Heart Rate and Outcome in Diastolic Heart Failure

Study Questions:

What is the association of discharge heart rate with outcomes in hospitalized patients with diastolic heart failure (HF)?

Methods:

The study cohort was comprised of 8,873 hospitalized patients with HF with preserved ejection fraction (HFpEF) (EF ≥50%) in the Medicare-linked OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure) registry. In this cohort, 6,286 had a stable heart rate, defined as ≤20 bpm variation between admission and discharge, and 38% of these (n = 2,369) had a discharge heart rate of <70 bpm. The investigators estimated propensity scores for each of the 6,286 patients with a discharge heart rate <70 bpm, to assemble a cohort of 2,031 pairs of patients with heart rate <70 versus ≥70 bpm, balanced on 58 baseline characteristics. The primary outcome of the current analysis was all-cause mortality during 6 (median 2.8) years of follow-up. Secondary outcomes included all-cause readmission, HF readmission, combined endpoints of HF readmission or all-cause mortality, and the combination of all-cause readmission or all-cause mortality.

Results:

In the matched cohort of 4,062 patients, the mean age was 79 ± 10 years, 66% were women, and 10% were African American. Of these, 3,455 patients (85%) had a normal discharge heart rate (60-100 bpm), 1,343 (33%) had a history of atrial fibrillation, and 2,611 (64%) received a discharge prescription for beta-blockers. Before matching, patients with a discharge heart rate <70 bpm had a higher mean age, and a greater proportion of these patients were white and had hypertension, coronary artery disease, and diabetes. During the follow-up period, all-cause mortality was 65% versus 70% for matched patients with a discharge heart rate <70 versus ≥70 bpm, respectively (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.80-0.93; p < 0.001). A heart rate <70 bpm was also associated with a lower risk for the combined endpoint of HF readmission or all-cause mortality (HR, 0.90; 95% CI, 0.84-0.96; p = 0.002), but not with HF readmission (HR, 0.93; 95% CI, 0.85-1.01) or all-cause readmission (HR, 1.01; 95% CI, 0.95-1.08). With receipt of beta-blockers, the HR for mortality was 0.87; 95% CI, 0.79-0.95; p = 0.003, and for no utilization of beta-blockers, the HR was 0.85; 95% CI, 0.75-0.96; p = 0.009. Similar associations were observed regardless of heart rhythm; for example, when atrial fibrillation was absent, the HR was 0.86; with 95% CI, 0.78-0.94; p = 0.003, and when it was present, the HR was 0.87; 95% CI, 0.77-0.99; p = 0.031.

Conclusions:

The investigators concluded that in hospitalized systolic HF patients, a lower discharge heart rate was independently associated with a lower risk of all-cause mortality, but not readmission.

Perspective:

This is an important study because it suggests that lower heart rate is an important prognostic marker in patients with diastolic HF. The next step is to determine whether reductions in heart rate with pharmacotherapy will translate into better outcomes in HFpEF patients.

Clinical Topics: Arrhythmias and Clinical EP, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Chronic Heart Failure, Hypertension

Keywords: Atrial Fibrillation, Adrenergic beta-Antagonists, Coronary Artery Disease, Diabetes Mellitus, Geriatrics, Heart Failure, Heart Failure, Diastolic, Heart Failure, Systolic, Heart Rate, Hypertension, Outcome Assessment (Health Care), Patient Readmission, Stroke Volume


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