Heart rate reduction in cardiovascular disease and therapy

Assessment of the impact of resting heart rate on the risk of major adverse cardiovascular events after ischemic stroke: a retrospective observational study

BACKGROUND

Although elevated heart rate is a risk factor for cardiovascular morbidity and mortality in healthy people, the association between resting heart rate and major cardiovascular risk in patients after acute ischemic stroke remains debated. This study evaluated the association between heart rate and major adverse cardiovascular events after ischemic stroke.

METHODS

We conducted a retrospective cohort study analyzing data from the Chang Gung Research Database for 21,655 patients with recent ischemic stroke enrolled between January 1, 2010, and September 30, 2018. Initial in-hospital heart rates were averaged and categorized into 10-beats per minute (bpm) increments. The primary outcome was the composite of hospitalization for recurrent ischemic stroke, myocardial infarction, or all-cause mortality. Secondary outcomes were hospitalization for recurrent ischemic stroke, myocardial infarction, and heart failure. Hazard ratios and 95% confidence intervals (CIs) were estimated using Cox proportional hazards models, using the heart rate < 60 bpm subgroup as the reference.

RESULTS

After a median follow-up of 3.2 years, the adjusted hazard ratios for the primary outcome were 1.13 (95% CI: 1.01 to 1.26) for heart rate 60-69 bpm, 1.35 (95% CI: 1.22 to 1.50) for heart rate 70-79 bpm, 1.64 (95% CI: 1.47 to 1.83) for heart rate 80-89 bpm, and 2.08 (95% CI: 1.85 to 2.34) for heart rate ≥ 90 bpm compared with the reference group. Heart rate ≥ 70 bpm was associated with increased risk of all secondary outcomes compared with the reference group except heart failure.  CONCLUSIONS: Heart rate is a simple measurement with important prognostic implications. In patients with ischemic stroke, initial in-hospital heart rate was associated with major adverse cardiovascular events.

Bioavailability and Metabolism of Bioactive Peptide IRW with Angiotensin-Converting Enzyme 2 (ACE2) Upregulatory Activity in Spontaneously Hypertensive Rats

Peptide IRW is the first food-derived angiotensin-converting enzyme 2 (ACE2) upregulator. This study aimed to investigate the pharmacokinetic characteristics of IRW and identify the metabolites contributing to its antihypertensive activity in spontaneously hypertensive rats (SHRs). Rats were administered 100 mg of IRW/kg of the body weight via an intragastric or intravenous route. The bioavailability (F %) was determined to be 11.7%, and the half-lives were 7.9 ± 0.5 and 28.5 ± 6.8 min for gavage and injection, respectively. Interestingly, significant blood pressure reduction was not observed until 1.5 h post oral administration, or 2 h post injection, indicating that the peptide's metabolites are likely responsible for the blood pressure-lowering activity. Time-course metabolomics revealed a significant increase in the level of kynurenine, a tryptophan metabolite, in blood after IRW administration. Kynurenine increased the level of ACE2 in cells. Oral administration of tryptophan (W), but not dipeptide IR, lowered the blood pressure and upregulated aortic ACE2 in SHRs. Our study supports the key role of tryptophan and its metabolite, kynurenine, in IRW's blood pressure-lowering effects.

Evaluating the applicability of ivabradine in acute heart failure

BACKGROUND

While ivabradine has demonstrated benefits in heart rate control and prognosis for chronic heart failure patients, its application in acute decompensated heart failure remains underexplored.

HYPOTHESIS

For patients with acute decompensated heart failure with reduced ejection fraction (HFrEF) who are intolerant to β-blockers or unable to further titrate their dosage, the use of ivabradine is hypothesized to be effective and safe is improving outcomes.

METHODS

This retrospective, multicenter database analysis included patients with hospitalized decompensated heart failure with a left ventricular ejection fraction of ≤40% from June 1, 2015 to December 31, 2020. The exclusion criteria were a baseline heart rate of <70 bpm, previous use of ivabradine, mortality during admission, existing atrial fibrillation, or atrial flutter. The primary outcome was the composite of cardiovascular death and hospitalization for heart failure.

RESULTS

Of the 4163 HFrEF patients analyzed, 684 (16.4%) were administered ivabradine during their index admission. After matching, there were 617 patients in either group. The results indicated that ivabradine use was not significantly associated with the risk of the primary composite outcome (hazard ratio: 1.10; 95% confidence interval: 0.94-1.29). Similarly, the risk of secondary outcomes and adverse renal events did not significantly differ between the ivabradine and non-ivabradine cohorts (all p > .05).

CONCLUSION

For hospitalized acute decompensated heart failure patients who are intolerant to β-blockers or cannot further titrate them, ivabradine offers a consistent therapeutic effect. No significant disparities were noted between the ivabradine and non-ivabradine groups in heart failure hospitalization and cardiovascular death.

Association between Obstructive Sleep Apnea and Heart Failure in Adults-A Systematic Review

BACKGROUND

Heart failure (HF) patients commonly experience obstructive sleep apnea (OSA), which may worsen their condition. We reviewed a diverse range of studies to investigate the prevalence of OSA in HF patients, the effects of positive airway pressure (PAP) treatment, and the potential impact of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and sacubitril/valsartan on OSA outcomes.

METHODS

We analyzed case-control, observational studies, and randomized controlled trials. Prevalence rates, PAP treatment, and HF pharmacotherapy were assessed.

RESULTS

Numerous studies revealed a high prevalence of OSA in HF patients, particularly with preserved ejection fraction. PAP treatment consistently improved an apnea-hypopnea index, left ventricular ejection fraction, oxygen saturation, and overall quality of life. Emerging evidence suggests that SGLT2i and sacubitril/valsartan might influence OSA outcomes through weight loss, improved metabolic profiles, and potential direct effects on upper airway muscles.

CONCLUSIONS

The complex interplay between OSA and HF necessitates a multifaceted approach. PAP treatment has shown promising results in improving OSA symptoms and HF parameters. Additionally, recent investigations into the effects of HF pharmacotherapy on OSA suggest their potential as adjunctive therapy. This review provides insights for clinicians and researchers, highlighting the importance of addressing OSA and HF in patient management strategies.

Impact of heart rate, aortic compliance and stroke volume on the aortic regurgitation fraction studied in an ex vivo pig model

INTRODUCTION

Drug therapy to reduce the regurgitation fraction (RF) of high-grade aortic regurgitation (AR) by increasing heart rate (HR) is generally recommended. However, chronic HR reduction in HFREF patients can significantly improve aortic compliance and thereby potentially decrease RF. To clarify these contrasts, we examined the influence of HR, aortic compliance and stroke volume (SV) on RF in an ex vivo porcine model of severe AR.

METHODS

Experiments were performed on porcine ascending aorta with aortic valves (n=12). Compliance was varied by inserting a Dacron graft close to the aortic valve. Both tube systems were connected to a left heart simulator varying HR and SV. AR was accomplished by punching a 0.3 cm2 hole in one aortic cusp. Flow, RF, SV and aortic pressure were measured, aortic compliance with transoesophageal ultrasound probes.

RESULTS

Compliance of the aorta was significantly reduced after Dacron graft insertion (0.55%±0.21%/mm Hg vs 0.01%±0.007%/mm Hg, p<0.001, respectively). With increasing HR, RF was significantly reduced in each steady state of the native aorta (HR 40 bpm: 88%±7% vs HR 120 bpm: 42%±10%; p<0.001), but Dacron tube did not affect RF (HR 40 bpm: 87%±8%; p=0.79; HR 120 bpm: 42%±3%; p=0.86). Increasing SV also reduced RF independent of the stiff Dacron graft.

CONCLUSION

Aortic compliance did not affect AR in the ex vivo porcine model of AR. RF was significantly reduced with increasing HR and SV. These results affirm that HR lowering and negative inotropic drugs should be avoided to treat severe AR.

Heart Rate During Sleep in PTSD Patients: Moderation by Contact with a Service Dog

There is growing interest in the potential health benefits of dog ownership in both the lay and scientific communities. Large reductions in risk for cardiovascular disease and all-cause mortality in dog owners relative to non-owners have been observed in epidemiological samples. Persons diagnosed with posttraumatic stress disorder exhibit elevated risk for cardiovascular disease. The current study tested a sample of 45 U.S. military veterans with deployment-related posttraumatic stress disorder employing an intensive, longitudinal, within-subjects design contrasting sleep heart rate on nights with and without a service dog. As participants were engaged in residential psychiatric treatment, sleep opportunities, waking activities, meals, and medications, were consistently scheduled. The primary recording methodology, mattress actigraphy, enabled passive quantification of heart rate over a total sample of 1097 nights. Service dog contact was associated with reduced sleep heart rate especially in participants with more severe PTSD. Longer-term longitudinal studies will be needed to assess the durability and asymptotic magnitude of this effect. An unexpected effect of nights in study was associated with increased heart rate consistent with hospitalization-associated deconditioning.

The effect of mindfulness therapy in acromegaly, a pilot study

BACKGROUND

Patients with acromegaly have often several comorbidities, including decreased quality of life, mood alterations and chronic pain. Mindfulness is effective at improving mood, quality of life and pain management; however, there is no data available on its effect in patients with acromegaly.

OBJECTIVE

We aimed at evaluating changes in quality of life, mood, pain, sleep, self-compassion, life satisfaction, blood pressure and heart rate after a mindfulness program.

DESIGN AND PATIENTS

This was a randomized, multicentre, international clinical trial (Barcelona-BCN and Bergamo-BG) of 60 patients, 30 per centre.

MEASUREMENTS

The intervention group participated in an 8-week face-to-face group program; the control group followed normal clinical routine. In BG, patients performed a classic Mindfulness Based Stress Reduction program; in BCN they performed an adapted program including elements of mindfulness and compassion with a greater focus on daily life.

RESULTS

In the BCN intervention group there was an increase in night-time hours in bed (p = 0.05) after the program. In both centres there was a trend to a reduction of the time to start sleeping (p = 0.06 BCN, p = 0.07 BG). In BCN, the intervention group reduced the pain score compared to the control group (p = .02), and an improvement in self-compassion was found (p = .04). In both centres, heart rate decreased significantly in the intervention group during a single 2-hour session. This was evidenced at the first and the last program session (BCN p = .013 and p = .009; BG < 0.001 and p = .04). A training effect was found in BG, where heart rate fell more in the last session than in the first (p = 002).

CONCLUSIONS

We have demonstrated for the first time the value of a mindfulness program in patients with acromegaly, analysing possible effects and advantages, and clarifying the usefulness of a specific protocol for the disease.

Optimal Heart Rate Control Improves Long-Term Prognosis of Decompensated Heart Failure with Reduced Ejection Fraction

Background and Objectives: An elevated heart rate is an independent risk factor for cardiovascular disease; however, the relationship between heart rate control and the long-term outcomes of patients with heart failure with reduced ejection fraction (HFrEF) remains unclear. This study explored the long-term prognostic importance of heart rate control in patients hospitalized with HFrEF. Materials and Methods: We retrieved the records of patients admitted for decompensated heart failure with a left ventricular ejection fraction (LVEF) of ≤40%, from 1 January 2005 to 31 December 2019. The primary outcome was a composite of cardiovascular death or hospitalization for heart failure (HHF) during follow-up. We analyzed the outcomes using Cox proportional hazard ratios calculated using the patients' heart rates, as measured at baseline and approximately 3 months later. The mean follow-up duration was 49.0 ± 38.1 months. Results: We identified 5236 eligible patients, and divided them into five groups on the basis of changes in their heart rates. The mean LVEFs of the groups ranged from 29.1% to 30.6%. After adjustment for all covariates, the results demonstrated that lesser heart rate reductions at the 3-month screening period were associated with long-term cardiovascular death, HHF, and all-cause mortality (p for linear trend = 0.033, 0.042, and 0.003, respectively). The restricted cubic spline model revealed a linear relationship between reduction in heart rate and risk of outcomes (p for nonlinearity > 0.2). Conclusions: Greater reductions in heart rate were associated with a lower risk of long-term cardiovascular death, HHF, and all-cause mortality among patients discharged after hospitalization for decompensated HFrEF.

Relationships between sympathetic markers and heart rate thresholds for cardiovascular risk in chronic heart failure

BACKGROUND

Results of recent clinical trials have shown that in heart failure (HF) heart rate (HR) values > 70 beats/minute are associated with an increased cardiovascular risk. No information is available on whether the sympathetic nervous system is differently activated in HF patients displaying resting HR values above or below this cutoff.

METHODS

In 103 HF patients aged 62.7 ± 0.9 (mean ± SEM) years and in 62 heathy controls of similar age we evaluated muscle sympathetic nerve traffic (MSNA, microneurography) and venous plasma norepinephrine (NE, HPLC assay), subdividing the subjects in different groups according to their resting clinic and 24-h HR values.

RESULTS

In HF progressively greater values of clinic or 24-h HR were associated with a progressive increase in both MSNA and NE. HR cutoff values adopted in large scale clinical trials for determining cardiovascular risk, i.e., 70 beats/minute, were associated with MSNA values significantly greater than the ones detected in patients with lower HR, this being the case also for NE. In HF both MSNA and NE were significantly related to clinic (r = 0.92, P < 0.0001 and r = 0.81, P < 0.0001, respectively) and 24-h (r = 0.91, P < 0.0001 and r = 0.79, P < 0.0001, respectively) HR. The behavior of sympathetic markers described in HF was specific for this clinical condition, being not observed in healthy controls.

CONCLUSIONS

Both clinic and 24-h HR values greater than 70 beats/minute are associated with an increased sympathetic activation, which parallels for magnitude the HR elevations. These findings support the relevance of using in the therapeutic approach to HF drugs exerting sympathomoderating properties.

Resting heart rate and risk of left and right heart failure in 0.5 million Chinese adults

OBJECTIVES

To compare the shape and strength of the associations of resting heart rate (RHR) with incident heart failure (HF) and pulmonary heart disease (PHD) in Chinese adults.

METHODS

The prospective China Kadoorie Biobank recruited >0.5 million adults from 10 geographically diverse regions (5 urban, 5 rural) of China during 2004-2008. After an 11-year follow-up, 6082 incident cases of HF and 5572 cases of PHD, were recorded among 491 785 participants with no prior history of heart disease or use of beta-blockers at baseline. Cox regression yielded HRs for each disease associated with usual RHR after adjustment for confounding factors.

RESULTS

The mean (SD) baseline RHR was 79 (12) (men 78 (12); women 80 (11)) bpm, and these decreased with increasing age (by about 1 bpm per 10 years). Usual RHR showed J-shaped associations with HF and log-linear associations PHD. For HF, each 10 bpm higher usual RHR was associated with an adjusted HR of 1.25 (95% CI 1.17 to 1.34) for RHR>75 bpm. For PHD, each 10 bpm higher RHR was associated with HR of 1.74 (1.67-1.81) across the full range of usual RHR. For HF at RHR>75 bpm but not PHD, the HRs per 10 bpm higher RHR were approximately halved by further adjustment for diabetes and hypertension.

CONCLUSIONS

RHR was strongly positively associated with PHD throughout the range studied, but was only associated with HF at RHR>75 bpm, and the strength of the associations with HF were only one-third of those with PHD.

Mobile Heart Rate Variability Biofeedback as a Complementary Intervention After Myocardial Infarction: a Randomized Controlled Study

BACKGROUND

To enhance effective prevention programs after myocardial infarction (MI), the study examined the effects and feasibility of mobile biofeedback training on heart rate variability (HRV-BF).

METHODS

Forty-six outpatients aged 41 to 79 years with a documented MI were randomized to HRV-BF versus usual care. Generalized estimating equation (GEE) analyses were performed to test improvements in measures of short- and long-time HRV, namely, the standard deviation of the normal-to-normal intervals (SDNN) and well-being after 12 weeks of HRV-BF.

RESULTS

There were intervention effects for short-time HRV (d > 0.4, p < 0.04), which were partly replicated in the GEE models that accounted for control variables: In the HRV-BF group, the high-frequency HRV (group × time interaction: β = 0.59, p = 0.04) compensated for significantly lower baseline levels than the group with usual care. In an optimal dose sample (on average two HRV-BF sessions a day), SDNN significantly increased after HRV-BF (p = 0.002) but not in the waitlist control group. Compensatory trends of HRV-BF were also found for high-frequency HRV and self-efficacy. No adverse effects of the intervention were found but neither were effects on long-time HRV measures.

CONCLUSION

The results showed the feasibility of self-guided HRV-BF for almost all post-MI patients. HRV-BF as an adjunctive behavioral treatment increased HRV, which is an indicator of lower cardiovascular risk, and self-efficacy, which suggests heightened psychological resilience. These benefits warrant confirmation and tests of sustainability in larger studies.

TRIAL REGISTRATION

The trial has not been registered due to its starting point in 2017 predating the publication of the applicable CONSORT extension for reporting social and psychological intervention trials in 2018.

Recent Advances in Atherosclerotic Disease Screening Using Pervasive Healthcare

Atherosclerosis screening helps the medical model transform from therapeutic medicine to preventive medicine by assessing degree of atherosclerosis prior to the occurrence of fatal vascular events. Pervasive screening emphasizes atherosclerotic monitoring with easy access, quick process, and advanced computing. In this work, we introduced five cutting-edge pervasive technologies including imaging photoplethysmography (iPPG), laser Doppler, radio frequency (RF), thermal imaging (TI), optical fiber sensing and piezoelectric sensor. IPPG measures physiological parameters by using video images that record the subtle skin color changes consistent with cardiac-synchronous blood volume changes in subcutaneous arteries and capillaries. Laser Doppler obtained the information on blood flow by analyzing the spectral components of backscattered light from the illuminated tissues surface. RF is based on Doppler shift caused by the periodic movement of the chest wall induced by respiration and heartbeat. TI measures vital signs by detecting electromagnetic radiation emitted by blood flow. The working principle of optical fiber sensor is to detect the change of light properties caused by the interaction between the measured physiological parameter and the entering light. Piezoelectric sensors are based on the piezoelectric effect of dielectrics. All these pervasive technologies are noninvasive, mobile, and can detect physiological parameters related to atherosclerosis screening.

The Association of Extreme Tachycardia and Sustained Return of Spontaneous Circulation after Nontraumatic Out-of-Hospital Cardiac Arrest

Objective

Heart rate (HR), an essential vital sign that reflects hemodynamic stability, is influenced by myocardial oxygen demand, coronary blood flow, and myocardial performance. HR at the time of the return of spontaneous circulation (ROSC) could be influenced by the β1-adrenergic effect of the epinephrine administered during cardiopulmonary resuscitation (CPR), and its effect could be decreased in patients who have the failing heart. We aimed to investigate the association between HR at the time of ROSC and the outcomes of adult out-of-hospital cardiac arrest (OHCA) patients.

Methods

This study was a secondary analysis of a cardiac arrest registry from a single institution from January 2008 to July 2014. The OHCA patients who achieved ROSC at the emergency department (ED) were included, and HR was retrieved from an electrocardiogram or vital sign at the time of ROSC. The patients were categorized into four groups according to the HR (bradycardia (HR < 60), normal HR (60 ≤ HR ≤ 100), tachycardia (100 < HR < 150), and extreme tachycardia (HR ≥ 150)). The primary outcome was the rate of sustained ROSC and the secondary outcomes were the rate of one-month survival and six-month good neurologic outcome.

Results

A total of 330 patients were included. In the univariate logistic regression model, the rate of sustained ROSC increased by 17% as HR increased by every 10 beats per minute (bpm) (odds ratio (OR), 1.171; 95% confidence interval (CI), 1.077–1.274, p < 0.001). In the multivariate logistic regression model, extreme tachycardia was independently associated with a high probability of sustained ROSC compared to normal heart rate (OR, 15.96; 95% CI, 2.04–124.93, p=0.008).

Conclusion

Extreme tachycardia (HR ≥ 150) at the time of ROSC is independently associated with a high probability of sustained ROSC in nontraumatic adult OHCA patients.

Association of pulse rate with outcomes in heart failure with reduced ejection fraction: a retrospective cohort study

BACKGROUND

In a real-world setting, the effect of pulse rate measured at the time of diagnosis and serially during follow-up and management, on outcomes in heart failure with reduced ejection fraction (HFrEF), has not been well-studied. Furthermore, how beta-blockade use in a real-world situation modifies this relation between pulse rate and outcomes in HFrEF is not well-known. Hence, we identified a large, national, real-world cohort of HFrEF to examine the association of pulse rate and outcomes.

METHODS

Using Veterans Affairs (VA) national electronic health records we identified incident HFrEF cases between 2006 and 2012. We examined the associations of both baseline and serially measured pulse rates, with mortality and days hospitalized per year for heart failure and for any cause, using crude and multivariable Cox proportional hazards and Poisson or negative binomial models, respectively. The exposure was examined as continuous, dichotomous, and categorical. Post-hoc analyses addressed the interaction of pulse rate and beta-blocker target dose.

RESULTS

We identified 51,194 incident HFrEF cases (67 ± 12 years, 98% male, 77% white. A significant positive, near linear relationship was observed for both baseline and serially measured pulse rates with all-cause mortality, all-cause hospitalization and heart failure hospitalization after adjusting for covariates including beta-blocker use. Patients who had a pulse rate ≥ 70 bpm in the past 6 months had 36% (95% CI: 31-42%), 25% (95% CI: 19-32%), and 51% (95% CI: 33-72%) increased rates of mortality, all-cause hospitalization, and heart failure hospitalization, respectively, compared to patients with pulse rates < 70 bpm. A minority of subjects (15%) were treated with guideline directed beta blockade ≥50% of recommended target dose, among whom better outcomes were seen compared to those who did not achieve target dose in patients with pulse rates both above and below 70 beats per minute.

CONCLUSIONS

High pulse rate, both at the time of diagnosis and during follow-up, is strongly associated with increased risk of adverse outcomes in HFrEF patients, independent of the use of beta-blockers. In a real-world setting, the majority of HFrEF patients do not achieve target dose of beta-blockade; greater use of strategies to reduce heart rate may improve outcomes in HFrEF.

Effect of If Current Blockade on Newborn Rat Heart Isolated According to Langendorff

The study examined the effects of hyperpolarization-activated funny current (If) on HR and coronary flow in Langendorff-isolated hearts from newborn rats. Blockade of If current with ZD7288 changed the examined cardiac parameters. The blocker in a concentration of 10^-9 M decreased HR by 26.8% (p≤0.05). In concentrations 10^-8, 10^-7, 10^-6, and 10^-5 M ZD7288 produced minor differently directed effects. In a concentration of 10^-5 M, ZD7288 reduced coronary flow in the isolated heart (p≤0.01). In other concentrations, the blocker produced no significant effects on coronary flow.

What “new” factors should be considered when assessing cardiovascular risk?

One of the causes of high mortality from cardiovascular diseases is the lack of effective measures for the primary and secondary prevention of cardiovascular complications (CCO), due to the difficulty of timely identification risk factors (RF) and individuals with a high individual risk of CCO. This is especially true for patients from low/mean risk. This group is heterogeneous. Often, clinical manifestations of atherosclerosis occur for the first time without “classical” RF. Possible factors that increase the risk of developing cardiovascular diseases and CCO, are: heart rate, increased formation of advanced glycation endproducts, disorders of bone mineral metabolism, thyroid function, low adherence to therapy, psychosocial factors and climatic features. This review is devoted to the analysis of the evidence base of the influence of these “new” CCO RF and the individual patient prognosis.

Physical activity may compensate for prolonged TV time regarding pulse rate-a cross-sectional study

BACKGROUND

Regular exercise reduces pulse rate, but it is less clear how prolonged sitting time affects pulse rate. Our hypothesis was that high physical activity could compensate for prolonged sitting time regarding the pulse rate.

METHODS

Regression analysis was performed on cross-sectional data including 47,457 men and women based on two Swedish cohort studies, EpiHealth (18-45 years) and LifeGene (45-75 years). Self-reported leisure time physical activity was given in five levels, from low (level 1) to vigorous (level 5), and television time was used as a proxy of sitting time.

RESULTS

A higher physical activity (level 4 compared to level 1) was associated with a lower pulse rate in middle-aged females (-2.7 beats per minute [bpm]; 95% CI -3.3 to -2.2) and males (-4.0 bpm; 95% CI -4.7 to -3.4). The relationship between physical activity and pulse rate was strongest in the young. A prolonged television time (3 h compared to 1 h per day) was associated with a slightly higher pulse rate in middle-aged females (+0.6 bpm; 95% CI +0.3 to +0.8) and males (+0.9 bpm; 95% CI +0.7 to +1.2). Among participants with a prolonged television time (3 h), those with a high physical activity (level 4) had a lower pulse rate compared to those with a low physical activity (level 1).

CONCLUSIONS

A prolonged television time was associated with a high pulse rate, while high physical activity was associated with a low pulse rate. The results suggest that a high physical activity could compensate for a prolonged television time regarding pulse rate.

Beta blockers and chronic heart failure patients: prognostic impact of a dose targeted beta blocker therapy vs. heart rate targeted strategy

BACKGROUND

Beta blockers improve survival in patients with chronic systolic heart failure (CHF). Whether physicians should aim for target dose, target heart rate (HR), or both is still under debate.

METHODS AND RESULTS

We identified 1,669 patients with systolic CHF due to ischemic heart disease or idiopathic dilated cardiomyopathy from the University Hospital Heidelberg and the Clinic of Ludwigshafen, Germany. All patients were treated with an angiotensin converting enzyme inhibitor or angiotensin receptor blocker and had a history of CHF known for at least 6 months. Target dose was defined as treatment with ≥ 95% of the respective published guideline-recommended dose. Target HR was defined as 51-69 bpm. All-cause mortality during the median follow-up of 42.8 months was analysed with respect to beta blocker dosing and resting HR. 201 (12%) patients met the dose target (group A), 285 (17.1%) met the HR target (group B), 627 (37.6%) met no target (group C), and 556 (33.3%) did not receive beta blockers (Group D). 5-year mortality was 23.7, 22.7, 37.6, and 55.6% for group A, B, C, and D, respectively (p <  0.001). Survival for group A patients with a HR ≥ 70 bpm was 28.8% but 14.8% if HR was 50-70 bpm (p = 0.054).

CONCLUSIONS

Achieving guidelines recommended beta blocker dose or to HR control has a similar positive impact on survival. When on target dose, supplemental HR control additionally improves survival.

If Channel as an Emerging Therapeutic Target for Cardiovascular Diseases: A Review of Current Evidence and Controversies

In 2015, non-communicable diseases accounted for 39.5 million (70%) of the total 56.4 million deaths that occurred globally, of which 17.7 million (45%) were due to cardiovascular diseases. An elevated heart rate is considered to be one of the independent predictors and markers of future cardiovascular diseases. A variety of experimental and epidemiological studies have found that atherosclerosis, heart failure, coronary artery disease, stroke, and arrhythmia are linked to elevated heart rate. Although there are established drugs to reduce the heart rate, these drugs have undesirable side effects. Hence, the development of new drugs that selectively inhibit the heart rate is considered necessary. In the search for such drugs, almost four decades ago the I_f channel, also known as the “funny channel,” emerged as a novel site for the selective inhibition of heart rate. These I_f channels, with a mixed sodium and potassium inward current, have been identified in the sinoatrial node of the heart, which mediates the slow diastolic depolarization of the pacemaker of the spontaneous rhythmic cells. The hyperpolarization-activated cyclic nucleotide-gated (HCN) subfamily is primarily articulated in the heart and neurons that are encoded by a family of four genes (HCN1-4) and they identify the funny channel. Of these, HCN-4 is the principal protein in the sinoatrial node. Currently, funny channel inhibition is being targeted for the treatment and prevention of cardiovascular diseases such as atherosclerosis and stroke. A selective I_f channel inhibitor named ivabradine was discovered for clinical use in treating heart failure and coronary artery disease. However, inconsistencies regarding the clinical effects of ivabradine have been reported in the literature, suggesting the need for a rigorous analysis of the available evidence. The objective of this review is therefore to assess the current advances in targeting the I_f channel associated with ivabradine and related challenges.

Water ingestion decreases cardiac workload time-dependent in healthy adults with no effect of gender

Ingestion of water entails a variety of cardiovascular responses. However, the precise effect remains elusive. We aimed to determine in healthy adults the effect of water on cardiac workload and to investigate potential gender differences. We pooled data from two controlled studies where blood pressure (BP) and heart rate (HR) were continuously recorded before and after the ingestion of 355 mL of tap water. Additionally, we calculated double product by multiplying systolic BP with HR and evaluated spectral parameters referring to vagal tone. All parameters were investigated for potential differences based on gender. In response to water, HR, systolic BP, and double product decreased significantly during the first 30 min. However, these effects were attenuated for HR and double product and even abolished for systolic BP over the subsequent 30 min. Over the entire post-drink period (60 min), decreases in HR and double product (all P < 0.05) were observed. Spectral markers for vagal tone increased with the on-set of the water drink and remained elevated until the end (P < 0.005). No significant gender difference in cardiac workload parameters was observed. We provide evidence that drinking water decreases, in a time-dependent fashion, cardiac workload and that these responses appear not to be influenced by gender.

Effect of ivabradine on cardiovascular outcomes in patients with stable angina: meta-analysis of randomized clinical trials

BACKGROUND

Although there are established drugs for treatment of cardiovascular diseases, due to adverse effects these drugs may not be clinically applicable to all patients. Recent trends have seen the emergence of drugs which act on funny current channels to induce selective heart rate reduction. Ivabradine is one such drug developed for coronary artery disease and heart failure. There is inconsistent evidence about the effect of this selective inhibitor in reduction of cardiovascular related mortality and morbidity. Such an inconsistency warrants the need for a meta-analysis to consider the effectiveness and efficacy of Ivabradine in the treatment of coronary artery disease and heart failure.

METHODS

Randomized controlled trials with a minimum follow-up period of one year were searched in Pub Med/Medline, Embase, Cochrane Central Register of Controlled Trials published between 1980 and 2016.Each eligible study was assessed for risk of bias by using the Cochrane Risk of Bias Assessment tool. The outcomes assessed in this study included: all cause mortality, cardiovascular-related mortality, hospitalization for new or worsening heart failure, and adverse events. Subgroup analysis and publication bias were assessed. We used Mantel-Haenszel method for random-effects. Analysis was done using RevMan5.1™.This study was registered in PROSPERO as [PROSPERO 2016:CRD42016035597].

RESULT

Three trials with a total of 36,577 participants met the meta-analysis criteria. Pooled analysis showed that ivabradine is not effective in reducing cardiovascular deaths (OR: 1.02; CI:0.91-1.15,P = 0.74), all-cause mortality (OR:1.00; CI:0.91-1.10,P = 0.98), coronary revascularization (OR: 0.93, CI: 0.77-1.11, P = 0.41) and hospital admission for worsening of heart failure (OR: 0.94, CI: 0.71-1.25, P = 0.69). However, the drug was found to significantly increase adverse events: phosphenes (OR:7.77, CI: 4.4-14.6,P < 0.00001), blurred vision (OR:3.07,CI:2.18-4.32,P < 0.00001), symptomatic bradycardia (OR: 6.23, CI: 4.2-9.26, P < 0.00001), and atrial fibrillation (OR: 1.35, CI: 1.19-1.53, P < 0.0001). Subgroup analysis by duration of follow up on cardiovascular outcomes found that there is no difference in effect of ivabradine depending on the duration of follow up. There was no publication bias in reporting of included studies.

CONCLUSION

This meta-analysis suggests that ivabradine is not effective in reducing cardiovascular-related morbidity and mortality unless used for specific conditions. On the contrary, the use of this drug was strongly associated with the onset of untoward and new adverse events. This finding strongly supports previous findings and further informs the rational and evidence-informed clinical use of ivabradine.

Predictors of Post-discharge Mortality Among Patients Hospitalized for Acute Heart Failure

Acute Heart Failure (AHF) is a " multi-event disease" and hospitalisation is a critical event in the clinical course of HF. Despite relatively rapid relief of symptoms, hospitalisation for AHF is followed by an increased risk of death and re-hospitalisation. In AHF, risk stratification from clinically available data is increasingly important in evaluating long-term prognosis. From the perspective of patients, information on the risk of mortality and re-hospitalisation would be helpful in providing patients with insight into their disease. From the perspective of care providers, it may facilitate management decisions, such as who needs to be admitted and to what level of care (i.e. floor, step-down, ICU). Furthermore, risk-stratification may help identify patients who need to be evaluated for advanced HF therapies (i.e. left-ventricle assistance device or transplant or palliative care), and patients who need early a post-discharge follow-up plan. Finally, risk stratification will allow for more robust efforts to identify among risk markers the true targets for therapies that may direct treatment strategies to selected high-risk patients. Further clinical research will be needed to evaluate if appropriate risk stratification of patients could improve clinical outcome and resources allocation.

Effectiveness and Tolerability of Ivabradine with or Without Concomitant Beta-Blocker Therapy in Patients with Chronic Stable Angina in Routine Clinical Practice

Introduction

In the prospective, open-label, non-interventional, multicenter RESPONSI_fVE study, the effectiveness, response rates and tolerability of ivabradine with or without beta blocker (BB) were evaluated in patients with chronic stable angina pectoris (AP) in daily clinical practice.

Methods

In patients with AP, ivabradine was given twice daily in flexible doses for 4 months. Resting heart rate (HR), number of angina attacks, short-acting nitrate use, severity of symptoms [by Canadian Cardiovascular Society (CCS) score] and tolerability with or without existing BB therapy were documented and analyzed using descriptive statistical methods.

Results

In total, 1250 patients with AP (mean age 66.0 ± 10.9 years, 59.6% male, 31.9% previous myocardial infarction) and an indication for ivabradine were included. Sixty-five percent of all patients received BB. Further concomitant standard medication included aspirin (74.2%), statins (69.3%), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (84.2%), diuretics (40.0%), long-acting nitrates (15.7%), and calcium antagonists (21.4%). After 4 months of ivabradine treatment (mean daily dose 11.0 ± 2.7 mg), mean HR was reduced from 82.4 ± 11.8 beats per minute (bpm) to 67.1 ± 8.4 bpm. The average number of angina attacks/week decreased from 1.2 ± 1.9 to 0.1 ± 0.6 and the average use of short-acting nitrates/week from 1.5 ± 2.8 units to 0.2 ± 1.0 units. CCS classification of patients improved from 76% classified in CCS grades II or III and 24% in CCS grade I to 66% classified in CCS grade I and only 35% remaining in CCS grades II or III at study end. Response rate to ivabradine (defined as HR <70 bpm or HR reduction ≥10 bpm) reached 87%. HR reduction, symptomatic improvement and response rates were comparable in patients with or without BB. Adverse drug reactions were reported for 2.2% of patients.

Conclusion

In this prospective study over a four-month period in clinical practice, ivabradine effectively reduced HR, angina attacks, and nitrate consumption in patients with AP with or without concomitant BB therapy. Ivabradine improved CCS scores and achieved a high treatment response rate with good general tolerability.

Funding

Servier.

Trial registration

Controlled-trials.com identifier, ISRCTN73861224.

Effects of renal sympathetic denervation on cardiac systolic function after myocardial infarction in rats

This study investigated the therapeutic effects of renal denervation on cardiac systolic function after myocardial infarction (MI) in rats and the mechanism involved. Fifty male SD rats were randomly assigned to the sham group (n = 15), the MI group (n = 20), and the MI plus renal denervation group (n = 15). MI was established through thoracotomic ligation of the anterior descending artery. Renal denervation was achieved by laparotomic stripping of the renal arterial adventitial sympathetic nerve, approximately 3 mm from the abdominal aorta. Left ventricular function and hemodynamics were measured several weeks following MI. The left ventricular systolic function of the MI group was significantly reduced and the systolic blood pressure (SBP) remarkably declined. In rats with MI treated with renal denervation, the left ventricular ejection fraction (EF), fractional shortening (FS) and SBP markedly improved compared with the MI group. However, heart rate and fibrosis decreased significantly. These findings suggest that renal denervation has therapeutic effects on post-MI cardiac dysfunction. These effects are associated with increased left ventricular ejection fraction (LVEF) and SBP, as well as reduced heart rate and fibrosis. This may represent a new approach to the treatment of post-MI remodeling and subsequent heart failure.

Effect of Smoking on Blood Pressure and Resting Heart Rate: A Mendelian Randomization Meta-Analysis in the CARTA Consortium

BACKGROUND

Smoking is an important cardiovascular disease risk factor, but the mechanisms linking smoking to blood pressure are poorly understood.

METHODS AND RESULTS

Data on 141 317 participants (62 666 never, 40 669 former, 37 982 current smokers) from 23 population-based studies were included in observational and Mendelian randomization meta-analyses of the associations of smoking status and smoking heaviness with systolic and diastolic blood pressure, hypertension, and resting heart rate. For the Mendelian randomization analyses, a genetic variant rs16969968/rs1051730 was used as a proxy for smoking heaviness in current smokers. In observational analyses, current as compared with never smoking was associated with lower systolic blood pressure and diastolic blood pressure and lower hypertension risk, but with higher resting heart rate. In observational analyses among current smokers, 1 cigarette/day higher level of smoking heaviness was associated with higher (0.21 bpm; 95% confidence interval 0.19; 0.24) resting heart rate and slightly higher diastolic blood pressure (0.05 mm Hg; 95% confidence interval 0.02; 0.08) and systolic blood pressure (0.08 mm Hg; 95% confidence interval 0.03; 0.13). However, in Mendelian randomization analyses among current smokers, although each smoking increasing allele of rs16969968/rs1051730 was associated with higher resting heart rate (0.36 bpm/allele; 95% confidence interval 0.18; 0.54), there was no strong association with diastolic blood pressure, systolic blood pressure, or hypertension. This would suggest a 7 bpm higher heart rate in those who smoke 20 cigarettes/day.

CONCLUSIONS

This Mendelian randomization meta-analysis supports a causal association of smoking heaviness with higher level of resting heart rate, but not with blood pressure. These findings suggest that part of the cardiovascular risk of smoking may operate through increasing resting heart rate.

Repeated heart rate measurement and cardiovascular outcomes in left ventricular systolic dysfunction

BACKGROUND

Elevated resting heart rate is associated with increased cardiovascular risk, particularly in patients with left ventricular systolic dysfunction. Heart rate is not monitored routinely in these patients. We hypothesized that routine monitoring of heart rate would increase its prognostic value in patients with left ventricular systolic dysfunction.

METHODS

We analyzed the relationship between heart rate measurements and a range of adverse cardiovascular outcomes, including hospitalization for worsening heart failure, in the pooled placebo-treated patients from the morBidity-mortality EvAlUaTion of the If inhibitor ivabradine in patients with coronary disease and left ventricULar dysfunction (BEAUTIFUL) trial and Systolic Heart failure treatment with the If inhibitor ivabradine (SHIFT) Trial, using standard and time-varying covariate Cox proportional hazards models. By adjusting for other prognostic factors, models were fitted for baseline heart rate alone or for time-updated heart rate (latest heart rate) alone or corrected for baseline heart rate or for immediate previous time-updated heart rate.

RESULTS

Baseline heart rate was strongly associated with all outcomes apart from hospitalization for myocardial infarction. Time-updated heart rate increased the strengths of associations for all outcomes. Adjustment for baseline heart rate or immediate previous time-updated heart rate modestly reduced the prognostic importance of time-updated heart rate. For hospitalization for worsening heart failure, each 5 beats/min increase in baseline heart rate and time-updated heart rate was associated with a 15% (95% confidence interval, 12-18) and 22% (confidence interval, 19-40) increase in risk, respectively. Even after correction, the prognostic value of time-updated heart rate remained greater.

CONCLUSIONS

In patients with left ventricular systolic dysfunction, time-updated heart rate is more strongly related with adverse cardiovascular outcomes than baseline heart rate. Heart rate should be measured to assess cardiovascular risk at all assessments of patients with left ventricular systolic dysfunction.

[Update on therapy of chronic heart failure. Innovations and studies from last year]

Chronic heart failure is one of the most common chronic diseases worldwide with increasing prevalence and incidence. Due to the high morbidity and mortality a standardized and evidence-based therapy is crucial. The present review article gives an overview about the innovations in 2014 based on the current guidelines of the European Society of Cardiology. First, improvements in established medication regimens regarding beta blockers and mineralocorticoid receptor antagonists as well as treatment options for heart rate reduction will be explained. Second, new pharmacological developments, such as angiotensin receptor neprilysin inhibition will be discussed. Finally, new insights into common comorbidities of patients with chronic heart failure, such as atrial fibrillation and hyperkalemia will be presented.

Systems Pharmacology Dissecting Holistic Medicine for Treatment of Complex Diseases: An Example Using Cardiocerebrovascular Diseases Treated by TCM

Holistic medicine is an interdisciplinary field of study that integrates all types of biological information (protein, small molecules, tissues, organs, external environmental signals, etc.) to lead to predictive and actionable models for health care and disease treatment. Despite the global and integrative character of this discipline, a comprehensive picture of holistic medicine for the treatment of complex diseases is still lacking. In this study, we develop a novel systems pharmacology approach to dissect holistic medicine in treating cardiocerebrovascular diseases (CCDs) by TCM (traditional Chinese medicine). Firstly, by applying the TCM active ingredients screened out by a systems-ADME process, we explored and experimentalized the signed drug-target interactions for revealing the pharmacological actions of drugs at a molecule level. Then, at a/an tissue/organ level, the drug therapeutic mechanisms were further investigated by a target-organ location method. Finally, a translational integrating pathway approach was applied to extract the diseases-therapeutic modules for understanding the complex disease and its therapy at systems level. For the first time, the feature of the drug-target-pathway-organ-cooperations for treatment of multiple organ diseases in holistic medicine was revealed, facilitating the development of novel treatment paradigm for complex diseases in the future.

Etiology-specific assessment of predictors of long-term survival in chronic systolic heart failure

BACKGROUND

We sought to identify prognostic factors of long-term mortality, specific for the underlying etiology of chronic systolic heart failure (CHF).

METHODS AND RESULTS

Between 1995 and 2009 baseline characteristics, treatment and follow-up data from 2318 CHF-patients due to ischemic (ICM; 1100 patients) or dilated cardiomyopathy (DCM; 1218 patients) were prospectively compared. To calculate hazard ratios with 95%-confidence intervals cox regression was used. We respectively established etiology-specific multivariable models of independent prognostic factors. During the follow-up period of up to 14.8 years (mean = 53.1 ± 43.5 months; 10,264 patient-years) 991 deaths (42.8%) occurred. In the ICM-cohort, 5-year-survival was 53.4% (95% CI: 49.9-56.7%), whereas in DCM-patients it was higher (68.1% (95% CI: 65.1-71.0%)). Age, ejection fraction, or hyponatremia were independent predictors for mortality in both cohorts, whereas diabetes, COPD, atrial fibrillation and a heart rate of ≥ 80/min carried independent predictive power only in ICM-patients.

CONCLUSION

This study demonstrates the disparity of prognostic value of clinically derived risk factors between the two main causes of CHF. The effects of covariables in DCM-patients were lower, suggesting a less modifiable disease through risk factors considering mortality risk. An etiology-specific prognostic model may improve accuracy of survival estimations in CHF.

Systolic blood pressure variation and mean heart rate is associated with cognitive dysfunction in patients with high cardiovascular risk

Elevated systolic blood pressure (SBP) correlates to cognitive decline and incident dementia. The effects of heart rate (HR), visit to visit HR variation, and visit to visit SBP variation are less well established. Patients without preexisting cognitive dysfunction (N=24 593) were evaluated according to mean SBP, SBP visit to visit variation (coefficient of variation [standard deviation/mean×100%], CV), mean HR, and visit to visit HR variation (HR-CV) in the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial and the Telmisartan Randomized Assessment Study in ACE Intolerant Subjects with Cardiovascular Disease. Cognitive function was assessed with mini mental state examination. Cognitive dysfunction (fall in mini mental state examination ≤24 points), important cognitive decline (drop of ≥5 points), and cognitive deterioration (drop of >1 point per year or decline to <24 points) were assessed. SBP and HR were measured over 10.7±2.2 (mean±SD) visits. Mean SBP, mean HR, and SBP-CV were associated with cognitive decline, dysfunction, and deterioration (all P<0.01, unadjusted). After adjustment, only SBP-CV (P=0.0030) and mean HR (P=0.0008) remained predictors for cognitive dysfunction (odds ratios [95% confidence intervals], 1.32 [1.10-1.58] for 5th versus 1st quintile of SBP-CV and 1.40 [1.18-1.66] for 5th versus 1st quintile of mean HR). Similar effects were observed for cognitive decline and deterioration. SBP-CV and mean HR showed additive effects. In conclusion, SBP-CV and mean HR are independent predictors of cognitive decline and cognitive dysfunction in patients at high CV risk.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT 00153101.

Novel and nonpharmacologic approaches to cardio-protection in hypertension

Hypertension has wide (30-45 %) prevalence in the general population and is related to important increases in overall cardiovascular morbidity and mortality. Despite lifestyle modifications and optimal medical therapy (three drugs, one being diuretic), about 5-20 % of hypertensives are affected by resistant hypertension. Chronic high blood pressure has adverse effects on the heart and other organs such as the kidneys and vasculature. Renal sympathetic denervation and baroreceptor stimulation are invasive approaches initially investigated to treat resistant hypertension. Their pleiotropic effects appear promising in cardiovascular remodeling, heart failure and arrhythmias and could potentially affect cardiovascular morbidity and mortality.

The relation between resting heart rate and cancer incidence, cancer mortality and all-cause mortality in patients with manifest vascular disease

BACKGROUND

Previous studies suggest that elevated resting heart rate (RHR) is related to an increased risk of cancer mortality. The aim of this study was to evaluate the relation between RHR and cancer incidence and mortality in patients with vascular disease.

METHODS

Patients with manifest vascular disease (n=6007) were prospectively followed-up for cancer incidence and mortality. At baseline, RHR was obtained from an electrocardiogram. The relation between RHR and cancer incidence, cancer mortality and total mortality was assessed using competing risks models.

RESULTS

During a median follow-up of 6.0 years (interquartile range: 3.1-9.3) 491 patients (8%) were diagnosed with cancer and 907 (15%) patients died, 248 (27%) died from cancer. After adjustment for potential confounders, the hazard ratio (HR) for incident cancer per 10 beats/min increase in RHR was 1.00 (95% confidence interval [CI]: 0.93-1.07). There was a trend toward an increased risk of colorectal cancer in patients with higher RHR (HR 1.15, 95% CI 0.97-1.36). The risk of all-cause mortality was increased in patients in the highest quartile of RHR compared to the lowest quartile (HR 1.86, 95% CI 1.53-2.27), but no effect of RHR on cancer mortality was observed (HR 1.01, 95% CI 0.70-1.46).

CONCLUSIONS

In patients with manifest vascular disease, elevated RHR was related to a higher risk of premature all-cause mortality, but this was not due to increased cancer mortality. RHR was not related to risk of overall cancer incidence, although a relation between elevated RHR and incident colorectal cancer risk could not be ruled out.

Ivabradine treatment in a chronic heart failure patient cohort: symptom reduction and improvement in quality of life in clinical practice

Introduction

In the prospective, open-label multicenter INTENSIFY study, the effectiveness and tolerability of ivabradine as well as its impact on quality of life (QOL) in chronic systolic heart failure (CHF) patients were evaluated over a 4-month period.

Methods

In CHF patients with an indication for treatment with ivabradine, resting heart rate (HR), heart failure symptoms [New York Heart Association (NYHA) class, signs of decompensation], left ventricular ejection fraction, brain natriuretic peptide (BNP) values, QOL, and concomitant medication with focus on beta-blocker therapy were documented at baseline, after 4 weeks, and after 4 months. The results were analyzed using descriptive statistical methods.

Results

Thousand nine hundred and fifty-six patients with CHF were included. Their mean age was 67 ± 11.7 years and 56.9% were male. 77.8% were receiving beta-blockers. Other concomitant medications included angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (83%), diuretics (61%), aldosterone antagonists (18%), and cardiac glycosides (8%). At baseline, the mean HR of patients was 85 ± 11.8 bpm, 51.1% and 37.2% of patients were classified as NYHA II and III, respectively, and 22.7% showed signs of decompensation. BNP concentrations were tracked in a subgroup, and values exceeding 400 pg/mL were noted in 53.9% of patients. The mean value of the European quality of life-5 dimensions (EQ-5D) QOL index was 0.64 ± 0.28. After 4 months of treatment with ivabradine, HR was reduced to 67 ± 8.9 bpm. Furthermore, the proportion of patients presenting with signs of decompensation decreased to 5.4% and the proportion of patients with BNP levels >400 pg/mL dropped to 26.7%, accompanied by a shift in NYHA classification towards lower grading (24.0% and 60.5% in NYHA I and II, respectively). EQ-5D index improved to 0.79 ± 0.21.

Conclusion

Over 4 months of treatment, ivabradine effectively reduced HR and symptoms in CHF patients in this study reflecting daily clinical practice. These benefits were accompanied by improved QOL and good general tolerability.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-014-0147-3) contains supplementary material, which is available to authorized users.

[Acute and chronic heart failure in light of the new ESC guidelines]

In June 2012, the New Guidelines for the Treatment of Acute and Chronic Heart Failure of the European Society of Cardiology were published. According to the EMPHASIS-HF trial, mineralocorticoid receptor antagonists are indicated in all stages of symptomatic chronic heart failure under treatment with β-blockers and ACE inhibitors. Based on the SHIFT trial, patients with class NYHA II-IV heart failure, an ejection fraction <35%, and sinus rhythm with a heart rate of >70/min despite pharmacological treatment including β-blockers at the maximum tolerated dose should be treated with ivabradin. The RAFT trial justified the extended indication for CRT systems. In acute heart failure, the RELAX-AHF trial showed promising results with serelaxin. This manuscript summarizes the innovations of the new guidelines and the underlying clinical trials.

Registry in Germany focusing on level-specific and evidence-based decision finding in the treatment of heart failure: REFLECT-HF

BACKGROUND

In Germany, care for patients with chronic heart failure (HF) is provided by hospital-based cardiologists (HBC), office-based cardiologists (OBC) and general practitioners (GP). We aimed to compare patient characteristics, diagnostic approaches and therapeutic decisions.

METHODS

Multi-centre, cross-sectional, observational survey at 48 physicians. Patients (n = 384) were required to have previously diagnosed HF and NYHA class ≥ II and/or a left ventricular ejection fraction of <50 %. A total of 384 patients were included at 5 HBCs, 26 OBCs and 18 GPs.

RESULTS

A mean of 18.8 % of all patients at HBCs practices had heart failure, compared to a smaller proportion of 13.9 and 6.7 % at OBCs and GPs, respectively. Echo facility was available for all HBCs and OBCs, but for 16.7 % of GPs (p < 0.0001 for trend). Patients at HBCs had a higher NYHA class (65.6 % had class III/IV; p < 0.0001) compared to 36.8 % at OBCs and 39.3 % at GPs. Usage of three guideline-recommended pharmaceutical treatments was more than 80 %: diuretics (83.1 %), renin-angiotensin system blocking agents (91.4 %) and betablockers (90.1 %) with no differences between physician groups. Mineralocorticoid receptor antagonists (MRAs, overall 47.7 %) were more frequently prescribed by OBCs (54.7 %; p = 0.0007 for trend) than HBCs (43.8 %) and GPs (31.0 %). Ivabradin was not frequently used (11.0 % at OBCs, 4.9 % at HBCs and 0 % at GPs; p = 0.0163 for trend). The proportion of patients with CRT (8.6 %), ICD (23.5 %) and CABG (23.1 %) was not statistically different between groups.

CONCLUSION

REFLECT-HF demonstrates that there are some differences in evidence-based treatment decisions between the three main health services (HBC, OBC and GP) providing care for patients with HF in Germany. Advocating adherence to guideline recommendations and earlier adoption of these evidence-based treatments across all levels of care might further improve patient care.

Heart rate is associated with increased risk of major cardiovascular events, cardiovascular and all-cause death in patients with stable chronic cardiovascular disease: an analysis of ONTARGET/TRANSCEND

AIMS

Heart rate was proposed as an emergent cardiovascular (CV) risk factor. Previous studies have shown associations between increased heart rate and CV risk in various populations. We aimed to evaluate the prognostic relevance of heart rate in a large contemporaneous medically optimized cohort of patients with stable chronic CV disease.

METHODS AND RESULTS

In a post hoc analysis of the ONTARGET/TRANSCEND trials, we evaluated associations between baseline and average heart rate in trial with CV risk in 31, 531 patients followed for a median of 5 years. The primary outcome, major vascular events (MVE), was a composite of CV death, myocardial infarction (MI), stroke, and congestive heart failure (CHF). Pre-specified secondary outcomes included all-cause death and the individual components of the primary outcome. Associations between heart rate and outcomes were computed with heart rate as a continuous variable, baseline heart rate >70 vs ≤ 70 bpm, and across heart rate quintiles, adjusting for other markers of risk, beta-blocker and non-dihydropyridine calcium channel blocker use. For each 10 bpm increase in baseline and average heart rate, we observed a significant increase in risk of MVE, CV death, CHF and all-cause death. There was a continuous relationship between MVE and baseline and, more importantly, average in-trial heart rate, with no observed threshold. MVE, CV death, stroke, CHF, and all-cause death increased across heart rate quintiles. There was no association between MI and HR. Results were consistent in clinically relevant subgroups. There were modest but significant improvements in C-statistic and in statistical measures of model calibration for models that included heart rate for MVE, CV death, CHF and all-cause death.

CONCLUSIONS

This large study examined and quantitated associations between heart rate and CV events in a contemporary medically optimized population with stable CV disease. Resting and, in particular, in-trial average heart rate are independently associated with significant increases in CV events and all-cause death.

The prognostic significance of heart rate in patients hospitalized for heart failure with reduced ejection fraction in sinus rhythm: insights from the EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure: Outcome Study With Tolvaptan) trial

OBJECTIVES

The purpose of this study was to characterize the relationship between heart rate and post-discharge outcomes in patients with hospitalization for heart failure (HHF) with reduced ejection fraction (EF) in sinus rhythm.

BACKGROUND

A reduction in heart rate improves clinical outcomes in patients with chronic heart failure and in sinus rhythm, but the association between heart rate and post-discharge outcomes in patients with HHF is presently unclear.

METHODS

This post-hoc analysis of the EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure: Outcome Study With Tolvaptan) trial examined 1,947 patients with HHF and EF ≤40% not in atrial fibrillation/flutter or pacemaker dependent.

RESULTS

The median follow-up period was 9.9 months. At baseline, patients with a higher heart rate tended to be younger with lower EF and were more likely to have worse New York Heart Association functional class and higher natriuretic peptide levels. After adjustment for clinical risk factors, baseline heart rate was not predictive of all-cause mortality (p ≥ 0.066). However, at ≥70 beats/min, every 5-beat increase in 1-week post-discharge heart rate was independently associated with increased all-cause mortality (hazard ratio: 1.13 [95% confidence interval: 1.05 to 1.22]; p = 0.002). Similarly, every 5-beat increase ≥70 beats/min in 4-week post-discharge heart rate was predictive of all-cause mortality (hazard ratio: 1.12 [95% confidence interval: 1.05 to 1.19]; p = 0.001).

CONCLUSIONS

In this large cohort of patients with HHF with reduced EF and in sinus rhythm, baseline heart rate did not correlate with all-cause mortality. In contrast, at ≥70 beats/min, higher heart rate in the early post-discharge period was independently predictive of death during subsequent follow-up. Further study of post-discharge heart rate as a potential therapeutic target in this high-risk population is encouraged.

Heart rate and heart failure: the role of ivabradine therapy

PURPOSE OF REVIEW

The clinical data about the impact of heart rate reduction in heart failure therapy will be reviewed.

RECENT FINDINGS

Clinical and experimental studies showed an association between elevated resting heart rate and mortality risk in heart failure patients. This review summarizes that heart rate level at rest and its extent of reduction is a sensitive indicator for outcome in heart failure. In addition to the nonspecific heart rate reducing drugs like β-blockers, cardiac glycosides and Ca(2+) antagonists, ivabradine is a highly selective heart rate reducing agent without modifying ventricular contractility and atrioventricular conduction in humans and animals, and has recently been shown to improve cardiovascular outcomes in patients with systolic heart failure by lowering the heart rate only. The present and future role of heart rate reduction in the spectrum of heart failure disease and therapy will be outlined and evaluated.

SUMMARY

Elevated heart rate at rest represents a key indicator of adverse outcome in heart failure and implies a major treatment target in these patients.

Orthostatic function after renal sympathetic denervation in patients with resistant hypertension

INTRODUCTION

Catheter-based renal denervation (RDN) reduces local and whole-body sympathetic activity and blood pressure (BP) in patients with resistant hypertension. However, safety concerns exist concerning the development of orthostatic dysfunction after RDN.

METHODS AND RESULTS

In 36 patients (65 ± 7.6 years, 75% male) with resistant hypertension (office BP 162 ± 24/91 ± 14 mm Hg) treated with 4.8 ± 1.7 antihypertensive drugs, tilt table testing (TTT) was performed before and three months after RDN. Response to RDN was defined as a reduction in office systolic BP (SBP) ≥ 10 mm Hg three months after RDN. Responders (n=26; 72.2%) and non-responders (n=10; 27.8%) were evaluated separately. After RDN, office SBP and diastolic BP (DBP) were reduced by 29 ± 6.2/14 ± 3.6 mm Hg (p<0.0001; p=0.0002) only in responders. During TTT, SBP and DBP in supine position were only reduced in responders. Resting heart rate (HR) decreased in responders but not in non-responders by 5.9 ± 1.7beats/min (p=0.0016). Mean and minimal SBP were not altered during passive tilting. In the responder group, ∆SBP was reduced in the initial phase of tilting. The adaptive increase of HR was preserved in both groups after RDN, while only in responders mean and minimal HR were reduced after passive tilting. Following drug provocation, mean and minimal SBP during all phases of passive tilting remained unchanged. ∆SBP, ∆HR and total number of (pre-)syncopes were neither influenced by RDN nor differing between responders and non-responders.

CONCLUSIONS

In patients with resistant hypertension, RDN reduced office BP, supine BP and HR during TTT without causing orthostatic dysfunction or (pre-)syncopes three months after treatment.

Treating resistant hypertension: role of renal denervation

Arterial hypertension is the most prevalent risk factor associated with increased cardiovascular morbidity and mortality. Although pharmacological treatment is generally well tolerated, 5%–20% of patients with hypertension are resistant to medical therapy, which is defined as blood pressure above goal (>140/90 mmHg in general; >130–139/80–85 mmHg in patients with diabetes mellitus; >130/80 mmHg in patients with chronic kidney disease) despite treatment with ≥3 antihypertensive drugs of different classes, including a diuretic, at optimal doses. These patients are at significantly higher risk for cardiovascular events, in particular stroke, myocardial infarction, and heart failure, as compared with patients with nonresistant hypertension. The etiology of resistant hypertension is multifactorial and a number of risk factors have been identified. In addition, resistant hypertension might be due to secondary causes such as primary aldosteronism, chronic kidney disease, renal artery stenosis, or obstructive sleep apnea. To identify patients with resistant hypertension, the following must be excluded: pseudo-resistance, which might be due to nonadherence to medical treatment; white-coat effect; and inaccurate measurement technique. Activation of the sympathetic nervous system contributes to the development and maintenance of hypertension by increasing renal renin release, decreasing renal blood flow, and enhancing tubular sodium retention. Catheter-based renal denervation (RDN) is a novel technique specifically targeting renal sympathetic nerves. Clinical trials have demonstrated that RDN significantly reduces blood pressure in patients with resistant hypertension. Experimental studies and small clinical studies indicate that RDN might also have beneficial effects in other diseases and comorbidities, characterized by increased sympathetic activity, such as left ventricular hypertrophy, heart failure, metabolic syndrome and hyperinsulinemia, atrial fibrillation, obstructive sleep apnea, and chronic kidney disease. Further controlled studies are required to investigate the role of RDN beyond blood pressure control.