Heart Rate and Rhythm and the Benefit of Beta-Blockers in Patients With Heart Failure



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).


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.


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


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).


of 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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