scholarly journals Beta-blockers or Digoxin for Atrial Fibrillation and Heart Failure?

2016 ◽  
Vol 2 (1) ◽  
pp. 35 ◽  
Author(s):  
Laurent Fauchier ◽  
Guillaume Laborie ◽  
Nicolas Clementy ◽  
Dominique Babuty ◽  
◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Beta Blocker ◽  
Rate Control ◽  
Beta Blockers ◽  
Therapeutic Option ◽  
Systolic Dysfunction ◽  
Ventricular Rate ◽  
Channel Blockers ◽  
Reduced Ejection Fraction

In patients with atrial fibrillation (AF) and heart failure (HF) with or without systolic dysfunction, either rhythm control or rate control is an acceptable primary therapeutic option. If a rate control strategy is chosen, treatment with a beta-blocker is almost always required to achieve rate control. Adequate ventricular rate control is usually a resting rate of less than 100 beats per minute, but lower resting rates may be appropriate. Non-dihydropyridine calcium channel blockers are often contraindicated when AF is associated with HF with systolic dysfunction. There have been recent debates on a possible reduced efficacy of beta-blockers as well as safety issues with digoxin when treating HF patients with AF. The benefit of beta-blockers on survival may be lower in patients with HF with reduced ejection fraction when AF is present. Digoxin does not improve survival but may help to obtain satisfactory rate control in combination with a beta-blocker. Digoxin may be useful in the presence of hypotension or an absolute contraindication to beta-blocker treatment.

scholarly journals Emerging role of ivabradine for rate control in atrial fibrillation

2016 ◽  
Vol 10 (6) ◽  
pp. 348-352 ◽  
Author(s):  
Sarah L. Turley ◽  
Kerry E. Francis ◽  
Denise K. Lowe ◽  
William D. Cahoon
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Rate Control ◽  
Beta Blockers ◽  
Control Treatment ◽  
Ventricular Rate ◽  
Channel Blockers ◽  
Target Heart Rate ◽  
Heart Failure Patients

Control of ventricular rate is recommended for patients with paroxysmal, persistent, or permanent atrial fibrillation (AF). Existing rate-control options, including beta-blockers, nondihydropyridine calcium channel blockers, and digoxin, are limited by adverse hemodynamic effects and their ability to attain target heart rate (HR). Ivabradine, a novel HR-controlling agent, decreases HR through deceleration of conduction through If (‘funny’) channels, and is approved for HR reduction in heart failure patients with ejection fraction less than 35% and elevated HR, despite optimal pharmacological treatment. Because If channels were thought to be expressed solely in sinoatrial (SA) nodal tissue, ivabradine was not investigated in heart failure patients with concomitant AF. Subsequent identification of hyperpolarization-activated cyclic nucleotide-gated cation channel 4 (HCN4), the primary gene responsible for If current expression throughout the myocardium, stimulated interest in the potential role of ivabradine for ventricular rate control in AF. Preclinical studies of ivabradine in animal models with induced AF demonstrated a reduction in HR, with no significant worsening of QT interval or mean arterial pressure. Preliminary human data suggest that ivabradine provides HR reduction without associated hemodynamic complications in patients with AF. Questions remain regarding efficacy, safety, optimal dosing, and length of therapy in these patients. Prospective, randomized studies are needed to determine if ivabradine has a role as a rate-control treatment in patients with AF.

P3517Failure to achieve adequate heart rate control in women during therapy optimization

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
V Kutyifa ◽  
J W Erath ◽  
A Burch ◽  
B Assmus ◽  
D Bondermann ◽  
...  
Keyword(s):  
Heart Failure ◽  
Heart Rate ◽  
Beta Blocker ◽  
Rate Control ◽  
Beta Blockers ◽  
Heart Rate Control ◽  
Blocker Therapy ◽  
Cardioverter Defibrillator ◽  
Beta Blocker Therapy ◽  
The Mean

Abstract Background Previous studies highlighted the importance of adequate heart rate control in heart failure patients, and suggested under-treatment with beta-blockers especially in women. However, data on women achieving effective heart rate control during beta-blocker therapy optimization are lacking. Methods The wearable cardioverter defibrillator (WCD) allows continuous monitoring of heart rate (HR) trends during WCD use. In the current study, we assessed resting HR trends (nighttime: midnight-7am) in women, both at the beginning of WCD use and at the end of WCD use to assess the adequacy of beta-blockade following a typical 3 months of therapy optimization with beta-blockers. An adequate heart rate control was defined as having a nighttime HR <70 bpm at the end of the 3 months. Results There were a total of 21,453 women with at least 30 days of WCD use (>140 hours WCD use on the first and last week). The mean age was 67 years (IQR 58–75). The mean nighttime heart rate was 72 bpm (IQR 65–81) at the beginning of WCD use, that decreased to 68 bpm (IQR 61–76) at the end of WCD use with therapy optimization. Women had an insufficient heart rate control with resting heart rate ≥70 bpm in 59% at the beginning of WCD use that decreased to 44% at the end of WCD use, but still remained surprisingly high. Interestingly, there were 21% of the women starting with HR ≥70 bpm at the beginning of use (BOU) who achieved adequate heart rate control by the end of use (EOU). Interestingly, 6% of women with adequate heart rate control at the start of therapy optimization ended up having higher heart rates >70 bpm at the end of the therapy optimization time period (Figure). Figure 1 Conclusions A significant proportion of women with heart failure and low ejection fraction do not reach an adequate heart rate control during the time of beta blocker initiation/titration. The wearble cardioverter defibrillator is a monitoring device that has been demonstrated in this study to appropriately identify patients with inadequate heart rate control at the end of the therapy optimization period. The WCD could be utilized to improve management of beta-blocker therapy in women and improve the achievement of adequate heart rate control in women.

P1666Do beta-blockers increase the risk for hospitalizations in heart failure with preserved ejection fraction? A secondary analysis of beta-blocker use in the TOPCAT trial

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
D N Silverman ◽  
T B Plante ◽  
M I Infeld ◽  
S P Juraschek ◽  
G Dougherty ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Beta Blocker ◽  
Proportional Hazards ◽  
Beta Blockers ◽  
Secondary Analysis ◽  
Cox Proportional Hazards ◽  
Chronic Obstructive ◽  
Obstructive Pulmonary Disease ◽  
Reduced Ejection Fraction

Abstract Background The use of beta-blockers for treatment of heart failure (HF) with a reduced ejection fraction (EF) is unequivocally beneficial, but their role in the treatment of preserved EF (HFpEF) remains unclear. Purpose In a contemporary HFpEF cohort, we sought to assess the association of HF hospitalizations and the use of beta-blockers in patients with an EF above and below 50%. Methods The TOPCAT trial tested spironolactone vs. placebo among patients with HFpEF, including some with mild reductions in EF between 45–50%. The primary outcome was a composite of cardiovascular (CV) mortality, aborted cardiac arrest, or HF hospitalizations. Medication use, including beta-blockers, was reported at each visit and hospitalization. In the 1,761 participants from the Americas, we compared the association of beta-blocker use (vs. no use) and HF hospitalization or CV mortality using Cox proportional hazards models adjusted for baseline demographics, history of myocardial infarction, atrial fibrillation, chronic obstructive pulmonary disease, asthma, and hypertension. The analyses were repeated in the EF strata ≥50% and <50%. Results Among patients included in the current analysis (mean age 72 years, 50% female, 78% white), 1,496/1,761 (85%) received beta-blockers and 1,566/1,761 (89%) had an EF ≥50%. HF hospitalizations and CV mortality occurred in 399/1,761 (23%) and 223/1,761 (13%) of participants, respectively. Beta-blocker use was associated with an increase in risk of HF hospitalization among patients with preserved EF ≥50% [HR 1.56, (95% CI 1.09–2.24), p=0.01] and was associated with a reduction in risk of hospitalization in patients with an EF <50% [HR 0.42, (95% CI 0.18- 0.99), p<0.05]. We found a significant interaction for EF threshold and beta-blocker use on incident HF hospitalizations (p=0.01). There were no differences in CV mortality. Figure 1. Kaplan Meier incidence plots Conclusions Beta-blocker use was associated with an increase in HF hospitalizations in patients with HFpEF (EF≥50%) but did not affect CV mortality. Further research is needed to confirm these findings and elucidate causality.

scholarly journals SO057BETA-BLOCKERS ARE ASSOCIATED WITH REDUCED MORTALITY IN PATIENTS WITH HEART FAILURE WITH REDUCED EJECTION FRACTION AND ADVANCED CHRONIC KIDNEY DISEASE: COHORT STUDY

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Edouard L Fu ◽  
Alicia Uijl ◽  
Friedo W Dekker ◽  
Lars H Lund ◽  
Gianluigi Savarese ◽  
...  
Keyword(s):  
Heart Failure ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Ejection Fraction ◽  
Beta Blocker ◽  
Beta Blockers ◽  
Advanced Chronic Kidney Disease ◽  
Reduced Ejection Fraction ◽  
Patients With Heart Failure ◽  
All Cause Mortality

Abstract Background and Aims Beta-blockers reduce mortality and morbidity in patients with heart failure (HF) with reduced ejection fraction (HFrEF). However, patients with advanced chronic kidney disease (CKD) were underrepresented in landmark trials. We evaluated if beta-blockers are associated with improved survival in patients with HFrEF and advanced CKD. Method We identified 3906 persons with an ejection fraction &lt;40% and advanced CKD (eGFR &lt;30 mL/min/1.73m2) enrolled in the Swedish Heart Failure Registry during 2001-2016. The associations between beta-blocker use, 5-year all-cause mortality, and the composite of time to cardiovascular (CV) mortality/first HF hospitalization were assessed by multivariable Cox regression. Analyses were adjusted for 36 variables, including demographics, laboratory measures, comorbidities, medication use, medical procedures, and socioeconomic status. To assess consistency, the same analyses were performed in a positive control cohort of 12,673 patients with moderate CKD (eGFR &lt;60-30 mL/min/1.73m2). Results The majority (89%) of individuals with HFrEF and advanced CKD received treatment with beta-blockers. Median (IQR) age was 81 (74-86) years, 36% were women and median eGFR was 26 (20-28) mL/min/173m2. During 5 years of follow-up, 2086 (53.4%) individuals had a subsequent HF hospitalization, and 2954 (75.6%) individuals died, of which 2089 (70.1%) due to cardiovascular causes. Beta-blocker use was associated with a significant reduction in 5-year all-cause mortality [adjusted hazard ratio (HR) 0.86; 95% confidence interval (CI) 0.76-0.96)] and CV mortality/HF hospitalization (HR 0.87; 95% CI 0.77-0.98). The magnitude of the associations between beta-blocker use and outcomes was similar to that observed for HFrEF patients with mild/moderate CKD, with adjusted HRs for all-cause mortality and CV mortality/HF hospitalization of 0.85 (95% CI 0.78-0.91) and 0.88 (95% CI 0.82-0.96), respectively. Conclusion Despite lack of trial evidence, the use of beta-blockers in patients with HFrEF and advanced CKD was high in routine Swedish care, and was independently associated with reduced mortality to the same degree as HFrEF with moderate CKD.

scholarly journals Beta-blockers Associated with a Mortality Benefit in Patients with Systolic Dysfunction and Elevated Serum Bilirubin

2014 ◽  
Vol 8 (1) ◽  
pp. 76-82
Author(s):  
Christopher Labos ◽  
Vivian Nguyen ◽  
Nadia Giannetti ◽  
Thao Huynh
Keyword(s):  
Heart Failure ◽  
Beta Blocker ◽  
Beta Blockers ◽  
Systolic Dysfunction ◽  
Tertiary Care ◽  
Elevated Serum ◽  
Secondary Endpoint ◽  
Cardiac Transplant ◽  
All Cause Mortality ◽  
The Impact

Background:Hyperbilirubinemia is associated with increased mortality in heart failure (HF) patients. We evaluated the impact of evidence-based medical therapy, in particular beta-blocker on the survival of patients with HF and hyperbilirubinemia.Methods and Results:We reviewed the charts of all patients followed at our tertiary care heart failure clinic. Hyperbilirubinemia was defined as total bilirubin >30 µmol/L (1.5 times the upper limit of our laboratory value). The primary endpoint was all-cause mortality. The secondary endpoint was a composite of death, cardiac transplant or ventricular assistance device implantation (VAD). Of 1035 HF patients, 121 patients (11.7%) had hyperbilirubinemia. Median follow-up was 556 days. Hyperbilirubinemia was associated with an eight-fold increase in all-cause mortality, hazard ratio (HR): 8.78[95% Confidence Intervals (CI): 5.89-13.06]. Beta-blocker use was associated with approximately 60% reduction in all-cause mortality (HR: 0.38, 95% CI:0.15-0.94) and 70% reduction in the composite secondary endpoint (HR:0.31, 95% CI:0.13-0.71) in patients with hyperbilirubinemia.Conclusion:HF patients with hyperbilirubinemia have increased early mortality, need for cardiac transplantation or VAD. Beta-blocker use was associated with early survival benefit in these patients. Bilirubin levels should be monitored in patients with HF and early initiation of beta-blockers in patients with hyperbilirubinemia should be considered.

scholarly journals Skin Sympathetic Nerve Activity and Rate Control of Atrial Fibrillation

2018 ◽  
Vol 1 (1) ◽  
Author(s):  
Anthony Douglas II ◽  
Takashi Kusayama, MD, PhD ◽  
Peng Sheng Chen, M.D
Keyword(s):  
Atrial Fibrillation ◽  
Beta Blocker ◽  
Rate Control ◽  
Sympathetic Nerve ◽  
Sympathetic Nerve Activity ◽  
Ventricular Rate ◽  
Strong Correlations ◽  
Nerve Activity ◽  
Blocker Therapy ◽  
Beta Blocker Therapy

Background and Hypothesis  Lifetime risks for atrial fibrillation (AF) are 1 in 4 for people 40 years of age and older. Rate and rhythm control are both important strategies in managing patients with AF. However, not all patients respond to beta blocker therapy. We hypothesize that sympathetic tone is important in rate control of AF, but the importance varied among patients.  Experimental Design or Project Methods  neuECG is a new noninvasive method to record skin sympathetic nerve activity (SKNA) and electrocardiogram. The present research recruited and recorded 2 paroxysmal and 3 persistent AF patients for 24 hours using neuECG. The average voltage of SKNA (aSKNA) and ventricular rate during AF was analyzed in one-min windows.  Results  The preliminary data reveal strong correlations (r=.783, r=.640, respectively, p<0.0001 for both) between aSKNA (1.19 ± 0.21 µV) and ventricular rate (110 ± 8 bpm) in the paroxysmal AF. High correlations were consistently observed when data were analyzed on an hourly basis. In comparison, strong correlations were found between aSKNA (1.13 ± 0.2 µV) and ventricular rate (88 ± 8.6 bpm) in persistent AF (r=.496, r= .796, r=.636 respectively, p<0.001 for both cases). However, hourly correlations displayed much higher variability between aSKNA and ventricular rate than that observed for paroxysmal AF.   Conclusion and Potential Impact.  aSKNA positively correlates with ventricular rate during AF. This relationship is stronger and more consistent during paroxysmal than persistent AF. These findings may be important in determining the efficacy of beta blocker therapy in rate control of AF. 

scholarly journals 107Antecedent cardiovascular disease, medication use, and risk of developing ALS: a population-based nested case-control study

2021 ◽  
Vol 50 (Supplement_1) ◽  
Author(s):  
Hoda Abdel Magid ◽  
Barbara Topal ◽  
Valerie McGuire ◽  
Jessica Hinman ◽  
Edward Karasakis ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Case Control Study ◽  
Beta Blockers ◽  
Medication Use ◽  
Population Based ◽  
Case Control ◽  
Channel Blockers ◽  
Nested Case Control ◽  
Control Study

Abstract Background We investigated the association between hypertension, ischemic heart disease, heart failure, acute myocardial infarction, and atrial fibrillation with the risk of amyotrophic lateral sclerosis (ALS). This study also examined associations with use of angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptors blockers (ARBs), calcium channel blockers, beta blockers, and antiarrhythmics Methods We conducted a population-based nested case-control study in the Medicare fee for service population, including 3,714 enrollees ages 65 and above with newly diagnosed ALS between 2006-2014. Cases were compared with 18,750 sex-, age, county, and enrollment-matched controls. Odds ratios (OR) and 95% Confidence Intervals (CIs) were estimated using conditional logistic regression models adjusting for diabetes, obesity, tobacco use, socioeconomic status, and controlling for confounding by indication. Medication use was identified through claims pharmacy data and similarly analyzed using a dose response approach. Results The fully adjusted OR for any CVD diagnosis was 0.93 (95% CI 0.86–1.02). Our results varied across cause-specific CVD diagnoses. We observed inverse associations for heart failure (OR 0.79; 95% CI 0.70–0.89) and atrial fibrillation (OR 0.81; 95% CI 0.76–0.92). ALS risk was reduced with use of ACEIs (OR 0.84; 95% CI 0.77–0.91), calcium channel blockers (OR 0.64; 95% CI 0.59–0.70), and beta blockers (OR 0.76; 95% CI 0.71–0.83). Conclusions In this large population-based Medicare study, the risk of ALS was 7% lower among individuals with any CVD diagnosis. Key messages Our findings suggest having a cardiovascular condition or use of a CVD medication may be protective for ALS.

scholarly journals Readmissions, Death and Its Associated Predictors in Heart Failure With Preserved Versus Reduced Ejection Fraction

2021 ◽  
Author(s):  
Wan Ting Tay ◽  
Tiew‐Hwa Katherine Teng ◽  
Oliver Simon ◽  
Wouter Ouwerkerk ◽  
Jasper Tromp ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Ejection Fraction ◽  
Recurrent Events ◽  
Cox Regression ◽  
Beta Blockers ◽  
Unique Identifier ◽  
Reduced Ejection Fraction ◽  
Asian Patients ◽  
All Cause Mortality

Background Data on rehospitalizations for heart failure (HF) in Asia are scarce. We sought to determine the burden and predictors of HF (first and recurrent) rehospitalizations and all‐cause mortality in patients with HF and preserved versus reduced ejection fraction (preserved EF, ≥50%; reduced EF, <40%), in the multinational ASIAN‐HF (Asian Sudden Cardiac Death in Heart Failure) registry. Methods and Results Patients with symptomatic (stage C) chronic HF were followed up for death and recurrent HF hospitalizations for 1 year. Predictors of HF hospitalizations or all‐cause mortality were examined with Cox regression for time to first event and other methods for recurrent events analyses. Among 1666 patients with HF with preserved EF (mean age, 68±12 years; 50% women), and 4479 with HF with reduced EF (mean age, 61±13 years; 22% women), there were 642 and 2302 readmissions, with 28% and 45% attributed to HF, respectively. The 1‐year composite event rate for first HF hospitalization or all‐cause death was 11% and 21%, and for total HF hospitalization and all‐cause death was 17.7 and 38.7 per 100 patient‐years in HF with preserved EF and HF with reduced EF, respectively. In HF with preserved EF, consistent independent predictors of these clinical end points included enrollment as an inpatient, Southeast Asian location, and comorbid chronic kidney disease or atrial fibrillation. The same variables were predictive of outcomes in HF with reduced EF except atrial fibrillation, and also included Northeast Asian location, older age, elevated heart rate, decreased systolic blood pressure, diabetes, smoking, and non‐usage of beta blockers. Conclusions One‐year HF rehospitalization and mortality rates were high among Asian patients with HF. Predictors of outcomes identified in this study could aid in risk stratification and timely interventions. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01633398.

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