Prognostic significance of remotely monitored nocturnal heart rate in heart failure patients with reduced ejection fraction

Published:October 27, 2022DOI:


      Elevated resting heart rate is a risk factor for cardiovascular events.


      The purpose of this study was to investigate the clinical significance of nocturnal heart rate (nHR) and 24-hour mean heart rate (24h-HR) obtained by continuous remote monitoring (RM) of implantable devices.


      We analyzed daily-sampled trends of nHR, 24h-HR, and physical activity in patients on β-blocker therapy for chronic heart failure and with implantable cardioverter-defibrillators or cardiac resynchronization therapy defibrillators (CRT-Ds). Patients were grouped by average nHR and 24h-HR quartile during follow-up to estimate the respective incidence of nonarrhythmic death and device-treated ventricular tachycardia/fibrillation (VT/VF).


      The study cohort included 1330 patients (median age 69 years [interquartile range 61–77 years]; 41% [n = 550] with CRT-D; median follow-up 25 months [interquartile range 13–42 months]). Compared with patients in the lowest nHR quartile (≤57 beats/min) group, patients in the highest quartile group (>65 beats/min) had an increased risk of nonarrhythmic death (adjusted hazard ratio [AHR] 2.25; 95% confidence interval [CI] 1.13–4.50; P = .021) and VT/VF (AHR 1.98; 95% CI 1.40–2.79; P < .001) and were characterized by the lowest level of physical activity (P ≤ .0004 vs every other nHR quartiles). The highest 24h-HR quartile group (>75 beats/min) showed an increased risk of VT/VF (AHR 2.13; 95% CI 1.52–2.99; P < .001) and a weaker though significant association with nonarrhythmic mortality (AHR 1.80; 95% CI 1.00–3.22; P = .05) as compared with the lowest 24h-HR quartile group (≤65 beats/min).


      In remotely monitored patients with implantable cardioverter-defibrillator/CRT-D on β-blocker therapy for heart failure, elevated heart rates (nHR >65 beats/min and 24h-HR >75 beats/min) were associated with increased mortality and VT/VF risk. nHR showed a stronger association than 24h-HR with worst prognosis and lowest physical activity.


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        • Kannel W.B.
        • Kannel C.
        • Paffenbarger R.S.J.R.
        • Cupples L.A.
        Heart rate and cardiovascular mortality: the Framingham Study.
        Am Heart J. 1987; 113: 1489-1494
        • Fox K.
        • Ford I.
        • Steg P.G.
        • Tendera M.
        • Robertson M.
        • Ferrari R.
        on behalf of the BEAUTIFUL investigators. Heart rate as a prognostic risk factor in patients with coronary artery disease and left-ventricular systolic dysfunction (BEAUTIFUL): a subgroup analysis of a randomised controlled trial.
        Lancet. 2008; 372: 817-821
        • Böhm M.
        • Swedberg K.
        • Komajda M.
        • et al.
        Heart rate as a risk factor in chronic heart failure (SHIFT): the association between heart rate and outcomes in a randomised placebo-controlled trial.
        Lancet. 2010; 376: 886-894
        • Oliva F.
        • Sormani P.
        • Contri R.
        • et al.
        Heart rate as a prognostic marker and therapeutic target in acute and chronic heart failure.
        Int J Cardiol. 2018; 253: 97-104
        • Habal M.V.
        • Nanthakumar K.
        • Austin P.C.
        • Freitas C.
        • Labos C.
        • Lee D.S.
        Heart rate in patients with reduced ejection fraction: relationship between single time point measurement and mean heart rate on prolonged implantable cardioverter defibrillator monitoring.
        BMC Cardiovasc Disord. 2018; 18: 17
        • Zanotto G.
        • D’Onofrio A.
        • Della Bella P.
        • et al.
        Organizational model and reactions to alerts in remote monitoring of cardiac implantable electronic devices: a survey from the Home Monitoring Expert Alliance project.
        Clin Cardiol. 2019; 42: 76-83
        • Heidenreich P.A.
        • Bozkurt B.
        • Aguilar D.
        • et al.
        2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
        J Am Coll Cardiol. 2022; 79: e263-e421
        • Palatini P.
        • Julius S.
        Elevated heart rate: a major risk factor for cardiovascular disease.
        Clin Exp Hypertens. 2004; 26: 637-644
        • Jouven X.
        • Zureik M.
        • Desnos M.
        • Guerot C.
        • Ducimetiere P.
        Resting heart rate as a predictive risk factor for sudden death in middle-aged men.
        Cardiovasc Res. 2001; 50: 373-378
        • Fox K.
        • Borer J.S.
        • Camm A.J.
        • et al.
        for the Heart Rate Working Group. Resting heart rate in cardiovascular disease.
        J Am Coll Cardiol. 2007; 50: 823-830
        • Castagno D.
        • Skali H.
        • Takeuchi M.
        • et al.
        Association of heart rate and outcomes in a broad spectrum of patients with chronic heart failure: results from the CHARM (Candesartan in Heart Failure: Assessment of Reduction in Mortality and morbidity) program.
        J Am Coll Cardiol. 2012; 59: 1785-1795
        • Vazir A.
        • Claggett B.
        • Jhund P.
        • et al.
        Prognostic importance of temporal changes in resting heart rate in heart failure patients: an analysis of the CHARM program.
        Eur Heart J. 2015; 36: 669-675
        • Ahmadi-Kashani M.
        • Kessler D.J.
        • Day J.
        • et al.
        Heart rate predicts outcomes in an implantable cardioverter-defibrillator population.
        Circulation. 2009; 120: 2040-2045
        • Kramer D.B.
        • Mitchell S.L.
        • Monteiro J.
        • et al.
        Patient activity and survival following implantable cardioverter-defibrillator implantation: the ALTITUDE activity study.
        J Am Heart Assoc. 2015; 4e001775
        • Kelly J.P.
        • Ballew N.G.
        • Lin L.
        • et al.
        Association of implantable device measured physical activity with hospitalization for heart failure.
        JACC Heart Fail. 2020; 8: 280-288
        • D’Onofrio A.
        • Solimene F.
        • Calò L.
        • et al.
        Combining home monitoring temporal trends from implanted defibrillators and baseline patient risk profile to predict heart failure hospitalizations: results from the SELENE HF study.
        Europace. 2022; 24: 234-244
        • Beinart R.
        • Kutyifa V.
        • McNitt S.
        • et al.
        Relation between resting heart rate and the risk of ventricular tachyarrhythmias in MADIT-RIT.
        Europace. 2020; 22: 281-287
        • Volders P.
        Novel insights into the role of the sympathetic nervous system in cardiac arrhythmogenesis.
        Heart Rhythm. 2010; 7: 1900-1906
        • Aktaş M.K.
        • Younis A.
        • Zareba W.
        • et al.
        Survival after implantable cardioverter-defibrillator shocks.
        J Am Coll Cardiol. 2021; 77: 2453-2462
        • Siddiqi N.
        • Tchou P.
        • Niebauer M.J.
        • Wilkoff B.L.
        • Varma N.
        Influence of “high” defibrillation thresholds on patient survival and impact of system modification.
        J Cardiovasc Electrophysiol. 2022; 33: 234-240
        • Sharma A.D.
        • Wilkoff B.L.
        • Richards M.
        • et al.
        Lower rate limit for pacing by cardiac resynchronization defibrillators: should lower rate programming be reconsidered?.
        Heart Rhythm. 2021; 18: 2087-2093
        • Biffi M.
        • Iori M.
        • De Maria E.
        • et al.
        The role of atrial sensing for new-onset atrial arrhythmias diagnosis and management in single-chamber implantable cardioverter-defibrillator recipients: results from the THINGS registry.
        J Cardiovasc Electrophysiol. 2020; 31: 846-853
        • Biffi M.
        • Massaro G.
        • Candelora A.
        • et al.
        Less is more: can we achieve cardiac resynchronization with 2 leads only?.
        Int J Cardiol. 2017; 249: 184-190
        • Biffi M.
        • D’Onofrio A.
        • Pignalberi C.
        • et al.
        Rate-responsive pacing and atrial high rate episodes in cardiac resynchronization therapy patients: is low heart rate the key?.
        Clin Cardiol. 2019; 42: 820-828

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