Key result
Beta-blocker-induced heart rate reduction is linked to ~17% lower mortality and HF per 10 bpm.
Why the study?
In patients with HFrEF on sub-optimal beta-blocker doses, changes in heart rate following treatment intensification might be important regardless of underlying rhythm, but prognostic significance in sinus rhythm versus AF was unclear.
Does a decrease in heart rate following beta-blocker uptitration improve outcomes in patients with HFrEF in sinus rhythm versus atrial fibrillation?
Observational (n=1,548)
Yes
Does a decrease in heart rate following beta-blocker uptitration improve outcomes in patients with HFrEF in sinus rhythm versus atrial fibrillation?
Hazard Ratio: 0.83 (95% CI 0.75–0.91)
p-value: p=<0.001
A decrease in heart rate following beta-blocker uptitration is associated with improved outcomes in HFrEF patients regardless of whether they are in sinus rhythm or atrial fibrillation, though achieved heart rate is only prognostic in AF patients with high baseline heart rates.
Should not yet alter beta-blocker titration targets in HFrEF; leaves open whether heart rate reduction is causal across rhythms.
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.
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Mordi et al. (2019) conducted an observational in Heart failure with reduced ejection fraction (HFrEF) (n=1,548). Decrease in heart rate following beta-blocker uptitration vs. No decrease or increase in heart rate was evaluated on Combined outcome of all-cause mortality and heart failure hospitalisation (HR 0.83, 95% CI 0.75-0.91, p=<0.001). A decrease in heart rate at 9 months following beta-blocker uptitration was associated with a reduced incidence of mortality and heart failure hospitalization in both sinus rhythm (HR 0.83 per 10 bpm decrease) and atrial fibrillation (HR 0.89 per 10 bpm decrease) patients.
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