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

Dipak Kotecha, Marcus D. Flather, Douglas G Altman, Jane Holmes, Giuseppe Rosano, John Wikstrand, Milton Packer, Andrew J.S. Coats, Luis Manzano, Michael Böhm, Dirk Jan van Veldhuisen, Bert Andersson, Hans Wedel, Thomas G. von Lueder, Alan S. Rigby, Åke Hjalmarson, John Kjekshus, John George Franklin Cleland, Beta-Blockers in Heart Failure Collaborative Group

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Abstract

Background The 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). Objectives This 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. Methods The 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 post-randomization. Results A 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). Conclusions Regardless 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.

Original languageEnglish
Pages (from-to)2885-2896
Number of pages12
JournalJournal of the American College of Cardiology
Volume69
Issue number24
DOIs
Publication statusPublished - 20 Jun 2017

Keywords

  • atrial fibrillation
  • intention-to-treat analysis
  • randomized controlled trials

Cite this

Kotecha, D., Flather, M. D., Altman, D. G., Holmes, J., Rosano, G., Wikstrand, J., ... Beta-Blockers in Heart Failure Collaborative Group (2017). Heart Rate and Rhythm and the Benefit of Beta-Blockers in Patients With Heart Failure. Journal of the American College of Cardiology, 69(24), 2885-2896. https://doi.org/10.1016/j.jacc.2017.04.001
Kotecha, Dipak ; Flather, Marcus D. ; Altman, Douglas G ; Holmes, Jane ; Rosano, Giuseppe ; Wikstrand, John ; Packer, Milton ; Coats, Andrew J.S. ; Manzano, Luis ; Böhm, Michael ; van Veldhuisen, Dirk Jan ; Andersson, Bert ; Wedel, Hans ; von Lueder, Thomas G. ; Rigby, Alan S. ; Hjalmarson, Åke ; Kjekshus, John ; Cleland, John George Franklin ; Beta-Blockers in Heart Failure Collaborative Group. / Heart Rate and Rhythm and the Benefit of Beta-Blockers in Patients With Heart Failure. In: Journal of the American College of Cardiology. 2017 ; Vol. 69, No. 24. pp. 2885-2896.
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title = "Heart Rate and Rhythm and the Benefit of Beta-Blockers in Patients With Heart Failure",
abstract = "Background The 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). Objectives This 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. Methods The 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 post-randomization. Results A 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). Conclusions Regardless 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.",
keywords = "atrial fibrillation, intention-to-treat analysis, randomized controlled trials",
author = "Dipak Kotecha and Flather, {Marcus D.} and Altman, {Douglas G} and Jane Holmes and Giuseppe Rosano and John Wikstrand and Milton Packer and Coats, {Andrew J.S.} and Luis Manzano and Michael B{\"o}hm and {van Veldhuisen}, {Dirk Jan} and Bert Andersson and Hans Wedel and {von Lueder}, {Thomas G.} and Rigby, {Alan S.} and {\AA}ke Hjalmarson and John Kjekshus and Cleland, {John George Franklin} and {Beta-Blockers in Heart Failure Collaborative Group}",
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Kotecha, D, Flather, MD, Altman, DG, Holmes, J, Rosano, G, Wikstrand, J, Packer, M, Coats, AJS, Manzano, L, Böhm, M, van Veldhuisen, DJ, Andersson, B, Wedel, H, von Lueder, TG, Rigby, AS, Hjalmarson, Å, Kjekshus, J, Cleland, JGF & Beta-Blockers in Heart Failure Collaborative Group 2017, 'Heart Rate and Rhythm and the Benefit of Beta-Blockers in Patients With Heart Failure', Journal of the American College of Cardiology, vol. 69, no. 24, pp. 2885-2896. https://doi.org/10.1016/j.jacc.2017.04.001

Heart Rate and Rhythm and the Benefit of Beta-Blockers in Patients With Heart Failure. / Kotecha, Dipak; Flather, Marcus D.; Altman, Douglas G; Holmes, Jane; Rosano, Giuseppe; Wikstrand, John; Packer, Milton; Coats, Andrew J.S.; Manzano, Luis; Böhm, Michael; van Veldhuisen, Dirk Jan; Andersson, Bert; Wedel, Hans; von Lueder, Thomas G.; Rigby, Alan S.; Hjalmarson, Åke; Kjekshus, John; Cleland, John George Franklin; Beta-Blockers in Heart Failure Collaborative Group.

In: Journal of the American College of Cardiology, Vol. 69, No. 24, 20.06.2017, p. 2885-2896.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - Heart Rate and Rhythm and the Benefit of Beta-Blockers in Patients With Heart Failure

AU - Kotecha, Dipak

AU - Flather, Marcus D.

AU - Altman, Douglas G

AU - Holmes, Jane

AU - Rosano, Giuseppe

AU - Wikstrand, John

AU - Packer, Milton

AU - Coats, Andrew J.S.

AU - Manzano, Luis

AU - Böhm, Michael

AU - van Veldhuisen, Dirk Jan

AU - Andersson, Bert

AU - Wedel, Hans

AU - von Lueder, Thomas G.

AU - Rigby, Alan S.

AU - Hjalmarson, Åke

AU - Kjekshus, John

AU - Cleland, John George Franklin

AU - Beta-Blockers in Heart Failure Collaborative Group

PY - 2017/6/20

Y1 - 2017/6/20

N2 - Background The 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). Objectives This 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. Methods The 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 post-randomization. Results A 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). Conclusions Regardless 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.

AB - Background The 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). Objectives This 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. Methods The 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 post-randomization. Results A 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). Conclusions Regardless 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.

KW - atrial fibrillation

KW - intention-to-treat analysis

KW - randomized controlled trials

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