What is the target pulse rate for patients with heart failure, particularly those with heart failure with reduced ejection fraction (HFrEF) on beta-blocker therapy, such as metoprolol succinate (metoprolol)?

Target Pulse Rate for Patients with Heart Failure

For heart failure patients in sinus rhythm on beta-blocker therapy, aim for a resting heart rate <70 beats/min, though achieving the target beta-blocker dose (carvedilol, metoprolol succinate, or bisoprolol) is the primary goal regardless of the achieved heart rate. 1, 2

Heart Rate Targets Based on Rhythm

Patients in Sinus Rhythm (HFrEF)

• Target resting heart rate: <70 beats/min is associated with improved outcomes, with each 10 beats/min increase in heart rate associated with significantly increased mortality (adjusted HR: 1.11-2.46 per 10 beats/min increase). 3, 4

• However, achieving target beta-blocker dose takes priority over achieving a specific heart rate, as the MERIT-HF trial demonstrated that metoprolol CR/XL significantly reduced mortality and hospitalizations independent of baseline heart rate, achieved heart rate, or change in heart rate. 2

• The relationship between lower achieved heart rate and better prognosis exists only for patients in sinus rhythm (HR: 1.16 per 10 beats/min increase), not for those in atrial fibrillation. 4

Patients with Atrial Fibrillation and Heart Failure

• Target heart rate: 60-100 beats/min at rest, with one study suggesting up to 110 beats/min may be acceptable. 1

• In the AF-CHF study, the target rate was <80 beats/min at rest and <110 beats/min during a 6-minute walk test. 1

• Important caveat: Lower ventricular rates <70 beats/min may be associated with worse outcomes in patients with AF and heart failure. 1

• Beta-blockers remain first-line for rate control in HFrEF with AF, reducing mortality and hospitalizations beyond just rate control effects. 1

Practical Titration Strategy

Primary Approach

• Start with low-dose evidence-based beta-blocker (carvedilol, metoprolol succinate, or bisoprolol) and uptitrate every 1-2 weeks using small increments until target dose is achieved. 5

• Do not stop uptitration based solely on heart rate unless the patient develops symptomatic bradycardia or heart rate <50 beats/min. 2

• The goal is to reach the target doses used in clinical trials: carvedilol 25-50 mg twice daily, metoprolol succinate 200 mg daily, or bisoprolol 10 mg daily. 5

When Heart Rate Remains Elevated Despite Beta-Blocker

• If heart rate ≥70 beats/min in sinus rhythm despite maximally tolerated beta-blocker, consider adding ivabradine (starting dose 2.5-5 mg twice daily). 1, 5

• Ivabradine is indicated specifically for patients with LVEF ≤35%, NYHA class II-IV symptoms, and resting heart rate ≥70 beats/min despite evidence-based beta-blocker dosing. 1

• In the real-world setting, 30.4% of well-managed HFrEF patients still have heart rate ≥70 beats/min despite achieving ≥50% of target beta-blocker dose. 3

Critical Contraindications and Safety Thresholds

Absolute Contraindications from FDA Label

• Heart rate <45 beats/min is a contraindication to metoprolol in the setting of myocardial infarction. 6

• Second- and third-degree heart block, significant first-degree heart block (PR interval ≥0.24 sec), or moderate-to-severe cardiac failure decompensation. 6

Monitoring During Titration

• Assess heart rate, blood pressure, and symptoms at each dose increment (every 1-2 weeks). 5

• If symptomatic bradycardia develops or heart rate drops below 50 beats/min, reduce beta-blocker dose rather than discontinuing entirely. 5

• For asymptomatic bradycardia with heart rate 50-60 beats/min, continue current dose without further uptitration. 5

Common Pitfalls to Avoid

• Never accept suboptimal beta-blocker doses simply because heart rate appears "controlled" – the mortality benefit comes from the beta-blocker itself, not just heart rate reduction. 2, 4

• Do not use non-evidence-based beta-blockers (e.g., atenolol, propranolol) as they lack proven mortality benefit in HFrEF. 5

• Avoid combining verapamil or diltiazem with beta-blockers in AF, as this combination is contraindicated. 1

• In patients with AF and HFrEF, achieving strict rate control (<60 beats/min) may be harmful – lenient control (60-100 beats/min) is preferred. 1

• Recognize that 30-40% of well-managed patients will have persistent elevated heart rate despite optimal therapy – this does not represent treatment failure if target beta-blocker doses are achieved. 3