Heart Rate and Outcomes in Hospitalized Patients With Heart Failure With Preserved Ejection Fraction

Q: What are the key findings of this study?

A discharge heart rate <70 beats/min was associated with lower all-cause mortality (65% vs 70%; HR 0.86, 95% CI 0.80-0.93, p<0.001) in hospitalized patients with HFpEF.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Hospitalized heart failure with preserved ejection fraction (HFpEF) (n=4062). Intervention: Discharge heart rate =70 beats/min. Primary outcome: All-cause mortality (HR 0.86, 95% CI 0.80 to 0.93, p=<0.001).

Q: What does this research mean for the field?

A discharge heart rate of <70 beats/min is independently associated with a lower risk of all-cause mortality in hospitalized patients with heart failure with preserved ejection fraction. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To evaluate the association between discharge heart rate and long-term clinical outcomes in hospitalized patients with heart failure with preserved ejection fraction.

Phillip Hong Lam; Daniel J. Dooley; PRAKASH C. DEEDWANIA; Steven N Singh; Deepak L. Bhatt; Charity Johanna Morgan; Javed Butler; Selma F. Mohammed; Wen-Chih Wu; Gurusher Singh Panjrath; Michael R. Zile; Michel White; Cherinne Arundel; Thomas E. Love; Marc R. Blackman; Richard M. Allman; Wilbert S. Aronow; Stefan D. Anker; Gregg C. Fonarow; Ali Ahmed

doi:10.1016/j.jacc.2017.08.022

Key result

Discharge heart rate <70 bpm linked to ~14% lower mortality in hospitalized HFpEF patients.

HR 0.86
95% CI 0.80 to 0.93
P<0.001
n=4,062

Why the study?

Although a lower heart rate is associated with better outcomes in HF with reduced EF, less was known about the association between discharge heart rate and outcomes in hospitalized patients with HFpEF.

Does a discharge heart rate <70 beats/min reduce all-cause mortality compared to a discharge heart rate ≥70 beats/min in hospitalized older patients with HFpEF?

Key Points

To evaluate the association between discharge heart rate and long-term clinical outcomes in hospitalized patients with heart failure with preserved ejection fraction.
Using the Medicare-linked OPTIMIZE-HF registry, propensity scores based on 58 baseline characteristics assembled 2,031 matched pairs (N=4,062; mean age 79 ± 10 years; 66% women) with stable heart rates.
Patients with discharge heart rates <70 beats/min were compared to those with ≥70 beats/min over 6 years of follow-up (median 2.8 years).
All-cause mortality was 65% in patients with discharge heart rate <70 beats/min versus 70% in those with ≥70 beats/min (HR: 0.86; 95% CI: 0.80 to 0.93; p < 0.001).
A discharge heart rate <70 beats/min was associated with a lower rate of the combined endpoint of HF readmission or all-cause mortality (HR: 0.90; 95% CI: 0.84 to 0.96; p = 0.002).
No significant associations occurred for HF readmission (HR: 0.93; 95% CI: 0.85 to 1.01) or all-cause readmission (HR: 1.01; 95% CI: 0.95 to 1.08).

Study Design

Type

Cohort (n=4,062)

Multicenter

Yes

Structured PICO

Does a discharge heart rate <70 beats/min reduce all-cause mortality compared to a discharge heart rate ≥70 beats/min in hospitalized older patients with HFpEF?

P

Population

4,062 propensity score-matched hospitalized older adults (mean age 79, 66% women) with HFpEF (EF >=50%) and stable inpatient heart rate from the US Medicare-linked OPTIMIZE-HF registry, followed for up to 6 years (median 2.8 years).

E

Exposure

Discharge heart rate <70 beats/min (observational exposure)

C

Comparator

Discharge heart rate ≥70 beats/min, propensity score-matched 1:1 on 58 baseline characteristics

O

Outcome

All-cause mortality during 6 years (median 2.8 years) of follow-up, ascertained via Medicare 100% MedPAR and Beneficiary Summary Fileshard clinical

Main Result

Hazard Ratio: 0.86 (95% CI 0.8–0.93)

Absolute Event Rate: 65% vs 70%

p-value: p=<0.001

Limitations

Potential bias due to unmeasured confounders despite propensity score matching
Lack of data on heart rate prior to hospital admission
Restricted to fee-for-service Medicare beneficiaries, limiting generalizability
Possible bias due to unmeasured confounders despite propensity score matching
Lack of data on heart rate before hospital admission, which might underestimate true associations if baseline characteristics were affected by prevalent heart rate
Analysis was restricted to fee-for-service Medicare beneficiaries, which might limit generalizability

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Implication

In hospitalized older patients with HFpEF, a discharge heart rate <70 beats/min is independently associated with a lower risk of long-term all-cause mortality, though it does not significantly reduce hospital readmissions.

Abstract

BACKGROUND A lower heart rate is associated with better outcomes in patients with heart failure (HF) with reduced ejection fraction (EF). Less is known about this association in patients with HF with preserved ejection fraction (HFpEF). OBJECTIVES The aims of this study were to examine associations of discharge heart rate with outcomes in hospitalized patients with HFpEF. METHODS Of the 8,873 hospitalized patients with HFpEF (EF ≥50%) in the Medicare-linked OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry, 6,286 had a stable heart rate, defined as ≤20 beats/min variation between admission and discharge. Of these, 2,369 (38%) had a discharge heart rate of <70 beats/min. Propensity scores for discharge heart rate <70 beats/min, estimated for each of the 6,286 patients, were used to assemble a cohort of 2,031 pairs of patients with heart rate <70 versus ≥70 beats/min, balanced on 58 baseline characteristics. RESULTS The 4,062 matched patients had a mean age of 79 ± 10 years, 66% were women, and 10% were African American. During 6 years (median 2.8 years) of follow-up, all-cause mortality was 65% versus 70% for matched patients with a discharge heart rate <70 versus ≥70 beats/min, respectively (hazard ratio [HR]: 0.86; 95% confidence interval [CI]: 0.80 to 0.93; p < 0.001). A heart rate <70 beats/min was also associated with a lower risk for the combined endpoint of HF readmission or all-cause mortality (HR: 0.90; 95% CI: 0.84 to 0.96; p = 0.002), but not with HF readmission (HR: 0.93; 95% CI: 0.85 to 1.01) or all-cause readmission (HR: 1.01; 95% CI: 0.95 to 1.08). Similar associations were observed regardless of heart rhythm or receipt of beta-blockers. CONCLUSIONS Among hospitalized patients with HFpEF, a lower discharge heart rate was independently associated with a lower risk of all-cause mortality, but not readmission.

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Cite This Study

Lam et al. (2017) conducted a cohort in Hospitalized heart failure with preserved ejection fraction (HFpEF) (n=4,062). Discharge heart rate <70 beats/min vs. Discharge heart rate >=70 beats/min was evaluated on All-cause mortality (HR 0.86, 95% CI 0.80 to 0.93, p=<0.001). A discharge heart rate <70 beats/min was associated with lower all-cause mortality (65% vs 70%; HR 0.86, 95% CI 0.80-0.93, p<0.001) in hospitalized patients with HFpEF.

synapsesocial.com/papers/6af18f3f4f09e92e86757d61 https://doi.org/10.1016/j.jacc.2017.08.022

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Heart Rate and Outcomes in Hospitalized Patients With Heart Failure With Preserved Ejection Fraction

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Heart Rate and Outcomes in Hospitalized Patients With Heart Failure With Preserved Ejection Fraction

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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