Is There an Optimal Heart Rate Threshold?



The HCPLive Peer Exchange: Advances in Heart Failure Management features expert opinion and analysis from leading physician specialists on the latest developments in heart failure research, diagnosis, and management.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University and an associate director of surgical intensive care at the New York-Presbyterian Hospital in New York City.

The panelists are:

  • Michael Felker, MD, MHS, Professor of Medicine, Chief of the Heart Failure Section, Director of the Heart Center Clinical Research Unit, and Director of the Advanced Heart Failure Fellowship at Duke University School of Medicine
  • Jim Januzzi, MD, Roman W. DeSanctis Endowed Distinguished Clinical Scholar in Medicine at Massachusetts General Hospital and Hutter Professor of Medicine at Harvard Medical School
  • Christian Schulze, MD, PhD, Associate Professor of Medicine, Division of Cardiology at Columbia University Medical Center, and Director of Research for the Center of Advanced Cardiac Care at Columbia University Medical Center

This Peer Exchange segment focuses on what the SHIFT trial reveals to us about a possible optimal target heart rate. It also includes a discussion of the real-world US population and how it compares to patients from SHIFT, as well as the effect of ivabradine on hospitalization rates.

“If you can get your patient to 60 beats per minute or less, that appears to be the optimal target heart rate in a non-paced heart failure patient,” says Januzzi. Felker disagrees though, and thinks that “no one knows for sure what the optimal heart rate actually is.” Although 60 beats per minute might be a valid treatment target, the indication for ivabradine treatment is for patients with 75 beats per minute, even higher than the >70 beats per minute used as part of the SHIFT trial eligibility criteria, because “75 was the consensus” as the number “associated with poor outcomes,” according to Schulze.

Even though the clinical trials include patients with high baseline heart rates, what is known from real-world experience so far in Europe is that “patients do get the drug at lower resting heart rates, there’s no question,” says Januzzi, but he cautions, “I would argue pretty strenuously that that’s an area where I believe beta blockade really needs to be emphasized first.” There is a “definite possibility for benefit” using maximal beta blockade, maybe ivabradine, for a heart rate of 65 or 70, he says.

Another noteworthy point about the SHIFT trial population is that, since the trial was performed in Europe, which means there were no African Americans included, and these patients could have “morphisms of the beta receptor, genetic differences,” says Felker, which raises questions about how the trial data will align with the real-world population in the United States. It remains to be seen how ivabradine will fare in other populations not covered by the SHIFT trial, such as “patients in atrial fibrillation, patients who are paced,” says Januzzi.

In terms of hospitalizations, a subset of patients in the SHIFT trial did go back to the hospital, says Schulze. In this subset, “first hospitalizations were reduced by ivabradine by more than 20%,” he says, and patients who were more severely affected and returned to the hospital more than once “had a reduction in their risk for these hospitalizations by more than 35%, so that was a substantial impact.”

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