Prognostic impact of heart rate in elderly with systolic heart failure and concomitant atrial fibrillation

Objective: The present study aimed to investigate the impact of resting heart rate (HR) on 5-year all-cause mortality in patients 80 years with heart failure (HF) with reduced ejection fraction (HFrEF) and concomitant atrial fibrillation (AF) after optimal up-titration of beta-blockers (BBs).Methods: Patients (n=185) aged 80 years with HF and left ventricular ejection fraction 40% were included between January 2000 and January 2008 from two university hospitals, Sahlgrenska and ostra and retrospectively studied from January 2 to May 30, 2013. Up-titrations of guideline recommended medications were performed at HF outpatient clinics.Results: Of whole study population, 54% (n=100) had AF. After optimal up-titration of BBs and angiotensin converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), mean HR in patients with AF was 7315 beats/minute (bpm), 36% had resting HR65 bpm. Five-year all-cause mortality among patients with AF was significantly lower in patients with HR65 bpm (63%) compared to HR>65 (80%). Cox proportional-hazard regression analysis adjusted for clinically important baseline variables and doses of ACEIs/ARBs and BBs demonstrated resting HR65 bpm as an independent predictor of improved survival compared to resting HR>65 bpm (HR 0.3, 95%CI 0.1-0.7, P 0.005).Discussion: In octogenarians with HFrEF and concomitant AF, lowering resting HR to levels as low as HR65 bpm was still associated with improved survival from all-cause mortality. Our data indicate that mortality in AF became comparable to SR when patients were on maximally up-titrated beta-blocker doses with HR as low as 75 bpm.