Elsevier

American Heart Journal

Volume 165, Issue 4, April 2013, Pages 567-574.e6
American Heart Journal

Clinical Investigation
Heart Failure
Admission heart rate and in-hospital outcomes in patients hospitalized for heart failure in sinus rhythm and in atrial fibrillation

https://doi.org/10.1016/j.ahj.2013.01.007Get rights and content

Background

Prior studies have suggested an association between higher heart rate and higher mortality, particularly in chronic heart failure (HF). Whether this relationship holds true in patients hospitalized with HF and differs between patients in sinus rhythm (SR) and atrial fibrillation (AF) has not been well studied.

Methods

We examined 145,221 admissions for HF from 295 hospitals enrolled in Get With The Guidelines-Heart Failure from January 2005 through September 2011. The associations of admission heart rate with in-hospital outcomes were evaluated overall and by heart rhythm.

Results

Patients presenting at higher heart rate tended to be younger and have less comorbidities. In-hospital mortality had a J-shaped relationship with heart rate, with the lowest mortality rate associated with heart rates between 70 and 75. However, the relationship differed between patients presenting in SR and AF: at heart rates above 100, the mortality curve for AF plateaued, whereas that for SR continued to rise. Higher heart rate was independently associated with higher mortality (SR adjusted OR 1.21, 95% CI 1.15-1.28 per 10 beat per minute increase in heart rate between 70-105; AF adjusted OR 1.20, 95% CI 1.14-1.27). Findings were similar when stratifying patients by ischemic etiology, diabetes, ejection fraction, blood pressure, and β-blocker use.

Conclusions

Higher admission heart rate is independently associated with worse outcomes in patients admitted for HF, including those in SR and AF. Whether early heart rate reduction improves outcomes in patients hospitalized with HF is worthy of investigation.

Section snippets

Data source

Data were collected through the GWTG-HF program, a national data collection and quality improvement initiative. Details of the GWTG-HF program have been described previously.10 Trained personnel at participating sites abstracted data on consecutive eligible patients using standardized definitions and submitted clinical information using a point-of-service, internet-based Patient Management Tool (Outcome Sciences, Cambridge, MA). All participating institutions are required to comply with local

Sample characteristics

The study cohort included 145,221 admissions reported to GWTG-HF between January 2005 and September 2011 from 295 sites. Among patients with information available on presenting heart rhythm, 77,850 (68.6%) admissions were in SR, 35,636 (31.4%) were in AF. Baseline characteristics of the patients as stratified by quartiles of heart rate for the overall cohort are shown in Table I (with hospital characteristics shown in the online Appendix Supplementary Table I). The median admission heart rate

Discussion

In this study of over 145,000 admissions for HF, presenting heart rate was independently associated with higher rates of in-hospital mortality. The lowest rates of in-hospital mortality occurred between heart rates of 70-75 beat/min, with increased mortality both below and above this range. To the best of our knowledge, this is the first study to demonstrate a J-shaped relationship between mortality and heart rate in acute HF independent of known patient and hospital factors. There also appears

Conclusions

This study provides important insights into the relationship of admission heart rate and in-hospital outcomes among patients hospitalized for acute HF. Higher admission heart rate is independently associated with worse outcomes, including increased mortality, longer length of stay, and lower likelihood of being discharged home. However, the slope of this relationship is different at higher heart rates between patients in SR and AF. In addition, patients with HF and preserved EF had a higher

Funding/Support

The GWTG-HF program is provided by the American Heart Association. GWTG-HF has been funded in the past through support from Medtronic, GlaxoSmithKline, Ortho-McNeil, and the American Heart Association Pharmaceutical Roundtable.

Disclosures

ALB (none), MVG (DCRI employee), AFH (Johnson & Johnson research; Amylin research; Corthera consultant), EDP (PI of the analytic center for the GWTG), CWY (none), DLB (Medscape Cardiology; Boston VA Research Institute, SCPC; Honoraria: ACC, DCRI, Slack Publications, WebMD; Research Grants: Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Medtronic, Sanofi Aventis, The Medicines Company), GCF (NHLBI research, Consultant: Novartis, Gambro, Medtronic).

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