Heart rate achieved or beta‐blocker dose in patients with chronic heart failure: which is the better target?

Abstract

AimsTo investigate whether the mortality of patients with chronic heart failure (CHF) due to left ventricular systolic dysfunction (LVSD) is more strongly related to beta-blocker dose or to heart rate. It is known that beta-blockers reduce mortality in patients with CHF and LVSD, but the primary mechanism of action is uncertain. Methods and resultsPatients with an ejection fraction ≤40%, who were in sinus rhythm both at an initial (visit 1) and at a 4-month clinic review (visit 2), were followed for a maximum of 36 months. The relationships between heart rate, beta-blocker dose, and survival in a multivariable model were examined. Of 654 eligible patients, 381 (58%) were started on beta-blockers prior to the initial visit, increasing to 537 (82%) by visit 2. During follow-up, 142 (22%) patients died. Neither resting heart rate nor beta-blocker dose at visit 1 predicted mortality (P ¼ 0.09 and P ¼ 0.99), but resting heart rate at visit 2 did (P ¼ 0.02). Beta-blocker use at visit 2 was associated with better outcome (P ¼ 0.03) but with little variation in outcome according to dose. Patients with a heart rate of 58 -64 b.p.m. at visit 2 had the best prognosis. ConclusionsThe use of beta-blockers and resting heart rate at visit 2 both independently indicated prognosis, but beta-blocker dose did not. Beta-blockers may reduce mortality by several mechanisms; one that may be specific to blockade of adrenergic receptors and another related to heart rate reduction. Achieving a target heart rate range may be an appropriate therapeutic goal for patients with CHF.--

Aging and Heart Rate in Heart Failure: Clinical Implications for Long-term Mortality

“…Second, and even more remarkable, we observed that lower heart rates are associated with better prognoses in younger patients (<75 years), whereas a U-shaped mortality risk curve was observed in older patients, with a nadir at 68 beats/min. Our results are consistent with the increasingly strong evidence of a relationship between resting heart rate and global outcomes among patients with HF and depressed LVEF in SR, [13][14][15] suggesting that patients with higher heart rates have poorer prognoses. Moreover, a recently published I-Preserve substudy 16 found that heart rate control is also important in patients in SR with preserved ejection fraction, similar to our findings.…”

“…Data derived from the SHIFT (Systolic Heart Failure Treatment With the I(f) Inhibitor Ivabradine Trial) study 2 (mean patient age, 60 years) suggest a target cardiac heart rate of less than 60 beats/min but do not define an optimal heart rate range. In an older cohort of patients with a median age of 70 years (interquartile range, 63-76 years), Cullington et al 15 advised not decreasing the heart rate below 50 beats/min and found lower mortality at heart rates (achieved in the second visit to their clinic at 4 months) between 58 and 64 beats/min; their results indicated worse outcomes with heart rates of less than 58 beats/ min. This observation in a cohort of patients with 25% of the population older than 76 years seems to agree with our results.…”

Complementary and Synergic Role of Combined Beta-blockers and Ivabradine in Patients with Chronic Heart Failure and Depressed Systolic Function: A New Therapeutic Option?

“…62 Thus, it may be hypothesised that achieving a HR within the target range may be a more appropriate therapeutic goal than optimising beta-blocker dose in patients with CHF. In SHIFT, patients with the lowest risk reached a HR <60 bpm; therefore it might be reasonable, at present, to recommend this target in daily practice.…”

Admission heart rate and in-hospital outcomes in patients hospitalized for heart failure in sinus rhythm and in atrial fibrillation

“…In a study of patients with chronic HF, heart rate at a 4-month followup clinic visit, but not the initial clinic visit, indicated prognosis independent of β-blocker use or dose, with patients having a heart rate of 58 to 64 beat/min having the best prognosis. 18 Most studies have evaluated heart rate at a single time point, but the interplay between heart rate and outcomes is likely more complex, particularly in the acute setting.…”