Beta‐Blocker Therapy for Heart Failure: Should the Therapeutic Target Be Dose or Heart Rate Reduction?

Abstract

Therapeutic target with β blockers in heart failure, i.e., target heart rate reduction or β‐blocker dose, is controversial. To resolve this controversy, the authors studied 152 heart failure patients on β blockers who were divided into four groups based on median peak exercise heart rate reduction as compared with predicted and prescription of at least 50% recommended β‐blocker dose. Event‐free survival (vs. death or assist device placement or urgent transplantation) was compared. Baseline and peak exercise heart rates were 74±14 and 116±21 bpm, respectively. Median heart rate reduction at peak exercise was 35%. When median or higher peak heart rate reduction was achieved, there were no significant survival differences noted between patients on different β‐blocker doses. With below‐median peak heart rate reduction, there was a strong trend toward better event‐free survival with higher β‐blocker doses. In conclusion, the results suggest that higher heart rate reduction is associated with better outcomes for heart failure patients overall and, for patients with persistently elevated heart rates, higher β‐blocker doses provided additional benefit.

Importance of baseline heart rate as a predictor of cardiac functional recovery in newly diagnosed heart failure with reduced ejection fraction

“…These studies showed incremental benefit of increasing doses of BB with respect to improvement in LVEF and reduction in CV mortality . There has been long‐standing debate as to whether the benefits of BB are solely related to HR reduction vs alternative mechanisms, with the therapeutic value likely being multifactorial . In our study, target doses of BB therapy were more frequently achieved in patients whose LV function recovered, and we found a relationship between achievement of target doses of BB and freedom from the composite endpoint of all‐cause mortality and HF hospitalizations.…”

Heart rate control with adrenergic blockade: Clinical outcomes in cardiovascular medicine

“…As a result, it was suggested that the HR-lowering effect of β-blockers was a major contributor to the clinical benefit associated with these agents. In a study of 152 patients with HF who were receiving β-blocker therapy, greater reductions in HR were associated with better clinical outcomes for patients overall, and higher β-blocker doses provided additional clinical benefits among patients with persistently elevated HR 39. These results suggest that the magnitude of reduction in HR may be more important than achieving the target dose of β-blocker therapy in patients with HF 38,39.…”

“…In a study of 152 patients with HF who were receiving β-blocker therapy, greater reductions in HR were associated with better clinical outcomes for patients overall, and higher β-blocker doses provided additional clinical benefits among patients with persistently elevated HR 39. These results suggest that the magnitude of reduction in HR may be more important than achieving the target dose of β-blocker therapy in patients with HF 38,39. In the Cardiac Insufficiency BIsoprolol Study (CIBIS), treatment of 557 patients with bisoprolol reduced HR by approximately 15 beats/minute relative to placebo ( P < 0.001), and HR change was the most powerful predictor of survival ( P < 0.01) 40.…”

Heart rate: Predictor of cardiovascular risk

“…As a result, it was suggested that RHR lowering effect of beta-blockers was a major contributor to the clinical benefit associated with these agents. A study of 152 patients with heart failure who were receiving beta-blocker therapy showed that higher beta-blocker doses provided additional clinical benefits among patients with persistently elevated RHR 24 . These results suggest that the magnitude of reduction in RHR may be more important than achieving the target dose of beta-blocker therapy in patients with heart failure 24 .…”