β-Blocker Doses and Heart Rate in Patients with Heart Failure: Results from the National Norwegian Heart Failure
Torfinn Eriksen-Volnes1,2, Arne Westheim3, Lars Gullestad4,5,6
1Department of Medicine and Healthcare, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
Insights
A resting heart rate (HR) of 70 bpm or higher in heart failure with reduced ejection fraction (HFrEF) patients is linked to poorer outcomes. Many patients with elevated HR were undertreated with beta-blockers, suggesting a need for dose optimization and potential use of ivabradine.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Medicine
Background:
- European Society of Cardiology (ESC) guidelines recommend beta-blockers for chronic heart failure (HF) with reduced ejection fraction (HFrEF).
- Titration to the highest tolerated beta-blocker dose is advised, but achieved heart rate (HR) is often overlooked.
- This study investigates achieved HR in HFrEF patients on beta-blocker therapy.
Purpose of the Study:
- To examine the relationship between achieved heart rate (HR) and beta-blocker use in patients with HFrEF.
- To identify factors associated with a resting HR of 70 bpm or higher.
- To assess the impact of achieved HR on clinical outcomes in HFrEF.
Main Methods:
- Analysis of 2,689 patients with HFrEF and sinus rhythm from the National Norwegian Heart Failure Registry.
- Beta-blocker doses calculated as a percentage of ESC target doses.
- Statistical analysis including Student's t-test, Pearson's chi-squared test, and linear regression to predict HR ≥70 bpm.
Main Results:
- One-third of patients exhibited a resting HR ≥70 bpm.
- Patients with HR ≥70 bpm were younger, had higher NYHA class, more comorbidities (diabetes, COPD), and higher NT-proBNP levels.
- 1-year mortality increased with higher HR categories, ranging from 3.1% (<70 bpm) to 9.1% (>89 bpm).
Conclusions:
- An achieved HR ≥70 bpm in HFrEF patients with sinus rhythm correlates with adverse clinical variables and outcomes.
- A significant proportion of patients with HR ≥70 bpm were not at target beta-blocker dose, indicating undertreatment or intolerance.
- Increased beta-blocker titration and consideration of ivabradine for HR ≥70 bpm are suggested.
Background:
Use of β-blockers and titration to the highest tolerated dose are highly recommended by the European Society of Cardiology (ESC) guidelines for treatment of chronic heart failure (HF) with a reduced ejection fraction (HFrEF), but little attention has been paid to the achieved heart rate (HR) during this treatment.
Objectives:
The aim of the present study was to examine the achieved HR in relation to the use of β-blockers in these patients.
Methods:
All of the patients (n = 2,689) in the National Norwegian Heart Failure Registry as part of the Norwegian Cardiovascular Disease Registry with a sinus rhythm and left ventricular ejection fraction (LVEF) <40% at stable follow-up visiting specialised hospital outpatient HF clinics in Norway were included. The β-blocker doses were calculated as a percent of the target dose according to ESC HF guidelines. Differences between baseline variables according to the achieved HR were analysed by the Student's t test for continuous variables and Pearson's χ2 test for categorical variables. Linear regression was used to determine the predictors of HR ≥70 beats/min (bpm) in the multivariate analysis.
Results:
One third of the patients had a resting HR ≥70 bpm. Of the patients with an HR ≥70 bpm, 72.3% used less than the target dose of β-blocker; they were younger and had a higher NYHA class, more diabetes mellitus and chronic obstructive pulmonary disease (COPD), and higher N-terminal pro-B type natriuretic peptide (NT-proBNP) levels and estimated glomerular filtration rates compared to the patients with an HR <70 bpm. The 1-year mortality was 3.1, 3.7, 5.8, and 9.1% among the patients with an HR <70, 70-79, 80-89, and >89 bpm, respectively. Only 2 patients used ivabradine.
Conclusions:
In patients with HFrEF and sinus rhythm, an HR ≥70 bpm was associated with worse clinical variables and outcomes. A high proportion of the patients who had an HR ≥70 bpm was not treated with or/did not tolerate the target dose of a β-blocker, although the β-blocker dose was higher than in patients with an HR <70 bpm. This may suggest that increased efforts should be made to further increase the β-blocker dose, and treatment with ivabradine could be considered among patients with an HR ≥70 bpm.
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