Prognostically optimal heart rate at discharge in hospitalized patients with heart failure and atrial fibrillation

Abstract Background The management of heart rate (HR) is crucial for improving the clinical prognosis of patients with heart failure (HF) and atrial fibrillation (AF). Tachycardia induced by AF can cause decompensation of HF and subsequent hospitalization, but guidelines do not mention a specific target HR for patients with HF and persistent AF. Indeed, the prognostic impact of HR at discharge for hospitalized patients with HF and AF is still unclear. Purpose The purpose of this study was to determine the optimal HR at discharge for improving the prognosis of hospitalized patients with HF and AF. Methods In this observational study, 334 patients with persistent AF were analyzed from a database of 1,930 consecutive patients hospitalized for HF. Patients with sinus rhythm or paroxysmal AF, those with cardiac pacemakers or other antiarrhythmic devices, and those whose HR was not recorded at discharge were excluded. Participants were divided into 4 groups based on HR at discharge, with every 10 beats per minute (bpm) increment: HR <60 bpm (N=79), 61 bpm < HR <70 bpm (N=89), 71 bpm < HR <80 bpm (N=101), and 81 bpm < HR (N=65). The association between HR at discharge and the incidence of composite death from any cause and rehospitalization due to HF was analyzed as the primary endpoint. Results The average age of participants was 78 years, and 60% were men. At discharge, the clinical profiles of patients in the 4 groups were comparable. During the median follow-up period of 356 days, the primary endpoint occurred in 133 patients (39.8%). Kaplan-Meier analysis showed a significantly higher incidence of the primary endpoint in patients with HR >81 bpm at discharge than in those with HR <60 bpm at discharge (log-rank test for trend: p=0.039, Figure A). After adjusting for diverse covariates, including the use of beta-blockers, multivariable Cox regression analysis revealed that HR >81 bpm at discharge was associated with the primary endpoint, with a hazard ratio of 1.75 (95% confidence interval: 1.03–2.98) compared to HR <60 bpm. Restricted cubic spline confirmed that HR >81 bpm at discharge was an independent predictor for the primary endpoint by a referred HR of 61 bpm (Figure B). Conclusions This observational study suggests that for better clinical outcomes, the HR at discharge for patients with HF and persistent AF should be controlled to less than 80 bpm.Figure AFigure B