The Effect of 5-Hz Repetitive Transcranial Magnetic Stimulation on the Left DLPFC on Heart Rate Variability in Ischemic Stroke Patients: A Randomized Controlled Trial (RCT)

Stroke remains a leading cause of morbidity and mortality worldwide, with autonomic dysfunction contributing substantially to adverse outcomes and impaired recovery. Heart rate variability (HRV) is a well-established marker of autonomic regulation, yet therapeutic strategies to modulate HRV in stroke patients remain limited. Repetitive transcranial magnetic stimulation (rTMS) has emerged as a non-invasive neuromodulation technique with potential to improve cortical excitability and autonomic balance. This randomized controlled trial investigated the effect of 5 Hz rTMS applied to the left dorsolateral prefrontal cortex (DLPFC) on HRV parameters in ischemic stroke patients. Participants were randomized into rTMS and control groups, and HRV was assessed at baseline and after intervention using time-domain, frequency-domain, and autonomic nervous system (ANS) indices. Results demonstrated that the rTMS group experienced significant improvements in time-domain measures (HR, SDNN, RMSSD) and frequency-domain components (VLF, LF, HF) compared to the control group, which showed either decline or inconsistent changes. While parasympathetic and sympathetic indices (PNS, SNS) did not reach statistical significance, trends toward improved autonomic modulation were observed in the rTMS group. These findings indicate that rTMS exerts a robust modulatory effect on HRV, particularly through interval variability and spectral components, while global sympatho-vagal indices may require longer intervention or larger sample sizes to detect meaningful change. Overall, the study highlights the potential of rTMS as a novel adjunctive therapy for autonomic regulation in ischemic stroke rehabilitation, supporting its role in enhancing cardiovascular adaptability and recovery outcomes.