Resting Heart Rate and CV Outcomes in Hypertension: Revisiting the Accessible Clinical Marker

Hypertension remains a major contributor to cardiovascular morbidity and mortality; however, cardiovascular risk extends beyond blood pressure control alone. Resting heart rate (RHR), a simple, inexpensive and routinely available clinical parameter, is increasingly recognized as an important cardiovascular risk marker. Elevated RHR has been associated with hypertension, cardiovascular events and mortality, yet it remains less-recognized in routine risk assessment. ^{1, 2} Importantly, this risk phenotype is evident even among younger Indian hypertensive individuals; the BEAT study reported a mean RHR of 82 bpm among 3,743 hypertensive adults aged 18–55 years. ³ These findings highlight the need to consider RHR as an integral component of cardiovascular risk evaluation in hypertensive patients.

Elevated Resting Heart Rate and Impact Across the Cardiovascular Continuum

Resting heart rate (RHR) has evolved from a routinely measured vital sign to an important cardiovascular risk marker. Elevated RHR reflects increased sympathetic activity and imposes haemodynamic stress through increased myocardial oxygen demand, reduced diastolic coronary perfusion and vascular strain. ^{1, 4} Across the cardiovascular continuum, persistent RHR elevation may contribute to endothelial dysfunction, arterial stiffness, atherosclerotic progression and unfavorable cardiac remodelling, thereby accelerating the transition from risk factors to overt cardiovascular disease. ⁵ In individuals with hypertension, elevated RHR may further amplify cardiovascular burden by acting synergistically with increased blood pressure, increasing the risk of coronary artery disease, heart failure, stroke and mortality. ^{1, 6} Thus, assessment of RHR provides an opportunity to identify cardiovascular risk beyond conventional blood pressure measurements. (Figure 1)

Figure 1: Elevated Heart Rate & Sequels Across Cardiovascular Disease Continuum

Note: ↑ indicates an increase; + indicates a positive effect/association contributing to the progression of cardiovascular changes.

Resting Heart Rate and Cardiovascular Outcomes: What Does the Evidence Tell Us?

Elevated resting heart rate (RHR) is increasingly recognized as an independent predictor of cardiovascular outcomes, providing prognostic information beyond conventional risk factors, including blood pressure (BP). The VALUE trial evaluated 15,193 high-risk hypertensive patients over five years and demonstrated that every 10 bpm increase in baseline heart rate was associated with a 16% higher risk of composite cardiac events (HR 1.16; 95% CI 1.12–1.20). Importantly, elevated heart rate remained associated with increased cardiovascular events even among patients with controlled BP, suggesting that achieving BP targets alone may not fully address residual cardiovascular risk. ⁸

Indian evidence highlights the relevance of this risk phenotype in younger hypertensive populations. The BEAT study, including young hypertensive patients (18–55 years), reported a mean RHR of 82 bpm and demonstrated a significant correlation between RHR and systolic as well as diastolic BP. ¹ These findings suggest that elevated RHR is prevalent early in the Indian hypertension patient journey and may represent an important marker for cardiovascular risk stratification.

Together, these data support incorporating RHR assessment alongside BP evaluation to effectively characterize cardiovascular risk in hypertension.

Targeting Elevated RHR in Hypertension: Indian Evidence with Telmisartan and Metoprolol

Recognition of elevated resting heart rate (RHR) as an important cardiovascular risk marker has highlighted the need for strategies addressing both blood pressure (BP) and heart rate (HR). The complementary actions of telmisartan, an angiotensin II receptor blocker (ARB), and metoprolol succinate, a β1-selective blocker, provide dual modulation of the renin–angiotensin–aldosterone system and sympathetic activity in hypertension management.

Effect on Telmisartan–Metoprolol FDC in Hypertension – Indian Experience: In a multi-centric, randomized, double-blind trial conducted across 10 Indian centres, 264 patients with stage I–II hypertension received telmisartan 40 mg/metoprolol succinate ER 50 mg or telmisartan 40 mg/bisoprolol 5 mg for 12 weeks. Both fixed-dose combinations produced significant BP reductions from week 2, sustained through week 12. By study completion, 86.7% and 91.4% of patients in the telmisartan–metoprolol group achieved systolic (<140 mmHg) and diastolic (<90 mmHg) BP targets, respectively, compared with 88.3% and 89.8% in the telmisartan–bisoprolol FDC group. Both antihypertensive combinations demonstrated comparable efficacy, safety, and tolerability, with no serious adverse events reported in Indian patients with hypertension. ⁹

Real-World Indian Data Demonstrate Clinical Utilization of Telmisartan–Metoprolol FDC: A retrospective multi-centric cross-sectional study evaluated 2,012 hypertensive patients across 457 clinical sites in India, receiving telmisartan–metoprolol FDC. Patients had a mean baseline BP of 148/94 mmHg and mean pulse rate of 85 bpm. The FDC was used for a mean duration of 5.82 months; 60.58% of patients were treatment-naïve, while 39.41% were switched from previous antihypertensive therapy. Among switched patients, prior therapies included ARB monotherapy (35.6%), β-blocker monotherapy (18.2%), calcium channel blockers (18.3%) and ARB–diuretic combinations (11.3%). These findings demonstrate the real-world utilization of telmisartan–metoprolol FDC across diverse Indian clinical settings. ¹⁰

Key Clinical Takeaways

• Elevated resting heart rate should be recognized as an important cardiovascular risk marker in hypertension, particularly given its presence among younger Indian hypertensive individuals and its association with adverse cardiovascular outcomes beyond conventional BP assessment. ^1–3

• Cardiovascular risk assessment in hypertension should extend beyond blood pressure control, with routine RHR evaluation helping identify patients with increased sympathetic activity, haemodynamic stress and possible residual cardiovascular risk.

• In appropriately selected hypertensive patients requiring combined BP and HR control, telmisartan–metoprolol offers complementary RAAS and sympathetic modulation-based treatment options, with Indian clinical evidence supporting its efficacy, safety and real-world utilization. ^{9, 10}

Abbreviations: ARB, angiotensin II receptor blocker; BP, blood pressure; CAD, coronary artery disease; CVD, cardiovascular disease; CV, cardiovascular; ER, extended release; FDC, fixed-dose combination; HR, heart rate; RAAS, renin–angiotensin–aldosterone system; RHR, resting heart rate; VALUE, Valsartan Antihypertensive Long-term Use Evaluation trial; CI, confidence interval.