Abstract
Background:
The
relationship between mortality and heart rate remains unclear for
patients with heart failure with reduced ejection fraction in either
sinus rhythm or atrial fibrillation (AF).
Objectives:
This
analysis explored the prognostic importance of heart rate in patients
with heart failure with reduced ejection fraction in randomized
controlled trials comparing beta-blockers and placebo.
Methods:
The
Beta-Blockers in Heart Failure Collaborative Group performed a
meta-analysis of harmonized individual patient data from 11 double-blind
randomized controlled trials. The primary outcome was all-cause
mortality, analyzed with Cox proportional hazard ratios (HR) modeling
heart rate measured at baseline and approximately 6 months
post-randomization.
Results:
A
higher heart rate at baseline was associated with greater all-cause
mortality for patients in sinus rhythm (n = 14,166; adjusted HR: 1.11
per 10 beats/min; 95% confidence interval [CI]: 1.07 to 1.15; p <
0.0001) but not in AF (n = 3,034; HR: 1.03 per 10 beats/min; 95% CI:
0.97 to 1.08; p = 0.38). Beta-blockers reduced ventricular rate by
12 beats/min in both sinus rhythm and AF. Mortality was lower for
patients in sinus rhythm randomized to beta-blockers (HR: 0.73 vs.
placebo; 95% CI: 0.67 to 0.79; p < 0.001), regardless of baseline
heart rate (interaction p = 0.35). Beta-blockers had no effect on
mortality in patients with AF (HR: 0.96, 95% CI: 0.81 to 1.12; p = 0.58)
at any heart rate (interaction p = 0.48). A lower achieved resting
heart rate, irrespective of treatment, was associated with better
prognosis only for patients in sinus rhythm (HR: 1.16 per 10 beats/min
increase, 95% CI: 1.11 to 1.22; p < 0.0001).
Conclusions:
Regardlessof pre-treatment heart rate, beta-blockers reduce mortality in patients
with heart failure with reduced ejection fraction in sinus rhythm.
Achieving a lower heart rate is associated with better prognosis, but
only for those in sinus rhythm
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