Effect of Beta-Blocker Therapy, Maximal Heart Rate, and Exercise Capacity During Stress Testing on Long-Term Survival (from The Henry Ford Exercise Testing Project).
Whether lower heart rate thresholds (defined as the percentage of age-predicted maximal heart rate achieved, or ppMHR) should be used to determine chronotropic incompetence in patients on beta-blocker therapy (BBT) remains unclear. In this retrospective cohort study, we analyzed 64,549 adults without congestive heart failure or atrial fibrillation (54 ± 13 years old, 46% women, 29% black) who underwent clinician-referred exercise stress testing at a single health care system in Detroit, Michigan from 1991 to 2009, with median follow-up of 10.6 years for all-cause mortality (interquartile range 7.7 to 14.7 years). Using Cox regression models, we assessed the effect of BBT, ppMHR, and estimated exercise capacity on mortality, with adjustment for demographic data, medical history, pertinent medications, and propensity to be on BBT. There were 9,259 deaths during follow-up. BBT was associated with an 8% lower adjusted achieved ppMHR (91% in no BBT vs 83% in BBT). ppMHR was inversely associated with all-cause mortality but with significant attenuation by BBT (per 10% ppMHR HR: no BBT: 0.80 [0.78 to 0.82] vs BBT: 0.89 [0.87 to 0.92]). Patients on BBT who achieved 65% ppMHR had a similar adjusted mortality rate as those not on BBT who achieved 85% ppMHR (p >0.05). Estimated exercise capacity further attenuated the prognostic value of ppMHR (per-10%-ppMHR HR: no BBT: 0.88 [0.86 to 0.90] vs BBT: 0.95 [0.93 to 0.98]). In conclusion, the prognostic value of ppMHR was significantly attenuated by BBT. For patients on BBT, a lower threshold of 65% ppMHR may be considered for determining worsened prognosis. Estimated exercise capacity further diminished the prognostic value of ppMHR particularly in patients on BBT.
Department of Cardiology, Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland.
Rupert K
RK
Hung
Department of Cardiology, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Cardiac Center, Ministry of National Guard, Health Affairs, Riyadh, Saudi Arabia; Department of Cardiology, Henry Ford Hospital, Detroit, Michigan.
Mouaz H
MH
Al-Mallah
Department of Cardiology, Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland.
Seamus P
SP
Whelton
Department of Cardiology, Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland.
Erin D
ED
Michos
Department of Cardiology, Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland.
Roger S
RS
Blumenthal
Department of Cardiology, Henry Ford Hospital, Detroit, Michigan.
Jonathan K
JK
Ehrman
Department of Cardiology, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Cardiac Center, Ministry of National Guard, Health Affairs, Riyadh, Saudi Arabia.
Clinton A
CA
Brawner
Department of Cardiology, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Cardiac Center, Ministry of National Guard, Health Affairs, Riyadh, Saudi Arabia.
Steven J
SJ
Keteyian
Department of Cardiology, Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland. Electronic address: mblaha1@jhmi.edu.
Michael J
MJ
Blaha
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D002423:Cause of Death / Q000639:trends; D005080:Exercise Test / Q000379:methods*; D017079:Exercise Tolerance / Q000502:physiology*; D005260:Female; D005500:Follow-Up Studies; D005544:Forecasting; D006333:Heart Failure / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D006339:Heart Rate / Q000502:physiology*; D006352:Heart Ventricles / Q000503:physiopathology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D014481:United States / Q000453:epidemiology
D000319:Adrenergic beta-Antagonists
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