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Heart rate score and outcomes in ICD patients: insights from the prospective randomized INTRINSIC RV trial

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Abstract

Background

Heart rate score (HRSc), the percentage of atrial sensed and paced beats in the largest 10 beat/min bin of a device histogram and mean intrinsic heart rate (MIHR), predicted survival in nonrandomized studies of implantable defibrillator (ICD) patients. We evaluated whether HRSc and MIHR independently predicted mortality and heart failure (HF) hospitalization in the prospective, randomized, controlled INTRINSIC RV trial.

Methods and results

The INTRINSIC RV trial enrolled 1530 patients receiving dual-chamber ICDs. This analysis involves patients (n = 1471) for whom MIHR and HRSc data were available. Mean follow-up was 10.4 months. The relationship between pre-randomization MIHR and HRSc on the primary endpoint of all-cause mortality and HF hospitalization was assessed using multivariate regression and Cox modeling. As categorical variables, MIHR > 70 bpm and HRSc > 70% were considered high.

Results

The median baseline MIHR and HRSc were 74 (IQR = 16) and 50% (IQR = 20) respectively. As a continuous variable, for every 1% increase in HRSc, death/HF hospitalization increased by 1% (95%CI: 1.002–1.017; p = 0.01). Regression analysis showed baseline MIHR was associated with HRSc (p = 0.01); for every 1 beat/min increase in MIHR, HRSc increased by 1.8%. A MIHR > 70 bpm and HRSc ≥ 70% predicted, but were independently associated with, the primary endpoint (HR: 1.39; 95%CI: 1.10–1.76, p = 0.005 for MIHR and HR: 1.654; 95%CI: 1.11–2.46, p = 0.01 for HRSc). Male gender (HR: 0.75), history of HF (HR: 1.29), and atrial fibrillation (HR: 1.37) also predicted death/hospitalization in the Cox model.

Conclusions

In this large, prospectively studied ICD population, HRSc was a robust and independent predictor of death/HF hospitalization. High MIHR and high HRSc were associated but each predicted outcomes independently.

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Fig. 1

Reproduced with permission from Olshansky B et al. [4]

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Abbreviations

HRSc:

Heart rate score

MIHR:

Mean intrinsic heart rate

ICD:

Implantable cardioverter defibrillator

HF:

Heart failure

ROC:

Receiver operating characteristic

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Funding

This study was supported by an Investigator Sponsored Research (ISR) grant from Boston Scientific to the University of Louisville Research Foundation with Dr. Rakesh Gopinathannair as principal investigator.

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Authors and Affiliations

  1. Kansas City Heart Rhythm Institute, 5100 W 110th St, Ste 200, Overland Park, KS, 66211, USA

    Rakesh Gopinathannair

  2. Medical Devices Consultants LLC, Saint Paul, MN, USA

    Arjun Sharma

  3. Boston Scientific Corp, Minneapolis, MN, USA

    Paul Jones

  4. University of Louisville, Louisville, KY, USA

    Connor English & Stephen Furmanek

  5. University of Iowa Hospitals and Clinics, Iowa City, IA, USA

    Brian Olshansky

Authors
  1. Rakesh Gopinathannair
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  2. Arjun Sharma
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  3. Paul Jones
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  4. Connor English
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  5. Stephen Furmanek
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  6. Brian Olshansky
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Corresponding author

Correspondence to Rakesh Gopinathannair.

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Conflict of interest

Rakesh Gopinathannair, MD: Consultant/Honoraria—Abbott Medical, Boston Scientific, Zoll Medical; Physician Advisor—Altathera, PaceMate. Arjun Sharma, MD: Consultant to VivaQuant, Stock (significant)- Boston Scientific Corporation. Brian Olshansky, MD: Boehringer Ingelheim – GLORIA AF co-coordinator, Lundbeck – speaker and consultant, Amarin – Chair, DSMB (REDUCE IT), Sanofi Aventis – consultant. Paul Jones, MS: Boston Scientific Corporation. All the other authors have no relevant conflicts of interest to disclose.

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What’s New?

1. In a randomized trial of dual-chamber ICDs, the pre-randomization heart rate score (HRSc), the percent of atrial sensed and paced beats in the largest 10 beat/min bin on a device histogram, independently predicted death or HF hospitalization.

2. This is novel evidence that high HRSc, a marker of chronotropic incompetence and a reduction in heart rate variability, is associated with adverse outcomes in an ICD population.

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“How does chronotropic incompetence/’low HR reserve’ affect outcomes? How to measure it? Sharing data on the impact of HR score (% of A-sensed & paced beats in the largest 10 bpm bin on CIED histogram) on death/HF hosp. in ICD pts in the INTRINSIC RV trial @esc_journals #EPeeps”

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Gopinathannair, R., Sharma, A., Jones, P. et al. Heart rate score and outcomes in ICD patients: insights from the prospective randomized INTRINSIC RV trial. J Interv Card Electrophysiol 64, 87–93 (2022). https://doi.org/10.1007/s10840-021-01091-y

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  • DOI: https://doi.org/10.1007/s10840-021-01091-y

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