In-hospital beta-blocker initiation is associated with improved survival in AF-HFpEF with tachycardia
S Naito, Y Iemura, K Kikkawa, S Ueshima, Y Horizawa, K Miyoshi, M Ogata, N Okuda, Y Kawahara, A Tani, T Murakami, T Ando, S Ishihara, H Komiyama, K JujoAbstract
Background
Beta-blockers are not routinely recommended in HFpEF1. However, they remain guideline-supported for rate control in patients with concomitant atrial fibrillation (AF), creating a therapeutic paradox in AF-HFpEF2. In AF-HFpEF, tachycardia may worsen diastolic dysfunction, suggesting that heart rate could be a modifiable prognostic factor3. However, the prognostic impact of initiating beta-blockers during hospitalization remains unclear.
Purpose
To evaluate the prognostic impact of in-hospital beta-blocker initiation in HFpEF patients presenting with AF, and to assess effect modification by admission tachycardia (heart rate ≥100 bpm).
Methods
We conducted a retrospective multicenter registry analysis using the combined COEDO HF and OHR HF databases. Among 1,138 patients hospitalized for heart failure, 464 had HFpEF. Of 207 patients with AF at admission, 144 not receiving beta-blockers at baseline were included. In-hospital initiation was defined as starting a beta-blocker during the index hospitalization, including at discharge. Follow-up began at the time of admission. The primary endpoint was all-cause death (ACD), and the secondary endpoint was cardiovascular death (CVD). Kaplan–Meier and Cox proportional hazards models were used, adjusting for clinically relevant baseline covariates. Stratified analyses were performed by admission tachycardia (HR ≥100 bpm). Median follow-up was 358.5 days (IQR 47–500).
Results
Beta-blockers were initiated during the index hospitalization in 55 patients (38.2%). Patients in the initiation group presented with higher admission heart rates compared with the non-initiation group (97 vs. 83 bpm, p=0.003). During follow-up, 48 ACDs and 20 CVDs occurred. Kaplan–Meier analysis demonstrated significantly lower ACD (log-rank p=0.008) and CVD (p=0.040) in the initiation group. In stratified analyses, the association was more pronounced among patients presenting with tachycardia (heart rate ≥100 bpm). In this subgroup, in-hospital beta-blocker initiation was significantly associated with lower ACD (HR 0.092, 95% CI 0.012–0.720). In contrast, among patients with admission HR <100 bpm, the association with ACD was HR 0.57 (95% CI 0.27–1.19; p=0.134), and the interaction between initiation and tachycardia was p = 0.10.
Conclusions
In HFpEF patients hospitalized with AF who were not previously treated with beta-blockers, in-hospital initiation was associated with reduced all-cause mortality. AF-HFpEF with tachycardia may represent a modifiable high-risk phenotype.figure 1