Tachycardia in hypertension: a saga of progress despite prejudice, confusion, and inertia.

Tachycardia is a strong predictor of both hypertension and excessive cardiovascular risk. This association is robust and prevails after multivariate adjustments for other cardiovascular risk factors. Despite the strong evidence, various guidelines do not list tachycardia as a risk factor because of unwarranted assumption that tachycardia is only a marker of patient's emotional state. Already in 1945, Levy et al showed that individuals with "transient tachycardia" at baseline developed 2-fold higher rates of "true" hypertension than the control group. In the general population of Tecumseh, Mich, tachycardia proved to be a permanently reproducible feature of prehypertension. In hypertension, fast heart rate is associated with high cardiac output, and this "hyperkinetic" hemodynamic picture is different from established hypertension. However, Lund Johansen has shown that after 20 years of observation, the cardiac output and stroke volume significantly decreased and a typical picture of high vascular resistance, treatment-requiring, established hypertension emerged. So far, only the 2007 European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines acknowledged the validity of heart rate in evaluation of cardiovascular patients. The best way to convince the public is to demonstrate that lowering the heart rate with a drug without influence on blood pressure reduces cardiovascular events.