Increasing heart rate in heart failure with preserved ejection fraction: a sensible way to go?

This commentary refers to ‘Accelerated atrial pacing reduces left-heart filling pressure: a combined clinical-computational study’, by T. van Loon et al., https://doi.org/10.1093/eurheartj/ehae718 and the discussion piece ‘Rate acceleration in heart failure with preserved ejection fraction: towards different strokes for different folks’, by T. van Loon et al., https://doi.org/10.1093/eurheartj/ehaf110. We found the paper by van Loon et al.1 in the latest issue of the European Heart Journal quite intriguing. The authors propose that increasing heart rate in patients with heart failure with preserved ejection fraction (HFpEF) results in a decrease in filling pressure and as such alleviates an important characteristic of HFpEF, the increase in left atrial volume. The authors performed an ablation for atrial fibrillation, during which they increased heart rate by atrial pacing, while measuring left atrial pressure (LAP). In addition, they attempted to gain more insight in left atrial and left ventricular volumes, filling and ejection rates by combining the real-life data obtained in patients with their virtual CIRC-ADEPT model. Both real-life data and the model showed that increasing heart rate initially reduced LAP and left atrial volume; however, while pacing beyond a certain heart rate, LAP increased again.