1. VALUTAZIONE AUTONOMICA
STRATIFICAZIONE
RISCHIO ARITMICO STUDIO
DISAUTONOMIE
(ES. DIABETE)
DIAGNOSTICA
DELLA SINCOPE
TILT TEST

2. TILT TEST
STUDIO DI TOLLERANZA
ALL’ORTOSTATISMO PASSIVO
40 MINUTI CON TAVOLO ELEVATO
A 60-70°
POTENZIAMENTO CON FARMACI
DOPO 20 MINUTI

3. Quantifying HRV
Approach 1: The Physiologist’s Paradigm
HR data collected over short period of time
(~5-20 min), with or without interventions,
under carefully controlled laboratory
conditions.
Approach 2: The Clinician’s and the
Epidemiologists’s Paradigm
Ambulatory Holter Recordings collected over
24-hours or less, usually on outpatients.

4. Quantifying HRV
Approach 1: How much variability is there?
Time Domain and Geometric Analyses
Approach 2: What are the underlying
rhythms? What physiologic process do they
represent? How much power does each
underlying rhythm have?
Frequency Domain Analysis
Approach 3: How much complexity or self-
similarity is there?
Non-Linear Analyses

5. Time Domain HRV
Calculated from normal-to-normal interbeat
(N-N) intervals
SDNN-Standard deviation of N-N intervals
in ms (Total HRV)
SDANN-Standard deviation of 5- min mean
values of N-Ns for each 5 minute interval in
ms (Circadian HRV)
o Both reflect “longer-term” HRV

6.  SDNNIDX-Average of standard
deviations of N-Ns for each 5 min
interval in ms (Combined sympathetic
and parasympathetic HRV)
o Reflects “intermediate-term” HRV
 AVGNN-Average of N-N intervals in ms
o Equivalent to heart rate of normal-to-
normal beats. (HR=60,000/AVNN)
Time Domain HRV

7. Time Domain HRV
Calculated from differences between
successive N-N intervals
rMSSD-Root mean square of successive
differences of N-N intervals in ms
pNN50-Percent of successive N-N
differences >50 ms
Referred to as “short-term” HRV and reflect
parasympathetic influence on heart rate

8.  Based on autoregressive techniques or
fast Fourier transform (FFT).
Frequency Domain HRV
 Partitions the total variance in heart rate
into underlying rhythms that occur at
different frequencies.
 These frequencies can be associated with
different intrinsic, autonomically-
modulated periodic rhythms.

9. What are the Underlying Rhythms?
One rhythm
5 seconds/cycle or
12 times/min
5 seconds/cycle=
1/5 cycle/second
1/5 cycle/second=
0.2 Hz

10. What are the Underlying Rhythms?
Three Different Rhythms
High Frequency = 0.25 Hz (15
cycles/min
Low Frequency = 0.1 Hz (6
cycles/min)
Very Low Frequency = 0.016 Hz
(1 cycle/min)

11. 0 100 200 300 400 500 600
-750.000
250.000
1250.000
ILV
[l]
48
80
112
DAP_Fina
[mmHg]
90
130
170
SAP_Fina
[mmHg]
740
900
1060
HP
[msec]
File: C:libCape_TownHRVBASS_AN0BASALWO (09-Aug-2002) Selection: 1-1236 (617.5 sec)
Analysis Date: 29-Sep-2004 - 10:32
time [sec]

12. 160 180 200 220 240 260 280 300 320 340 360
-300.000
100.000
500.000
ILV
[l]
48
80
112
DAP_Fina
[mmHg]
88
120
152
SAP_Fina
[mmHg]
825
925
1025
HP
[msec]
File: C:libCape_TownHRVBASS_AN0BASALWO (09-Aug-2002) Selection: 318-746 (214.0 sec)
Analysis Date: 29-Sep-2004 - 10:37
time [sec]

13. 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5
0
2000
4000
6000
8000
10000
12000
14000
HP
C:LIBLQTSHRVBASS_AN0BASALWO (09-Aug-2002)
HP (342 - 734) - PSD AR (Ord=40) and BT (Bw=0.015) - Detrend: Linear
Date: 11/8/2002 Time: 22:42
Statistics:
Mean: 954.45
SD: 31.86
CV: 3.34
pnn50: 5.83
RMSSD: 28.6
LF/HF: 1.40
LF(NU): 0.58
HF(NU): 0.42
Bin Ent: 0.50
Shan Ent: 0.73
Total Power: 1012
IntegrationDecomposition
AR BT
VLF: 111.9 97.6
BT Peak Freq
0.012
LF: 510.7 515.6
HF: 352.2 354.8
VLF: 0.022 155.6
LF: 0.09 489.3
HF: 0.232 349.6
Band Freq Power
1 0.022 155.6
2 0.071 243
3 0.109 246.4
4 0.163 37.8
5 0.22 83
6 0.247 228.8
7 0.293 4.13
8 0.35 4.05
9 0.403 2.51
10 0.452 3.55
11 0.507 2.55
12 0.553 1.29
13 0.625 0.152
14 0.752 0.031
15 0.813 0.025
# Freq Power
Signal: HP (2 Hz Resampled) - Detrend: Linear
Duration: 196 Sec (342:734)
AR Model Order: 40 (AIC Order: 12)
BT Bandwidth: 0.015 Hz
BASAL W.O.

14. 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5
0
0.5
1
1.5
2
2.5
x 10
4
HP
C:LIBLQTSHRVDU_PLES0BASALWO (20-Nov-2002)
HP (110 - 356) - PSD AR (Ord=36) and BT (Bw=0.015) - Detrend: Linear
Date: 24/11/2002 Time: 17:54
Statistics:
Mean: 898.69
SD: 31.78
CV: 3.54
pnn50: 17.52
RMSSD: 37.3
LF/HF: 0.47
LF(NU): 0.32
HF(NU): 0.68
Bin Ent: 0.46
Shan Ent: 0.68
Total Power: 1006
IntegrationDecomposition
AR BT
VLF: 80.5 93.6
BT Peak Freq
0.018
LF: 287.6 278.8
HF: 603.9 593.7
VLF: 0.022 125.8
LF: 0.098 264.6
HF: 0.26 558.3
Band Freq Power
1 0.022 125.8
2 0.074 128.9
3 0.12 135.7
4 0.172 98.3
5 0.226 246.9
6 0.283 77.6
7 0.351 50.3
8 0.373 135.4
9 0.474 6.98
10 0.51 6.92
11 0.53 -0.385
12 0.608 1.99
13 0.667 0.276
14 0.754 0.645
15 0.84 0.088
# Freq Power
Signal: HP (2 Hz Resampled) - Detrend: Linear
Duration: 123 Sec (110:356)
AR Model Order: 36 (AIC Order: 19)
BT Bandwidth: 0.015 Hz
BASAL HRV WO
0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5
-180
-90
0
90
180
0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5
0
0.2
0.4
0.6
0.8
1
0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5
0
0.5
1
1.5
2
2.5
x 10
40 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5
0
1
2
3
x 10
5C:LIBLQTSHRVDU_PLES0BASALWO (20-Nov-2002) Date: 24/11/2002 Time: 17:49
ILV(110-356)HP(110-356)
AR order: 30
BT bandwidth: 0.015
BT smooth : 2
Detrend: Linear
Duration: 123 sec
Selection: From 110 to 356
Freq: 0.0195 Hz
p(MSC=0) = 0.168
MSC AR: 0.46
MSC BT: 0.36
ø AR: 99/-261
ø BT: 111/-249
Delay AR: 37.0 s
Delay BT: 35.0 s
Grp Delay AR: 3.1 s

15. 100 200 300 400 500 600
-750.000
250.000
1250.000
ILV
[l]
44
60
76
DAP_Fina
[mmHg]
68
100
132
SAP_Fina
[mmHg]
550
590
630
HP
[msec]
File: C:libCape_TownTILTBASS_AN0TILTWO (09-Aug-2002) Selection: 64-1250 (593.0 sec)
Analysis Date: 29-Sep-2004 - 10:46
time [sec]
10 minute tilt

16. 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5
0
200
400
600
800
1000
1200
1400
HP
C:LIBLQTSTILTBASS_AN0TILTWO (09-Aug-2002)
HP (562 - 1016) - PSD AR (Ord=40) and BT (Bw=0.015) - Detrend: Linear
Date: 14/8/2002 Time: 21:01
Statistics:
Mean: 589.11
SD: 7.78
CV: 1.32
pnn50: 0.00
RMSSD: 3.0
LF/HF: 9.21
LF(NU): 0.90
HF(NU): 0.10
Bin Ent: 0.28
Shan Ent: 0.89
Total Power: 60.5
IntegrationDecomposition
AR BT
VLF: 23.7 22.9
BT Peak Freq
0.012
LF: 25.3 25.1
HF: 2.75 2.83
VLF: 0.018 33
LF: 0.082 23.9
HF: 0.283 2.59
Band Freq Power
1 0.018 33
2 0.072 17.4
3 0.109 6.43
4 0.212 0.444
5 0.269 1.32
6 0.314 0.508
7 0.39 0.317
8 0.463 0.132
9 0.52 0.392
10 0.572 0.093
11 0.637 0.132
12 0.692 0.105
13 0.737 0.033
14 0.792 0.044
15 0.852 0.023
# Freq Power
Signal: HP (2 Hz Resampled) - Detrend: Linear
Duration: 227 Sec (562:1016)
AR Model Order: 40 (AIC Order: 16)
BT Bandwidth: 0.015 Hz
TILT W.O.

17. 30 40 50 60 70 80 90 100 110
-250.000
-50.000
150.000
ILV
[l]
55
75
95
DAP_Fina
[mmHg]
90
130
170
SAP_Fina
[mmHg]
480
800
1120
HP
[msec]
File:C:libCape_TownNITRATODU_PLES0BRSWO (20-Nov-2002) Selection:42-230 (94.0 sec)
Analysis Date:29-Sep-2004 - 09:34
time [sec]
Baroreflex test with TNT

18. 900 905 910 915 920 925 930 935 940 945
-170.000
-50.000
70.000
ILV
[l]
78
88
98
DAP_Fina
[mmHg]
133
145
157
SAP_Fina
[mmHg]
1060
1300
1540
HP
[msec]
File: C:libCape_TownNITRATODU_PLES0BRSWO (20-Nov-2002) Selection: 1792-1900 (54.0 sec)
Analysis Date: 29-Sep-2004 - 09:43
time [sec]
Baroreflex test with PHE

19. Beat # D SAP D RR SAP RR
966 -23 82 137 1042
----------------------------------------------------------------
967 -25 50 135 1010
----------------------------------------------------------------
968 -25 93 135 1053
----------------------------------------------------------------
969 -20 119 140 1079
----------------------------------------------------------------
970 -22 120 139 1080
----------------------------------------------------------------
971 -22 96 138 1056
----------------------------------------------------------------
972 -23 65 137 1025
----------------------------------------------------------------
973 -26 57 135 1017
----------------------------------------------------------------
974 -22 159 138 1119
----------------------------------------------------------------
975 -19 234 142 1194
----------------------------------------------------------------
976 -18 272 143 1232
----------------------------------------------------------------
977 -19 224 142 1184
----------------------------------------------------------------
978 -14 364 146 1324
----------------------------------------------------------------
979 -11 336 149 1296
----------------------------------------------------------------
980 -12 413 149 1373
----------------------------------------------------------------
981 -13 364 147 1324
----------------------------------------------------------------
982 -17 551 144 1511
----------------------------------------------------------------
983 -15 528 146 1488
----------------------------------------------------------------
984 -20 566 141 1526
----------------------------------------------------------------
985 -11 617 149 1577
----------------------------------------------------------------
Slope = 30.96 ± 12.18 ms/mmHg (p=0.0000)
R
2
= 0.61, Se
2
= 266800.87, Sx
2
= 440.82
DRR (Final - Initial) = 535 ms, DSAP (Final - Initial) = 12 mmHg
Basal RR = 961 ms, Basal SAP = 160 mmHg
C:libLQTSNITRATODU_PLES0BRSWO
-26 -24 -22 -20 -18 -16 -14 -12 -10
0
100
200
300
400
500
600
700
DSAP [mmHg]
DRR[ms]
PHE WO 1

20. Beat # D SAP D RR SAP RR
37 -1 43 160 1003
----------------------------------------------------------------
38 -3 39 157 999
----------------------------------------------------------------
39 -1 52 159 1012
----------------------------------------------------------------
40 -3 43 158 1003
----------------------------------------------------------------
41 -6 9 154 969
----------------------------------------------------------------
42 -5 19 155 979
----------------------------------------------------------------
43 -8 -22 152 939
----------------------------------------------------------------
44 -13 -99 147 862
----------------------------------------------------------------
45 -13 -81 147 880
----------------------------------------------------------------
46 -15 -98 145 863
----------------------------------------------------------------
47 -22 -159 139 802
----------------------------------------------------------------
48 -23 -171 137 790
----------------------------------------------------------------
49 -24 -177 136 784
----------------------------------------------------------------
50 -29 -207 132 754
----------------------------------------------------------------
51 -34 -233 127 728
----------------------------------------------------------------
52 -35 -264 125 697
----------------------------------------------------------------
53 -36 -276 124 685
----------------------------------------------------------------
54 -34 -238 126 723
----------------------------------------------------------------
55 -35 -225 125 736
----------------------------------------------------------------
56 -39 -234 122 727
----------------------------------------------------------------
57 -43 -250 117 711
----------------------------------------------------------------
58 -45 -266 116 695
----------------------------------------------------------------
59 -47 -275 114 686
----------------------------------------------------------------
60 -49 -295 111 666
----------------------------------------------------------------
61 -50 -306 110 655
----------------------------------------------------------------
62 -51 -323 109 638
----------------------------------------------------------------
63 -50 -338 111 623
----------------------------------------------------------------
Slope = 7.30 ± 0.64 ms/mmHg (p=0.0000)
R
2
= 0.96, Se
2
= 18697.25, Sx
2
= 7849.72
DRR (Final - Initial) = -380 ms, DSAP (Final - Initial) = -49 mmHg
Basal RR = 961 ms, Basal SAP = 160 mmHg
C:libLQTSNITRATODU_PLES0BRSWO
-60 -50 -40 -30 -20 -10 0
-350
-300
-250
-200
-150
-100
-50
0
50
100
DSAP [mmHg]
DRR[ms]
TNT WO 1

21. Beat # D SAP D RR SAP RR
553 -17 44 144 1004
----------------------------------------------------------------
554 -16 15 145 975
----------------------------------------------------------------
555 -21 -41 140 920
----------------------------------------------------------------
556 -17 -37 144 924
----------------------------------------------------------------
557 -17 -30 144 931
----------------------------------------------------------------
558 -22 -78 139 883
----------------------------------------------------------------
559 -21 -99 139 862
----------------------------------------------------------------
560 -20 -70 140 891
----------------------------------------------------------------
561 -21 -88 139 873
----------------------------------------------------------------
562 -28 -124 133 837
----------------------------------------------------------------
563 -30 -145 131 816
----------------------------------------------------------------
564 -28 -134 132 827
----------------------------------------------------------------
565 -31 -141 130 820
----------------------------------------------------------------
566 -34 -169 126 792
----------------------------------------------------------------
567 -34 -161 126 800
----------------------------------------------------------------
568 -32 -149 128 812
----------------------------------------------------------------
569 -34 -185 126 776
----------------------------------------------------------------
570 -33 -209 127 752
----------------------------------------------------------------
571 -32 -205 128 756
----------------------------------------------------------------
572 -33 -206 128 755
----------------------------------------------------------------
573 -35 -220 126 741
----------------------------------------------------------------
574 -34 -238 126 723
----------------------------------------------------------------
575 -31 -218 129 743
----------------------------------------------------------------
576 -31 -211 129 750
----------------------------------------------------------------
577 -33 -221 127 740
----------------------------------------------------------------
578 -38 -239 123 722
----------------------------------------------------------------
579 -38 -261 122 700
----------------------------------------------------------------
580 -36 -235 124 726
----------------------------------------------------------------
581 -37 -212 124 749
----------------------------------------------------------------
582 -38 -212 123 749
----------------------------------------------------------------
583 -40 -238 120 723
----------------------------------------------------------------
584 -39 -257 122 704
----------------------------------------------------------------
585 -37 -239 123 722
----------------------------------------------------------------
586 -36 -224 124 737
----------------------------------------------------------------
587 -40 -238 121 723
----------------------------------------------------------------
588 -40 -248 121 713
----------------------------------------------------------------
589 -36 -229 124 732
----------------------------------------------------------------
Slope = 10.44 ± 1.12 ms/mmHg (p=0.0000)
R
2
= 0.91, Se
2
= 21550.77, Sx
2
= 2016.00
DRR (Final - Initial) = -272 ms, DSAP (Final - Initial) = -20 mmHg
Basal RR = 961 ms, Basal SAP = 160 mmHg
C:libLQTSNITRATODU_PLES0BRSWO
-45 -40 -35 -30 -25 -20 -15
-300
-250
-200
-150
-100
-50
0
50
DSAP [mmHg]
DRR[ms]
TNT WO 2

22. Beat # D SAP D RR SAP RR
1287 -19 132 141 1092
----------------------------------------------------------------
1288 -16 46 144 1006
----------------------------------------------------------------
1289 -15 101 145 1061
----------------------------------------------------------------
1290 -19 124 142 1084
----------------------------------------------------------------
1291 -16 75 145 1035
----------------------------------------------------------------
1292 -11 221 149 1181
----------------------------------------------------------------
1293 -14 276 146 1236
----------------------------------------------------------------
1294 -11 262 149 1222
----------------------------------------------------------------
1295 -10 406 151 1366
----------------------------------------------------------------
1296 -14 320 146 1280
----------------------------------------------------------------
1297 -12 325 148 1285
----------------------------------------------------------------
1298 -11 352 149 1312
----------------------------------------------------------------
1299 -13 480 147 1440
----------------------------------------------------------------
1300 -9 492 152 1452
----------------------------------------------------------------
1301 -6 520 155 1480
----------------------------------------------------------------
1302 -7 613 153 1573
----------------------------------------------------------------
1303 -3 538 158 1498
----------------------------------------------------------------
1304 0 462 160 1422
----------------------------------------------------------------
1305 -3 461 157 1421
----------------------------------------------------------------
1306 -9 394 152 1354
----------------------------------------------------------------
1307 -16 351 144 1311
----------------------------------------------------------------
1308 -18 296 143 1256
----------------------------------------------------------------
1309 -21 133 140 1093
----------------------------------------------------------------
1310 -17 137 143 1097
----------------------------------------------------------------
Slope = 23.63 ± 8.17 ms/mmHg (p=0.0000)
R
2
= 0.62, Se
2
= 236523.31, Sx
2
= 692.69
DRR (Final - Initial) = 5 ms, DSAP (Final - Initial) = 2 mmHg
Basal RR = 961 ms, Basal SAP = 160 mmHg
C:libLQTSNITRATODU_PLES0BRSWO
-25 -20 -15 -10 -5 0
0
100
200
300
400
500
600
700
DSAP [mmHg]
DRR[ms]
PHE WO 2

24. n=106 n=86
msec/mmHg
BRS POST-MI AND RISK FOR VF
Resistant
36
32
28
24
20
16
12
8
4
0
Susceptible
n=192
Schwartz, Circulation 1988

25. 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5
0
1000
2000
3000
4000
5000
HP
C:LIBLQTSTILTDU_PLES0TILTBB (18-Nov-2002)
HP (1838 - 2016) - PSD AR (Ord=36) and BT (Bw=0.015) - Detrend: Linear
Date: 24/11/2002 Time: 18:07
Statistics:
Mean: 1271.15
SD: 21.35
CV: 1.68
pnn50: 11.43
RMSSD: 36.8
LF/HF: 1.91
LF(NU): 0.66
HF(NU): 0.34
Bin Ent: 0.19
Shan Ent: 0.53
Total Power: 453.3
IntegrationDecomposition
AR BT
VLF: 72.3 71.3
BT Peak Freq
0.039
LF: 140 135.8
HF: 158.6 166.7
VLF: 0.027 17.2
LF: 0.071 210.5
HF: 0.251 110.5
Band Freq Power
1 0.027 17.2
2 0.044 142.4
3 0.129 68.1
4 0.184 47.2
5 0.265 39.3
6 0.286 4.2
7 0.362 24
8 0.403 100.6
9 0.429 8.7
10 0.525 0.749
11 0.61 0.416
12 0.677 0.288
13 0.723 0.143
14 0.784 0.223
15 0.848 0.147
# Freq Power
Signal: HP (2 Hz Resampled) - Detrend: Linear
Duration: 89 Sec (1838:2016)
AR Model Order: 36 (AIC Order: 7)
BT Bandwidth: 0.015 Hz
0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5
-180
-90
0
90
180
0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5
0
0.2
0.4
0.6
0.8
1
0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5
0
2000
4000
6000
8000
10000
0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5
0
1
2
3
4
x10
5C:LIBLQTSTILTDU_PLES0TILTBB (18-Nov-2002) Date: 24/11/2002 Time: 18:07
ILV(1838-2016)HP(1838-2016)
AR order: 30
BT bandwidth: 0.015
BT smooth : 2
Detrend: Linear
Duration: 89 sec
Selection: From 1838 to 2016
Freq: 0.0195 Hz
p(MSC=0) = 0.216
MSC AR: 0.88
MSC BT: 0.4
ø AR: -149/-149
ø BT: -146/-146
Delay AR: 21.0 s
Delay BT: 21.0 s
Grp Delay AR: -5.3 s
RECOVERY BB