Revisiting the clinical evidence of heart rate target in patients with heart failure treated with beta-blockers

Background: The SHIFT study (Systolic Heart failure treatment with the I f inhibitor ivabradine Trial) demonstrated the importance of elevated heart rate (defined as > 70 beats per minute [bpm]) despite beta-blocker use as a treatment target in patients with heart failure with reduced ejection fraction (HFrEF). Limited data are available that describe the proportion of HFrEF patients that have an elevated heart rate despite beta-blocker therapy. Methods: We analyzed data from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) to describe discharge heart rate as a function of beta-blocker use and dose. We included adult patients with a left ventricular ejection fraction <40% and excluded those with a history of a pacemaker or cardiac resynchronization therapy. For beta-blockers, we considered the 3 evidence-based beta-blockers as well as atenolol and described the dose at discharge as a percentage of the target daily dose (categories included no beta-blocker, <25%, 25-49%, > 50%). Results: Among 14,186 patients hospitalized with acute HFrEF between January 2003 and December 2004, the median discharge heart rate was 76 bpm (25 th -75 th percentile, 68-86). Of these, 10,264 (72%) were discharged on a beta-blocker. For patients not on a beta-blocker, the median discharge heart rate was 80 bpm (70-88), compared to 77 bpm (68-87) on <25% target dose, 75 bpm (66-84) on 25-49% target dose, and 74 bpm (66-83) on > 50% target dose (P<0.001) (Figure). For patients on > 50% target dose of a beta-blocker, 1397(65%) had a heart rate > 70 bpm. Conclusion: Despite treatment with beta-blockers, a substantial proportion of HFrEF patients have an elevated heart rate at hospital discharge.

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HIGH-DOSE BETA-BLOCKERS (BB) AND OUTCOMES IN PATIENTS WITH HEART FAILURE AND PRESERVED EJECTION FRACTION (HFPEF) AND HEART RATE ≥70 BEATS PER MINUTE (BPM)

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(18)31405-0 ◽

2018 ◽

Vol 71 (11) ◽

pp. A864

Author(s):

Phillip Hong Lam ◽

Daniel Dooley ◽

Apostolos Tsimploulis ◽

Helen Sheriff ◽

Charles Faselis ◽

...

Keyword(s):

Heart Failure ◽

Heart Rate ◽

Ejection Fraction ◽

Beta Blockers ◽

High Dose ◽

Preserved Ejection Fraction ◽

Patients With Heart Failure

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533 Underuse of ACE inhibitors, beta-blockers and spironolactone in patients with heart failure is primarily due to lack of initiation of treatment

European Journal of Heart Failure Supplements ◽

10.1016/s1567-4215(06)80330-9 ◽

2006 ◽

Vol 5 (1) ◽

pp. 116-116

Author(s):

G GISLASON ◽

J RASMUSSEN ◽

S ABILDSTROM ◽

T SCHRAMM ◽

P BUCH ◽

...

Keyword(s):

Heart Failure ◽

Ace Inhibitors ◽

Beta Blockers ◽

Patients With Heart Failure

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Discharge heart rate and clinical outcomes in hospitalized heart failure patients with coexisted atrial fibrillation

European Heart Journal ◽

10.1093/ehjci/ehaa946.1157 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

F Xing ◽

X Bai ◽

J Li

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Heart Rate ◽

Clinical Outcome ◽

Confidence Interval ◽

Clinical Outcomes ◽

Beta Blockers ◽

Funding Source ◽

Proportional Hazard ◽

Cox Proportional Hazard

Abstract Background Whether discharge heart rate for hospitalized heart failure (HF) patients with coexisted atrial fibrillation (AF) is associated with long-term clinical outcomes and whether this association differs between patients with and without beta-blockers have not been well studied. Purpose We investigated the associations between discharge heart rate and clinical outcomes in hospitalized HF patients with coexisted AF, while stratified to beta-blockers at discharge. Methods The study cohort included 1631 HF patients hospitalized primarily with AF, which was from the China PEACE Prospective Heart Failure Study. Clinical outcome was 1-year combined all-cause mortality and HF hospitalization after discharge. We analyzed association between outcome and heart rate at discharge with restricted cubic spline and Cox proportional hazard ratios (HR). Results The median age was 68 (IQR: 60- 77) years, 41.9% were women, discharge heart rate was (median (IQR)) 75 (69- 84) beats per minute (bpm), and 60.2% received beta-blockers at discharge. According to the result of restricted cubic spline plot, the relationship between discharge heart rate and clinical outcome may be nonlinear (P<0.01). Based on above result, these patients were divided into 3 groups: lowest <65 bpm, middle 65–86 bpm and highest ≥87 bpm, clinical outcomes occurred in 128 (64.32%), 624 (53.42%) and 156 (59.32%) patients in the lowest, middle, and highest groups respectively. In the Cox proportional hazard analysis, the lowest and highest groups were associated with increased risks of clinical outcome compared with the middle group (HR: 1.289, 95% confidence interval (CI): 1.056 - 1.573, p=0.013; HR: 1.276, 95% CI: 1.06 - 1.537, p=0.01, respectively). And a significant interaction between discharge heart rate and beta-blocker use was observed (P<0.001 for interaction). Stratified analysis showed the lowest group was associated with increased risks of clinical outcomes in patients with beta-blockers (HR: 1.584, 95% confidence interval (CI): 1.215–2.066, p=0.001). Conclusion There may be a U-curve relationship between discharge heart rate and clinical outcomes in hospitalized HF patients with coexisted AF. They may have the best clinical outcomes with heart rates of 65 - 86 bpm. And strict heart rate control (<65 bpm) may be avoided for patients who discharge with beta-blockers. Figure 1 Funding Acknowledgement Type of funding source: Other. Main funding source(s): This work was supported by the National Key Research and Development Program (2017YFC1310803) from the Ministry of Science and Technology of China; the CAMS Innovation Fund for Medical Science (2017-I2M-B&R-02); the 111 Project from the Ministry of Education of China (B16005).

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P3517Failure to achieve adequate heart rate control in women during therapy optimization

European Heart Journal ◽

10.1093/eurheartj/ehz745.0381 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

V Kutyifa ◽

J W Erath ◽

A Burch ◽

B Assmus ◽

D Bondermann ◽

...

Keyword(s):

Heart Failure ◽

Heart Rate ◽

Beta Blocker ◽

Rate Control ◽

Beta Blockers ◽

Heart Rate Control ◽

Blocker Therapy ◽

Cardioverter Defibrillator ◽

Beta Blocker Therapy ◽

The Mean

Abstract Background Previous studies highlighted the importance of adequate heart rate control in heart failure patients, and suggested under-treatment with beta-blockers especially in women. However, data on women achieving effective heart rate control during beta-blocker therapy optimization are lacking. Methods The wearable cardioverter defibrillator (WCD) allows continuous monitoring of heart rate (HR) trends during WCD use. In the current study, we assessed resting HR trends (nighttime: midnight-7am) in women, both at the beginning of WCD use and at the end of WCD use to assess the adequacy of beta-blockade following a typical 3 months of therapy optimization with beta-blockers. An adequate heart rate control was defined as having a nighttime HR <70 bpm at the end of the 3 months. Results There were a total of 21,453 women with at least 30 days of WCD use (>140 hours WCD use on the first and last week). The mean age was 67 years (IQR 58–75). The mean nighttime heart rate was 72 bpm (IQR 65–81) at the beginning of WCD use, that decreased to 68 bpm (IQR 61–76) at the end of WCD use with therapy optimization. Women had an insufficient heart rate control with resting heart rate ≥70 bpm in 59% at the beginning of WCD use that decreased to 44% at the end of WCD use, but still remained surprisingly high. Interestingly, there were 21% of the women starting with HR ≥70 bpm at the beginning of use (BOU) who achieved adequate heart rate control by the end of use (EOU). Interestingly, 6% of women with adequate heart rate control at the start of therapy optimization ended up having higher heart rates >70 bpm at the end of the therapy optimization time period (Figure). Figure 1 Conclusions A significant proportion of women with heart failure and low ejection fraction do not reach an adequate heart rate control during the time of beta blocker initiation/titration. The wearble cardioverter defibrillator is a monitoring device that has been demonstrated in this study to appropriately identify patients with inadequate heart rate control at the end of the therapy optimization period. The WCD could be utilized to improve management of beta-blocker therapy in women and improve the achievement of adequate heart rate control in women.

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Remote monitoring of patients with heart failure during the first national lockdown for COVID-19 in France

European Heart Journal - Digital Health ◽

10.1093/ehjdh/ztab044 ◽

2021 ◽

Author(s):

Sylvain Ploux ◽

Marc Strik ◽

Saer Abu-Alrub ◽

F Daniel Ramirez ◽

Samuel Buliard ◽

...

Keyword(s):

Heart Failure ◽

Health Care ◽

Heart Rate ◽

Remote Monitoring ◽

Marked Decrease ◽

Clinical Status ◽

Health Care Use ◽

Physiological Variables ◽

Patients With Heart Failure ◽

Vital Parameters

Abstract Background Multiparametric remote monitoring of patients with heart failure (HF) has the potential to mitigate the health risks of lockdowns for COVID-19. Aims To compare health care use, physiological variables, and HF decompensations during one month before and during the first month of the first French national lockdown for COVID-19 among patients undergoing remote monitoring. Methods Transmitted vital parameters and data from cardiac implantable electronic devices were analyzed in 51 patients. Medical contact was defined as the sum of visits and days of hospitalization. Results The lockdown was associated with a marked decrease in cardiology medical contact (118 days before vs 26 days during, -77%, p = 0.003) and overall medical contact (180 days before vs 79 days during, -58%, p = 0.005). Patient adherence with remote monitoring was 84±21% before and 87±19% during lockdown. The lockdown was not associated with significant changes in various parameters, including physical activity (2±1 to 2±1 h/day), weight (83±16 to 83±16 kg), systolic blood pressure (121±19 to 121±18 mmHg), heart rate (68±10 to 67±10 bpm), heart rate variability (89±44 to 78±46 ms, p = 0.05), atrial fibrillation burden (84±146 vs 86±146 h/month), or thoracic impedance (66±8 to 66±9 Ω). Seven cases of HF decompensations were observed before lockdown, all but one of which required hospitalization, versus six during lockdown, all but one of which were managed remotely. Conclusions The lockdown restrictions caused a marked decrease in health care use but no significant change in the clinical status of HF patients under multiparametric remote monitoring. lay summary The first French COVID-19 lockdown had a huge detrimental impact on conventional health care use (-78% in cardiology medical contact). However the lockdown had little impact over the short-term, if any, on vital parameters and the clinical status of patients with heart failure who were adherent to multiparametric remote monitoring. This remote monitoring strategy allowed early identification and home management of most of the heart failure decompensations during the lockdown.

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