Early Loss of Heart Rate Complexity Predicts Mortality Regardless of Mechanism, Anatomic Location, or Severity of Injury in 2178 Trauma Patients

Background. Reduced heart rate (HR) complexity (e.g., a lack of randomness or unpatterned variability) is an established predictor of trauma patient mortality. However, this finding has not been validated across the diverse spectrum of traumatic injury, and underlying mechanisms of this relationship are poorly understood. Materials and Methods. Two thousand one hundred seventy-eight trauma patients were admitted directly to the intensive care unit (ICU), and had sufficient (> 6 h) continuous integer heart rate data within the first d. Patients were stratified by location of isolated severe injury (head, torso, both, or neither), primary mechanism (blunt or penetrating), and probability of survival, an accepted scoring system based on age, admission vital signs, and injury type and severity. HR multiscale entropy (MSE) was calculated (sum of scales, Costa's algorithm, physionet.org, m = 2, r = 0.15) to estimate complexity. Univariate analysis was performed by comparing MSE between survivors and nonsurvivors in each subgroup. Multivariate analysis incorporated logistic regression to characterize the relationship between MSE and risk of death, controlling for probability of survival. The MSE odds ratios (OR) and area under the receiver operator curve (AUC) were calculated. Results. Reduced MSE was significantly associated with increasing mortality, and was independent of probability of survival in all multivariate analyses (OR 0.87-0.94). This range of odds ratios implies that a patient with an MSE of 15 has roughly a 2- to 6-fold increase in odds of death versus a patient with an MSE of 25. The relationship between MSE and death was moderately stronger in patients with isolated severe head injury versus torso injury, and significantly stronger in patients with penetrating versus blunt mechanism of injury. MSE measured early in the hospital stay remained a robust predictor of mortality in all subgroups, even stratified by narrow ranges of probability of survival. Conclusions. Early reduction of heart rate complexity is an important risk factor across diverse injury etiology. This suggests common underlying physiologic mechanisms linking the loss of biologic complexity to death. (C) 2009 Elsevier Inc. All rights reserved.