CARDIOVASCULAR JOURNAL OF AFRICA • Vol 21, No 4, July/August 2010
236
AFRICA
Increased heart rate in high-risk hypertensives related to
increased heart failure and sudden death
High-risk hypertensives with a heart rate
above 80 beats per minute (bpm) have an
increased risk of cardiovascular events,
particularly heart failure and sudden
death, according to a new analysis of
the
V
alsartan Anti-hypertensive
L
ong-
term
U
se
E
valuation (VALUE) trial,
presented at the 2010 American Society
of Hypertension congress (ASH).
1
Both
baseline and in-trial tachycardia, meas-
ured every year by ECG, were strong,
independent predictors of cardiovascular
events.
The VALUE trial, first reported almost
six years ago, showed that valsartan and
amlodipine-based therapy were essen-
tially equal in reducing the primary
endpoints of cardiac morbidity or mortal-
ity in patients with hypertension and at
least one high-risk factor.
2
The study was
conducted over five years.
The researchers also identified that
most of the risk occurred in those trial
participants with heart rates of 79 bpm or
more. There was a striking increase in the
primary endpoint in the highest quintile
of heart rate (
≥
79 bpm) compared with
the pooled lower four quintiles.
Annual incidence of new primary
endpoint events in the highest quintile
(compared with the lower four) was 30%
higher in the first year of the study, 55%
higher in the third year, 52% more in the
fourth, and 46% higher in the fifth year
of the study. A similar trend was seen
throughout the trial for the heart failure
and sudden death components of the
endpoint.
The negative effect of the in-trial
tachycardia was not modified by the
blood pressure control achieved in the
study. The relative increase in the primary
endpoint of the tachycardic group was
68% in the blood pressure-controlled and
63% in the blood pressure-uncontrolled
groups (
p
<
0.0001).
The results of the SHI
f
T trial will
answer unequivocally whether reducing
the heart rate in patients with systolic
heart failure with the specific heart rate-
lowering agent ivabradine, will improve
prognosis. The trial randomised to either
ivabradine or placebo, heart failure
patients in NYHA classes II to IV, with
ejection fraction less than 35% and a
heart rate greater than 70 bpm, who were
already being treated with beta-blockers,
ACE inhibitors and diuretics. The primary
endpoint of the study is cardiovascular
death and hospitalisation for heart failure.
The SHI
f
T study is the largest ever
study undertaken in heart failure, with
6 500 patients. The results of the SHI
f
T
study will be announced at the hotline
session on 29 August 2010 at the
European Society of Cardiology’s annual
congress in Stockholm.
This trial is pivotal to the clinician’s
perception of the value of heart rate
lowering with ivabradine to reduce cardio-
vascular morbidity and mortality in these
high-risk cardiovascular patients.
J Aalbers, Special Assignments Editor
1. Julius S, Palatini P, Kjeldsen S,
et al
.
Tachycardia predicts CV events in theVALUE
trial. American Society of Hypertension
2010 scientific meeting. May 1–4, 2010,
NewYork, NY. Abstract LB-OR-01.
2. VALUE study highlights the need for aggres-
sive blood pressure lowering in high-risk
patients.
Cardiovasc J Afr
2004;
15
(4):
191–192.
3. New ASCOT analysis: Beta-blockers not
beneficial in hypertensives with tachycardia
hypertension. September 15, 2009, published
ahead of print.
