What is the recommended resting and exercise heart‑rate target for patients with established coronary artery disease, and how should it be achieved with medications and lifestyle measures?

Heart Rate Target for Coronary Artery Disease Patients

For patients with established coronary artery disease, the resting heart rate should be lowered to 55-60 beats per minute when using beta-blockers for antianginal purposes. 1

Resting Heart Rate Targets

Primary Target for Symptomatic CAD

• Target resting heart rate: 55-60 bpm when beta-blockers are used for angina control 1
• This target applies specifically when beta-blockers are prescribed for symptom relief in chronic coronary syndromes 1
• Heart rate measurement should be performed after 5 minutes of rest in the sitting position 1

Risk Stratification by Heart Rate

• Heart rate ≥70 bpm identifies high-risk patients with CAD and left ventricular dysfunction who face increased cardiovascular death (34% increased risk), heart failure hospitalization (53% increased risk), and myocardial infarction (46% increased risk) 2
• Each 5 bpm increase above 70 bpm confers an 8% increase in cardiovascular death risk 2
• The relationship between elevated heart rate and adverse outcomes is continuous, with risk rising progressively above 60 bpm 3

Exercise Heart Rate Targets

During Cardiac Rehabilitation

• Healthy individuals should exercise at 60-75% of maximum heart rate for 30-45 minutes, 4-5 times weekly 1
• For patients with established CAD, exercise prescription must be based on comprehensive clinical assessment including exercise test results 1
• Minimum recommendation: 150-300 minutes per week of moderate-intensity aerobic activity or 75-150 minutes of vigorous-intensity activity 1

Achieving Heart Rate Targets with Medications

First-Line Pharmacological Approach

Beta-Blockers as Primary Therapy:

• Beta-blockers represent the cornerstone of heart rate management in CAD patients 1, 4
• Achieve specified heart rate endpoints in approximately 70% of patients 4
• Should be titrated to doses used in clinical trials, particularly in post-MI patients for at least 3 years 1
• Critical caveat: Nearly half of CAD patients with elevated resting heart rate are not receiving beta-blockers, and those who are often remain undertitrated 5

Alternative First-Line Options:

• Calcium channel blockers (CCBs) can be used as monotherapy or combined with beta-blockers, tailored to patient hemodynamic profile and comorbidities 1
• Non-dihydropyridine CCBs (diltiazem, verapamil) reduce resting heart rate by 8-23 bpm and exercise heart rate by 20-34 bpm 4
• Contraindication: Non-dihydropyridine CCBs should be avoided in patients with heart failure due to systolic dysfunction 4

Second-Line and Add-On Therapy

Ivabradine for Specific Populations:

• Should be considered as add-on therapy in patients with LVEF <40% and inadequate symptom control despite beta-blockers 1
• May be used in patients with heart rate ≥70 bpm and reduced left ventricular function 4
• Works by selectively inhibiting the If current in the sinoatrial node without other cardiovascular effects 6
• Not recommended as add-on therapy in CCS patients with LVEF >40% and no clinical heart failure 1
• Contraindicated when combined with non-dihydropyridine CCBs or strong CYP3A4 inhibitors 1

Other Antianginal Agents:

• Long-acting nitrates, nicorandil, ranolazine, and trimetazidine can be added to beta-blockers/CCBs or used as initial combination therapy in selected patients 1
• Selection should be tailored to the underlying pathophysiology (obstructive CAD, vasospasm, or microvascular dysfunction) 1

Lifestyle Measures for Heart Rate Control

Exercise-Based Interventions

• Multidisciplinary exercise-based cardiac rehabilitation is mandatory to reduce all-cause and cardiovascular mortality while improving quality of life 1
• Home-based cardiac rehabilitation and mobile health interventions should be considered for long-term adherence 1
• Physiological heart rate reduction through exercise training increases parasympathetic drive and improves outcomes 6

Additional Lifestyle Modifications

• Smoking cessation is essential as smoking independently increases resting heart rate 5
• Weight reduction in overweight patients (BMI ≥25 kg/m²) or obese patients (BMI ≥30 kg/m²) 1
• Limit caffeine and alcohol intake, which can elevate heart rate 7
• Cognitive behavioral interventions to achieve healthy lifestyle changes 1

Common Pitfalls and Clinical Considerations

Undertitration Problem

• The most significant clinical failure is undertitration of beta-blockers despite lack of true contraindications 5
• Even patients receiving beta-blockers often fail to reach target heart rates <70 bpm 5
• Response to initial antianginal therapy must be reassessed and treatment adapted if adequate control is not achieved 1

Special Populations

• Post-MI patients with reduced LVEF: Strong evidence supports beta-blocker use 1
• Post-ACS patients with LVEF >40%: No large RCTs support routine beta-blocker prescription after uncomplicated ACS 1
• Patients with HFrEF: Beta-blockers provide prognostic benefit beyond symptom control 1

Monitoring and Adjustment

• Female sex, NYHA class I-II, and increased BMI are independent determinants of higher resting heart rate 5
• Lack of beta-blocker therapy is the main determinant of elevated heart rate (OR 3.35) 5
• Treatment should be individualized based on blood pressure, comorbidities (particularly heart failure, COPD, peripheral arterial disease), and drug interactions 1