title: Heart Rate or Beta-Blocker Dose? Association With Outcomes in Ambulatory Heart Failure Patients With Systolic Dysfunction: Results From the HF-ACTION Trial.
abstract: OBJECTIVE
  This study aimed to compare whether reduced heart rate (HR) or higher beta-blocker (BB) dose affected outcomes to a greater extent in the HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) trial population.
  
  
  BACKGROUND
  Recent data have shown that HR is an important modifiable factor in reducing mortality in heart failure (HF) patients. It has also been shown that titration of doses of BBs improves outcomes of morbidity and mortality in chronic HF patients with reduced ejection fraction. We aimed to compare whether reduced HR or higher BB dose affected outcomes to a greater extent in the HF-ACTION trial population.
  
  
  METHODS
  HF-ACTION was a randomized, multicenter trial enrolling 2,331 ambulatory HF patients with systolic dysfunction (New York Heart Association functional class II to IV, left ventricular ejection fraction <0.35) randomized to exercise training versus usual care, with median follow-up of 2.5 years. BB dose at baseline was standardized by use of carvedilol equivalents. BB dose and HR were analyzed by discrete groups (higher/lower dose; higher/lower HR). The relationship of BB dose, HR, and the primary endpoint of all-cause mortality or all-cause hospitalization and other cardiovascular secondary endpoints were determined before and after adjustment for variables found to be significantly associated with outcome in the HF-ACTION cohort.
  
  
  RESULTS
  There was a significant inverse relationship between either BB dose (higher was better) or HR (lower was better) and all-cause death or hospitalization in unadjusted analysis; however, only BB dose was significant for improved mortality outcomes. After adjustment for other predictors of outcome, only BB dose remained significant for improving all-cause death or hospitalization. BB dose, but not HR, was associated with improved outcomes of other cardiovascular endpoints in unadjusted analysis but did not remain significant when adjusted for other predictors of outcome in this cohort.
  
  
  CONCLUSIONS
  There were more associated improvements in outcomes with higher BB dose than with reduced HR in this well-treated HF cohort with systolic dysfunction, which suggests that titration of BB doses may confer a greater benefit than reduction of HR in such patients. (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training [HF-ACTION]; NCT00047437).
authors.affiliation: Duke University and Duke Clinical Research Institute, Durham, North Carolina. Electronic address: mona.fiuzat@duke.edu.
authors.forename: Mona
authors.initials: M
authors.lastname: Fiuzat
authors.affiliation: Duke University and Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Daniel
authors.initials: D
authors.lastname: Wojdyla
authors.affiliation: Montefiore Einstein Center for Heart and Vascular Care, Bronx, New York.
authors.forename: Ileana
authors.initials: I
authors.lastname: Pina
authors.affiliation: University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Kirkwood
authors.initials: K
authors.lastname: Adams
authors.affiliation: Thomas Jefferson University, Philadelphia, Pennsylvania.
authors.forename: David
authors.initials: D
authors.lastname: Whellan
authors.affiliation: Duke University and Duke Clinical Research Institute, Durham, North Carolina; Inova Heart & Vascular Institute, Falls Church, Virginia.
authors.forename: Christopher M
authors.initials: CM
authors.lastname: O'Connor
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage*; D002423:Cause of Death / Q000639:trends; D004305:Dose-Response Relationship, Drug; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D006339:Heart Rate / Q000187:drug effects / Q000502:physiology*; D006801:Humans; D008297:Male; D010045:Outpatients; D015996:Survival Rate / Q000639:trends; D013599:Systole; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D016277:Ventricular Function, Left / Q000187:drug effects*
chemical_list: D000319:Adrenergic beta-Antagonists
keywords: beta-blockers; dose; exercise; heart failure; heart rate; mortality