What is the target heart rate for patients with heart failure?

Target Heart Rate in Heart Failure

For patients with heart failure and reduced ejection fraction (HFrEF) in sinus rhythm, the target resting heart rate is <70 beats per minute (bpm), achieved primarily through uptitration of beta-blockers to guideline-directed target doses, with ivabradine added if heart rate remains ≥70 bpm despite maximally tolerated beta-blocker therapy. 1

Heart Rate Targets Based on Heart Rhythm

HFrEF Patients in Sinus Rhythm

Primary Goal: Resting heart rate <70 bpm 1, 2

• Beta-blockers should be uptitrated to target doses (bisoprolol 10 mg daily, carvedilol 25-50 mg twice daily, or metoprolol succinate 200 mg daily) before considering additional heart rate reduction 1
• Ivabradine is indicated when: 1, 2
  • Patient has symptomatic HFrEF (NYHA class II-III)
  • LVEF ≤35%
  • Sinus rhythm with resting heart rate ≥70 bpm
  • Already on maximally tolerated beta-blocker dose
  • This reduces heart failure hospitalizations and cardiovascular death 1

Evidence strength: The SHIFT trial demonstrated that each 5-bpm increase in heart rate was associated with a 16% increase in cardiovascular events, and heart rates <60 bpm on treatment were associated with the best outcomes 3. However, only 26% of SHIFT patients were on guideline-defined target beta-blocker doses, and ivabradine benefit decreased as beta-blocker doses increased 2.

HFrEF Patients in Atrial Fibrillation

Initial Target: Resting heart rate <110 bpm (lenient control) 4

• This lenient approach should be the first-line strategy for most patients with AF and heart failure 4
• Based on the RACE II trial showing non-inferiority of lenient versus strict control 4

Stricter Target: Resting heart rate <80 bpm and <110 bpm during moderate exercise 4

• Consider stricter control when: 4
  • Ongoing symptoms despite lenient control
  • Suspicion of tachycardia-induced cardiomyopathy
  • Significant exercise intolerance

Medication selection for AF with HFrEF (LVEF ≤40%): 4

• First-line: Beta-blockers or digoxin
• Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in reduced ejection fraction 4
• Consider combination therapy (beta-blocker plus digoxin) if single agent inadequate 4

For refractory rate control: AV nodal ablation with permanent pacemaker or cardiac resynchronization therapy should be considered, with ≥95% pacemaker dependency required to maximize benefit 1, 4

Clinical Context and Monitoring

Why Heart Rate Matters

• Every 10-bpm increase in resting heart rate is associated with an 8% increase in major cardiovascular events 5
• Heart rate ≥70 bpm is associated with 36% increased mortality, 25% increased all-cause hospitalization, and 51% increased heart failure hospitalization compared to <70 bpm 6
• The relationship between heart rate and mortality is J-shaped, with optimal rates between 70-75 bpm in hospitalized patients, but the curve differs between sinus rhythm and AF 7

Monitoring Strategy

• Assess heart rate at rest and during exertion 4
• Consider 24-hour Holter monitoring to evaluate rate control throughout daily activities 4
• For patients on ivabradine, target heart rate is 50-60 bpm, with dose adjustments (2.5 mg, 5 mg, or 7.5 mg twice daily) based on tolerance 2
• Recheck heart rate after each medication uptitration, typically at 2-week intervals 1

Common Pitfalls to Avoid

Do not accept suboptimal beta-blocker dosing: Only 15% of real-world HFrEF patients achieve ≥50% of target beta-blocker dose, yet this is critical for mortality benefit 6. Beta-blockers reduce mortality by 34%, the highest relative risk reduction among GDMT medication classes 8.

Do not add ivabradine before maximizing beta-blockers: The mortality benefit of beta-blockers is well-established, while ivabradine primarily reduces hospitalizations without mortality benefit 1, 2. Ivabradine showed little benefit in patients already on target beta-blocker doses 2.

Do not stop uptitrating beta-blockers when symptoms improve at lower doses: Clinical trials demonstrated benefits at target doses, and repeated uptitration attempts often succeed even after initial failures 1, 8.

For AF patients, do not automatically pursue strict rate control: Start with lenient control (<110 bpm) as it is non-inferior for most patients and reserve stricter targets for those with persistent symptoms 4.