Redefining β-blocker response in heart failure patients with sinus rhythm and atrial fibrillation: a machine learning cluster analysis

Background Mortality remains unacceptably high in patients with heart failure and reduced left ventricular ejection fraction (LVEF) despite advances in therapeutics. We hypothesised that a novel artificial intelligence approach could better assess multiple and higher-dimension interactions of comorbidities, and define clusters of beta-blocker efficacy in patients with sinus rhythm and atrial fibrillation. Methods Neural network-based variational autoencoders and hierarchical clustering were applied to pooled individual patient data from nine double-blind, randomised, placebo-controlled trials of beta blockers. All-cause mortality during median 1.3 years of follow-up was assessed by intention to treat, stratified by electrocardiographic heart rhythm. The number of clusters and dimensions was determined objectively, with results validated using a leave-one-trial-out approach. This study was prospectively registered with ClinicalTrials.gov (NCT00832442) and the PROSPERO database of systematic reviews (CRD42014010012). Findings 15 659 patients with heart failure and LVEF of less than 50% were included, with median age 65 years (IQR 56-72) and LVEF 27% (IQR 21-33). 3708 (24%) patients were women. In sinus rhythm (n=12 822), most clusters demonstrated a consistent overall mortality benefit from beta blockers, with odds ratios (ORs) ranging from 0.54 to 0.74. One cluster in sinus rhythm of older patients with less severe symptoms showed no significant efficacy (OR 0.86, 95% CI 0.67-1.10; p=0.22). In atrial fibrillation (n=2837), four of five clusters were consistent with the overall neutral effect of beta blockers versus placebo (OR 0.92, 0.77-1.10; p=0.37). One cluster of younger atrial fibrillation patients at lower mortality risk but similar LVEF to average had a statistically significant reduction in mortality with beta blockers (OR 0.57, 0.35-0.93; p=0.023). The robustness and consistency of clustering was confirmed for all models (p<0.0001 vs random), and cluster membership was externally validated across the nine independent trials. Interpretation An artificial intelligence-based clustering approach was able to distinguish prognostic response from beta blockers in patients with heart failure and reduced LVEF. This included patients in sinus rhythm with suboptimal efficacy, as well as a cluster of patients with atrial fibrillation where beta blockers did reduce mortality. Copyright (C) 2021 The Author(s). Published by Elsevier Ltd.