Background Amongst patients with heart failure (HF) due to left ventricular systolic dysfunction (LVSD) in sinus rhythm, those with higher resting heart rate (HR) have a worse prognosis. Reducing sinus rate to 50–60 bpm improves outcomes. If beta blockers (BB) are not tolerated or HR remains >70 bpm despite BB, ivabradine may reduce HR and improve outcome.
Aims To characterise patients attending a HF clinic and identify the proportion eligible for optimisation of BB or ivabradine treatment. The clinic accepts referrals from primary and secondary care and offers long term follow-up regardlesss of LVEF.
Methods and Results Between January 2013 and July 2013, 1000 consecutive HF clinic follow-up appointments were reviewed and demographic, clinical and echocardiographic data were collected in patients who attended (n = 959, 644 male). The median duration between initial assessment and follow-up was 941 (IQR 347–2153) days. Most patients had mild to moderate HF (25% NYHA I, 51% NYHA II and 24% NYHA III/IV). Median agewas 76 (IQR 68–82) years,NTproBNP 1091 ng/L (IQR 396–2230) and ejection fraction (EF) 45 (IQR 36–54)%, with 370 patients (39%) having a reduced EF (< 40%), of whom 257 were in sinus rhythm (mean HR 69 ± 12 bpm) and 113 in atrial fibrillation (mean HR 75 ± 15 bpm). Patients treated with BB (n = 331, 92%) had a mean HR of 69 ± 12 bpm compared to 82 ± 19 bpm in those not taking BB.
In those with LVSD, sinus rhythm and a HR above 70 bpm (n = 90), 18 patients were already treated with guideline-target doses of BB, 24 had BB dose increased, 19 were known to be intolerant of higher dose and 26 were eligible for uptitration of BB but did not receive appropriate advice (‘missed indication’). Thirty seven patients who were receiving maximally tolerated BB doses or were BB intolerant, were eligible for ivabradine. Seven patients were already taking ivabradine at the time of assessment and in 5 of these the dose was increased, 13 were started on treatment following the clinic visit, and in 17 patients, the indication was initially ‘missed’.
Conclusion Among patients with LVSD (about 37% of those with HF), most are treated with a BB at a dose that maintains HR <70 bpm and only about 10% are eligible for ivabradine (~4% of overall HF clinic population). However, even in an expert clinic missed opportunities to intervene to reduce HR are common. Education and audit should increase awareness among physicians about the importance of managing heart rate in patients in sinus rhythm.
- heart failure
- heart rate
- drug therapy
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