Key result
Beta-blockers reduced all-cause mortality by 27% compared to placebo in patients with heart failure and reduced ejection fraction in sinus rhythm, but had no effect on mortality in patients with atrial fibrillation.
Why the study?
The relationship between mortality and heart rate remains unclear for patients with HFrEF in either sinus rhythm or atrial fibrillation.
Do beta-blockers reduce all-cause mortality in patients with HFrEF in sinus rhythm or atrial fibrillation?
Meta-Analysis (n=17,378)
Double-blind
Randomized
Yes
Do beta-blockers reduce all-cause mortality in patients with HFrEF in sinus rhythm or atrial fibrillation?
Beta-blockers reduce mortality in HFrEF patients in sinus rhythm regardless of baseline heart rate, but do not improve survival in those with atrial fibrillation.
Answers are grounded in this paper and cite their sources.
Supports rhythm-specific beta-blocker decisions in HFrEF; leaves open randomized confirmation in atrial fibrillation.
BACKGROUND: The relationship between mortality and heart rate remains unclear for patients with heart failure with reduced ejection fraction in either sinus rhythm or atrial fibrillation (AF). OBJECTIVES: This analysis explored the prognostic importance of heart rate in patients with heart failure with reduced ejection fraction in randomized controlled trials comparing beta-blockers and placebo. METHODS: The Beta-Blockers in Heart Failure Collaborative Group performed a meta-analysis of harmonized individual patient data from 11 double-blind randomized controlled trials. The primary outcome was all-cause mortality, analyzed with Cox proportional hazard ratios (HR) modeling heart rate measured at baseline and approximately 6 months post-randomization. RESULTS: A higher heart rate at baseline was associated with greater all-cause mortality for patients in sinus rhythm (n = 14,166; adjusted HR: 1.11 per 10 beats/min; 95% confidence interval [CI]: 1.07 to 1.15; p < 0.0001) but not in AF (n = 3,034; HR: 1.03 per 10 beats/min; 95% CI: 0.97 to 1.08; p = 0.38). Beta-blockers reduced ventricular rate by 12 beats/min in both sinus rhythm and AF. Mortality was lower for patients in sinus rhythm randomized to beta-blockers (HR: 0.73 vs. placebo; 95% CI: 0.67 to 0.79; p < 0.001), regardless of baseline heart rate (interaction p = 0.35). Beta-blockers had no effect on mortality in patients with AF (HR: 0.96, 95% CI: 0.81 to 1.12; p = 0.58) at any heart rate (interaction p = 0.48). A lower achieved resting heart rate, irrespective of treatment, was associated with better prognosis only for patients in sinus rhythm (HR: 1.16 per 10 beats/min increase, 95% CI: 1.11 to 1.22; p < 0.0001). CONCLUSIONS: Regardless of pre-treatment heart rate, beta-blockers reduce mortality in patients with heart failure with reduced ejection fraction in sinus rhythm. Achieving a lower heart rate is associated with better prognosis, but only for those in sinus rhythm.
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Kotecha et al. (2017) conducted a meta-analysis in Heart failure and reduced ejection fraction (HFrEF) (n=17,378). Beta-blockers vs. Placebo was evaluated on All-cause mortality (in patients with sinus rhythm) (HR 0.73, 95% CI 0.67-0.79, p=<0.001). Beta-blockers reduced all-cause mortality by 27% compared to placebo in patients with heart failure and reduced ejection fraction in sinus rhythm, but had no effect on mortality in patients with atrial fibrillation.
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