Prognostic Value of the Change in Heart Rate From the Supine to the Upright Position in Patients With Chronic Heart Failure

Abstract

Background: The prognostic value of the change in heart rate from the supine to upright position (∆HR) in patients with chronic heart failure (HF) is unknown.

Methods and results: ∆HR was measured in patients enrolled in the Trial of Intensified Medical Therapy in Elderly Patients with Congestive Heart Failure (TIME-CHF) who were in sinus rhythm and had no pacemaker throughout the trial (n=321). The impact of ∆HR on 18-month outcome (HF hospitalization-free survival) was assessed. In addition, the prognostic effect of changes in ∆HR between baseline and month 6 on outcomes in the following 12 months was determined. A lower ∆HR was associated with a higher risk of death or HF hospitalization (hazard ratio 1.79 [95% confidence interval {95% CI} 1.19-2.75] if ∆HR ≤3 beats/min [bpm], P=0.004). In the multivariate analysis, lower ∆HR remained an independent predictor of death or HF hospitalization (hazard ratio 1.75 [95% CI, 1.18-2.61] if ∆HR ≤3 bpm, P=0.004) along with ischemic HF etiology, lower estimated glomerular filtration rate, presence and extent of rales, and no baseline β-blocker use. In patients without event during the first 6 months, the change in ∆HR from baseline to month 6 predicted death or HF hospitalization during the following 12 months (hazard ratio=2.13 [95% CI 1.12-5.00] if rise in ∆HR <2 bpm; P=0.027).

Conclusions: ∆HR as a simple bedside test is an independent prognostic predictor in patients with chronic HF. ∆HR is modifiable, and changes in ∆HR also provide prognostic information, which raises the possibility that ∆HR may help to guide treatment.

Clinical trial registration information: URL: www.isrctn.org. Unique identifier: ISRCTN43596477.

Keywords: TIME‐CHF; autonomic nervous system; heart failure; heart rate/heart rate variability; prognosis.

Figure 1

Heart failure (HF) hospitalization‐free survival (A), survival (B), and hospitalization‐free survival (C) in patients with baseline ∆HR >3 bpm vs baseline ∆HR ≤3 bpm. CI indicates confidence interval.

Figure 2

Heart failure (HF) hospitalization‐free survival (A), survival (B), and hospitalization‐free survival (C) in patients with a 5‐point score (ΔHR ≤3 bpm, ischemic HF etiology, eGFR <47 mL/min per 1.73 m², no β‐blocker use at baseline, and the presence of rales at baseline) of 0 or 1 point (score 0 or 1), a score of 2 points (score 2), and a score of 3, 4, or 5 points (score 3, 4, or 5). Hazard ratios (95% confidence intervals) for a score of 3, 4, or 5 points and a score of 2 points, respectively, with a score a 0 or 1 point as referent are as follows: HF hospitalization‐free survival (A) 8.21 (4.20‐16.08) and 3.72 (1.82‐7.58), survival (B) 8.61 (3.38‐21.96) and 4.60 (1.73‐12.25), and hospitalization‐free survival (C) 2.41 (1.69‐3.44) and 1.29 (0.88‐1.89).

Figure 3

HF hospitalization‐free survival according to the change in ΔHR from baseline to month 6 (Change_0→6∆HR; <2 bpm vs ≥2 bpm) after month 6.