association, Inc. All rights reserved.
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