Background: Randomized data suggest that lenient rate control (resting heart rate <110 bpm) is noninferior to strict rate control (resting heart rate <80 bpm) in patients with atrial fibrillation (AF). However, the optimal rate control strategy in patients with AF and heart failure (HF) remains unknown.
Methods: Using data from the Get With The Guidelines-HF Program linked with Medicare data from July 1, 2011 to September 30, 2014, we identified patients with HF and AF and evaluated the association of heart rate at discharge with subsequent outcomes and the differential association by ejection fraction.
Results: Of 13 981 patients with AF, 9 100 (65.0%) had strict rate control, 4 617 (33.0%) had lenient rate control, and 264 (1.9%) had poor rate control by resting heart rate on the day of discharge. After multivariable adjustment inclusive of medical therapy, compared with strict rate control, lenient rate control was associated with higher adjusted risks of all-cause death (HR 1.21, 95% CI 1.11-1.33, p<0.001), all-cause readmission (HR 1.09, 95% CI 1.03-1.15, p<0.002), all-cause death or all-cause readmission (HR 1.11, 95% CI 1.05-1.18, p<0.001), but not cardiovascular readmission (HR1.08, 95% CI 1.00-1.16, p=0.051) at 90 days. Associations were largely comparable among patients with poor rate control and with heart rate modeled as a continuous variable (Table). The presence or absence of reduced ejection fraction did not impact the magnitude of most observed associations.
Conclusions: Among patients with HF and AF, 2 out of 3 patients had a heart rate that met strict-control heart rate goals at discharge. Heart rates above 80 bpm at discharge were associated with adverse outcomes irrespective of left ventricular ejection fraction.