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Using Heart Rate Variability for Health

Monitoring
Can measuring heart rate variability with your smartphone predict the onset of an
illness?

Welltory Follow
Mar 28 · 16 min read

As the COVID-19 outbreak continues to spread, the FDA has warned

consumers against buying at-home testing kits for SARS-CoV-2. As of March
23, the Food and Drug Administration hasn’t authorized any self-
administered tests. If you suspect you have COVID-19, contact your
healthcare provider and follow their instructions.

Still, if that doesn’t alleviate your concern, you can try an additional science-
based method to track your physical well-being — heart rate variability. A
health marker that you can measure with your smartphone, heart rate
variability can help you spot the onset of an illness before you feel any
symptoms and monitor your recovery if you get sick.
What is heart rate variability?
We’ve made changes to our Terms of Service and Privacy Policy. They take effect on September 1,
2020, and we encourage you to review them. By continuing to use our services, you agree to the
Heart
new rate
Terms of variability (HRV) is a the
Service and acknowledge measure of variations
Privacy Policy applies toin the time intervals
you.
between your heartbeats — how “uneven” your heartbeat is. First designed to
Continue
track astronaut performance in the 1960s, this metric has now become well-
studied. Scientists use HRV for different purposes, for instance:

• to measure stress levels

• to separate healthy people from those with chronic health conditions

• to assess the immune system

• to predict the speed of recovery after a severe illness

All of this makes HRV a valuable tool for tracking your physical well-being.
For example, you can spot the onset of illness — including COVID-19 —
before you develop symptoms.

HRV can also help you understand how well your body is coping with being
sick. If your scores get progressively worse, it can be a signal that you should
call your doctor or even go to the ER.

Finally, HRV is a good way to monitor recovery. Healthcare professionals

could potentially use HRV readings to identify which patients need
immediate intervention, evaluate how effective treatments are, etc.

How does HRV work?

As we’ve already mentioned, HRV measures how uneven your heartbeat is.
This variability is a good thing — your heartbeat is not supposed to have an
even rhythm. Higher variability shows that your nervous system is good at
adapting to changes inside and outside of your body. When you start
breathing faster, take a sip of coffee, or have a stressful thought, your
autonomic nervous system sends signals that adjust your heart rate. And
since everything changes all the time, your heart never beats evenly.

The higher your heart rate variability, the better your body is at adapting to
changes and stressors. When you’re overwhelmed by stress or are in bad
 shape
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changes and maintaining homeostasis — a stable internal environment. It’s a
Continue
signal you need to take measures and regain balance.

How can you measure HRV?

There are two ways — you can use the camera on your smartphone or a
special heart rate monitor.

The Welltory app uses the heartbeat data tracked through the camera or
heart rate monitor to calculate different HRV metrics, using time-domain
analysis and frequency-domain analysis.

Key time-domain metrics include RR, SDNN, pNN50, and rMSSD. All of
these metrics essentially estimate how heart rate variability changes over
time to evaluate the balance between your nervous system’s sympathetic and
parasympathetic activity.

The two most widely used measures of HRV are SDNN and rMSSD. They’re
calculated based on RR intervals — the time intervals between heartbeats.
SDNN is basically the standard deviation of a measurement’s RR intervals,
while rMSSD is the root mean square of successive differences. Research
shows that SDNN provides a more accurate assessment of sympathetic
activity: the activation of “fight-or-flight” in response to stress, the ability to
adapt to changes and continue functioning and being productive. rMSSD is a
measure of parasympathetic activity — how well you are able to “rest-and-
digest” and recover from stress.
We’ve made changes to our Terms of Service and Privacy Policy. They take effect on September 1,
2020, and we encourage you to review them. By continuing to use our services, you agree to the
new Terms of Service and acknowledge the Privacy Policy applies to you.
There is an additional type of analysis that might help you understand
Continue
which process is now dominating in your body — stress or recovery. It’s
called frequency-domain analysis: it uses metrics that are calculated by
transforming the length of each RR interval into waves to measure their
frequency. The resulting waves are then divided into three bands: low-
frequency (LF), high frequency (HF) and very low frequency (VLF).

Welltory calculates the share of each power spectrum and the sum of all
spectra, or total power. But we use these metrics with caution. Research has
shown that frequency-domain analysis can be highly inaccurate: for instance,
taking a deep breath affects LF power and consciously controlling your breath
affects HF. Plus, these metrics often vary significantly throughout the day.

This means that you need to stick to very strict guidelines if you want to draw
meaningful conclusions from frequency-domain analysis:

• take measurement lying down

• measure at the same time every day

• lie down for at least 5 minutes before measuring

• use the bathroom before measuring

• don’t measure if you’re on your period

If you stick to all of these guidelines and notice significant changes in your
frequency-domain metrics, then we might — cautiously — draw some
conclusions about the state of your autonomic nervous system.
We’ve made changes to our Terms of Service and Privacy Policy. They take effect on September 1,
2020, and we encourage you to review them. By continuing to use our services, you agree to the
new Terms of Service and acknowledge the Privacy Policy applies to you.

Continue

How can you use HRV to spot the onset of illness?

We’ve already established that HRV metrics might fluctuate when you’re sick.
But how exactly can you spot the onset of COVID-19?

Scientists are currently trying to find biomarkers that could help identify
people with SARS-CoV-2 even before they develop symptoms. One biomarker
they’ve been able to pinpoint is the C-reactive protein (CRP) — a marker of
systemic inflammation in the body. Clinical data from infected patients has
shown that CRP in COVID-19 patients changes before other blood test
parameters — a sign this marker could be useful in detecting the first signs of
infection:

“The clinical data of 33 patients with respiratory symptoms caused by the novel
coronavirus in Wenzhou city from January 15 to February 12,2020, were
thoroughly reviewed. According to the patients’ histories, the patients were
divided into two groups: those who spent time in the main epidemic area and
those who did not spend time in the main epidemic area. <…> Respiratory
tract ailments and systemic symptoms were the primary symptoms of novel
coronavirus infection in the secondary epidemic area; these symptoms are not
typical. The abnormal increase in serum amyloid protein (SAA) may be used as
an auxiliary index for diagnosis and treatment. CRP changes before other
blood parameters and thus may be an effective evaluation index for
patients with COVID-19 infection,” — Analysis of COVID-19 clinical features
in secondary epidemic area, Weiping Ji, Gautam Bishnu, Zhenzhai Cai, Xian
Shen, published on March 13, 2020.

Problem is, you can’t do blood tests every day in order to track changes in
your CRP levels. That’s where HRV measurements come into play — there are
 a number
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“Hamaad et al. (2005) tested the association

Continue between time and frequency
domain indices of heart rate variability and circulating IL-6, high sensitivity
CRP (hs-CRP) and white cell counts, in a sample of 100 patients with proven
acute coronary syndrome. In addition, they compared these metrics with healthy
controls (n = 49) and estimated possible relationships on repeated measures at
4 months in recovery (n = 51). They found modest negative correlations
between all inflammatory biomarkers and mainly SDNN, VLF and LF
power. The strongest associations were seen between WBC and SDNN (r =
−0.351). However, relationships did not persist on multivariate analyses after a
4-month period. According to the authors, the correlations were observed largely
among heart rate variability indices reflecting sympathetic activity, suggesting
that the inflammatory response in acute coronary events may be associated with
sympathetic activation instead of vagal withdrawal.”

“In another study, Lanza and colleagues (2006) assessed heart rate variability
and measured CRP serum levels within 24 h of admission in 531 patients with
unstable angina pectoris. They found a significant negative correlation
between CRP levels and all heart rate variability metrics derived from
both time and frequency domain, with the highest correlation coefficient
with SDNN and VLF. After categorizing patients into 4 subgroups according to
CRP quartile levels, significantly lower heart rate variability values were found
in the upper CRP quartile. The subsequent multivariate analysis revealed that
SDNN and VLF were the most significant predictors of increasing CRP, whereas
CRP was a strong predictor of impaired ANS activity as well.”

“In a similar study (Nolan et al., 2007), a negative correlation between CRP
and heart rate variability frequency components was reported, whereas a
decreased HF power (reflecting vagal tone) in the high CRP quartile,
compared to the lowest one, was found.”

“Psychari et al. (2007) also reported a strong inverse association between

CRP and several heart rate variability indices (SDNN, HF, and LF).”
 “Recently,
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cohort of 862 subjects recruited from the Heart and Soul Study, which assessed
Continue
health outcomes in 1.024 outpatients with stable CAD. They found that SDNN
was inversely and significantly associated with inflammatory indices,
after adjustment of all covariates.”

To sum up these findings, SDNN has the strongest correlation with increased
CRP levels. If you notice your SDNN falling for several days in a row, this may
be a sign you’re getting sick. Same goes for rMSSD.

Another worrying signal is a decrease in HF power: it reflects your vagal tone

and tends to fall when CRP levels are rising. Lowered LF and VLF power
values can also be indicative of a spike in CRP levels.

In other words, altered HRV measures during the COVID-19 incubation

period should be reflecting the stress your body is experiencing because of
the developing inflammation.

Keep in mind that heart rate variability readings can fluctuate throughout the
day. To eliminate these fluctuations and ensure you’re monitoring trends
from one day to the next, take measurements at the same time every morning
and every evening in the same position. HF, LF, and VLF values are even more
sensitive than SDNN and rMSSD, so they must be interpreted with extra
caution.

TL;DR: How can HRV help you spot the onset of COVID-19
before you develop symptoms?
Look out for the following signs:

• SDNN and rMSSD values drop for several days in a row

• For 300-beat measurements taken while lying down, HF, LF and VLF
values drop for several days in a row

• pNN50, on the other hand, may either stay intact or also start dropping
 • Ifmade
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infection, which may or may not be COVID-19.
Continue
• Seeing a drop in HRV metrics and elevated CRP? It’s best to self-
quarantine for at least two weeks. If you need to leave the house, wear a
mask to prevent the asymptomatic spread of the virus — you might be
asymptomatic or still be in the incubation period.

What if you already have symptoms?

Let’s recap. The three most common symptoms of COVID-19 include:

• fever

• dry cough

• shortness of breath

Other potential symptoms include:

• sore throat

• headaches

• fatigue

• body aches

• diarrhea (rare)

• stuffy nose (rare)

 Runny
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an allergy.
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Suppose you’ve developed symptoms associated with the novel coronavirus.

Continue
How can HRV help you?

You’ve been tested and you are positive for COVID-19. Your doctor told
you to stay at home and monitor your symptoms.
Measuring your HRV can help you track the course of your illness and notice
if things get worse.

The most common complication of COVID-19 is pneumonia. It can further

lead to acute respiratory distress syndrome (ARDS), lung failure and even
death. So it’s important to closely monitor your condition in order to spot the
first signs of pneumonia. HRV can help.

Researchers have compared patients with pneumonia with healthy control

subjects. They’ve noticed that having pneumonia decreases your total power
and VLF power by 3 to 5 times. If you have pneumonia, your LF power also
drops compared to your normal range. Most importantly, people with
pneumonia have an LF/HF ratio lower than 1.

“Inflammatory reflex, through the activation of vagus nerve, controls the

immune response to injury. Alterations of cardiac autonomic control we found in
community-acquired pneumonia (CAP) patients could be seen as the final
consequence of a complex interaction between systemic inflammation, that could
trigger the inflammatory reflex, and hypoxia, that could trigger central and
peripheral autonomic reflexes. Autonomic alterations in this population,
characterized by a lower level of total variability and a reduction of LF
components, could be partially related to the activation of the above
mentioned excitatory different reflexes and these results were more
evident in patients with severe CAP, compared to those without severe CAP
on admission. In summary, CAP patients with a more severe disease on
admission seem to show a loss of rhythmic sympathetic oscillation, with a
predominant respiratory oscillation characterizing HRV. These findings were
consistent across different evaluations of the severity of the disease on
 admission.”
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al., published
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Respiratory Research on August 04, 2016.
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Another study has shown that an LF/HF ratio lower than 1 is associated with
a 6-fold increase in the likelihood of pneumonia in immunocompromised
patients. The risk of complications is also predicted by a low rMSSD value: if
rMSSD is lower than 10, patients are 5 times more likely to have
complications:

“90 patients with hip fractures admitted to Kongsberg hospital between 2008
and 2013 were invited to participate in the study.<…> One in three patients
experienced at least one complication. Seven percent developed pneumonia, and
two percent died before discharge. Due to low numbers of myocardial infarctions
and stroke, these patients were not analysed separately, but were included in the
analysis of overall complications. There were no differences in HRV parameters
comparing patients with and without beta blockers. Patients with complications
had significantly lower rMSSD and TP preoperatively (p = 0.043 and 0.03,
respectively) compared to patients without. The likelihood ratio to develop
complications in case of rMSSD < 10 was 4.9. Patients that experienced
postoperative infections (pneumonia and urinary tract infection) had
significantly lower VLF preoperatively, compared to patients without such
complications (p = 0.04). In patients with postoperative urinary tract infections
there was also decreased VLF (p = 0.02), and we found a tendency towards
lowered VLF in patients with postoperative pneumonia (p = 0.091). There
was a significant association between pneumonia and LF/HF<1 (p =
0.031). The likelihood ratio to develop pneumonia in case of LF/HF < 1
was 6.1.” — Decreases in heart rate variability are associated with
postoperative complications in hip fracture patients, Gernot Ernst et al.,
published in PLOS One on July 25, 2017.

If you see such changes in the course of your COVID-19 infection, it’s a
warning sign. Especially if the drop in heart rate variability measures is
coupled with trouble breathing, persistent pain or pressure in the chest,
confusion, or bluish lips or face.
 You are
We’ve madeinchanges
the hospital getting
to our Terms treatment
of Service and Privacy for COVID-19
Policy. complications.
They take effect on September 1,
2020, and we encourage you to review them. By continuing to use our services, you agree to the
Now it’s the doctors’ responsibility to monitor your condition. But you can
new Terms of Service and acknowledge the Privacy Policy applies to you.
still use HRV as a science-based tool to track your recovery and the
Continue
effectiveness of the treatments you get. Of course, that’s true only if you’re
not already on a ventilator — in this case HRV readings will be altered by the
machine and will no longer be valuable for health monitoring.

Doctors taking care of patients during the COVID-19 outbreak should also
take a closer look at HRV. In a hospital that is over capacity, it’s difficult to
make decisions about whose condition is truly critical and requires
immediate assistance. Heart rate variability has been shown to be helpful in
identifying patients who are in critical condition:

“A consecutive cohort of patients visiting the ED of a university teaching hospital

who met the criteria of sepsis over a 6-month period were enrolled in this study.
General demographics, vital signs, laboratory data, and Mortality in Emergency
Department Sepsis score were obtained in the ED; the in-patient medical record
was reviewed; and a series of continuous 10-minute electrocardiographic signals
were recorded for off-line HRV analysis to assess the in-hospital mortality of the
patients. One hundred thirty-two patients aged 27 to 86 years who met the
inclusion criteria were enrolled. According to the in-hospital outcome, the
patients were categorized into 2 groups: nonsurvivors (n = 10) and
survivors (n = 122). The baseline HRV measures, including SDNN, TP,
VLFP, LFP, and LFP/HFP ratio, of nonsurvivors were significantly lower,
whereas the nHFP was significantly higher, than those of survivors.
Multiple logistic regression model identified SDNN and nHFP as the
significant independent variables in the prediction of in-hospital
mortality for ED patients with sepsis. The receiver operating characteristic
area for SDNN and nHFP in predicting the risk of death was 0.700 and 0.739,
respectively. Heart rate variability measures, especially the SDNN and nHFP,
may be used as valuable predictors of in-hospital mortality in patients with
sepsis attending the ED.” — Heart rate variability measures as predictors of in-
hospital mortality in ED patients with sepsis, Wei-Lung Chen et al., published
in The American journal of emergency medicine in June 2008.
 “Indexes
We’ve madeof heart to
changes rate
ourvariability (HRV)
Terms of Service andappear to reflect
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take effect on may have 1,
September
2020, and we encourage
prognostic you to review
value in patients withthem.
acuteByexacerbation
continuing to use
of our services,
chronic you agree to the
obstructive
new Terms of Service and acknowledge the Privacy Policy applies to you.
pulmonary disease (AECOPD). We hypothesized that AECOPD without adequate
Continue
treatment response would demonstrate impaired cardiac autonomic regulation
and changes in HRV after emergency department (ED) treatment. Patients with
AECOPD requiring admission after ED treatment had a greater increase in
HF% and greater decrease in LF/HF ratio compared to those discharged.
Our study demonstrates patients with ΔHF% >7.1 or ΔLF/HF% ≦-0.39
require admission despite 24 h of ED treatment.” — Changes of heart rate
variability predicting patients with acute exacerbation of chronic obstructive
pulmonary disease requiring hospitalization after Emergency Department
treatment, Tseng CY et al., published in Journal of the Chinese Medical
Association in January 2018.

If you look at the data from the previously mentioned research, you will see
that patients who are likely to get better in a week have a less severe drop in
total power and VLF, and an LF/HF ratio just slightly below 1. More critical
patients see their VLF drop more than 10-fold compared to healthy people,
and their LF/HF ratio is around 0.78:

“A total of 48 patients (64 %) reached clinical stability before 7 days of hospital

admission. In comparison to patients who reached CS within 7 days, those
who reached CS after 7 days had significantly lower total power (p =
0.001) and lower VLF component (p = 0.003).” — Cardiovascular
autonomic alterations in hospitalized patients with community-acquired
pneumonia, Stefano Aliberti et al., published in Respiratory Research on August
04, 2016.

These changes in your HRV metrics can show if your current treatment is
ineffective or if you require intensive care.

You haven’t been tested and are at home wondering if you have
COVID-19.
Unfortunately, not everyone is able to get their hands on COVID-19 tests —
there are no FDA-approved at-home kits yet, and medical professionals have
 to choose
We’ve who gets
made changes tested.
to our TermsYoung people
of Service with Policy.
and Privacy mild symptoms might
They take effect just get a1,
on September
2020, and we encourage
recommendation toyou to at
stay review
homethem.
forBy continuing
two weeks to usemonitor
and our services, yousymptoms
their agree to the
new Terms of Service and acknowledge the Privacy Policy applies to you.
in case they get worse. What can you do in this scenario?
Continue
Of course, HRV measurements won’t show if you have COVID-19 or another
respiratory infection. But they can help you track the course of your illness
and take action if you see a drastic drop in your scores.

TL;DR: You already have symptoms of a respiratory illness. How can

measuring HRV help?

• HRV can’t help you differentiate between COVID-19 and other respiratory
infections. If possible, you should get tested for SARS-CoV-2.

• If your symptoms are mild and you’re at home, you can use HRV to
monitor your condition. A significant — 3 to 5-fold and more — drop in
VLF and total power, coupled with difficulty breathing, is a sign that
you’re not doing well.

• An important thing to monitor is your LF/HF ratio. If it drops lower than

1 and stays like that for a long time, this might mean that you have a
higher risk of developing pneumonia.

• If you are already in the hospital with COVID-19 complications, it’s

important to take your VLF power and LF/HF ratio into consideration.
VLF power that has dropped 10-fold or more or an LH/HF ratio much
lower than 1 — around 0.78 — are signs that your treatment isn’t
working well.

• Doctors can also use SDNN to identify patients who need immediate
assistance. People with significantly lower SDNN are less likely to survive,
so they need to be admitted to intensive care first.

• If you are already on a ventilator, don’t use heart rate variability to track
your condition and recovery — the readings will be altered by the
machines.

How do I use HRV to track my recovery and overall well-being?

 HRV made
We’ve isn’t changes
a “one-size-fits-all”
to our Terms ofmarker. There
Service and are
Privacy some
Policy. ranges
They for different
take effect on September 1,
2020, and we
metrics thatencourage you to review
are considered them. Bybut
“normal,” continuing
in facttoyour
use our services,
norm you agree to the
is strictly
new Terms of Service and acknowledge the Privacy Policy applies to you.
individual. That’s why it’s so important to track your HRV regularly: you’ll
Continue
know your personal baseline for each metric and will see if something
changes drastically.

Are you in good health? Great. It’s time to start tracking your HRV. Welltory’s
smart algorithms need some time to calibrate your data and establish your
personal baseline. It’s a good time for you to see what your measurements
look like when you’re in good shape. Plus, it can curb your anxiety: if your
HRV scores aren’t getting worse, you are probably not coming down with
COVID-19.

Let’s recap. Here are the signs that you are fine:

• Time-domain metrics — SDNN and rMSSD — are stable or increasing

• For 300-beat measurements taken while lying down before bedtime each
day, HF, LF and VLF are NOT dropping significantly over time

• LF/HF ratio is a little over 1 and stays that way

If your HRV metrics drop for several days in a row, you’ll know something’s
up. Plus, you’ll be able to track your recovery if you do get sick — wait before
your HRV scores stabilize before you go back to business as usual.
 If youmade
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our Terms of COVID-19
Service orPolicy.
and Privacy are a They
researcher interested
take effect in 1,
on September
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studying encourage you to review
progression them. Byfor
patterns continuing to use we
COVID-19, our have
services, you agreean
launched to the
new Terms of Service and acknowledge the Privacy Policy applies to you.
open data research project aimed at analyzing heart rate variability data from
people sick with coronavirus here. Continue

Join us! This is the first open data study for people diagnosed with COVID-19
that includes wearable and heart rate variability data.

Coronavirus Covid 19 Heart Rate Variability Apple Watch Science

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