Lower heart rate in patients with acute heart failure: the role of left ventricular ejection fraction

Figures & data

Table 1. Baseline characteristics across heart rate quartiles.

	Q1 (N = 915)	Q2 (N = 915)	Q3 (N = 916)	Q4 (N = 915)	Total (N = 3,661)	p value
Demographics and medical history
Age, years	76.1 (9.9)	74.7 (10.5)	72.8 (12.5)	71.9 (11.7)	73.9 (11.3)	<0.001
Male, n (%)	500 (54.6%)	483 (52.8%)	496 (54.1%)	448 (49.0%)	1927 (52.6%)	0.063
Hypertension, n (%)	760 (83.1%)	742 (81.1%)	694 (75.8%)	686 (75.0%)	2882 (78.7%)	<0.001
Dyslipidemia, n (%)	563 (61.5%)	518 (56.6%)	470 (51.3%)	438 (47.9%)	1989 (54.3%)	<0.001
Diabetes mellitus, n (%)	430 (47.0%)	435 (47.5%)	403 (44.0%)	343 (37.5%)	1611 (44.0%)	<0.001
Former smoker, n (%)	74 (8.1%)	91 (9.9%)	124 (13.5%)	157 (17.2%)	446 (12.2%)	<0.001
Coronary artery disease, n (%)	394 (43.1%)	355 (38.8%)	286 (31.2%)	201 (22.0%)	1236 (33.8%)	<0.001
Prior admission for AHF, n (%)	294 (32.1%)	269 (29.4%)	209 (22.8%)	189 (20.7%)	961 (26.2%)	<0.001
NYHA functional class, n						<0.001
I–II	739 (80.8%)	756 (82.6%)	811 (88.5%)	812 (88.7%)	3118 (85.2%)
III–IV	176 (19.2%)	159 (17.4%)	105 (11.5%)	103 (11.3%)	543 (14.8%)
Vital signs
Heart rate, bpm	68 (60, 74)	87 (82, 90)	104 (100, 110)	134 (125, 150)	95 (78, 120)	<0.001
SBP, mmHg	140 (120, 160)	140 (120, 160)	145 (125, 170)	140 (123, 166)	140 (122, 163)	<0.001
DBP, mmHg	70 (60, 80)	77 (69, 90)	82 (70, 97)	89 (75, 100)	80 (68, 92)	<0.001
Clinical signs
Edema, n (%)	632 (69.1%)	577 (63.1%)	547 (59.7%)	518 (56.6%)	2274 (62.1%)	<0.001
Pleural effusion, n (%)	458 (50.1%)	472 (51.6%)	443 (48.4%)	411 (44.9%)	1784 (48.7%)	0.029
Electrocardiogram
Atrial fibrillation, n (%)	314 (34.3%)	337 (36.8%)	328 (35.8%)	674 (73.7%)	1653 (45.2%)	<0.001
Branch block, n (%)	349 (38.1%)	289 (31.6%)	298 (32.5%)	234 (25.6%)	1170 (32.0%)	<0.001
Echocardiogram
LVEF (%)	55 (40, 64)	50 (37, 61)	46 (34, 59)	50 (36, 61)	50 (36, 61)	<0.001
LVEDD, mm	54.0 (48.0, 60.0)	55.0 (49.0, 62.0)	56.0 (49.0, 62.0)	54.4 (48.0, 61.0)	55.0 (48.3, 61.0)	0.002
IVS, mm	12.0 (10.4, 13.0)	12.0 (10.0, 13.0)	11.5 (10.0, 13.0)	11.1 (10.0, 13.0)	12.0 (10.0, 13.0)	<0.001
PWT, mm	11.3 (10.0, 13.0)	11.2 (10.0, 12.6)	11.0 (10.0, 12.0)	11.0 (10.0, 12.0)	11.0 (10.0, 12.2)	<0.001
Left atrium diameter, mm	44.0 (40.0, 48.0)	43.0 (39.8, 48.0)	43.0 (39.0, 48.0)	43.1 (39.9, 47.7)	43.0 (39.7, 48.0)	0.032
TAPSE, mm	19.0 (16.7, 21.0)	18.8 (16.6, 21.0)	18.4 (16.1, 20.2)	18.0 (16.1, 20.0)	18.6 (16.4, 20.6)	<0.001
Laboratory data
Creatinine, mg/dl	1.2 (1, 1.7)	1.1 (0.9, 1.5)	1.1 (0.9, 1.4)	1.1 (0.9, 1.3)	1.1 (0.9, 1.5)	<0.001
eGFR, ml/min/1,73m^2	52.5 (37.2, 71)	59 (42.6, 76.1)	63.7 (46.9, 81.1)	63.6 (48.6, 78.3)	60.1 (43.6, 76.7)	<0.001
Hemoglobin, g/dl	11.8 (10.6, 13.1)	12.2 (10.9, 13.5)	12.6 (11.4, 14.1)	13.2 (11.9, 14.4)	12.4 (11.2, 13.9)	<0.001
CRP, mg/L	15.1 (9.2, 26.8)	16.5 (9.6, 28.8)	19.0 (10.7, 35.9)	21.2 (12.3, 36.6)	17.9 (10.0, 32.0)	<0.001
NT-proBNP, pg/mL	3500 (1758, 7847)	3741 (1993, 7986)	3840 (2079, 7741)	3250 (1809, 6453)	3572 (1907, 7490)	0.006
CA125, U/mL	51 (25, 128)	60.2 (27, 127)	57 (25, 131)	60 (28, 128)	57 (26, 128)	0.911
Previous treatment
Prior treatment with $\beta$-blockers, n (%)	492 (53.8%)	341 (37.3%)	250 (27.3%)	277 (30.3%)	1360 (37.1%)	<0.001
Prior treatment with digoxin, n (%)	49 (5.4%)	30 (3.3%)	27 (3.0%)	29 (3.2%)	135 (3.7%)	0.021
Prior treatment with antiarrhythmic, n (%)	101 (11.0%)	70 (7.7%)	55 (6.0%)	133 (14.5%)	359 (9.8%)	<0.001
Prior treatment with diuretics, n (%)	655 (71.6%)	584 (63.8%)	467 (51.0%)	454 (49.6%)	2160 (59.0%)	<0.001

Values expressed as mean (SD) and median (percentile 25% to percentile 75%); categorical variables are presented as percentages.

AHF: acute heart failure; CA125: carbohydrate antigen 125; CRR: C-reactive protein; DBP: diastolic blood pressure, eGFR; estimated glomerular filtration rate assessed by CKD-EPI equation; IVS: interventricular septum; LVEDD: left ventricle end diastolic diameter; LVEF: left ventricular ejection fraction; NT-proBNP: N-terminal propeptide brain natriuretic peptide; NYHA: New York Heart Association; PWT: posterior wall thickness; SBP: systolic blood pressure; TAPSE: tricuspid annular plane systolic excursion.

Table 2. Baseline characteristics across LVEF categories.

	$\le$40% (N = 1214)	41–49% (N = 570)	50–64% (N = 1229)	$\ge$65% (N = 648)	Total (N = 3,661)	p value
Demographics and medical history
Age, years	70.3 (12.6)	74.6 (10.5)	76.0 (10.0)	76.1 (9.9)	73.9 (11.3)	<0.001
Male, n (%)	866 (71.3%)	354 (62.1%)	486 (39.5%)	221 (34.1%)	1927 (52.6%)	<0.001
Hypertension, n (%)	877 (72.2%)	478 (83.9%)	998 (81.2%)	529 (81.6%)	2882 (78.7%)	<0.001
Dyslipidemia, n (%)	676 (55.7%)	328 (57.5%)	644 (52.4%)	341 (52.6%)	1989 (54.3%)	0.118
Diabetes mellitus, n (%)	532 (43.8%)	294 (51.6%)	526 (42.8%)	259 (40.0%)	1611 (44.0%)	<0.001
Former smoker, n (%)	226 (18.6%)	77 (13.5%)	100 (8.1%)	43 (6.6%)	446 (12.2%)	<0.001
Coronary artery disease, n (%)	515 (42.4%)	244 (42.8%)	347 (28.2%)	130 (20.1%)	1236 (33.8%)	<0.001
Prior admission for AHF, n (%)	316 (26.0%)	165 (28.9%)	305 (24.8%)	175 (27.0%)	961 (26.2%)	0.300
NYHA functional class, n						0.159
I–II	1045 (86.1%)	484 (84.9%)	1055 (85.8%)	534 (82.4%)	3118 (85.2%)
III–IV	169 (13.9%)	86 (15.1%)	174 (14.2%)	114 (17.6%)	543 (14.8%)
Vital signs
Heart rate, bpm	100 (81, 120)	97 (80, 117)	95 (77.8, 120)	90 (71.5, 114)	95 (78, 120)	<0.001
SBP, mmHg	136 (118, 156)	144 (124, 171)	144 (127, 169)	141.5 (125, 166.5)	140 (122, 163)	<0.001
DBP, mmHg	80 (70, 94)	80 (70, 95)	80 (69, 92)	75.2 (64, 90)	80 (68, 92)	<0.001
Clinical signs
Edema, n (%)	724 (59.6%)	339 (59.5%)	803 (65.3%)	408 (63.0%)	2274 (62.1%)	0.015
Pleural effusion, n (%)	599 (49.3%)	277 (48.6%)	595 (48.4%)	313 (48.3%)	1784 (48.7%)	0.963
Electrocardiogram
Atrial fibrillation, n (%)	408 (33.6%)	240 (42.1%)	655 (53.3%)	350 (54.0%)	1653 (45.2%)	<0.001
Branch block, n (%)	526 (43.3%)	215 (37.7%)	297 (24.2%)	132 (20.4%)	1170 (32.0%)	<0.001
Echocardiogram
LVEF (%)	32 (26, 36)	45 (43, 47)	58 (54, 61)	69 (66, 73)	50 (36, 61)	<0.001
LVEDD, mm	62.0 (57.0, 67.0)	57.0 (52.0, 62.0)	51.0 (46.0, 55.0)	48.0 (43.0, 52.0)	55.0 (48.3, 61.0)	<0.001
IVS, mm	10.9 (9.0, 12.0)	12.0 (10.2, 13.0)	12.0 (11.0, 13.0)	12.0 (11.0, 13.0)	12.0 (10.0, 13.0)	<0.001
PWT, mm	10.0 (9.0, 12.0)	11.3 (10.0, 12.5)	12.0 (10.7, 13.0)	12.0 (11.0, 13.0)	11.0 (10.0, 12.2)	<0.001
Left atrium diameter, mm	43.3 (39.6, 48.0)	43.0 (39.9, 48.0)	43.0 (39.9, 48.0)	43.1 (39.0, 48.0)	43.0 (39.7, 48.0)	0.963
TAPSE, mm	17.0 (15.2, 19.0)	18.1 (16.5, 20.0)	19.0 (17.0, 21.0)	20.0 (18.1, 21.6)	18.6 (16.4, 20.6)	<0.001
Laboratory data
Creatinine, mg/dl	1.2 (0.9, 1.5)	1.2 (0.9, 1.6)	1.1 (0.9, 1.4)	1.1 (0.9, 1.5)	1.1 (0.9, 1.5)	<0.001
eGFR, ml/min/1,73m^2	61.7 (44.8, 78.6)	58.1 (41.8, 74.9)	60.4 (45.1, 76.9)	57.9 (41.8, 74.0)	60.1 (43.6, 76.7)	0.029
Hemoglobin, g/dl	13.0 (11.7, 14.3)	12.7 (11.2, 14.1)	12.1 (10.8, 13.5)	12 (10.9, 13.3)	12.4 (11.2, 13.9)	<0.001
CRP, mg/L	15.4 (8.9, 26)	18.7 (10.7, 33.2)	19.9 (11.4, 35.6)	20 (10.2, 37.4)	17.9 (10, 32)	<0.001
NT-proBNP, pg/mL	5,088 (2,516, 10,697)	4,315 (2,129, 8,490)	3,075 (1,667, 5,748)	2,499 (1,362, 4,774)	3,572 (1,907, 7,490)	<0.001
CA125, U/mL	76 (33, 157)	60 (25, 126)	48 (23, 106)	47 (23, 107)	57 (26, 128)	<0.001
Previous treatment
Prior treatment with $\beta$-blockers, n (%)	436 (35.9%)	221 (38.8%)	462 (37.6%)	241 (37.2%)	1360 (37.1%)	0.673
Prior treatment with digoxin, n (%)	32 (2.6%)	15 (2.6%)	50 (4.1%)	38 (5.9%)	135 (3.7%)	<0.001
Prior treatment with antiarrhythmic, n (%)	119 (9.8%)	50 (8.8%)	112 (9.1%)	78 (12.0%)	359 (9.8%)	0.172
Prior treatment with diuretics, n (%)	654 (53.9%)	354 (62.1%)	736 (59.9%)	416 (64.2%)	2160 (59.0%)	<0.001

Values expressed as mean (SD) and median (percentile 25% to percentile 75%); categorical variables are presented as percentages.

AHF: acute heart failure; CA125: carbohydrate antigen 125; CRR: C-reactive protein; DBP: diastolic blood pressure, eGFR; estimated glomerular filtration rate assessed by CKD-EPI equation; IVS: interventricular septum; LVEDD: left ventricle end diastolic diameter; LVEF: left ventricular ejection fraction; NT-proBNP: N-terminal propeptide brain natriuretic peptide; NYHA: New York Heart Association; PWT: posterior wall thickness; SBP: systolic blood pressure; TAPSE: tricuspid annular plane systolic excursion.

Figure 1. Heart rate at admission as a predictor or LVEF. a. Total sample, b. Sinus rhythm, c. Atrial fibrillation, Bpm: Beats per minute; HR: heart rate; LVEF: left ventricular ejection fraction.

Figure 2. Predicted probability for each category of LVEF according to heart rate at admission. a. Predicted probability for LVEF ≤40% according to heart rate at admission. b. Predicted probability for LVEF 41–49% according to heart rate at admission. c. Predicted probability for LVEF 50–59% according to heart rate at admission. d. Predicted probability for LVEF ≥65% according to heart rate at admission. Bpm: Beats per minute; HR: heart rate; LVEF: left ventricular ejection fraction.

Figure 3. Predicted probability for each category of LVEF according to heart rate at admission in patients with sinus rhythm. a. Predicted probability for LVEF ≤40%. b. Predicted probability for LVEF 41–49%. c. Predicted probability for LVEF 50–59%. d. Predicted probability for LVEF ≥65%. Bpm: Beats per minute; HR: heart rate; LVEF: left ventricular ejection fraction.

Figure 4. Predicted probability for each category of LVEF according to heart rate at admission in patients with atrial fibrillation. a. Predicted probability for LVEF $\le$40%. b. Predicted probability for LVEF 41–49%. c. Predicted probability for LVEF 50–59%. d. Predicted probability for LVEF $\ge$65%. Bpm: Beats per minute; HR: heart rate; LVEF: left ventricular ejection fraction.