JOURNAL READING

Heart rate as an independent predictor of long term mortality of

acute heart failure patients in sinus rhythm according to their
ejection fraction: data from the AHEAD registry

Ujian seleksi PPDS Jantung dan Pembuluh

Darah FKKMK UGM periode Juli 2023
JOURNAL REVIEW
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BACKGROUND

• An elevated HR at admission for AHF whatever the EF has been associated with higher risk of
death and worsening HF at 7 days.

• The influence of HR at admission on prognosis disappeared after a few weeks in HFrEF patients in
sinus rhythm (SR) hospitalised for AHF.

• HR was not found to be a predictor of one year mortality in AHF in the INHF registry whatever the
EF

• The relationship between heart rate (HR) on admission with medium- and long-term prognosis as
well as the impact of ejection fraction (EF) of patients with acute heart failure (AHF) is unknown.
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MATERIAL & METHODS

• Study Population & Design

• - Population : All AHF patient ( from The AHEAD registry , Czech Republic with
with the signs and symptoms as defined by European guidelines ) who met the
inclusion and exclusion criteria
• - Prospective Cohort study with internal controls
• - The registry prospectively collected data between 2006 and 2012 regarding
7,318 hospitalizations for AHF with 6,242 first hospitalization during the
period.
• - A total of 2, 335 patients met the inclusion criteria.
• - All patients were followed up for at least three years.
• - The primary end-point was 6-month all-cause mortality and the secondary
end-point 12-month all-cause mortality.
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MATERIAL & METHODS

• Exclusion Criteria :
• Patient with :

• - Cardiogenic shock
• - Resuscitation before admission
• - AHF secondary to high output AHF (mainly due to thyroid storms or
anaemia), AHF from surgical or non-cardiac etiology.
• - Pulmonary embolism
• - Severe valve disease
• - Arrhythmias (atrial fibrillation, atrial flutter, ventricular tachycardia,
junctional rhythm, supraventricular tachycardia)
• - Atrioventricular block ≥ degree 2
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MATERIAL & METHODS

• Inclusion Criteria :
• Patient with :

• - AHF with confirmed left-ventricular dysfunction whatever the EF and/or who

responded positively to treatment (particularly to diuretic treatment)
• - Sinus Rhytm
• - Measurement of HR at admission by electrocardiogram.
• - Known EF , was measured at admission or during the course of
hospitalization.
• - All patients were fully informed about the registry and gave their signed
consent to participate.
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STATISTICAL METHODS

• - Patients were divided according to LV EF into three groups:

• 1. HFrEF (EF < 40%), 52.4% of total patients
• 2. HFmrEF (EF ≥ 40% and <50%), 22,3 % of total patients
• 3. HFpEF (EF ≥ 50%), 25,4 % of total patients

• - Mortality data were obtained from the centralized database of the

Ministry of Health of the Czech Republic.
• - Study was carried out in accordance with the 1975 Declaration of
Helsinki and in agreement with the ethical guidelines of the European
Independent Ethics Committee.
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STATISTICAL METHODS
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STATISTICAL METHODS
• The statistical analysis was performed using SPSS 23.0.0.0 :

- Baseline patient characteristics of all patients and three groups according to EF were
described using absolute & relative frequencies for categorical variables & median
supplemented by 5th–95th percentile.

• - AHF prognosis factors were evaluated  univariate logistic

• regression after HR exclusion.

• - All parameters were included in the full multivariate models & a multivariate logistic
regression model using a backward stepwise algorithm.
• - Predictors of 6 and 12-month mortality (outside of HR) were then adopted for
computation of mortality residuals stratified by ejection fraction categories.
• - The final multivariate model for the analysis of independent predictive factors for 6 and
12-month mortality in the three groups of patients (HFrEF, HFmrEF, HFpEF) was developed
using a forward stepwise algorithm for selection of independent predictors with heart rate
and pre-selected independent predictors forced into the model
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RESULTS
• 1. Baseline characteristics

• - HFpEF patients were more often women and older, they had more
often hypertension in their medical history and a higher systolic blood
pressure at admission but their HR at admission was significantly lower
than HFrEF patients (80 bpm vs. 91 bpm, p < 0.01).

• - Baseline characteristics of HFmrEF patients were in between

characteristics of group of HFrEF and HFpEF
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RESULTS
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RESULTS
• 2. Patient mortality

• Optimal prognostic
cutoffs of HR were
identified for both 6
and 12 months.
•;
• 1. For HFrEF at 100
bpm,
• 2. For HFmEF at 90
bpm
• 3. For HFpEF at 80 bpm
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RESULTS
• 3. HR as a predictor of all-cause 6 and 12-month mortality

• Increased age, decreased diastolic BP, lack of PCI during hospitalization, increased
creatinine level and increased HR (with different cut-offs according to EF
categories) were found as predictors whatever the EF.
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Discussion & Conclusion

• - In particular, HFpEF patients have a higher risk of in-hospital death when HR on
admission is above 105 bpm, making them more sensitive to HR compared to
HFrEF.
• - This finding fits suitable with the fact that from a pathophysiological viewpoint
inappropriately high HR reduces the time to left ventricular diastolic filling,
particularly in AHF patients with mid-range and preserved EF and possibly in
some HFrEF patients, a mechanism leading to the adverse outcome.
• - HR, is an easy parameter to measure especially in sinus rhythm patients. HR
generally depends on several factors such as stress (dyspnoea, being admitted to
hospital), previous medications including beta-blockers and sympathetic activity
of the patient. HR has been shown to be a prognostic factor for hospital mortality,
but not of longterm survival.
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Discussion & Conclusion

• - Survival rates at 6 and 12 months were 84.8% and 78% respectively.
• - The main reason that HR was identified as an independent prognostic factor
could be the fact that the analysis was performed on a homogenous group of
patients with sinus rhythm and some specific groups of patients were excluded.
• - Our study suggests that HR at admission appears to be an independent
prognostic parameter in AHF patients in sinus rhythm irrespective of EF and can
be used to classify patients according to the severity of the disease.
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CRITICAL APPRAISAL

•Journal Characteristics :

•Prospective Cohort study with internal controls

•Type: Prognosis
•Method: univariate logistic regression, multivariate logistic regression model , full
multivariate models
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Journal Characteristics
•Foreground question
•Does heart rate an independent predictor of long-term mortality in acute
heart failure patients in sinus rhythm according to their ejection fraction. ?

P= acute heart failure patients in sinus rhythm with reduced EF, Preserved EF, and mid-
range EF.

I = Elevated HR at admission

C = No Elevated HR at admission
O = Long-term Prognosis
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Journal Characteristics

validity assessment
• Section A: Was the study sample used, using strict inclusion and exclusion criteria, and a
representative sample? YES
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Journal Characteristics

validity assessment
• Section B: Was the sample observation carried out at the same disease stage? YES

• Section C: Was the sample observation period sufficient and complete ? NO, sample
observation period is sufficient But Incomplete
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Journal Characteristics

validity assessment
• Section D: Was the outcome to be studied carried out using objective criteria and carried out in a
"blind" manner? YES

• Section E: Were subsamples with different prognoses equalized for important prognostic factors
and validated? YES
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Journal Characteristics

Importance assessment
• Section A: How likely is it that an outcome will occur in a given timeframe? Survival rates at 6
and 12 months were 84.8% and 78% respectively

• Section B: How accurate are the prognosis estimate?

• No, there are no Confidence Intervals reported. But they have some significant level p values
(< .0.05) on the independent predictors of 6-month mortality in patients with acute heart failure.
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Journal Characteristics

Applicability assessment
• Section A: Were the characteristics of the sample in the study similar to patients in our practice?
• NO, because the physical characteristics of race, lifestyle, level of economic industrialization,
and Indonesian climate can be different from the Czech country, so the predictor factors can also
be different from the journal.

Section B: Do the results of the study influence our decisions about what to do or to tell our
patients?
No, 1. Because the resources, facilities and infrastructure of the ICU and even the ICCU to treat heart
failure patients (HFeRF, HFmRF, HFpRF) are not evenly distributed in all health facilities or hospitals. 2.
Most Indonesians have comorbidities (comorbidities), where if the management of comorbidities is not
good (patients and or the patient's family tends to hope for instant recovery so that "doctor shopping"
occurs, which will worsen the prognosis of his heart failure
 TERIMA KASIH
SALAM SEHAT SELALU