Discharge heart rate and 1-year clinical outcomes in heart failure patients with atrial fibrillation

Abstract

Background: The association between heart rate and 1-year clinical outcomes in heart failure (HF) patients with atrial fibrillation (AF), and whether this association depends on left ventricular ejection fraction (LVEF), are unclear. We investigated the relationship between discharge heart rate and 1-year clinical outcomes after discharge among hospitalized HF patients with AF, and further explored this association that differ by LVEF level.

Methods: In this analysis, we enrolled 1760 hospitalized HF patients with AF from the China Patient-centered Evaluative Assessment of Cardiac Events Prospective Heart Failure study from August 2016 to May 2018. Patients were categorized into three groups with low (<65 beats per minute [bpm]), moderate (65-85 bpm), and high (≥86 bpm) heart rate measured at discharge. Cox proportional hazard models were employed to explore the association between heart rate and 1-year primary outcome, which was defined as a composite outcome of all-cause death and HF rehospitalization.

Results: Among 1760 patients, 723 (41.1%) were women, the median age was 69 (interquartile range [IQR]: 60-77) years, median discharge heart rate was 75 (IQR: 69-84) bpm, and 934 (53.1%) had an LVEF <50%. During 1-year follow-up, a total of 792 (45.0%) individuals died or had at least one HF hospitalization. After adjusting for demographic characteristics, smoking status, medical history, anthropometric characteristics, and medications used at discharge, the groups with low (hazard ratio [HR]: 1.32, 95% confidence interval [CI]: 1.05-1.68, P = 0.020) and high (HR: 1.34, 95% CI: 1.07-1.67, P = 0.009) heart rate were associated with a higher risk of 1-year primary outcome compared with the moderate group. A significant interaction between discharge heart rate and LVEF for the primary outcome was observed (P for interaction was 0.045). Among the patients with LVEF ≥50%, only those with high heart rate were associated with a higher risk of primary outcome compared with the group with moderate heart rate (HR: 1.38, 95% CI: 1.01-1.89, P = 0.046), whereas there was no difference between the groups with low and moderate heart rate. Among the patients with LVEF <50%, only those with low heart rate were associated with a higher risk of primary outcome compared with the group with moderate heart rate (HR: 1.46, 95% CI: 1.09-1.96, P = 0.012), whereas there was no difference between the groups with high and moderate heart rate.

Conclusions: Among the overall HF patients with AF, both low (<65 bpm) and high (≥86 bpm) heart rates were associated with poorer outcomes as compared with moderate (65-85 bpm) heart rate. Among patients with LVEF ≥50%, only a high heart rate was associated with higher risk; while among those with LVEF <50%, only a low heart rate was associated with higher risk as compared with the group with moderate heart rate.

Trail registration: Clinicaltrials.gov; NCT02878811.

Conflict of interest statement

Dr. Jing Li reported receiving research grants, through Fuwai Hospital, from China for work to improve the management of hypertension and blood lipids and to improve care quality and patient outcomes of cardiovascular disease; receiving research agreements, through the National Center for Cardiovascular Diseases and Fuwai Hospital, from Amgen for a multicenter clinical trial assessing the efficacy and safety of omecamtiv mecarbil and for dyslipidemic patient registration; receiving a research agreement, through Fuwai Hospital, from Sanofi for a multicenter clinical trial on the effects of sotagliflozin; receiving a research agreement, through Fuwai Hospital, with the University of Oxford for a multicenter clinical trial of empagliflozin; receiving a research agreement, through the National Center for Cardiovascular Diseases, from AstraZeneca for clinical research methods training outside the submitted work; and receiving a research agreement, through the National Center for Cardiovascular Diseases, from Lilly for physician training outside the submitted work. No other disclosures were reported.

Copyright © 2021 The Chinese Medical Association, produced by Wolters Kluwer, Inc. under the CC-BY-NC-ND license.

Figures

Figure 1

Unadjusted cumulative incidence of 1-year clinical outcomes according to discharge heart rate groups. (A) The primary outcome, which was defined as a composite outcome of all-cause death and HF rehospitalization; (B) all-cause death; (C) heart failure rehospitalization; (D) composite outcome of all-cause death and all-cause rehospitalization. Bpm: Beats per minute; HF: Heart failure.

Figure 2

Associations between discharge heart rate and 1-year clinical outcomes in the entire cohort. (A) The primary outcome, which was defined as a composite outcome of all-cause death and HF rehospitalization; (B) all-cause death; (C) HF rehospitalization; (D) composite outcome of all-cause death and all-cause rehospitalization. The analysis used a Cox model with restricted cubic splines, corrected for age, sex, smoking status, medical history, LVEF, QRS duration, laboratory tests, NYHA classifications, SBP, and medication use at discharge, and the reference was the median of discharge heart rate (75 bpm). Solid lines represented HRs, and green light shaded areas represented 95% CI. Bpm: Beats per minute; CI: Confidence interval; HR: Hazard ratio; HF: Heart failure; HR: Hazard ratio; LVEF: Left ventricular ejection fraction; NYHA: New York Heart Association; SBP: Systolic blood pressure.

Figure 3

Associations between discharge heart rate and 1-year clinical outcomes in different subgroups of LVEF. (A) The primary outcome, which was defined as a composite outcome of all-cause death and HF rehospitalization; (B) all-cause death; (C) HF rehospitalization; (D) composite outcome of all-cause death and all-cause rehospitalization. The analysis used a Cox model with restricted cubic splines, corrected for age, sex, smoking status, medical history, QRS duration, laboratory tests, NYHA classifications, SBP, and medication use at discharge, and the reference was the median of discharge heart rate (75 bpm). Solid lines represented HRs, and light-shaded areas represented 95% CI. Red showed the results of patients with LVEF <50%, and blue showed the results of those with LVEF ≥50%. Bpm: Beats per minute; CI: Confidence interval; HR: Hazard ratio; HF: Heart failure; LVEF: Left ventricular ejection fraction; NYHA: New York Heart Association; SBP: Systolic blood pressure.