# Cardiac vagal activity is associated with insulin metabolism in heart failure: Results from the Myovasc study

## TL;DR

This study shows that insulin metabolism is linked to heart rate recovery in heart failure patients, suggesting a role for insulin in controlling cardiac vagal activity.

## Contribution

The study reveals that insulin status, particularly HOMA-IR and C-peptide, independently predicts parasympathetic reactivation in heart failure.

## Key findings

- HOMA-IR and C-peptide independently predict heart rate recovery after exercise in heart failure patients.
- Higher HbA1c and C-peptide levels are associated with reduced heart rate recovery over time.
- The relationship between insulin metabolism and vagal activity is strongest in patients with heart failure and type 2 diabetes.

## Abstract

Cardiac autonomic dysfunction plays a pivotal role in the heart failure syndrome. Metabolic dysregulation affects both autonomic function and heart failure, but these relationships remain incompletely understood. This study aimed at investigating the role of glucose and insulin metabolism for parasympathetic reactivation.

Data from the MyoVasc study (NCT04064450), a prospective heart failure cohort study, were analyzed. Participants underwent a highly standardized 5-hour examination, including venous blood sampling. To assess the impact of glucose and insulin metabolism (HbA1c, HOMA-IR, and C-peptide) on parasympathetic reactivation as reflected by heart rate recovery 60 s (HRR60) after cardiopulmonary exercise testing, multivariable linear regression models with adjustment for sex, age, clinical profile (cardiovascular risk factors and comorbidities) and medication were calculated in cross-sectional and longitudinal settings. Additional adjustment for complementary glucose or insulin status was performed to assess the dependency of each other. Analyses were carried out in symptomatic heart failure and across the spectrum of glucose metabolism dysfunction.

The analysis sample included 1,588 individuals (median age 64.0 years [IQR 55.0;72.0]; 33% women) in a fasting state. Symptomatic heart failure was present in 43.7% of the subjects. Median HRR60 was 21.0 beats per minute (IQR 14.0;28.0). In multivariable regression analysis with adjustment for age, sex, clinical profile, and medication, both HbA1c (\documentclass[12pt]{minimal}
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\begin{document}$$\:\widehat{{\upbeta\:}}$$\end{document}per SD −0.074, 95% CI [− 0.122;−0.026], P = 0.003) and HOMA-IR (\documentclass[12pt]{minimal}
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\begin{document}$$\:\widehat{{\upbeta\:}}$$\end{document}per SD −0.113 [− 0.165;−0.062], P < 0.0001) predicted HRR60. Additional adjustment for both glucose and insulin status, respectively, demonstrated that HOMA-IR (\documentclass[12pt]{minimal}
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\begin{document}$$\:\widehat{{\upbeta\:}}$$\end{document}per SD −0.097 [− 0.155;−0.040], P < 0.0001), but not HbA1c (\documentclass[12pt]{minimal}
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\begin{document}$$\:\widehat{{\upbeta\:}}$$\end{document}per SD −0.030 [− 0.084;0.025], P = 0.28), was independently related to HRR60. This finding was confirmed in subgroups with heart failure and type 2 diabetes. In all analyses, C-peptide was related to HRR60 independently of HbA1c with higher effect estimates than HOMA-IR (\documentclass[12pt]{minimal}
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\begin{document}$$\:\widehat{{\upbeta\:}}$$\end{document}per SD −0.171 [− 0.225;−0.117], P < 0.0001). Finally, higher HbA1c (\documentclass[12pt]{minimal}
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\begin{document}$$\:\widehat{{\upbeta\:}}$$\end{document}per SD −0.094, [− 0.171;−0.017], P = 0.017) and C-peptide (\documentclass[12pt]{minimal}
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\begin{document}$$\:\widehat{{\upbeta\:}}$$\end{document}per SD −0.076, [− 0.159;0.007], P = 0.075) were more strongly associated with a lower HRR60 after two years of follow-up.

This study demonstrates the relevance of insulin status for vagal activity of cardiac autonomic function, particularly in heart failure. The pathophysiological implications underlying the relationship between insulin status and parasympathetic activity merit further mechanistic exploration.

The online version contains supplementary material available at 10.1186/s12933-025-03040-9.