Dr. Patrycja Matusik is a physician-radiologist at University Hospital, Kraków, Poland. She completed her medicine degree and PhD at Jagiellonian University in Kraków. In her work she focuses primarily on cardiovascular imaging, lung diseases and neuroimaging.

 

In her scientific work, one of the main directions is heart rate variability (HRV). She went to the Cardiovascular Division at the Department of Medicine at Washington University School of Medicine in St. Louis, Missouri, USA on two occasions. There she completed internships in the field of advanced methods of ECG analysis under the mentorship of Prof. Phyllis K. Stein in the Heart Rate Variability Laboratory.

 

She is the co-author of several scientific papers published in peer-reviewed international journals, including the European Heart Journal. One of those paper, published in the Lupus, will be discussed today.  

https://pubmed.ncbi.nlm.nih.gov/29697012/

https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehac546/6926265

 

1. I read your bio in the intro, but I would please tell us a little more about your personal – why you are interested in lupus erythematosus.

 

First, I want to say thank you for inviting me to your podcast.

As you said I’m a physician radiologist from Poland. Privately, I’m a mother of 3-year-old Julia. My husband, Paweł Matusik, is also a doctor – a cardiologist, and together we combine our passion for scientific research.

 

I was inspired by lupus for the first time on my internship at the Heart Rate Variability Laboratory led by Prof. Phyllis K. Stein at Washington University in St. Louis. During the course of lupus, involvement of multiple organ systems, including the cardiovascular and autonomic nervous system, occurs. Therefore, we decided to bring together and summarize current knowledge about the scientific findings and potential clinical utility of heart rate variability measures in patients with systemic lupus erythematosus.

 

 

 

2. Please tell us what lupus erythematosus is and what can happen during the disease process as it relates to your publication “ Heart Rate Variability in patients with systemic lupus erythematosus: a systematic review and methodological considerations.”

 

Systemic lupus erythematosus is a chronic autoimmune disorder of the connective tissue that can involve joints, kidneys, skin, lungs, nervous system and heart. Cardiac involvement is of major concern in the clinical management of lupus patients. People with lupus may have chest pain due to inflammation of the sac around the heart (pericarditis). More serious but rare effects on the heart include inflammation of the walls of the coronary arteries (coronary artery vasculitis), which can lead to angina, and inflammation of the heart muscle (myocarditis), which can lead to heart failure. The valves of the heart can occasionally  be involved and may need to be surgically repaired. Importantly, people with lupus are at increased risk of coronary artery disease.

 

 

3. Before we discuss heart rate variability would you please talk to us about ANS involvement in lupus.

 

The prevalence of autonomic nervous system dysfunction in lupus has been reported to range from less than 10% to over 90% of patients, probably because of different definitions of autonomic nervous system dysfunction and differences in methods of assessing autonomic nervous system dysfunction in clinical practice. Patients with lupus may experience low health-related quality of life and have to a varying degree dysfunction of the autonomic nervous system. Importantly, significant autonomic imbalance towards sympathetic nervous system predominance or loss of parasympathetic nervous system regulation has been associated with an increased risk of developing cardiovascular disease, one of the leading causes of mortality in lupus patients.

 

4. In your paper “Heart Rate Variability in Patients with systemic lupus erythematosus” you used analysis of HRV. Please tell us about that.

 

Analysis of heart rate variability is a non-invasive and sensitive measure of autonomic nervous system function and may detect early autonomic nervous system involvement in lupus patients. Heart rate variability measurements are based on the fact that heart rate is controlled by continuously varying inputs from both the SNS (sympathetic or activing) and the PNS (parasympathetic or relaxation-inducing) branches of the autonomic nervous system to the sino-atrial node, the healthy heart’s pacemaker. In general, increased SNS activity elevates heart rate, while increased PNS activity reduces it. Thus the variation in the intervals between normal heart beats usually reflects the effect of the autonomic nervous system on the heart’s pacemaker. In general, heart rate variability is decreased in patients with various diseases, including patients with lupus, when compared to healthy people, consistent with the hypothesis that cardiac autonomic functioning is impaired in these clinical conditions. Low heart rate variability is related to a higher risk of cardiovascular events, such as sudden cardiac death, stroke or myocardial infarction, heart failure and coronary artery disease. However, higher values are not always better, as these may be a sign of disorganized/erratic sinus rhythm, or even of atrial fibrillation.

 

Heart rate variability parameters are derived from the time intervals between normal sinus heart beats (NN intervals) from ECG recordings and may be measured in several ways. Traditional HRV measures analyzed in the time and frequency domain that quantify ‘how much’ HRV there is can be considered to be linear measures. Non-linear methods of calculating HRV reflect the structure of the heart rate patterns (more random vs. more organized) and are only beginning to be explored in SLE patients. Furthermore, the novel index of HRV, heart rate turbulence has two components: turbulence onset, the immediate

PNS-mediated response of the heart rate to the loss of cardiac output associated with a premature ventricular contraction and turbulence slope, which captures the slope of the return to baseline heart rate after a premature ventricular contraction, which is believed

to reflect the health of baroreflex (blood pressure response) functioning.

 

5. Let’s talk about how you led the study, (briefly) and what your study found.

 

We performed systematic literature research and searched PubMed, Embase and Scopus databases (all online collections of published research) for the terms associated with systemic lupus erythematosus and heart rate variability. Finally, 11 publications were selected and analyzed. In the results, we observed that generally, heart rate variability, measured in the time and frequency domains, was reported to be decreased in patients with systemic lupus erythematosus compared with controls. In some studies, heart rate variability was found to correlate with inflammatory markers and albumin levels. A novel heart rate variability measure, heart rate turbulence onset, was shown to be increased, while heart rate turbulence slope was decreased in systemic lupus erythematosus patients consistent with an impaired ability to respond to the loss of cardiac output that comes with a mechanically abnormal, early heart beat among patients. Reports of associations of changes in heart rate variability parameters with increasing systemic lupus erythematosus activity were inconsistent, showing decreasing heart rate variability or no relationship. However, the low/high frequency ratio (measured in the frequency domain) and believed by some to reflect the balance between SNS and PNS control of the heart was, in some studies, reported to increase with increasing disease activity or to be inversely correlated with albumin levels. But I have to say that a lot of people in the HRV field do not have much faith in this measure or its meaning.

To sum up, our study shows that patients with systemic lupus erythematosus have abnormal heart rate variability, which reflects cardiac autonomic dysfunction and may be related to inflammatory cytokines but not necessarily to disease activity.

 

 

6. What results (if any) surprised you the most?

 

The most surprised was inconsistencies in results concerning associations between HRV and disease activity. Some investigators have reported significant relationships between HRV and disease activity as measured by different commonly used in clinical practise disease activity indices, as well as with cytokines and albumin levels, suggesting that HRV may potentially be a marker of disease activity. However, others have reported no correlation between HRV and disease activity. This may suggests that HRV may not reflect general lupus activity per se, but may specifically characterize ANS dysfunction in lupus, which may occur at different stages of the disease or in different subsets of patients. Another possible explanation for the inconsistent findings of the relationship of HRV and lupus activity may be that the investigators failed to distinguish between higher values of some HRV parameters that reflected better PNS functioning and higher values that reflected more disorganized neurocardiac functioning. It is because several HRV measures are confounded by the possibility that higher values may reflect an abnormally organized sinus rhythm (i.e. erratic sinus rhythm). Moreover, the length of the recording could be a factor-in lab vs. real life. It must be kept in mind that HRV assessed over 24 hours provides

much more information about real-time ANS functioning than HRV assessed for a very short period under laboratory conditions. Furthermore, even though the names of the HRV parameters may be the same for both 24-hour and short recordings (e.g. standard deviation of all NN intervals), in reality they do not mean the same thing in terms of ANS activity.

Therefore, our findings support the need for further studies to understand relationships between inflammatory and autonomic pathways and other factors, like age, gender etc. that might affect it.

 

7. How might this information be useful for patients with lupus?

 

Measurement of heart rate variability could be a useful clinical tool for monitoring autonomic dysfunction in systemic lupus erythematosus, and may potentially provide prognostic information, in other words help doctors identify patients at higher risk of progression or death and could be a marker for interventions that are helpful to patients. Decreased HRV has been associated with an increased risk of sudden cardiac death in other patient populations. HRV can potentially be used to assess the severity of autonomic dysfunction in lupus patients and studies of changes in HRV with interventions may lead to ways to decrease potential cardiovascular risk in lupus. Results could potentially be individualized to target the best treatment.  As a result, HRV assessment may prove to be useful in clinical practice regarding the care of patients with lupus.

 

Importantly, studies have shown that lupus is an independent risk factor for the development of atrial fibrillation, stressing the importance of cardiac assessment in this population. AF is a very irregular and fast heart rate increasingly seen in older adults that can lead to a stroke but treatable with appropriate blood thinners. Development of AF in patients with SLE is associated with increased mortality. Thus, early diagnosis and introduction of appropriate treatment is of great importance to help prevent adverse clinical outcomes. As we described in our paper published recently in EHJ, machine-learning-based HRV analysis may provide a significant advance in both predicting and detecting AF. With the use of the artificial intelligence, only a few HRV parameters are required for effective differentiation of AF from sinus rhythm in 60-second ECG segments. Studies so far have suggested that recent proposed ECG algorithms for automatic AF detection may constitute a valuable supplement to currently commonly used symptom and ECG-based approaches. This is especially notable considering the increasing availability, use and advances in potential AF detection tools, including mobile and wearable devices. These devices are used also by persons who do not have any clinical diagnoses and may be used for self-monitoring. Furthermore, such devices, in appropriate patients,

The selections of the appropriate AF screening tool and the duration of its use after suspicion of AF from an alternative, non-diagnostic device when AF is not seen on ECG during in-office follow-up will be an evolving area in clinical practice, among others in lupus patients.

 

 

8. Thank you for all that you do. How can my listeners follow your work?

 

Thank you once again for invitation me for your podcast. Your listeners may follow my work through my profile on Research Gate.

Thank you Dr Patrycja Matusik I am so thankful for your research on heart rate variability as a new way of looking at the autonomic or automatic nervous system in lupus and in other diseases such as cardiovascular diseases. Thank you for showing us that HRV may  act an early intervention tool help us as patients and help our physicians in a different way. I learned a lot about the important role that HRV plays in lupus and in other diseases like heart to give us an advanced indication of what might be about to happen. Thank you  Dr Matoosick for your ground breaking research.

So listeners let’s continue to follow Dr Matusik’s ground breaking research on HRV and let’s apply the research that we know already – that time in green spaces protects your heart and improves HRV by bringing balance to your autonomic nervous system. S0 get away from your iphone or computer screen and get yourself out that door, even for a few minutes, because we all need a little more of Your outside mindset.