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Background Chronotropic incompetence is common in patients with cardiovascular disease and is associated with increased risk of adverse events. We assessed the incremental prognostic value of heart rate reserve (HRR) over stress myocardial perfusion single-photon emission computed tomography (MPS) findings in patients with suspected coronary artery disease (CAD). Methods We studied 866 patients with suspected CAD undergoing exercise stress-MPS as part of their diagnostic program. The primary study endpoint was all-cause mortality. All patients were followed for at least 5 years. HRR was calculated as the difference between peak exercise and resting HR, divided by the difference of age-predicted maximal and resting HR and expressed as percentage. Results During 7 years follow-up, 61 deaths occurred, with a 7% cumulative event rate. Patients experiencing death were older ( P  &lt; .001), and had a higher prevalence of male gender ( P  &lt; .001) and diabetes ( P  &lt; .05). Patients with event also had lower values of HRR (65% ± 27% vs 73% ± 18%,  P  &lt; .0001) and higher prevalence of stress-induced myocardial ischemia (25% vs 8%,  P  &lt; .0001). Male gender, HRR and stress-induced ischemia were independent predictors of all-cause mortality (all  P  &lt; .01). HRR improved the prognostic power of a model including clinical data and MPS findings, increasing the global χ 2  from 66 to 82 ( P  &lt; .005). Conclusions Chronotropic incompetence has independent and incremental prognostic value in predicting all-cause mortality in patients with suspected CAD undergoing exercise stress-MPS. Hence, the evaluation of HRR may further improve patients’ risk stratification.

Prognostic value of heart rate reserve in patients with suspected coronary artery disease undergoing stress myocardial perfusion imaging