REVIEW article
Front. Neurol.
Sec. Stroke
This article is part of the Research TopicNeurocardiology: The Science of Heart-Brain InteractionsView all 6 articles
COMPREHENSIVE AUTONOMIC NERVOUS SYSTEM EVALUATION IN STROKE PATIENTS: HEART RATE VARIABILITY AS A CORNERSTONE FOR RECOVERY PREDICTION
Provisionally accepted
Markiian Chornyi*
Viktoriia Gryb- Ivano-Frankivsk National Medical University, Ivano-Frankivs’k, Ukraine
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Abstract Background: Autonomic nervous system (ANS) dysfunction significantly impacts stroke outcomes, yet standardized autonomic monitoring remains underutilized in clinical practice. Recent evidence highlights heart rate variability (HRV) as a robust prognostic marker, while complementary modalities like blood pressure variability (BPV) and pupillometry enhance risk stratification. Objective: To synthesize current evidence on multimodal ANS assessment in stroke patients, with HRV as the cornerstone biomarker, and provide practical recommendations for clinical implementation. Methods: We conducted a narrative review of peer-reviewed studies (2018-2024) from major databases, focusing on HRV and complementary ANS modalities in stroke patients. The analysis included 53 studies from diverse global regions, with a specific focus on technology-enabled investigations and prospective cohorts that emerged from 2022 to 2024. Results: Time-domain HRV metrics such as SDNN (standard deviation of all normal-to-normal RR intervals) and RMSSD (root mean square of successive differences) consistently predicted functional outcomes and cardiovascular complications post-stroke. Beat-to-beat blood pressure variability (BPV) within the first 24 hours post-ischemic stroke outperforms HRV alone for short-term prognosis, with an AUC improvement of 10-15%. Nocturnal HRV combined with BPV and endothelial function enhanced prediction of recurrent cerebrovascular events. Automated pupillometry, with Neurological Pupil index (NPi <3), predicts post-stroke delirium; integration with HRV metrics improves prognostic accuracy. Consumer-grade wearables demonstrated high agreement with ECG standards, enabling scalable remote monitoring. Conclusions: HRV-centered multimodal ANS assessment offers robust, non-invasive prognostic tools for stroke management. Integration with BPV, pupillometry, and wearable technology enhances risk stratification across acute and rehabilitation phases. Standardized protocols and technology adoption could transform stroke outcomes globally, particularly in resource-limited settings.
Keywords: Autonomic Nervous System, baroreflex sensitivity, blood pressure variability, cardiac autonomic neuropathy, Heart rate variability, prognosis, Pupillometry, Stroke
Received: 25 Sep 2025; Accepted: 10 Dec 2025.
Copyright: © 2025 Chornyi and Gryb. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Markiian Chornyi
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