Heart rate control in heart failure: insights from nationwide multicenter registry HEROES

Aim HEart failuRe ObsErvational Study of the Polish Cardiac Society (HEROES) is a prospective, multi-center, observational all-comers study aimed to assess clinical profile of heart failure (HF) pts (patients) in a representative national sample (41 centers). This analysis reports aspects of heart rate (HR) control and rate control drugs use in the modern era (2022-24). Methods Analysis of eCRF prospectively collected data from 1422 out-pts and in-pts (median age 69, IQR 60-76, 28.6% females) with complete 16 months follow-up (median: 485 days, interquartile range: 397–599 days) providing 16.2% (231/1422) mortality rate. The cohort included HFrEF/mrEF/pEF subgroups (heart failure with reduced, mildly reduced, preserved ejection fraction: 59/ 14/ 27%). Among the analyzed 1168 non-paced patients 36% were in atrial fibrillation (AF). Results Median recorded HR at presentation was 77 beats per minute, bpm (IQR 67-90), higher in pts in AF (85 bpm; IQR 75-100 vs 75 bpm; IQR 65-85 in sinus rhythm, p<0.0001) and in hospitalized pts (80 bpm, IQR70-92) than in in-pts (70 bpm; 64-89, p<0.0001). Baseline use of beta-adrenolytics was 80% (increasing to 95% at discharge) and ivabradine was used in 4% (increase to 5%), amiodarone in 11% and digitalis in 8.5%. Only 59% of outpatients in sinus rhythm presented with baseline HR=<70 and lenient control in AF was adequate. Discharge HR improved to 70 bpm (IQR 65-80), higher in pts in AF (75 bpm; IQR 66-82 vs 70 bpm; IQR 63-78 in sinus rhythm, p<0.0001). Presentation heart rate was predictive for mortality, effect driven by in-pts and pts insinus rhythm. Logistic regression showed 1% excess mortality risk per 1bpm increase in presentation HR. Kaplan-Meier curves analysis showed hazard ratio of 1.5 (p=0.0045) for dying in pts with snapshot HR>82 at presentation. For in-pts prediction cutoff was identified at admission HR >73bpm (HR=1.33 with borderline significance). Pts with HFpEF showed most significant relationship of presentation heart rate and mortality (logistic regression p=0.0004 vs p=0.12 for HFmrEF and p=0.55 for HFpEF). Presentation HR correlated with serum NT-proBNP (r=0.24, p<0.001) and inversely with KCCQ score (r=0.25, p<0.001). Conclusions Among the Polish patients from snapshot HEROES registry accelerated heart rate is common, correlating with worse Nt-proBNP and quality of life. HR at presentation is weakly but significantly related with total 16-months mortality with optimal cutoff >82bpm for entire cohort and sinus rhythm pts, and with >73bpm for hospitalized pts. Elevated heart rate was a remarkable predictor of mortality in the subset of patients with preserved ejection fraction.