We thank Dr. Latson for and appreciate his interesting comment on our study. As he stated, we demonstrated that the ratio of low frequency (LF) to high frequency (HF) of heart rate variability (HRV) predicts postspinal hypotension with high sensitivity and specifity.1,2These findings were confirmed in the control group of another study.3In addition, we demonstrated significant differences of normalized HF spectral power before subarachnoid block. These results may indicate that baseline HF is of predictive value as well, confirming the conclusions of Latson et al.  4 

We agree with the author that the type of HRV analysis may crucially influence the results. Latson et al.  investigated absolute values, whereas we analyzed the different frequency bands of the power spectrum as normalized units.

Currently, HRV-derived data are processed and presented in different ways. First, absolute HRV values are frequently analyzed and, as the author stated, may have advantages in the analysis of autonomic reflex integrity. Nevertheless, total power of HRV and its different parts decrease with increasing age, underlying cardiovascular disease, and impaired autonomic regulation.5–7Thus, an absolute HF of, for example, 1,000 ms2/Hz may be considered as below normal in young and healthy patients, normal in older healthy patients, and even above normal range in patients with coronary artery disease. Therefore, absolute values do not reflect the specific impact of the parasympathetic or the sympathetic activity of the autonomic regulation. Second, HRV data are normalized to total power. If the total power is high (e.g. , 10,000 ms2/Hz), an HF of 1,000 ms2/Hz is only 10%, reflecting a low parasympathetic activity in the individual. If the total power is only 2,000 ms2/Hz, the same absolute HF value would reflect a considerably higher parasympathetic activity. The aim of our studies was to identify a general predictor of postspinal hypotension; therefore, we investigated the different frequencies in normalized units and cannot comment on absolute HF values in our patients. Absolute values were analyzed as well, but demonstrated only a trend toward higher HF in normotensive patients compared with hypotensive patients. Therefore, we cannot recommend the analysis of absolute values for prediction of postspinal hypotension based on our data.

The guidelines of the Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology do not favor any one of the mathematical techniques, and each may have advantages and disadvantages.8 

However, the ratio of LF to HF was demonstrated to be the most valuable parameter of HRV in terms of prediction of postspinal hypotension.1–3This parameter reflects the balance of the autonomic nervous system and is independent of relative or absolute values because the ratio of absolute and normalized values is mathematically identical. Risk stratification based on the analysis of this autonomic balance was demonstrated to successfully guide prophylactic therapy.3 

We conclude that in a homogenous group of patients, analysis of absolute values of HRV parameters is probably the best method to determine reflex integrity or “gain.” If the trial’s patient population demonstrates a large variation with respect to age, sex, and underlying diseases, relative values may be more appropriate. LF to HF ratio may be particularly useful for HRV analysis because it is independent of this difference.

*University-Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany. hanss@anaesthesie.uni-kiel.de

Hanss R, Bein B, Ledowski T, Lehmkuhl M, Ohnesorge H, Scherkl W, Steinfath M, Scholz J, Tonner PH: Heart rate variability predicts severe hypotension after spinal anesthesia for elective cesarean delivery. Anesthesiology 2005; 102:1086–93
Hanss R, Bein B, Weseloh H, Bauer M, Cavus E, Steinfath M, Scholz J, Tonner PH: Heart rate variability predicts severe hypotension after spinal anesthesia. Anesthesiology 2006; 104:537–45
Hanss R, Bein B, Francksen H, Scherkl W, Bauer M, Doerges V, Steinfath M, Scholz J, Tonner PH: Heart rate variability–guided prophylactic treatment of severe hypotension after subarachnoid block for elective cesarean delivery. Anesthesiology 2006; 104:635–43
Latson TW, Ashmore TH, Reinhart DJ, Klein KW, Giesecke AH: Autonomic reflex dysfunction in patients presenting for elective surgery is associated with hypotension after anesthesia induction. Anesthesiology 1994; 80:326–37
Bonnemeier H, Richardt G, Potratz J, Wiegand UK, Brandes A, Kluge N, Katus HA: Circadian profile of cardiac autonomic nervous modulation in healthy subjects: Differing effects of aging and gender on heart rate variability. J Cardiovasc Electrophysiol 2003; 14:791–9
Wennerblom B, Lurje L, Tygesen H, Vahisalo R, Hjalmarson A: Patients with uncomplicated coronary artery disease have reduced heart rate variability mainly affecting vagal tone. Heart 2000; 83:290–4
Burger AJ, Charlamb M, Weinrauch LA, D’Elia JA: Short- and long-term reproducibility of heart rate variability in patients with long-standing type I diabetes mellitus. Am J Cardiol 1997; 80:1198–202
Heart rate variability: Standards of measurement, physiological interpretation and clinical use. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Circulation 1996; 93:1043–65