Objective To investigate the effect of 24-hour average heart rate (AHR) on all-cause mortality in elderly patients with coronary heart disease (CHD). Methods A total of 262 elderly CHD patients admitted in our hospital from June 2010 to June 2012 were recruited in this study. According to the results of 24-hour ambulatory electrocardiography (Holter examination) before discharge, they were divided into 24 h AHR≥75 times/min group (n=71) and 24 h AHR<75 times/min group (n=191) at the cut point of 75 times/min. The follow-up was carried out from December 1,0 to June 31,6, at an interval of 6 months, with all-cause death as the main endpoint. Their baseline data and laboratory indicators 24 h before discharge and causes of death during follow-up were collected and compared. SPSS statistics 19.0 was used to analyze the data. According to the data type, Student′s t test, Wilcoxon rank sum test and Chi-sqaure test were used for comparison between groups. Kaplan-Meier survival curve was plotted to analyze the cumulative survival rate between groups. Multivariate Cox proportional hazard model was applied to evaluate the risk factors of all-cause mortality in CHD patients during follow-up. Results The median period of follow-up was 40.7 months, and whole data of these patients were collected. Compared with the 24 h AHR<75 times/min group, the 24 h AHR≥75 times/min group had signifi-cantly higher white blood cell count, serum level of low-density lipoprotein cholesterol and urinary content of microalbumin (P<0.05). The total mortality rate during follow-up was 6.87%(18/262). [JP+1]The all-cause mortality rate [15.49%(11/71) vs 3.66%(7/191); P=0.002] and CHD mortality [9.86%(7/71) vs 1.57%(3/191); P=0.005] was obviously increased in the 24 h AHR≥75 times/min group than the 24 h AHR<75 times/min group. Kaplan-Meier survival analysis showed that the cumulative survival rate of patients with 24 h AHR≥75 times/min was statistically lower than that of the patients with 24 h AHR<75 times/min (P=0.001). Multivariate Cox proportional hazard model analysis showed that after adjustment for confounding factors, 24 h AHR≥75 times/min (HR=4.604, 95%CI 1.343-15.784; P=0.015) and smoking (HR=3.943,5%CI 1.009-15.412; P=0.049) were determined as independent risk factors for all-cause death in the elderly CHD patients. Conclusion The all-cause mortality is significantly increased in the elderly CHD patients with 24 h AHR≥75 times/min. So, the mortality may be reduced by controlling 24 h AHR and quitting smoking.