Who Benefits From Beta Blocker Withdrawal in HFpEF?

TOPLINE:

In patients with heart failure with preserved ejection fraction (HFpEF) and chronotropic incompetence, indexed left ventricular systolic volume (iLVESV) may predict those who could benefit most from stopping beta blocker treatment, new research suggested.

Chronotropic incompetence — the inability of the heart to increase heart rate (HR) with increasing demand — has been associated with worse clinical outcomes and functional capacity, and increasing HR by beta blocker withdrawal has emerged as a possible therapeutic option.

METHODOLOGY:

• Investigators performed a post hoc analysis of data from the multicenter, randomized, crossover trial, PRESERVE-HR, to investigate the short-term effects (2 weeks) of beta blocker withdrawal on peak oxygen consumption (peak VO2).
• The primary outcome was the association between beta blocker withdrawal and short-term changes in percentage of peak VO2 across indexed left ventricular diastolic volume (iLVEDV), iLVESV, and left ventricular ejection fraction (LVEF) in patients with HFpEF and chronotropic incompetence.

TAKEAWAY:

• Among the 52 participants (mean age, 73 years; 60% female), the mean resting HR was 65 beats per minute; peak HR was 97 bpm; peak VO2 was 12.4 mL/kg per minute; iLVESV percentage of peak VO2 was 72.4%; and the mean chronotropic incompetence was 0.41.
• The median iLVEDV was 44 mL/m2; iLVESV, 15 mL/m2; and LVEF, 64%.
• The median increase in peak HR after beta blocker cessation was plus 30 bpm, and although all patients benefited from the drug withdrawal, those with a lower iLVESV showed a greater short-term improvement in maximal functional capacity, suggesting that iLVESV may identify patients with HFpEF and chronotropic incompetence who will experience the most short-term benefits from stopping beta blockers.

IN PRACTICE:

“The current findings align with the notion that higher HRs might be particularly beneficial for patients with HFpEF with smaller LV volumes and hyperdynamic systolic function, which are features observed in individuals with lower iLVESV,” the authors wrote. “For these patients, an increased HR could potentially enhance cardiac output and counterbalance the decrease in stroke volume during exercise.”

SOURCE:

The study was led by Patricia Palau, MD, PhD, of the University of Valencia, Valencia, Spain, and published online on February 7 in JAMA Cardiology.

LIMITATIONS:

The study has several limitations. It is an open-label, small study with short-term follow-up. Results may be applicable only to stable patients with HFpEF and chronotropic incompetence on treatment with a beta blocker. In addition, the study was a nonprespecified analysis; echocardiographic parameters were limited; and the anaerobic threshold was not registered.

DISCLOSURES:

The work was supported by grants from the Spanish Ministry of Economy and Competitiveness through the Carlos III Health Institute: FIS, and co-funded with EDRF funds and CIBER Cardiovascular funds. Several coauthors reported fees and grants from industry outside the submitted work. See the study for full disclosures.