European Geriatric Medicine
https://doi.org/10.1007/s41999-019-00192-2
LETTER TO THE EDITOR
Heart rate variability: a possible marker of resilience
Sarah Damanti1,2   · Paolo Dionigi Rossi1 · Matteo Cesari1,3
Received: 19 March 2019 / Accepted: 3 April 2019
© European Geriatric Medicine Society 2019
The aging process is characterized by an exponential accu-
mulation of pathophysiological deficits that, from subcel-
lular and cellular abnormalities, gradually scale up to affect
organ functioning. The exponential trend of the phenom-
enon can be explained by the interactions among biological
systems so that the failure of one leads to the dysfunction
of others. The consequent exhaustion of the physiological
reserves reduces the organism capacity to react to stressors
[1], thus increasing the vulnerability to internal and external
stressors and the risk of incident adverse events. This condi-
tion is commonly named frailty [1].
In the past years, the term “resilience” has been intro-
duced in the geriatric field. Differently from frailty, resil-
ience describes the capacity of the organism to recover after
a stressor has exerted its negative effects on the organism [2].
Since the loss of integration among physiological domains
reduces both the redundancy and efficacy of the responses
to stressors, measures detecting the intersystem coordination
might be considered for estimating the organism resilience.
In this context, some physiological domains may play
a role more critical than others in the determination of the
resilience trait, for example those systems specifically acti-
vated in conditions of stress (e.g. autonomic nervous sys-
tem [ANS], hypothalamic-pituitary axis, innate immunity,
renin-angiotensin system, insulin/growth hormone/IGF-1
pathways) [3].
To our knowledge, various instruments are available for
measuring the static condition of frailty, but clinical meas-
ure has not yet been adopted for capturing the dynamic
mechanism of resilience. The ANS may offer a promising
* Sarah Damanti
sarah.damanti@hotmail.it
1
Geriatric Unit, Fondazione IRCCS Ca’ Granda Ospedale
Maggiore Policlinico, Milan, Italy
2
Nutritional Sciences PhD, University of Milan, Via
Francesco Sforza 35, 20100 Milan, Italy
3
Department of Clinical Sciences and Community Health,
University of Milan, Milan, Italy
opportunity to fill this gap through the non-invasive quanti-
fication of the heart rate variability (HRV) [4].
The HRV consists in the interval fluctuations between
sinus heartbeats. It is mainly determined by para- and
ortho-sympathetic influences on the pacemaker cell auto-
matic activity. It also depends on the interplay among mul-
tiple feedback loops (i.e. hormonal, temperature, circadian
rhythms). Under steady-state conditions, it may adequately
capture the integration of various regulatory mechanisms
and describe the ANS function. In healthy conditions (that
is, characterized by a high level of integration among physi-
ological domains), the HRV shows highly irregular and com-
plex dynamic patterns with fractal proprieties. The general-
ized reduction in the complexity of the dynamic interaction
among physiological domains, typical of aging [5], is instead
reflected by the reduction of HRV. Also, in pathologic con-
ditions (i.e. cardiovascular disorders, psychiatric illnesses)
which impair the coordinated activity of organs and systems
HRV appears less variable [4].
HRV has shown a predictive capacity for negative end-
points, as mortality [4]. This is consistently with the hypoth-
esis that HRV represents a measure of the biological reserves
of the individual. For example, in situations characterized
by clinical instability (i.e. sepsis, fetal distress, post-surgi-
cal complications), the HRV tends to decrease, even before
other parameters change (e.g. inflammatory markers).
In conclusion, HRV should be considered a marker of
resilience. Its multidimensional nature, longitudinal design,
and clinical relevance make it an ideal candidate for expand-
ing our knowledge in the novel field of resilience.
Compliance with ethical standards 
Conflict of interest  The authors declare that they have no conflict of
interest.
Ethical approval  No patient was involved.
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