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Heart Rate managementinHeart FailureAnggia Chairuddin LubisUniversitas Sumatera Utara
Indonesia: socioeconomic improvements led to increases in cardiovascular disease.
HF BurdenDocter and Patient perspectives High IncidenceMortality: 40-50% in 5 yearsRehospitalizationEconomic burden
Heart Rate Implications
Increasing Heart Rate Over Time Linked With Heart DiseaseMortalityNaumanJ, Janszky I, Vatten LJ, Wisløff U. Temporal changes in resting heart rate and deaths from ischemic heartdisease. JAMA 2011; 306:2579-2587Ischemic heartdiseasemortalityRetained aresting heartrate of 70bpm over the10 yearsIncreasedresting heartrate from 70bpm to 85bpm overthe10 years8.2 deaths/10000 person-years17.2 deaths/10000 personyears.adjusted hazardratio1.9(95% CI 1.0–3.6)Individuals who had a resting heart rate between 70 and 85 bpm but who had rates 85 bpm after 10 years were 80% more likely to die from ischemic heart diseasecompared with those who maintained a resting heart rate between 70 to 85 bpm(AHR 1.8; 95% CI 1.2–2.8).7
Framingham Heart Study60CHD .95% CI 1.20, 2.71CVD .95% CI 1.19, 2.37All Cause .95% CI 1.68, 2.83Age Adjusted 2-yearDeath per 10005040302010 65 8465-7475-84Resting Heart Rate (bpm)Data from the Framingham cohort demonstrating the relationship between heartrate and deathfrom all causes, cardiovascular disease, and coronary heart disease0among individuals with hypertension. Gillman et al. Am Heart J. 1993;125:11481154. 19938
Meta-analysis: beta-blocker dose, heart rate reduction, anddeath in patients with heart failureAnn Intern Med. 2009 Jun 2;150(11):784-94. For every heart rate reduction of 5 beats/min with beta-blocker treatment,a commensurate 18% reduction (CI, 6% to 29%) in the risk for death occurred(p for meta-regression 0.006).No significant relationship between all-cause mortality and beta-blockerdosing was observed (risk ratio for death, 0.74 [CI, 0.64 to 0.86]) in highdose beta-blocker trials vs. 0.78 [CI, 0.63 to 0.96] in low-dose beta-blockertrials (p for meta-regression 0.69).CONCLUSION:The magnitude of heart rate reduction is statisticallysignificantly associated with the survival benefit of betablockers in heart failure, whereas the dose of beta-blocker isnot.9
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HR as Predictor Of Beautiful study, Lancet, 2008; 372: 807-16.CARDIOVASCULAR DEATHHOSPITALISATION FOR MIHOSPITALISATION FOR HFREVASCULARISATION
The role of heart rate in cardiovascular diseaseElevated heart rate AtherosclerosisEndothelial dysfunction Oxidative stress Plaque stability Arterial stiffness IschemiaOxygen consumption Duration of diastole Coronary perfusion Chronic heart failureOxygen demand Ventricular efficiency Ventricular relaxation RemodelingCardiac hypertrophy
Problems.
Heart rate in recent HF registries IMPACT RECO IIIHF OUTCOME*ESC PILOT HF**1407 patients3480 patients2450 patientsPatients (%)54.655.653.43133.729.722.520.717.2HR 70 bpm*Courtesy of Prof Tavazzi**Courtesy of Prof MaggioniHR 75 bpmHR 80 bpm
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How tocontrolheart rate ?
Options Beta-blockerDigitalisAmiodaroneRate limiting Calcium-channel blockerIvabradineAblation
Sinus rhytm
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Ivabradine / Coralan A new drug to provide anatomical (sinus node)andfunctional selectivity (If channel)
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Achieves target heart rate of 60 bpmwith excellent tolerability 1,2* Baseline heart rate 85 bpm*75-84 bpm*65-74 bpm*60-64 bpm* 55-60 bpmNo Hypotension RiskMinimal Risk of Bradycardia1. Borer JS, Heuzey JY. Characterization of the heart rate-lowering action of ivabradine, a selective I(f) current inhibitor. Am J Ther. 2008;15:461-473.2. Swedberg K, Komajda M, Böhm M, et al. Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study. Lancet. 2010;376:875-885.
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Systolic Heart Failure Treatment with the IfInhibitor Ivabradine Trial (SHIFT)Lancet. 2010;376:875-885 The SHIFT trial, conducted at 677 centers in 37 countries 6500 patients with NYHA class 2-4 heart failure, an LVEF 35%, a resting heart rate 70 bpm, and a heart-failurehospitalization within the previous yearRandomized to receive placebo or ivabradine at a startingdose of 5 mg twice daily, with adjustments to achieve aresting heart rate of 50 to 60 bpmAll patients were on standard heart-failure medicationsaccording to guidelines
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Kaplan-Meier cumulative event curves fordifferent end points in SHIFT
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Atrial fibrillation
AF in HF
DigitalisEuropean Heart Journal 2015
ESC Guidelines BBCCBDigoxinAmiodarone
Conclusion Is heart rate important in HF ? How low is the HR target ? How is the strategy ?
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Terimakasih
Framingham: Congestive Heart Failure(based on Kannel, D'Agostino, Silbershatz, Belanger, Wilson, Levy. 'Profile for Estimating Risk of Heart Failure' - ArchIntern. Med. 1999) Probability of Congestive Heart Failure Within 4 Years forMen Aged 45 to 94 YearsWith Coronary Disease, Hypertension, or Valvular Disease*Model including vital capacity and chest x-ray results41
SHIFT: Patient treatment atrandomization Patients receiving the best recommended therapy according toGuidelines: Beta-Blockers: 89% ACEIs and/or ARBs: 91% Diuretics: 84% Aldosterone Antagonists: 61% Digitalis: 22%43
Ischemic heart disease mortality 8.2 deaths/10 000 person-years 17.2 deaths/10 000 person-years. 1.9 (95% CI 1.0-3.6) Increasing Heart Rate Over Time Linked With Heart Disease Mortality NaumanJ, Janszky I, Vatten LJ, Wisløff U. Temporal changes in resting heart rate and deaths from ischemic heart disease. JAMA 2011; 306:2579-2587
