Activated rate-response is associated with increased mortality risk in cardiac device carriers with acute heart failure

PLoS One. 2024 Apr 18;19(4):e0302321. doi: 10.1371/journal.pone.0302321. eCollection 2024.

Abstract

Aims: This study investigated whether an activated R-mode in patients carrying a cardiac implantable electronic device (CIED) is associated with worse prognosis during and after an episode of acutely decompensated heart failure (AHF).

Methods: Six hundred and twenty-three patients participating in an ongoing prospective cohort study that phenotypes and follows patients admitted for AHF were studied. We compared CIED carriers with activated R-mode stimulation (CIED-R) to CIED carriers not in R-mode (CIED-0) and patients without CIEDs (no-CIED). The independent impact of R-mode activation on 12-month all-cause death was examined using uni- and multivariable Cox proportional hazards regression taking into account potential confounders, and hazard ratios (HR) with their 95% confidence intervals (CI) were reported.

Results: Mean heart rate on admission was lower in CIED-R (n = 37, 16% women) vs. CIED-0 (n = 64, 23% women) or no-CIED (n = 511, 43% women): 70 bpm vs. 80 bpm or 82 bpm; both p<0.001. In-hospital mortality was similar across groups, but age- and sex-adjusted all-cause 12-month mortality risk was differentially affected by R-mode activation; CIED-R vs. CIED-0: HR 2.44, 95%CI 1.25-4.74; CIED-R vs. no-CIED: HR 2.61, 95%CI 1.59-4.29. These effects persisted after multivariable adjustment for potential confounders. Within CIED-R, mortality risk was similar in patients with pacemakers vs. ICDs and in subgroups with left ventricular ejection fraction (LVEF) <50% vs. ≥50%.

Conclusion: In patients admitted with AHF, R-mode stimulation was associated with a significantly increased 12-month mortality risk. Our findings shed new light on "admission heart rate" as a potentially treatable target in AHF. Our data are compatible with the concept that chronotropic incompetence contributes to an adverse outcome in these patients and may not be adequately treated through accelerometer-based R-mode stimulation.

MeSH terms

  • Defibrillators, Implantable*
  • Female
  • Heart Failure*
  • Humans
  • Male
  • Prospective Studies
  • Retrospective Studies
  • Stroke Volume
  • Ventricular Function, Left

Grants and funding

The Comprehensive Heart Failure Centre (CHFC) Würzburg is funded by the Federal Ministry of Education and Research, Integrated Research and Treatment Centre "Prevention of Heart Failure and its Complications”. Phase 1: BMBF 01EO1004. Phase 2: BMBF 01EO1504. M. T. Huttelmaier is funded by the Deutsche Forschungsgemeinschaft (DFG) (project number 413657723, Clinician Scientist Program, UNION-CVD). T. H. Fischer is funded by the DFG (project number 507130856) and the Deutsche Stiftung für Herzforschung (project number F/26/21). S. Frantz is supported by the DFG. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.