Exercise chronotropic incompetence phenotypes the level of cardiovascular risk and exercise gas exchange impairment in the general population.  An analysis of the Euro-EX prevention trial. 
Chronotropic insufficiency (CI) is defined as the inability of the heart to increase its rate commensurate with increased demand.  Exercise CI is an established predictor of major adverse cardiovascular events in patients with cardiovascular diseases.  The aim of this study was to evaluate how exercise CI phenotypes different levels of cardiovascular risk and how it may better perform in defining cardiovascular risk when analysed in the context of cardiopulmonary exercise test (CPET)-derived measures and standard echocardiography in a healthy population with variable cardiovascular risk profile.  Apparently healthy individuals (N = 702, 53.8% females) with at least one major cardiovascular risk factor (MCVRF; hypertension, diabetes, tabagism, dyslipidaemia, body mass index > 25), enrolled in the Euro-EX prevention trial, underwent CPET.  CI was defined as the inability to reach 80% of the chronotropic index, that is, the ratio of peak heart rate - rest heart rate/peak heart rate - age predicted maximal heart rate (AMPHR: 220 - age), they were divided into four groups according to the heart rate reserve (<80%>) and respiratory gas exchange ratio (RER; < 1.05>) as a marker of achieved maximal performance.  Subjects with a RER < 1.05 (n = 103) were excluded and the final population (n = 599) was divided into CI group (n = 472) and no-CI group (n = 177).  Compared with no-CI, CI subjects were more frequently females with a history of hypertension in a high rate.  CI subjects also exhibited a significantly lower peak oxygen uptake (VO2) and circulatory power and an echocardiographic pattern indicative of higher left atrial volume index and left ventricular mass index.  An inverse stepwise relationship between heart rate reserve and number of MCVRFs was observed (one MCVRF: 0.71 ± 0.23; two MCVRFs: 0.68 ± 0.24, three MCVRFs: 0.64 ± 0.20; four MCVRFs: 0.64 ± 0.23; five MCVRFs: 0.57 ± 18; p < 0.01).  In multivariate analysis the only variable found predicting CI was peak VO2 (p < 0.05; odds ratio 0.91; confidence interval 0.85-0.97).  In a population of apparently healthy subjects, exercise CI is common and phenotypes the progressive level of cardiovascular risk by a tight relationship with MCVRFs.  CI patients exhibit some peculiar abnormal exercise gas exchange patterns (lower peak VO2 and exercise oscillatory ventilation) and echo-derived measures (higher left atrium size and left ventricle mass) that may well anticipate evolution toward heart failure.