Quantifying the paradoxical effect of higher systolic blood pressure on mortality in chronic heart failure

Does previous hypertension affect outcome in acute heart failure?

BACKGROUND

The effect of previous long-term hypertension on mortality in acute heart failure (HF), regardless of blood pressure values, has not been well studied.

METHODS

Acute Heart Failure Database (AHEAD) - Czech HF registry enrolled 4153 consecutive patients with acute HF. We excluded severe forms (cardiogenic shock, pulmonary oedema, right HF) and analysed 2421 patients with known presence or absence of previous hypertension. Demographic, clinical and laboratory profile, treatment and mortality rates were assessed and predictors of outcome were identified.

RESULTS

Patients with previous hypertension (71.5%) were older, more of female gender, with worse pre-hospitalisation NYHA class, increased incidence of co-morbidities and higher left ventricular ejection fraction (LVEF). Although in-hospital mortality was similar in both cohorts (2.6%), survival at 1, 2 and 3-year was worse in the hypertensive group (75.6%, 65.9% and 58.7% vs. 80.7%, 74.2% and 69.8%; P<0.001). Nevertheless, hypertension was not associated with mortality in multivariate analysis and stronger predictors of outcome were identified (P<0.05): new-onset acute HF [hazard ratio (HR) 0.62] and increased body mass index (HR 0.68) proved to have a protective role. Advanced age (HR 1.86), diabetes (HR 1.45), lower LVEF (HR 1.28) and admission blood pressure (HR 1.54), elevated serum creatinine (HR 1.63), hyponatremia (HR 1.77) and anaemia (HR 1.40) were associated with worse survival.

CONCLUSION

Antecedent hypertension is frequent in patients with acute HF and contributes to organ and vascular impairment. However its presence has no independent influence on short- and medium-term mortality, which is influenced by other related co-morbidities.

Low systolic blood pressure at admission predicts long-term mortality in heart failure with preserved ejection fraction

BACKGROUND

Systolic blood pressure (SBP) at hospital admission predicts in-hospital and postdischarge mortality in patients with left ventricular systolic dysfunction. The relationship between admission SBP and mortality in heart failure with preserved (≥50%) ejection fraction (HFPEF) is still unclear.

METHODS AND RESULTS

We aimed to investigate the relationship between admission SBP and 5-year outcome in 368 consecutive patients hospitalized for new-onset HFPEF. Five-year all-cause mortality rates according to admission SBP categories (<120, 120-139, 140-159, 160-179, and ≥180 mm Hg) were 75 ± 7%, 53 ± 6%, 52 ± 7%, 55 ± 4%, and 60 ± 7%, respectively (P = .029). Survival analysis showed an inverse relation between admission SBP and mortality with increased risk of death for SBP <120 mm Hg. SBP <120 mm Hg independently predicted 5-year all-cause mortality (adjusted hazard ratio [HR] 1.69, 95% confidence interval [CI] 1.08-2.63) and cardiovascular mortality (adjusted HR 1.89, 95% CI 1.21-2.97). In patients discharged alive, after adjustment for medical treatment at discharge, admission SBP <120 mm Hg remained predictive of all-cause mortality (adjusted HR 1.52, 95% CI 1.04-2.43) and cardiovascular mortality (adjusted HR 1.69, 95% CI 1.06-2.73). There was no interaction between any of the therapeutic classes and outcome prediction of SBP.

CONCLUSIONS

In HFPEF, low SBP (<120 mm Hg) at the time of hospital admission is associated with excess long-term mortality. Further studies are required to determine the mechanism of this association.

Ambulatory blood pressure monitoring, 2D-echo and clinical variables relating to cardiac events in ischaemic cardiomyopathy following cardioverter-defibrillator implantation

AIMS

Evaluation of ambulatory blood pressure monitoring (ABPM), two-dimensional (2D) echo and clinical variables in predicting cardiac death and acute decompensated heart failure in patients with ischaemic cardiomyopathy and receiving a cardioverter-defibrillator implantation.

METHODS AND RESULTS

We studied 180 consecutive patients (169 men) on an out-patient basis, with systolic dysfunction (ejection fraction ≤35%) and previous myocardial infarction. All received a cardioverter defibrillator (ICD) (116 dual chamber, 36 monocameral and 28 biventricular), for primary prevention of sudden death and standard medical therapy for heart failure. Mean follow-up was 11.7 months. Two-dimensional echo was performed just before ICD implantation, ABPM and haematological samples 2 weeks later. Age, ejection fraction, creatinine, haemoglobin concentration, mean 24-h systolic blood pressure, mean 24-h diastolic blood pressure, mean 24-h heart rate, brain natriuretic peptide, QRS duration, % paced beats, ventricular scar, biventricular pacing, sex and diabetes were considered. Cox proportional hazards regression analysis was used to explore the relationship between events. ROC curves were built for each independent variable. Events occurred in 47 patients (26%); 7 deaths for refractory heart failure and 40 hospitalizations for acute decompensated heart failure. Low mean 24-h systolic blood pressure [hazard ratio 0.96, 95% confidence interval (CI) 0.93-0.99, P = 0.02], high creatinine (hazard ratio 1.61, 95% CI 1.06-2.47, P = 0.01), low haemoglobin concentration (hazard ratio 0.81, 95% CI 0.65-0.99, P = 0.04) and older age (hazard ratio 1.04, 95% CI 1.01-1.08, P = 0.02) were independent predictors of events.

CONCLUSIONS

Ambulatory systolic blood pressure, haemoglobin, creatinine and age can stratify risk of death and acute decompensated heart failure in patients with ischaemic cardiomyopathy and ICD in whom 2D-echo ejection fraction is not predictive.

Systolic blood pressure and incident heart failure in the elderly. The Cardiovascular Health Study and the Health, Ageing and Body Composition Study

BACKGROUND

The exact form of the association between systolic blood pressure (SBP) and heart failure (HF) risk in the elderly remains incompletely defined, especially in individuals not receiving antihypertensive drugs.

OBJECTIVE

To examine the association between SBP and HF risk in the elderly.

DESIGN

Competing-risks proportional hazards modelling of incident HF risk, using 10-year follow-up data from two NIH-sponsored cohort studies: the Cardiovascular Health Study (inception: 1989-90 and 1992-3) and the Health ABC Study (inception: 1997-8).

SETTING

Community-based cohorts.

PARTICIPANTS

4408 participants (age, 72.8 (4.9) years; 53.1% women, 81.7% white; 18.3% black) without prevalent HF and not receiving antihypertensive drugs at baseline.

MAIN OUTCOME MEASURES

Incident HF, defined as first adjudicated hospitalisation for HF.

RESULTS

Over 10 years, 493 (11.2%) participants developed HF. Prehypertension (120-139 mm Hg), stage 1 (140-159 mm Hg), and stage 2 (≥160 mm Hg) hypertension were associated with escalating HF risk; HRs versus optimal SBP (<120 mm Hg) in competing-risks models controlling for clinical characteristics were 1.63 (95% CI 1.23 to 2.16; p=0.001), 2.21 (95% CI 1.65 to 2.96; p<0.001) and 2.60 (95% CI 1.85 to 3.64; p<0.001), respectively. Overall 255/493 (51.7%) HF events occurred in participants with SBP <140 mm Hg at baseline. Increasing SBP was associated with higher HF risk in women than in men; no race-SBP interaction was seen. In analyses with continuous SBP, HF risk had a continuous positive association with SBP to levels as low as 113 mm Hg in men and 112 mm Hg in women.

CONCLUSIONS

There is a continuous positive association between SBP and HF risk in the elderly for levels of SBP as low as <115 mm Hg; over half of incident HF events occur in individuals with SBP <140 mm Hg.

Relation of baseline systolic blood pressure and long-term outcomes in ambulatory patients with chronic mild to moderate heart failure

We studied the impact of baseline systolic blood pressure (SBP) on outcomes in patients with mild to moderate chronic systolic and diastolic heart failure (HF) in the Digitalis Investigation Group trial using a propensity-matched design. Of 7,788 patients, 7,785 had baseline SBP data and 3,538 had SBP ≤ 120 mm Hg. Propensity scores for SBP ≤ 120 mm Hg, calculated for each of the 7,785 patients, were used to assemble a matched cohort of 3,738 patients with SBP ≤ 120 and >120 mm Hg who were well-balanced in 32 baseline characteristics. All-cause mortality occurred in 35% and 32% of matched patients with SBPs ≤ 120 and >120 mm Hg respectively, during 5 years of follow-up (hazard ratio [HR] when SBP ≤ 120 was compared to >120 mm Hg 1.10, 95% confidence interval [CI] 0.99 to 1.23, p = 0.088). HRs for cardiovascular and HF mortalities associated with SBP ≤ 120 mm Hg were 1.15 (95% CI 1.01 to 1.30, p = 0.031) and 1.30 (95% CI 1.08 to 1.57, p = 0.006). Cardiovascular hospitalization occurred in 53% and 49% of matched patients with SBPs ≤ 120 and > 120 mm Hg, respectively (HR 1.13, 95% CI 1.03 to 1.24, p = 0.008). HRs for all-cause and HF hospitalizations associated with SBP ≤ 120 mm Hg were 1.10 (95% CI 1.02 to 1.194, p = 0.017) and 1.21 (95% CI 1.07 to 1.36, p = 0.002). In conclusion, in patients with mild to moderate long-term systolic and diastolic HF, baseline SBP ≤ 120 mm Hg was associated with increased cardiovascular and HF mortalities and all-cause, cardiovascular, and HF hospitalizations that was independent of other baseline characteristics.

Association of systolic blood pressure with mortality in patients with heart failure with reduced ejection fraction: a complex relationship

BACKGROUND

In ambulatory patients with heart failure with reduced ejection fraction (HFrEF), high systolic blood pressure (SBP) is associated with better outcomes. However, it is not known whether there is a ceiling beyond which high SBP has a detrimental effect. Thus, our aim was to assess the linearity of association between SBP and mortality.

METHODS

We used the External Peer Review Program (EPRP) and Digitalis Investigation Group (DIG) trial databases of HFrEF patients. Linearity of association of SBP with mortality was assessed by plotting Martingale residuals against SBP. To assess the patterns of relationship of SBP with mortality, we used restricted cubic spline analysis with Cox proportional hazards model.

RESULTS

In patients with mild-to-moderate left ventricular systolic dysfunction (LVSD) (30% ≤ LVEF < 50%), SBP had a nonlinear association with mortality in both EPRP (n = 3,693) and DIG (n = 3,263) databases. In these patients, SBP had a significant U-shaped association with mortality in EPRP and a trend toward U-shaped relationship in DIG database. In patients with severe LVSD (LVEF <30%), SBP had a linear association with mortality in both EPRP (n = 2,906) and DIG (n = 3,537) databases, with lower SBP being associated with increased mortality.

CONCLUSIONS

Systolic blood pressure has a complex nonlinear association with mortality in patients with heart failure. Whereas it has a U-shaped association in patients with mild-to-moderate LVSD, it has a linear association with mortality in patients with severe LVSD. Recognition of this pattern of association of blood pressure profile may help clinicians in providing better care for their patients and help improve existing prediction models.

Age, race, diabetes, blood pressure, and mortality among hemodialysis patients

Observational studies involving hemodialysis patients suggest a U-shaped relationship between BP and mortality, but the majority of these studies followed large, heterogeneous cohorts. To examine whether age, race, and diabetes status affect the association between systolic BP (SBP; predialysis) and mortality, we studied a cohort of 16,283 incident hemodialysis patients. We constructed a series of multivariate proportional hazards models, adding age and BP to the analyses as cubic polynomial splines to model potential nonlinear relationships with mortality. Overall, low SBP associated with increased mortality, and the association was more pronounced among older patients and those with diabetes. Higher SBP associated with increased mortality among younger patients, regardless of race or diabetes status. We observed a survival advantage for black patients primarily among older patients. Diabetes associated with increased mortality mainly among older patients with low BP. In conclusion, the design of randomized clinical trials to identify optimal BP targets for patients with ESRD should take age and diabetes status into consideration.

Memory dysfunction, psychomotor slowing, and decreased executive function predict mortality in patients with heart failure and low ejection fraction

BACKGROUND

The purpose of this study was to evaluate whether dysfunction of specific cognitive abilities is a predictor of impending mortality in adults with systolic heart failure (HF).

METHODS

A total of 166 stable outpatients with HF completed cognitive function evaluation in language, working memory, memory, visuospatial ability, psychomotor speed, and executive function using a neuropsychological test battery. Demographic and clinical variables, comorbidity, depressive symptoms, and health-related quality of life were also measured. Patients were followed for 12 months to determine all-cause mortality.

RESULTS

There were 145 survivors and 21 deaths. In logistic regression analyses, significant predictors of mortality were lower left ventricular ejection fraction (LVEF) and poorer scores on measures of global congnitive function Mini-Mental State Examination [MMSE], working memory, memory, psychomotor speed, and executive function. Memory loss was the most predictive cognitive function variable (overall chi(2) = 17.97, df = 2, P < .001; Nagelkerke R(2) = 0.20). Gender was a significant covariate in 2 models, with men more likely to die. Age, comorbidity, depressive symptoms, and health-related quality of life were not significant predictors. In further analyses, significant predictors of mortality were lower systolic blood pressure and poorer global cognitive function, working memory, memory, psychomotor speed, and executive function, with memory being the most predictive.

CONCLUSIONS

As hypothesized, lower LVEF and memory dysfunction predicted mortality. Poorer global cognitive score as determined by the MMSE, working memory, psychomotor speed, and executive function were also significant predictors. LVEF or systolic blood pressure had similar predictive values. Interventions are urgently needed to prevent and manage memory loss in HF.

Low blood pressure and preserved systolic function in elders with heart failure

This literature review was performed to evaluate the relationship of systolic blood pressure (SBP) and preserved systolic function on morbidity and mortality in individuals older than 65 years with heart failure (HF). When prolonged, high SBP, defined as measurements greater than 140 to 160 mm Hg, is associated with increased risk of developing HF. Medications to lower SBP measurements to Joint National Committee VII goals of less than 140 mm Hg are often prescribed on the assumption that treatment guidelines result from a systematic analysis of clinical trials and efficacy of drug treatments. Lower limits of SBP are less defined in current guidelines optimizing HF. The electronic databases PubMed, CINAHL, and Google Scholar are searched for keywords heart failure, prognosis, preserved systolic function, and blood pressure (BP). Five scholarly research articles investigated the effects of variables, notably SBP and confirmed preserved systolic function, on HF, published in the English language between July 2006 and January 2009. Inclusion criteria were study samples consisting of individuals 65 years and older referred in this article as elders, with the diagnosis of HF with a focus on variables measuring SBP and systolic function when assessing outcomes. Low SBP is a risk factor for adverse outcomes in HF elders. Additionally, female elders more commonly had preserved systolic function, but presented with less classic symptoms of HF and were less likely to receive cardiology consultation. Considerations for future research are the inclusion of participants presenting with SBP of less than 110 mm Hg in clinical trials and updated evidence-based guidelines, defining acceptable increased target BP ranges, for sex- and age-adjusted HF patients with preserved systolic function.

Impact of baseline systolic blood pressure on long-term outcomes in patients with advanced chronic systolic heart failure (insights from the BEST trial)

The impact of baseline systolic blood pressure (SBP) on outcomes in patients with advanced chronic systolic heart failure (HF) has not been studied using a propensity-matched design. Of the 2,706 participants in the Beta-Blocker Evaluation of Survival Trial (BEST) with chronic HF, New York Heart Association class III to IV symptoms and left ventricular ejection fraction < or =35%, 1,751 had SBP < or =120 mm Hg (median 108, range 70 to 120) and 955 had SBP >120 mm Hg (median 134, range 121 to 192). Propensity scores for SBP >120 mm Hg, calculated for each patient, were used to assemble a matched cohort of 545 pairs of patients with SBPs < or =120 and >120 mm Hg who were balanced in 65 baseline characteristics. Matched Cox regression models were used to estimate associations between SBP < or =120 mm Hg and outcomes over 4 years of follow-up. Matched participants had a mean age +/- SD of 62 +/- 12 years, 24% were women, and 24% were African-American. HF hospitalization occurred in 38% and 32% of patients with SBPs < or =120 and >120 mm Hg, respectively (hazard ratio 1.33 SBP < or =120 was compared to >120 mm Hg, 95% confidence interval 1.04 to 1.69, p = 0.023). All-cause mortality occurred in 28% and 30% of matched patients with SBPs < or =120 and >120 mm Hg, respectively (hazard ratio 1.13 SBP < or =120 compared to >120 mm Hg, 95% confidence interval 0.86 to 1.49, p = 0.369). In conclusion, in patients with advanced chronic systolic HF, baseline SBP < or =120 mm Hg is associated with increased risk of HF hospitalization, but had no association with all-cause mortality.

Acute cardiovascular effects of apelin in humans: potential role in patients with chronic heart failure

BACKGROUND

Apelin, the endogenous ligand for the novel G protein-coupled receptor APJ, has major cardiovascular effects in preclinical models. The study objectives were to establish the effects of acute apelin administration on peripheral, cardiac, and systemic hemodynamic variables in healthy volunteers and patients with heart failure.

METHODS AND RESULTS

Eighteen patients with New York Heart Association class II to III chronic heart failure, 6 patients undergoing diagnostic coronary angiography, and 26 healthy volunteers participated in a series of randomized, double-blind, placebo-controlled studies. Measurements of forearm blood flow, coronary blood flow, left ventricular pressure, and cardiac output were made by venous occlusion plethysmography, Doppler flow wire and quantitative coronary angiography, pressure wire, and thoracic bioimpedance, respectively. Intrabrachial infusions of (Pyr(1))apelin-13, acetylcholine, and sodium nitroprusside caused forearm vasodilatation in patients and control subjects (all P<0.0001). Vasodilatation to acetylcholine (P=0.01) but not apelin (P=0.3) or sodium nitroprusside (P=0.9) was attenuated in patients with heart failure. Intracoronary bolus of apelin-36 increased coronary blood flow and the maximum rate of rise in left ventricular pressure and reduced peak and end-diastolic left ventricular pressures (all P<0.05). Systemic infusions of (Pyr(1))apelin-13 (30 to 300 nmol/min) increased cardiac index and lowered mean arterial pressure and peripheral vascular resistance in patients and healthy control subjects (all P<0.01) but increased heart rate only in control subjects (P<0.01).

CONCLUSIONS

Acute apelin administration in humans causes peripheral and coronary vasodilatation and increases cardiac output. APJ agonism represents a novel potential therapeutic target for patients with heart failure.

Systolic blood pressure and mortality in prevalent haemodialysis patients in the HEMO study

Previous studies of blood pressure and mortality in haemodialysis have yielded mixed results, perhaps due to confounding by comorbid conditions. We hypothesized that after improved accounting for confounding factors, higher systolic blood pressure (SBP) would be associated with higher all-cause mortality. We conducted a secondary analysis of data from the haemodialysis study, a randomized trial in prevalent haemodialysis patients. We used three proportional hazard models to determine the relative hazard at different levels of SBP: (1) Model-BL used baseline SBP; (2) Model-TV used SBP as a time-varying variable; and (3) Model-TV-Lag added a 3-month lag to Model-TV to de-emphasize changes in SBP associated with acute illness. In all the models, pre-dialysis SBP <120 mm Hg was associated with a higher risk of mortality compared with the referent group (140-159 mm Hg); higher pre-dialysis SBP was not associated with higher risk of mortality. In conclusion, we observed a robust association between lower pre-dialysis SBP and higher risk for all-cause and cardiovascular mortality in a well-characterized cohort of prevalent haemodialysis patients. Randomized clinical trials are needed to define optimal blood pressure targets in the haemodialysis population.

Association between hypotension, low ejection fraction and cognitive performance in cardiac patients

BACKGROUND AND PURPOSE

Impaired cardiac function can adversely affect the brain via decreased perfusion. The purpose of this study was to determine if cardiac ejection fraction (EF) is associated with cognitive performance, and whether this is modified by low blood pressure.

METHODS

Neuropsychological testing evaluating multiple cognitive domains, measurement of mean arterial pressure (MAP), and measurement of EF were performed in 234 individuals with coronary artery disease. The association between level of EF and performance within each cognitive domain was explored, as was the interaction between low MAP and EF.

RESULTS

Adjusted global cognitive performance, as well as performance in visuoconstruction and motor speed, was significantly directly associated with cardiac EF. This relationship was not entirely linear, with a steeper association between EF and cognition at lower levels of EF than at higher levels. Patients with low EF and low MAP at the time of testing had worse cognitive performance than either of these alone, particularly for the global and motor speed cognitive scores.

CONCLUSIONS

Low EF may be associated with worse cognitive performance, particularly among individuals with low MAP and for cognitive domains typically associated with vascular cognitive impairment. Further care should be paid to hypotension in the setting of heart failure, as this may exacerbate cerebral hypoperfusion.

Blood pressure and stroke in heart failure in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study

BACKGROUND AND PURPOSE

The prevalence of stroke is increased in individuals with heart failure (HF). The stroke mechanism in HF may be cardiogenic embolism or cerebral hypoperfusion. Stroke risk increases with decreasing ejection fraction and low cardiac output is associated with hypotension and poor survival. We examine the relationship among blood pressure level, history of stroke/transient ischemic attack (TIA), and HF.

METHODS

We compared the prevalence of self-reported history of stroke or TIA in the REasons for Geographic And Racial Differences in Stroke (REGARDS) participants with HF (as defined by current digoxin use) and without HF. We excluded participants with atrial fibrillation or missing data. We examined the relationship between HF and history of stroke/TIA within tertiles of systolic blood pressure (SBP) adjusting for patient demographic and health characteristics.

RESULTS

Prevalent stroke/TIA were reported by 66 (26.3%) of 251 participants with and 1805 (8.5%) of 21 202 participants without HF (P<0.0001). Within each tertile of SBP, the unadjusted OR (95% CI) for prior stroke/TIA among those with HF compared with those without HF (the reference group) was, 4.0 (2.8 to 5.8) for SBP <119.5 mm Hg, 2.7 (1.8 to 3.9) for SBP >or=119.5 but <131.5 mm Hg, and 2.3 (1.6 to 3.2) for SBP >or=131.5 mm Hg. After adjustment, the relationship between prior stroke/TIA and HF remained significant only within the lowest tertile of SBP (<119.5 mm Hg; 3.0; 1.5 to 6.1).

CONCLUSIONS

The odds of prevalent self-reported stroke/TIA are increased in participants with HF and most markedly increased in participants with low SBP. Longitudinal data are needed to determine whether this reflects stroke/TIA secondary to thromboembolism from poor cardiac function or secondary to cerebral hypoperfusion.