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Normative values of short-term heart rate variability in a cross-sectional

study of a Danish population. The DanFunD study

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research-article2022
SJP0010.1177/14034948221124020L. S. Brinth et al.Short Title

Scandinavian Journal of Public Health, 1–10

Original Article

Normative values of short-term heart rate variability in a cross-

sectional study of a Danish population. The DanFunD study

Louise S. Brinth1,2 , Torben JØrgensen3,4,5 , Jesper MehlseN6,

Marie W. Petersen7, Lise Gormsen7,8, Allan Linneberg3,9,
Per Fink7,8, Michael E. Benros10,11 & Thomas M. Dantoft3

1Department of Clinical Physiology and Nuclear Medicine, Herlev and Gentofte Hospital, University of Copenhagen,

Denmark, 2Department of Clinical Physiology, North Zealand Hospital, University of Copenhagen, Hillerød, Denmark,
3Centre for Clinical Research and Prevention, Bispebjerg/Frederiksberg Hospital, Copenhagen, Denmark, 4Department of

Public Health, Faculty of Health and Medical Science, University of Copenhagen, Denmark, 5Faculty of Medicine, Aalborg
University, Denmark, 6Section for Surgical Pathophysiology, Copenhagen University Hospital, Denmark, 7Research Clinic
for Functional Disorders and Psychosomatics, Aarhus University Hospital, Denmark, 8Institute of Clinical Medicine,
University of Aarhus, Denmark, 9Department of Clinical Medicine, Faculty of Health and Medical Science, University of
Copenhagen, Denmark, 10Biological and Precision Psychiatry, Mental Health Centre Copenhagen, Copenhagen University
Hospital, Gentofte, Denmark, 11Department of Immunology & Microbiology, Faculty of Health and Medical Sciences,
University of Copenhagen, Denmark

Abstract
Aims: The autonomic nervous system includes parasympathetic and sympathetic components that monitor and regulate
most of the bodily functions and play a central role in the physiology and homeostasis of the human body. Heart rate
variability is a non-invasive tool for quantification of rhythmic fluctuations in heart rate that reflects the function of the
autonomic nervous system. The study aims to describe the heart rate variability distribution in the general population,
stratified in sex and age groups, which is currently insufficiently described. Methods: A cross-sectional population-based
study recruited participants in 10 municipalities in the western part of the greater Copenhagen area in Denmark, including
6891 men and women aged 18–72 years (participation rate was 29.5%). Short-term heart rate variability measures were
obtained and related to age and gender. Results: Both time and frequency domain measures showed a huge variation in the
different sex and age groups. Women had a higher median heart rate than men, and the association with age was U-shaped.
Measures indicating a predominance of the parasympathetic component in relation to the sympathetic component were
more frequent in women and younger age groups. Conclusions: Both sex and age influence the heart rate variability
in this adult Danish population. Therefore, our age- and sex-related reference values of heart rate variability in
the time and frequency domain should be used in further epidemiological and clinical research.

Keywords: Autonomic nervous system, heart rate variability, cross-sectional population-based study, normative values, epidemiology

Background the bodily functions – often in an antagonistic inter-

The autonomic nervous system (ANS) plays a cen-
tral role in the physiology and homeostasis of the
human body. Both subsystems of ANS, the parasym-
pathetic nervous system (PNS) and the sympathetic
nervous system (SNS), monitor and regulate most of
play. ANS is centrally located in the reflex arcs and
has negative feedback mechanisms that maintain an
optimal internal environment [1]. Heart rate varia-
bility (HRV) is a non-invasive and inexpensive tool
for the quantification of rhythmic fluctuations in
heart rate (HR) reflecting the influence of SNS and

Correspondence: Thomas M. Dantoft, Centre for Clinical Research and Prevention, Bispebjerg/Frederiksberg Hospital, Main road, entrance 5, ground floor.
Nordre Fasanvej 57. Frederiksberg, 2000, Denmark. Email: thomas.meinertz.dantoft@regionh.dk

Date received 16 July 2021; reviewed 23 June 2022; accepted 28 July 2022

© Author(s) 2022
Article reuse guidelines: sagepub.com/journals-permissions
DOI: 10.1177/14034948221124020
https://doi.org/10.1177/14034948221124020
journals.sagepub.com/home/sjp
2 L. S. Brinth et al.
PNS on the sinus node, and HRV is thereby an
approximate measure of the ANS function [2].
The association between variations in heart rate,
health and disease states have been recognized for
more than 2000 years [2], but it is only during the
last 50 years that the distinct physiological rhythms
embedded in the oscillations of HR have been
described [2].
In 1996, the European Society of Cardiology and
the North American Society of Pacing and
Electrophysiology established a task force concern-
ing HRV methodology [3]. Since then, thousands of
papers on HRV have been published, and the impor-
tance of HRV as a measure of ANS activity in an
array of diseases has been recognized. Reduced HRV
can predict the risk of arrhythmia and mortality after
acute myocardial infarction [4] and is associated with
a poor prognosis in a wide range of other diseases,
including diabetes [5]. Psychophysiological research
has in recent years taken an interest in HRV, driven
by the association between the parasympathetic nerv-
ous system and self-regulation mechanisms [6].
Female sex is associated with higher overall varia-
bility in HR – with a tendency for this sex-depend-
ency to decline with age [7]. Furthermore, there is a
well-documented association between increasing age
and decreasing HRV, most notably with regard to
measures reflecting PNS activity and reactivity [3,8].
The demonstrated relationship between altered
HRV and both diagnosis and prognosis of an array of
conditions has highlighted the value of altered HRV
to predict conditions that profoundly influence pub-
lic health and has placed HRV as a measure of inter-
est in public health research. In 1996, the task force
emphasized the need for large prospective popula-
tion-based studies to establish normative values for
HRV, as the implementation of HRV measures in
clinical work as well as public health research has
been hampered by large inter-individual variation in
HRV, the lack of relevant reference values across sex
and age subsets, and reliance on cross-sectional stud-
ies collecting data from different selected materials
[3,9]. In recent years, studies have emerged present-
ing normative values of relevant HRV indices and
demonstrating the influence of age and sex on HRV.
However, most of these studies have been based on
small or selected populations and a narrow age span
and have employed different methodological
approaches [10–16].
With the present study, we aim to present norma-
tive values for the most commonly reported HRV
parameters in the time and frequency domain in age
and sex subsets in a large Danish population-based
study, the Danish Study of Functional Disorders
(DanFunD) (N=6891) [17].
Methods
Study population
Details of the DanFunD study have been reported
previously [17]. The DanFunD-II cohort is a ran-
dom sample of the general population obtained from
the Danish Central Personal Register. A total of
25,368 men and women aged 18–72 years living in
the western part of the greater Copenhagen area
were invited, of whom 7493 participated (29.5%).
The only exclusion criteria were not being born in
Denmark, not being a Danish citizen, or being preg-
nant. Written informed consent was obtained from
all participants, and the study was approved by the
Ethical Committee of Copenhagen County (Ethics
Committee: H-3-2012–0015) and the Danish Data
Protection Agency.
Participants were invited for a health examination,
including questionnaires, physical tests and biological
samples [17]. All examinations were performed
between 08:00 h and 15:00 h and lasted about 90 min.
Participants were examined after at least 6 h of fasting
and were asked to abstain from smoking at least one
hour prior to the examination. Participants were rest-
ing in the supine position for 5 min before the meas-
urement of continuous heart rate using the ‘E-motion’
heart rate monitor device (eMotion HRV, Bittium,
Kuopio, Finland). The analysis is based on the normal-
to-normal (NN) intervals between successive sinus
node derived heart beats, and the files were selected
and prepared accordingly. Measurements were per-
formed during 7 min of supine rest and normal breath-
ing. Both staff and subjects were instructed to refrain
from talking apart from necessary commands.
Patient and public involvement
There was no patient or public involvement in the
design of the study.
Data preparation
In concordance with current guidelines [3] the last 5
min of the 7 min supine rest and a sampling rate of
250 Hz were chosen. Analysis of HRV was per-
formed using a standardized analysis programme
(Kubios, v. 2.0, http://kubios.uku.fi) [18]. In 270
participants, RR intervals were not recorded due to
technical errors or known pacemaker-implant.
Participants with atrial fibrillation or excessive extra-
systoles, defined as more than 20 ectopic beats dur-
ing the 5-min sampling period, were excluded from
further analysis (n=100). Files with technical arte-
facts due to poorly attached electrodes or equipment
failure were also excluded (n=232) leaving 6891 for
 Normative values of heart rate variability in the general population. The DanFunD study 3
Table 1. Number of persons according to sex, age, BMI, and systolic and diastolic blood pressure in the Danish Study of Functional Dis-
orders (DanFunD). The DanFunD study was conducted between 2012 and 2015 and included 3152 men and 3739 women aged 18–72
years living in the western part of the greater Copenhagen area, Denmark.

Sex Age Number of persons BMI Systolic BP Diastolic BP Median

Median (25/75 IQR) Median (25/75 IQR) (25/75 IQR)
Male 18–29 273 23.6 (21.9/25.6) 120 (112/127) 71 (66/79)
n = 3152 30–39 296 24.7 (23.1/27.1) 120 (114/128) 75 (70/81)
40–49 633 25.9 (23.9/28.3) 126 (118/135) 81 (75/88)
50–59 822 26.5 (24.3/29.5) 132 (122/142) 84 (78/90)
60–72 1128 27.0 (24.7/29.8) 138 (128/151) 82 (76/89)
Female 18–29 346 22.5 (20.2/24.9) 111 (102/118) 68 (63/74)
n = 3739 30–39 348 23.6 (21.3/26.2) 113 (108/122) 71 (66/78)
40–49 811 24.2 (21.8/27.8) 118 (110/129) 75 (69/81)
50–59 1013 24.6 (22.2/28.1) 127 (117/138) 78 (71/85)
60–72 1221 25.4 (22.8/28.8) 138 (126/150) 80 (73/87)

BMI: body mass index; IQR: interquartile range; BP; blood pressure.

analysis. Ectopic beats were corrected using a thresh-
old-based artefact correction algorithm [19].
Detrending was performed using smoothness priors
with a lambda value of 500 [20].
Data analysis
From the NN intervals, the following statistical indices
were calculated: average heart rate (mean HR), RR
interval length based on NN intervals (meanNN), the
standard deviation of instantaneous of HR values
(STDHR) and NN (STDNN), and the root mean
square of successive difference (RMSSD) as the square
root of the mean squared differences between adjacent
NN intervals. pNN50 was calculated as the percentage
of successive NN intervals in the recording that differ
by more than 50 ms [3].
Power spectral density analysis allows for the esti-
mation of power as a function of frequency. In a short-
term recording of instantaneous heart rate, three main
spectral components are differentiated by non-para-
metric Fast Fourier Transformation using Welch’s peri-
odogram with a 300-s window with 50% overlap [21]:
very low frequency (VLF; <0.04 Hz), low frequency
(LF; 0.04–0.15 Hz) and high frequency (HF; 0.15–0.4
Hz) components. In short-term recordings (5 min or
less), total power and VLF variation have ill-defined
physiological meaning and are, therefore, not reported
[3]. The LF and HF variations are measured and
reported both as total power (LFtotal, HFtotal), nor-
malized units representing the relative values of each
power component proportional to the total power
(minus the VLF component) (LFnu, HFnu) and as the
ratio between LF and HF variation (LF/HF).
Statistical analysis
The 5th, 25th, 50th, 75th and 95th percentiles were
calculated for all age groups separately for men and
women. By means of the Kolmogorov–Smirnov test,
it was confirmed that data were not normally distrib-
uted, and consequently, non-parametric tests were
used to examine differences in various HRV meas-
ures, that is, the Mann–Whitney U test was used to
examine differences between men and women and
the Kruskal–Wallis test was used to examine age-
dependent differences for men and women, sepa-
rately. A p-value of 0.05 or below was considered
significant, and all calculations were performed using
SPSS statistics version 22 (IBM Corp, Armonk, NY,
USA).
To avoid the influence of heart diseases that could
possibly affect HRV, participants answering yes to
the question ‘has a doctor ever told you that you have
had a heart attack or other heart disease?’ (n=345)
were omitted in a sensitivity analysis, where the anal-
yses were repeated in the remaining 6546
participants.
Results
The number of cases categorized according to sex,
age and median and interquartile range of body mass
index (BMI), and systolic and diastolic blood pres-
sure is shown in Table 1.
Normative values are given as the 5th, 25th, 50th,
75th and 95th percentiles for HRV parameters
according to sex and five age groups (Tables 2 and
3).
Both mean HR and STDHR were higher in
women than in men. The association with age was
U-shaped for mean HR in both sexes, whereas the
association of STDHR with age declined with
increasing age (Table 2; Figure 1).
MeanNN was higher in men than in women, and
the age relation showed an inverse U-shaped curve in
both sexes. STDNN was higher in women than men
4 L. S. Brinth et al.
Table 2. The Danish Study of Functional Disorders (DanFunD) was conducted between 2012 and 2015 and included 3152 men and 3739
women aged 18–72 years living in the western part of the greater Copenhagen area, Denmark. Percentiles for time-domain heart rate vari-
ability measures are categorized according to age group and each sex. N=6891.

Variable Sex Age group Percentile p value for the sex-related p value for the age-related
differencesa differencesb
5th 25th 50th 75th 95th
MeanHR Male 18–29 47.65 56.94 62.43 69.44 79.20 ˂0.001 ˂0.001
30–39 47.40 53.66 59.68 65.93 76.82
40–49 45.83 54.23 60.22 66.72 78.63
50–59 47.90 55.76 61.44 68.42 82.39
60–72 49.95 57.21 63.75 71.24 84.26
Female 18–29 52.49 60.16 66.28 72.46 82.74 ˂0.001
30–39 50.85 58.71 64.90 70.71 80.62
40–49 49.89 57.86 63.92 69.82 79.73
50–59 51.04 58.02 63.70 69.52 79.55
60–72 52.63 60.39 66.28 72.45 83.12
STDHR Male 18–29 2.20 3.17 3.87 5.17 8.33 ˂0.001 ˂0.001
30–39 1.72 2.32 3.19 4.07 5.66
40–49 1.23 1.93 2.57 3.30 4.83
50–59 1.08 1.58 2.09 2.75 4.29
60–72 0.84 1.29 1.72 2.37 4.09
Female 18–29 2.18 3.33 4.38 5.53 8.16 ˂0.001
30–39 1.73 2.55 3.49 4.41 6.12
40–49 1.51 2.18 2.78 3.59 5.07
50–59 1.20 1.72 2.32 3.00 4.33
60–72 0.90 1.36 1.82 2.47 3.77
MeanNN Male 18–29 758.87 868.33 964.91 1058.26 1265.13 ˂ .001 ˂0.001
30–39 783.72 910.70 1008.50 1125.79 1276.13
40–49 763.98 902.10 997.37 1109.87 1310.49
50–59 729.16 878.63 978.08 1078.60 1254.26
60–72 712.12 843.67 943.42 1050.65 1202.01
Female 18–29 727.61 834.92 910.62 1004.75 1148.49 ˂0.001
30–39 746.17 849.34 927.81 1027.43 1189.42
40–49 753.46 861.14 942.03 1039.58 1206.50
50–59 757.47 864.48 943.81 1036.48 1176.37
60–72 722.55 828.95 906.70 995.03 1141.13
STDNN Male 18–29 24.45 39.33 52.02 69.71 112.10 0.037 ˂0.001
30–39 23.50 32.86 42.71 58.28 95.73
40–49 15.86 24.80 34.04 45.83 75.14
50–59 11.18 18.69 26.09 36.85 56.43
60–72 8.34 14.73 19.92 27.72 54.97
Female 18–29 22.50 36.76 52.54 74.06 123.49 ˂0.001
30–39 19.64 30.70 41.50 55.67 103.11
40–49 16.13 25.48 34.16 46.03 73.90
50–59 12.27 20.75 28.07 37.38 60.60
60–72 9.00 14.55 20.20 28.36 47.01 ˂0.001
RMSSD Male 18–29 16.77 34.43 51.14 73.90 128.80 ˂0.001
30–39 17.87 28.38 39.96 58.87 105.80
40–49 11.64 19.92 29.95 43.84 81.32
50–59 7.44 14.67 22.74 33.33 59.92
60–72 6.04 11.93 17.02 25.18 53.64 ˂0.001
Female 18–29 18.88 35.39 57.19 83.87 171.26
30–39 16.79 28.95 40.37 62.52 118.23
40–49 13.27 22.90 32.77 48.62 83.03

50–59 9.45 17.94 25.04 35.73 62.59

60–72 6.79 12.19 17.89 25.83 51.77
pNN50 Male 18–29 0.77 13.77 31.21 52.88 180.10 ˂0.001 ˂0.001
30–39 1.14 7.64 22.06 43.20 160.10
40–49 0.10 1.47 10.10 29.41 130.10
50–59 0.10 0.30 3.20 14.89 54.46
60–72 0.10 0.10 0.77 5.24 40.10

(Continued)
 Normative values of heart rate variability in the general population. The DanFunD study 5
Table 2. (Continued)

Variable Sex Age group Percentile p value for the sex-related p value for the age-related
differencesa differencesb
5th 25th 50th 75th 95th
Female 18–29 0.92 14.85 38.31 60.84 240.10 ˂0.001
30–39 0.26 7.78 24.16 48.86 250.10
40–49 0.10 2.87 12.89 34.74 110.10
50–59 0.10 0.65 4.95 18.06 60.10
60–72 0.10 0.10 0.90 6.42 42.09

aResult of Mann–Whitney U test comparing heart rate variability (HRV) measures between males and females independent of age.
bResult of Kruskal–Wallis tests comparing HRV measures between all five age groups of the same sex.
RMSSD: root mean square of successive difference ; Mean HR: average heart rate; STDHR: standard deviation of the HR intervals; MeanNN: average normal-
to-normal (NN) intervals between successive sinus node derived heart beats; STDNN: standard deviation of all NN intervals; RMSSD: root mean square of
successive difference; pNN50: percentage of successive NN intervals in the recording that differ by more than 50 milliseconds.

(Table 2), but curves were very close (Figure 1).
STDNN declined with increasing age in both sexes.
RMSSD and pNN50 values were higher in women
than in men and declined with increasing age in both
sexes.
The absolute measures of variability in the LF and
HF domains (LFtotal, HFtotal) were negatively cor-
related with age in both sexes. Men had higher LF
variation and lower HF variation compared with
women (Table 3; Figure 2).
The normative and relative measures in the fre-
quency domain (LFnu, HFnu and LF/HF) showed
that men had higher LFnu- and lower HFnu-variation
compared with women. Women had a relative
increase in LFnu and a relative decrease in HFnu
with advancing age. Men had a more complex pat-
tern with a tendency for LFnu to increase with age,
whereas the slight decrease in HFnu turned into an
increase in the 95th percentile. The increase in LF
and a concomitant decrease in HF with age resulted
in a marked increase in the LF/HF ratio in both sexes
but was most pronounced in women, where the LF/
HF ratio doubled when comparing the youngest and
oldest age groups. Men had a higher LF/HF ratio
than women (Table 3; Figure 2).
The sensitivity analysis excluding participants
with a previous heart attack or other heart disease did
not cause any substantial differences in the described
results (data not shown).
Discussion
This manuscript presents age- and sex-stratified ref-
erence values for selected HRV measures in the time
and frequency domains based on a population-based
cohort of 6891 adult Danes by using percentile val-
ues for 5-min recordings.
In general, we find age- and sex-related trends
similar to those observed in other studies [8,9,11–
13,15,16], but the reference values are different,
which could be due to differences in size and selec-
tion of material and different methodological
approaches.
In the healthy heart at rest, the sinus node is under
tonic PNS inhibitory control, and basal HR is, there-
fore, predominantly determined by the activity of the
PNS [1]. PNS control on the sinus node is transmit-
ted through large myelinated fibres exerting their
effect faster than sympathetic nerve fibres. Thus, high
and frequent changes in HR quantified by the time
domain parameters RMSSD and pNN50 and the
HF parameters of frequency domain analysis will
predominantly reflect PNS control on the sinus node.
The physiological explanation of the LF component
of HRV is less clear. Most likely, the LF HRV pre-
dominantly mirrors a baroreflex-mediated response
to the SNS mediated rhythmic oscillation of the
blood vessels – the so-called ‘Mayer waves’ [22].
Thus, these slower oscillations in HR, quantified by
the LF parameters in the frequency domain (LF,
LFnu), are thought to reflect the activity in the SNS.
However, it is important to recognize that the LF
HRV is also dependent on parasympathetic activity
and therefore mirrors both sympathetic and para-
sympathetic activity [22].
The myelin covering the vagal nerve is subject to
age-related degeneration [23], which may result in
decreasing conduction velocity and ultimately in
the well-established age-related decline in cardio-
vagal control [23,24], which is in accordance with
the age-related decline in the present study. We
find a U-shaped relationship between HR and age,
whereas we find other HRV measures to decline
linearly with age. In apparent contrast to our find-
ings, other studies have found a U-shaped correla-
tion between age and HRV parameters mirroring
primarily cardiovagal regulation (RMSSD) [25].
However, the increase in parasympathetic indices
seen with advancing age in other studies is seen in
octo- and nonagenarians with trough values for
6 L. S. Brinth et al.

Figure 1. The Danish Study of Functional Disorders (DanFunD) was conducted between 2012 and 2015 and included 3152 men and
3739 women aged 18–72 years living in the western part of the greater Copenhagen area, Denmark. Time-domain heart rate variability
measures are shown as median values according to age and sex.
RMSSD: root mean square of successive difference ; Mean HR: average heart rate; STDHR: standard deviation of the HR intervals; MeanNN: average normal-
to-normal (NN) intervals between successive sinus node derived heart beats; STDNN: standard deviation of all NN intervals; RMSSD: root mean square of
successive difference; pNN50: percentage of successive NN intervals in the recording that differ by more than 50 milliseconds.
 Normative values of heart rate variability in the general population. The DanFunD study 7
Table 3. The Danish Study of Functional Disorders (DanFunD) was conducted between the years 2012 and 2015 and included 3152 men
and 3739 women aged 18–72 years living in the western part of the greater Copenhagen area, Denmark. Percentiles for frequency-domain
heart rate variability measures are categorized according to age groups and each sex. N=6891.

Variable Sex Age group Percentile p value for the sex-related p value for the age-related
differencesa differencesb
5th 25th 50th 75th 95th
LFtotal Male 18–29 241.71 679.48 1162.37 2296.47 6255.35 ˂0.001 ˂0.001
30–39 200.58 518.57 946.79 1768.85 4845.48
40–49 113.44 300.90 585.45 1115.04 3274.10
50–59 48.36 157.86 347.53 776.23 2038.43
60–72 28.94 95.33 208.80 447.37 1455.30
Female 18–29 154.67 483.89 923.53 1969.11 5557.58 ˂0.001
30–39 113.85 307.84 670.28 1488.59 4381.61
40–49 81.02 242.77 510.38 935.80 2,513.07
50–59 51.88 166.30 360.47 675.11 2,136.23
60–72 30.16 90.37 179.29 391.41 1,252.37
HFtotal Male 18–29 132.89 447.64 911.97 1953.79 5935.02 ˂0.001 ˂0.001
30–39 106.09 298.68 532.66 1108.15 3674.64
40–49 38.98 130.39 284.74 611.05 1619.02
50–59 17.34 69.40 170.37 369.91 1111.83
60–72 10.60 42.32 88.97 199.89 782.06
Female 18–29 148.08 508.25 1249.58 2752.06 10,742.79 ˂0.001
30–39 107.87 345.70 662.58 1483.74 4341.96
40–49 69.33 206.39 415.01 931.10 2475.04
50–59 27.71 108.99 230.12 491.35 1486.29
60–72 13.21 51.26 114.95 242.85 877.45
LFnu Male 18–29 25.10 44.06 56.81 70.32 85.95 ˂0.001 ˂0.001
30–39 30.84 47.14 61.91 74.58 89.31
40–49 31.93 53.57 67.78 79.98 91.19
50–59 31.16 53.73 68.50 80.68 91.14
60–72 28.86 53.22 69.72 81.71 91.15
Female 18–29 14.52 29.97 44.25 58.74 78.59 ˂0.001
30–39 20.26 31.67 47.23 65.20 84.39
40–49 20.66 38.00 53.74 68.58 84.03
50–59 22.90 44.51 60.14 74.32 88.96
60–72 25.12 45.98 64.14 75.59 87.50
HFnu Male 18–29 13.96 29.68 43.17 55.93 74.84 ˂0.001 ˂0.001
30–39 10.68 25.39 38.02 52.85 69.14
40–49 8.81 20.02 32.16 46.41 68.06
50–59 8.85 19.32 31.46 46.24 68.82
60–72 8.84 18.28 30.21 46.67 71.12
Female 18–29 21.41 41.09 55.57 69.99 85.41 ˂0.001
30–39 15.60 34.77 52.69 68.01 79.72
40–49 15.93 31.39 46.13 61.96 79.12
50–59 11.03 25.61 39.83 55.49 76.82
60–72 12.48 24.39 35.77 53.92 74.76
LF/HF Male 18–29 0.34 .79 1.32 2.37 6.16 ˂0.001
30–39 0.45 .89 1.63 2.94 8.37
40–49 0.47 1.15 2.11 3.99 10.35
50–59 0.45 1.16 2.18 4.18 10.30
60–72 0.41 1.14 2.31 4.47 10.32
Female 18–29 0.17 0.43 0.80 1.43 3.67 ˂0.001
30–39 0.25 0.46 0.90 1.88 5.41
40–49 0.26 0.61 1.17 2.18 5.27
50–59 0.30 0.80 1.51 2.90 8.06
60–72 0.34 0.85 1.79 3.10 7.01

aResult of Mann–Whitney U test comparing heart rate variability (HRV) measures between all males and all females in the cohort.
bResult of Kruskal–Wallis tests comparing HRV measures between all five age groups of the same sex.
LFtotal: total low-frequency spectral power; HFtotal: total high-frequency spectral power; LFnu: normalized LF units representing the relative values of each
power component proportional to the total power, minus the VLF component; HFnu: normalized HF units representing the relative values of each power
component proportional to the total power, minus the VLF component; LF/HF: Ratio of LF-to-HF power

parasympathetic indices around the age of 70 – apparent increase in indices of HRV in the octo-
which may explain the apparent discrepancy as we and nonagenarians found by others may be due to
included few subjects above the age of 70. The survival bias.
8 L. S. Brinth et al.

Figure 2. The Danish Study of Functional Disorders (DanFunD) was conducted between 2012 and 2015 and included 3152 men and
3739 women aged 18–72 years living in the western part of the greater Copenhagen area, Denmark. Frequency-domain heart rate variability
measures are shown as median values according to age and sex.
LFtotal: total low-frequency spectral power; HFtotal: total high-frequency spectral power; LFnu: normalized LF units representing the relative values of each
power component proportional to the total power, minus the VLF component; HFnu: normalized HF units representing the relative values of each power
component proportional to the total power, minus the VLF component; LF/HF: Ratio of LF-to-HF power
 Normative values of heart rate variability in the general population. The DanFunD study
We confirm an overall tendency for higher values
in HRV measures reflecting PNS activity (RMSSD,
pNN50, HF, HFnu) in women compared with men.
Furthermore, we confirm a tendency in young
women (age 18–39 years) for the predominance of
HF variation (HF, HFnu) over LF variation (LF,
LFnu) and concomitant LF/HF ratios <1 in these
younger decades, reflecting higher parasympathetic
activity [7,10,16]. The sex-related difference sub-
sides with age as men in all the included age groups
(18–72 years) and women from the fourth decade
(40–72 years) have a predominance of LF variation
–more accentuated in men, which is reflected in
higher LF/HF ratios. In both sexes, LF/HF ratios
increase with age, mirroring a decrease in cardiovagal
regulation and an increase or stationary sympathetic
activity with advancing age [7,16]. As an apparent
and well-known paradox, we find that women have a
higher mean heart rate compared with men [7],
which is thought to be mediated not by higher SNS
activity but rather by the smaller size of the female
heart [26].
Our findings confirm previous findings in both
human and animal studies – that (young) females tend
to show greater parasympathetic activity compared
with men, which may explain some of the health dis-
parity between sexes – one example being the higher
cardiovascular morbidity in men as the higher cardio-
vagal control seen in females is cardioprotective
[27,28].The higher parasympathetic activity in women
may be related to the female sex hormone profile as
oestrogen and oxytocin increase vagal tone [28,29].
Strength and limitations
The physiological processes generating HRV are
mediated in the brain and transferred through the
parasympathetic (vagal) and sympathetic nerves to
the sinus node, thereby regulating the sinus node’s
pacemaker function. Thus, it is important to keep in
mind that HRV reflects autonomic regulation of the
heart and not generalized autonomic control and
activity. Under many circumstances, the autonomic
regulation of HR will be in concordance with auto-
nomic outflow to the rest of the body – but in some
circumstances, the autonomic outflow is differenti-
ated. One example is postprandially, where vagal
activity is suppressed in the heart but increased in the
gastrointestinal tract [30].
A major strength, besides the size of the study
(N=6891), is the use of a random selection of per-
sons from the background population, which we
believe will be valuable in both the research and clini-
cal settings even though the design may introduce
9
healthy user bias. However, omitting participants
with known heart disease did not significantly change
the overall pattern described or the normative values
calculated. Furthermore, data on BMI and blood
pressure (Table 1) support the generalizability of the
material. A limitation is the age span of 18–72 years,
and it would be valuable for future studies to include
the whole lifespan.
Analysis of HRV is an inexpensive, non-invasive
method that is based on something as readily availa-
ble as a continuous measurement of heart rate, and
data analysis has been made increasingly accessible
in the last decade through better analysis algorithms
making almost instant test results accessible. HRV
assesses activity in the ANS and reflects the ability of
the ANS to respond to a variety of physiological and
psychological stimuli. HRV has proven to be a prom-
ising marker for both physiological and psychological
processes and disease states at the group level.
Robust data on normative values for HRV, as we
present in this study, are crucial when measures of
HRV in both clinical and research setting must be
interpreted.
Conclusion
Both sex and age influence HRV in an adult Danish
population. Measures indicating a predominance of
the parasympathetic component in relation to the
sympathetic component were more frequent in
women and in the younger age groups. Therefore,
age- and sex-related reference values of HRV in the
time and frequency domain should be used in further
epidemiological and clinical research on HRV.
Acknowledgements
The DanFunD steering committee consists of
Professor MD DMSc Torben Jørgensen (PI), Professor
MD DMSc Per Fink, senior consultant MD PhD Lene
Falgaard Eplov, Professor MD PhD Allan Linneberg,
Professor MSc PhD Susanne Brix Pedersen and
Professor MD PhD Michael Eriksen Benros.
Data availability
Data cannot be made publicly available for ethical
and legal reasons. Public availability may compro-
mise participant privacy, and this would not comply
with Danish legislation. Access to the subset of data
included in this study can be gained through submit-
ting a request to The Capital Region Knowledge
Centre for Data Compliance, The Capital Region
Denmark: cru-fp-vfd@regionh.dk. Acquisition of
data is allowed only after permission to handle data
 10 L. S. Brinth et al.
has been obtained in accordance with the guidelines
stated by the Danish Data Protection Agency: http://
www.datatilsynet.dk/english.
Declaration of conflicting interests
The authors declared no potential conflicts of inter-
est with respect to the research, authorship, and/or
publication of this article.
Funding
The authors received no financial support for the
research, authorship, and/or publication of this article.
ORCID iDs
Louise S Brinth https://orcid.org/0000-0001-
6546-1308
Torben Jørgensen https://orcid.org/0000-0001-
9453-2830
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