Suboptimal heart rate control in heart failure despite optimal medical and device therapy in the real world

Abstract

Background: Adequate heart rate control is increasingly recognised as an important risk reduction strategy in management of chronic heart failure. We retrospectively analysed our population of heart failure patients undergoing device therapy for adequacy of heart rate control. Methods: Our specialist heart failure nurse-led service oversees treatment initiation, titration and monitoring of patients with heart failure, as per current NICE guidelines. After established medical therapy, eligible patients underwent biventricular pacemaker (CRT) implantation. Data on resting heart rate and rhythm were retrieved and compared before and after device implantation. All continuous data were reported as mean ± standard deviation, categorical data were reported as percentages. SPSS 18 was used for statistical analysis. Results: In the first six months period of 2012, 58 patients underwent CRT implantation (age 68±13 years, female 21%, 84% had ischaemic heart disease or dilated cardiomyopathy, LVEF 25±8%, QRS 154±30ms, 84% had LBBB). Before CRT, majority patients were in sinus rhythm (67%), some (22%) were in atrial fibrillation and minority were paced from the right ventricle apex (11%). On existing medical therapy (55% beta blocker, 65% ACE inhibitor or ARBs, 28% aldosterone blocker, 7% digoxin), baseline heart rate did not differ from heart rate at 6 months after device implantation (68±14 vs. 69±15, p=0.6269). However, after excluding patients with underlying atrial fibrillation at 6 months, 43% patients had HR≥70bpm and would benefit from further heart rate lowering. Conclusions: Our data suggests that a dedicated heart failure specialist team is essential in management of patients with heart failure. Nonetheless despite optimal medical and device therapy in the real world, a large portion of patients had suboptimal heart rate control.