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

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). 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. 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%. 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.

Copyright: © 2024 Huttelmaier et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

I have read the journal’s policy and the authors of this manuscript have the following competing interests: The AHF register was supported by an unrestricted grant of Boehringer Ingelheim (BI). BI was not involved in study design, data collection, data analysis and interpretation. Moritz T. Huttelmaier, Sascha Münsterer, Floran Sahiti, Nina Scholz, Judith Albert, Alexander Gabel, Christiane Angermann, Georg Ertl, Stefan Störk and Thomas H. Fischer declare that they have no conflict of interest. Caroline Morbach reports a research cooperation with the University of Würzburg and Tomtec Imaging Systems as well as a research cooperation with Tomtec Imaging Systems, both funded by a research grant from the Bavarian Ministry of Economic Affairs, Regional Development and Energy, Germany, Speakers bureau/travel grant/advisory board/patient eligibility board von Amgen, Tomtec, Orion Pharma, Alnylam, AKCEA, SOBI, Pfizer, Boehringer Ingelheim und EBR Systems, principal investigator in studies from Alnylam, AstraZeneca und Bayer. Stefan Frantz has received consultancy and lecture fees as well as support/ ravel grants for meetings from Abbot, Abiomed, Amarin, Amgen, AstraZeneca, Bayer, Berlin-Chemie, Biotronik, Boehringer, Bristol-Myers Squibb, Boehringer, Daiichi Sankyo, Edwards, Lilly, Novartis, Novo Nordisk, Pfizer, Sanofi-Aventis, Siemens, Vifor, Zoll. This does not alter our adherence to PLOS ONE policies on sharing data and materials.