Heart Rate as a Marker of Dilated Cardiomyopathy Relapse
- In patients with dilated cardiomyopathy who recover EF on medical therapy, attained heart rate and change in heart rate from baseline were associated with relapse.
- Association between heart rate and relapse persisted despite adjustment for BNP, baseline EF, and beta-blocker dose.
- In patients electing to come off medical therapy for dilated cardiomyopathy, a strategy of close surveillance involving heart rate may help guide imaging strategies to detect relapse early.
What is the association between change in heart rate and attained heart rate and the occurrence of relapse of cardiomyopathy in patients with recovered dilated cardiomyopathy (DCM)?
This was a post hoc analysis of TRED-HF (Therapy withdrawal in REcovered Dilated cardiomyopathy trial), an open-label randomized trial that examined the safety of phased withdrawal of heart failure (HF) therapy in patients with recovered DCM. All enrolled patients had a prior ejection fraction (EF) of ≤40% that improved to ≥50% with normal left ventricular (LV) end-diastolic volume and N-terminal pro–B-type natriuretic peptide (NT-proBNP) and were still on at least one HF medication. Patients were randomized to continued or withdrawal of therapy. After 6 months, patients continued on therapy had their medications also withdrawn between 6 and 12 months. Heart rate was checked every 4 weeks during therapy withdrawal. Primary endpoints were relapse of DCM.
Of 51 patients randomized, 26 were continued on therapy and 25 assigned to therapy withdrawal with heart rate data available on 49 patients. Overall, 20 patients had recurrence of DCM. All patients were in sinus rhythm at baseline. For patients with therapy withdrawn and relapse, there was a persistent and steady rise in mean heart rate between baseline and follow-up. Among patients who had therapy withdrawn but did not relapse, there was a less marked rise in mean heart rate between baseline and follow-up. After adjusting for difference in baseline heart rate, patients who had therapy withdrawn with relapse had a 10.4 bpm (95% confidence interval [CI], 4.0-16.8) greater rise in heart rate over the follow-up period than patients who had therapy withdrawn and did not relapse. Attained heart rate and change in heart rate from baseline were associated with the occurrence of primary relapse (per 10 bpm higher heart rate; hazard ratio, 1.92; 95% CI, 1.34-2.73; per 10 bpm change in heart rate from baseline, 1.99; 95% CI, 1.37-2.89). This association persisted despite adjustment for beta-blocker dose, age, NT-proBNP level, and LVEF at baseline.
In an analysis of the TRED-HF trial, attained heart rate and change in heart rate from baseline correlated with relapse among patients with DCM who had therapy withdrawn independent of other markers such as BNP levels and LVEF. This observation was not a proxy of beta-blocker dose.
With advancements in therapy for HF with reduced EF, recovery of LV function is occasionally seen. Such patients frequently are interested in coming off therapy and clinicians face the dilemma of how to appropriately follow-up such patients since risk for relapse of DCM is high. Unfortunately, cardiac magnetic resonance imaging is not always readily available and BNP monitoring is not a good early marker of relapse. In this study, rise in heart rate after therapy withdrawal was associated with relapse despite adjustment for BNP and baseline EF. This association did not change after adjusting for beta-blocker dose. While this study suggests an association between DCM relapse and heart rate after HF therapy withdrawal, a cause-effect relationship cannot be proven. Nonetheless, in clinical practice, careful clinical assessments including serial heart rate assessments can help guide early imaging to detect relapse in patients with recovered EF who are tapered off medical therapy.
Keywords: Adrenergic beta-Antagonists, Cardiomyopathies, Cardiomyopathy, Dilated, Diagnostic Imaging, Heart Failure, Heart Rate, Magnetic Resonance Imaging, Natriuretic Peptide, Brain, Peptide Fragments, Recurrence, Stroke Volume
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