Prognostic Significance of Changes in Heart Rate Following Uptitration of Beta-Blockers in Patients with Sub-Optimally Treated Heart Failure with Reduced Ejection Fraction in Sinus Rhythm versus Atrial Fibrillation

Ify Mordi (Lead / Corresponding author), Bernadet T. Santema, Marielle Kloosterman, Anna-Maria Choy, Michiel Rienstra, Isabelle C Van Gelder, Stefan D. Anker, John G. F. Cleland, Kenneth Dickstein, Gerasimos S. Filippatos, Pim van der Harst, Hans L. Hillege, Marco Metra, Leong Loke Ng, Wouter Ouwerkerk, Piotr Ponikowski, Nilesh J. Samani, Dirk Jan van Veldhuisen, Aeilko H. Zwinderman, Faiez ZannadAdriaan A. Voors, Chim Lang

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Abstract

Background: In patients with heart failure with reduced ejection fraction (HFrEF) on sub-optimal doses of beta-blockers, it is conceivable that changes in heart rate following treatment intensification might be important regardless of underlying heart rhythm. We aimed to compare the prognostic significance of both achieved heart rate and change in heart rate following beta-blocker uptitration in patients with HFrEF either in sinus rhythm (SR) or atrial fibrillation (AF).

Methods: We performed a post hoc analysis of the BIOSTAT-CHF study. We evaluated 1548 patients with HFrEF (mean age 67 years, 35% AF). Median follow-up was 21 months. Patients were evaluated at baseline and at 9 months. The combined primary outcome was all-cause mortality and heart failure hospitalisation stratified by heart rhythm and heart rate at baseline.

Results: Despite similar changes in heart rate and beta-blocker dose, a decrease in heart rate at 9 months was associated with reduced incidence of the primary outcome in both SR and AF patients [HR per 10 bpm decrease—SR: 0.83 (0.75–0.91), p < 0.001; AF: 0.89 (0.81–0.98), p = 0.018], whereas the relationship was less strong for achieved heart rate in AF [HR per 10 bpm higher—SR: 1.26 (1.10–1.46), p = 0.001; AF: 1.08 (0.94–1.23), p = 0.18]. Achieved heart rate at 9 months was only prognostically significant in AF patients with high baseline heart rates (p for interaction 0.017 vs. low).

Conclusions: Following beta-blocker uptitration, both achieved and change in heart rate were prognostically significant regardless of starting heart rate in SR, however, they were only significant in AF patients with high baseline heart rate.

Original languageEnglish
Pages (from-to)797-805
Number of pages9
JournalClinical Research in Cardiology
Volume108
Issue number7
Early online date4 Jan 2019
DOIs
Publication statusPublished - Jul 2019

Keywords

  • Atrial fibrillation
  • Beta-blockers
  • Heart failure
  • Heart rate

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    Mordi, I., Santema, B. T., Kloosterman, M., Choy, A-M., Rienstra, M., Van Gelder, I. C., Anker, S. D., Cleland, J. G. F., Dickstein, K., Filippatos, G. S., van der Harst, P., Hillege, H. L., Metra, M., Ng, L. L., Ouwerkerk, W., Ponikowski, P., Samani, N. J., van Veldhuisen, D. J., Zwinderman, A. H., ... Lang, C. (2019). Prognostic Significance of Changes in Heart Rate Following Uptitration of Beta-Blockers in Patients with Sub-Optimally Treated Heart Failure with Reduced Ejection Fraction in Sinus Rhythm versus Atrial Fibrillation. Clinical Research in Cardiology , 108(7), 797-805. https://doi.org/10.1007/s00392-018-1409-x