Resting Heart Rate Association with Cardiovascular Morbidity and Mortality and All-Cause Mortality According to Cluster of Cardiovascular Risk Factors—A Prospective Cohort Study with More than 20 Years of Follow-Up

Objectives: This study evaluated the association of resting heart rate (RHR) with major adverse cardiovascular events (MACEs) and all-cause mortality among adults without prior cardiovascular disease, stratified by baseline burden of cardiovascular risk factors (CVRFs). Methods: This was a prospective cohort study in a random sample of the general population aged ≥18 years in southeastern Spain. RHR was measured using an electrocardiogram. CVRFs (sedentary or light-to-moderate physical activity, body-mass index ≥ 25 kg/m2, non-HDL cholesterol ≥ 130 mg/dL, diabetes, hypertension, and smoking) were grouped in three clusters based on whether each subject has 0–2, 3, or ≥4 factors. During a mean 21.5-year follow-up, MACEs were collected and classified as all-cause mortality (outcome-1, n = 193 events) and combined cardiovascular morbidity and mortality (outcome-2, n = 291 events). Cox regression models were adjusted for multiple confounders. Results: The mean age of the participants (n = 1169) was 47.4 years (55.8% women). For every 10 bpm increase in RHR, the fully adjusted hazard ratio was 1.15 (95% CI: 1.03–1.28) for outcome-1 and 1.09 (1.00–1.20) for outcome-2. In the cluster with three CVRFs, the fully adjusted hazard ratios per 10 bpm RHR increase were 1.18 (95% CI 1.04–1.36) for outcome-1 and 1.15 (1.03–1.27) for outcome-2. In the clusters with 0–2 and ≥4 CVRFs, there were no statistically significant differences. Conclusions: RHR was independently associated with both cardiovascular events and all-cause mortality in the 3 CVRF cluster (intermediate cluster in terms of the burden of CVRFs), whose prognostic value may be clinically meaningful. These results highlight the importance of RHR and the comprehensive assessment of CVRFs in the primary prevention setting.