Heart Rate and Prognosis of Heart Failure with Reduced Ejection Fraction in Women and Men in Sinus Rhythm

Background: Resting heart rate (RHR) is a therapeutic target for heart failure with reduced ejection fraction (HFrEF), with reductions to 60 bpm improving outcomes. Elevated RHR is associated with increased mortality in HFrEF. However, sex-specific differences in mortality, particularly for women in sinus rhythm, remain unclear. We evaluated mortality rates at RHR thresholds of ≤60 bpm and ≤70 bpm in women and men with HFrEF. Methods: From February 2017 to January 2022, we assessed 2,984 patients (61 ± 13.8 years, 64.4% men) with HFrEF in sinus rhythm. Clinical and echocardiographic data were analyzed to examine RHR’s influence on mortality. Results: Over a mean follow-up of 3.7 ± 1.6 years, left ventricular ejection fraction improved in men (29.5% ± 6.7% to 36.7% ± 12.9%; p<0.001) and women (29.9% ± 6.4% to 38.0% ± 13.4%; p<0.001). Men had higher mortality (43.7% vs. 36.7%; p<0.001), with cumulative death incidence greater at RHR >60 bpm (p<0.001) and >70 bpm (p=0.011). Cox regression identified RHR as an independent predictor of mortality for men (HR=1.008; p=0.008) but not women. Conclusion: Elevated RHR increases mortality risk in men, suggesting a target near 60 bpm and closer to 70 bpm in women, supporting individualized RHR management.