Heart failure: elevated heart rate in sinus rhythm predicts adverse CV outcomes

Takeaway

• An elevated heart rate in sinus rhythm (SR) was an independent predictor of adverse cardiovascular outcomes in patients with heart failure and reduced ejection fraction (HFrEF), even after adjustment for N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) concentration.
• No association was observed between heart rate and outcomes in atrial fibrillation (Afib).

Why this matters

• Existing analyses have not adjusted for natriuretic peptide concentration which is a single most powerful predictor of outcomes in HF and natriuretic peptide.
• Very little is known about how change in heart rate relates to outcomes in SR.

Study design

• Analysis of the PARADIGM-HF and ATMOSPHERE trials (n=13,562; patients with chronic, ambulatory HFrEF in both SR [n=10,113] and Afib [n=3449]).
• Heart rate was analysed as a categorical (tertiles, T1-3) and continuous variable (per 10 bpm) separately in patients with SR or Afib.
• Primary outcome: composite of time to first occurrence of cardiovascular death/HF hospitalisation.
• Funding: Novartis.

Key results

• Higher mean heart rate was noted in patients with Afib (79.9±17.2 bpm) than those with SR (70.1±13.1 bpm; P<.001).
• Increase in NT-proBNP concentrations were noted from the lowest to highest tertile of heart rates in patients with SR (P<.001).
• A lower heart rate was associated with better Kansas City Cardiomyopathy Questionnaire scores in both Afib and SR (P<.001).
• Patients with SR showed greater risks (highest vs lowest heart rate tertiles) for:
  • pump failure death: adjusted HR (aHR), 1.70; P<.001 and
  • sudden death: aHR, 1.28; P=.011.
• A 10-bpm increase in baseline heart rate in patients with SR was associated with a significantly higher risk for (P<.05):
  • HF hospitalisation (aHR, 1.13);
  • CV death (aHR, 1.11);
  • pump failure death (aHR, 1.17);
  • sudden death (aHR, 1.07); and
  • all-cause death (aHR, 1.12).
• In patients with Afib, no association was seen between a 10-bpm increase in baseline heart rate and any of the outcomes of interest.

Limitations

• Retrospective analysis.