Heart Rate in Coronary Syndromes and Heart Failure

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Abstract

In the past 2 decades, there have been growing evidences that resting heart rate might be a marker of risk or even a risk factor for cardiovascular morbidity and mortality. This article reviews current evidences concerning the relation between heart rate and patients' outcome in different clinical settings such as acute coronary syndromes, left ventricular systolic dysfunction, and heart failure. The relationship between resting heart rate and the development of coronary artery disease, as well as all-cause and cardiovascular mortality, has been found to be strong, graded, and independent from other risk factors. Several lines of research indicate that heart rate plays an important role in the pathophysiology of atherosclerosis and in the clinical manifestations of coronary artery disease and that it is an independent prognostic factor in all coronary syndromes. The prognostic value of elevated heart rate in patients with heart failure has been tested in several clinical trials evaluating pharmacologic heart rate–lowering agents (eg, β-blockers). It is difficult to determine which percentage of the clinical benefit obtained with β-blockers is related to induced bradycardia because cardiac slowing is only one of the effects of these drugs. In the BEAUTIFUL trial, a subgroup analysis conducted in patients with resting HR more than 70 beats per minute showed that treatment with ivabradine was able to improve outcome. According to the results presented in this review, we can conclude that heart rate is a predictor of death in both stable coronary artery disease and acute coronary syndromes. Elevated heart rate is also able to negatively predict clinical outcomes in patients with heart failure. However, it is still unclear if heart rate reduction per se can improve prognosis.

Section snippets

Heart rate as cardiovascular and metabolic risk factor

The relationship between resting HR and cardiovascular risk and mortality has been clearly established in several large epidemiological studies for the last 30 years either in healthy subjects or in those affected by different cardiovascular diseases. In 1981, data derived from the Paris Prospective Study demonstrated that resting HR was able to predict total mortality in both men and women in 19,386 employees observed for more than 20 years. In men, the risk of cardiovascular mortality was

Heart rate and coronary artery disease

Coronary artery disease is common in the general population and represents an important public health problem; several epidemiological and clinical studies have identified well-known risk factors such as dyslipidemia, hypertension, diabetes mellitus, cigarette smoking, and obesity. All these factors may promote coronary atherosclerosis that is the pathophysiologic basis of the broad spectrum of clinical presentations of ischemic heart disease. Besides these classical risk factors, more

Heart rate and left ventricular dysfunction

The relation between resting HR and left ventricular dysfunction has been studied both in humans and animal models. In a recent study,33 the effect of different pacing rates (80 vs 60 bpm) on ventricular function of patients with heart failure and severe left ventricular systolic dysfunction (mean left ventricular ejection fraction, 26% ± 9%) treated with β-blockers was evaluated. Higher pacing rates (80 bpm) significantly increased mean left ventricular end-diastolic and systolic volumes and

Conclusion and future perspectives

According to the results presented in this review, we can conclude that there are consistent evidences that resting HR is able to predict life expectancy and, in healthy subjects, is an independent predictor of morbidity and mortality. Furthermore, resting HR is a predictor of death in both stable coronary artery disease and ACS, and these evidences are clearly supported by pathophysiologic background, clinical observations, and randomized clinical trials.

Elevated resting HR is also able to

Statement of Conflict of Interest

All authors declare that there are no conflicts of interest.

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