Associations of Poincaré Plot-Derived Parameters with Heart Rate Variability and Autonomic Reflex Testing in a Real-World Clinical Population

Background/Objectives: Poincaré plot analysis represents a nonlinear approach to heart rate variability (HRV) assessment, but the physiological meaning of several derived parameters remains unclear. This study aimed to evaluate associations between selected Poincaré plot-derived parameters, conventional HRV indices, and cardiovascular autonomic reflex tests in a real-world clinical population. Methods: This observational study included 269 adult patients referred for evaluation of suspected autonomic dysfunction. All participants underwent short-term resting ECG, cardiovascular autonomic reflex testing, and 24 h Holter ECG monitoring. Poincaré plot-derived parameters were analyzed in relation to short- and long-term HRV measures using the Spearman correlation with false discovery rate correction, and group comparisons were performed based on reflex test results. Results: Several Poincaré plot-derived parameters showed strong correlations with long-term HRV indices. VLI and LA were primarily associated with global and long-term autonomic variability, whereas VAI and SA were more closely related to parasympathetic modulation. Associations with short-term HRV were generally weak. Lower values of selected parameters were observed in patients with abnormal parasympathetic reflex tests, while no significant differences were found in relation to orthostatic hypotension. Conclusions: Poincaré plot-derived parameters capture complementary aspects of autonomic regulation beyond conventional HRV indices and may enhance autonomic phenotyping in clinical settings.