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

Longitudinal blood pressure and cardiovascular outcomes in heart failure: An individual patient data pooling analysis of clinical trials

AIMS

Previous analyses of the relationship between blood pressure (BP) and heart failure (HF) outcomes have primarily used baseline values rather than longitudinal measurements. We aimed to elucidate associations between longitudinal BP and clinical outcomes in patients with HF with reduced ejection fraction (HFrEF), mildly reduced ejection fraction (HFmrEF), and preserved ejection fraction (HFpEF).

METHODS AND RESULTS

We conducted a comprehensive analysis of 28 406 patients from eight trials, evaluating time-dependent BP categorized by tertiles and per 10 mmHg increments in BP on outcomes. The primary endpoint was the time to the first occurrence of a composite endpoint comprising cardiovascular death or HF hospitalization. Multivariate Cox regression analysis revealed a J-shaped relationship between BP and the composite outcome in HFrEF. Specifically, compared with the middle-level systolic BP (SBP), low SBP was associated with a higher risk of the composite endpoint (hazard ratio [HR] 1.71, 95% confidence interval [CI] 1.60-1.82; p < 0.001) and high SBP showed a non-significant change in risk (HR 1.07, 95% CI 0.97-1.18; p = 0.187). Conversely, a U-shaped relationship was observed in HFmrEF and HFpEF. Low SBP was linked to a higher risk of the composite endpoint (HR 1.74, 95% CI 1.47-2.07; p < 0.001), and high SBP similarly increased the risk (HR 1.77, 95% CI 1.45-2.17; p < 0.001).

CONCLUSIONS

The relationship between BP and HF outcomes is non-linear and closely tied to left ventricular ejection fraction. Low SBP consistently predicts a poor prognosis, whereas high SBP is associated with an increased risk in HFmrEF and HFpEF but not in HFrEF.

Prognostic Value of the Red Cell Distribution Width-to-eGFR Ratio (RGR) Across Chronic Heart Failure Phenotypes: A Retrospective Observational Pilot Study

Background/Objectives: This study aimed to investigate the prognostic value of the red cell distribution width-to-estimated glomerular filtration rate (RGR) ratio in patients hospitalized with chronic heart failure (CHF) and its potential interaction with NT-proBNP levels. By integrating anemia and renal dysfunction markers, the RGR may provide enhanced predictive insights regarding extended length of hospital stay (ELOS) > 7 days, in-hospital mortality, and 6-month all-cause mortality across specific CHF phenotypes. Methods: In this retrospective, single-center pilot observational study, 627 CHF admissions (January 2022-August 2024) were analyzed. Patients were classified according to the ESC guidelines into heart failure with reduced (HFrEF), mildly reduced (HFmrEF), or preserved ejection fraction (HFpEF). The RGR was calculated as red cell distribution width standard deviation (RDW-SD) divided by estimated glomerular filtration rate (eGFR). Predictive accuracy was evaluated using logistic regression, receiver operating characteristic (ROC) analyses, and stepwise Cox proportional hazard regression. Results: RGR was significantly higher in HFrEF than in HFpEF (p = 0.042) and predicted ELOS only in HFpEF (AUC = 0.619). In contrast, for in-hospital mortality, RGR achieved excellent discrimination in HFrEF (AUC = 0.945), outperforming RDW and NT-proBNP. In HFmrEF, RDW exhibited the highest predictive power (AUC = 0.826), whereas in HFpEF, NT-proBNP was the strongest predictor (AUC = 0.958), although RGR preserved good discrimination (AUC = 0.746). Across the entire cohort and HF phenotypes, RGR consistently emerged as a significant predictor in univariable analysis. In multivariable models, it improved the significance prognosis especially alongside NT-proBNP in the entire cohort and HFrEF. For 6-month all-cause mortality, RGR surpassed RDW in prediction in all HF phenotypes. Conclusions: The RGR independently predicts prolonged hospitalization, in-hospital, and 6-month mortality in CHF-often outperforming RDW and eGFR and being comparable to NT-proBNP, especially in HFrEF. These findings suggest that RGR may serve as a valuable risk stratification tool in CHF management.

A new simple chronic heart failure prognostic index based on five general parameters

BACKGROUND

Prognostic prediction in heart failure (HF) is challenging and no single marker has proven effective. We propose an index based on B-type natriuretic peptide (BNP) and four widely available parameters.

METHODS

We retrospectively analyzed adult outpatients with chronic HF with systolic dysfunction followed from January 2012 to December 2020. The new proposed index was calculated based on 5 parameters measured at the index visit. BASIC index = (BNP*(age)2) / (serum sodium*hemoglobin*estimated glomerular filtration rate). Patients were followed-up until January 2023; the primary endpoint was all-cause mortality. A receiver operator curve was used to assess the association of the index with outcome; a cut-off was chosen based on the curve. We used a Cox-regression analysis to determine the prognostic value of the index. Adjustments were made considering established prognostic predictors.

RESULTS

We studied 1065 patients. Mean age was 71 years, 65.8 % were male, 45.3 % had ischemic HF and 47.2 % had severe systolic dysfunction. During a 47-months median follow-up, 545 patients died (51.2 %). Median BASIC index: 11.7 (3.5-33.7). The area under the curve was 0.73 (0.70-0.76) vs 0.69 (0.66-0.72) for BNP, p < 0.001. The best cut-off value was 9.3; sensitivity = 71.4 %, specificity = 62.3 %, positive predictive value = 66.5 and negative predictive value = 67.5 %. Patients with a BASIC index above 9.3 had a multivariate-adjusted HR of all-cause mortality = 2.70 (2.20-3.22).

CONCLUSIONS

The incorporation of age, hemoglobin, serum sodium, glomerular filtration rate and BNP in an index significantly improves prognostic prediction when compared to BNP alone. Patients with a BASIC index above 9.3 have an almost 3-fold higher death-risk.

Systolic blood pressure increase in chronic heart failure associates with survival advantage

Background

The impact of systolic blood pressure (SBP) variation on chronic heart failure (HF) is largely unknown. We assessed the impact of SBP variation in patients with chronic HF.

Methods

This is a retrospective analysis of adult ambulatory patients with HF with left ventricular systolic dysfunction (LVSD). SBP variation = SBP at the index visit - SBP at the 1-year visit. Patients dying in the first year or with missing data concerning SBP were excluded. Patients with SBP increase ≥10 mmHg during the first year were compared with the remaining. Determinants of SBP increase were assessed by binary logistic regression analysis. The patients were followed up from the 1-year visit up to 5 years. The primary end point was all-cause mortality. A Cox regression analysis was used to determine the association of SBP variation with mortality.

Results

We studied 787 patients (68% male), with a mean age of 70 years. SBP increased by ≥10 mmHg in 277 patients (35.2%) and remained stable or decreased in 510. Patients in whom SBP increased more often presented severe LVSD and nonischemic HF; they had lower baseline SBP and were more medicated with loop diuretics. Independent predictors of SBP increase were lower basal SBP and loop diuretic use. Patients with a SBP increase ≥10 mmHg had a crude hazard ratio (HR) of all-cause mortality of 0.74 (0.59-0.94), and the multivariate-adjusted HR was 0.61 (0.46-0.79).

Conclusions

Patients with chronic HF with SBP increase ≥10 mmHg over the first year have a 39% reduction in the all-cause mortality risk irrespective of basal SBP, severity of ventricular dysfunction, and evidence-based drug use. Patients with SBP stability or decrease have a similarly poor prognosis.

Systolic blood pressure, a predictor of mortality and life expectancy following heart failure hospitalization, 2010-2023

BACKGROUND

Optimal systolic blood pressure (SBP) targets for the treatment of hospitalized acute decompensated heart failure (ADHF) patients are not known.

OBJECTIVES

To investigate the association between SBP <130 mmHg at discharge or within 30 days and all-cause mortality or years of life lost (YLL) after ADHF hospitalization.

METHODS

We analyzed medical records of 14,611 adults who survived ADHF hospitalization at 17 hospitals (2010-2022) with follow-up until May 2023. Sensitivity analysis included 10,515 patients with post-discharge SBP measured within 30 days.

RESULTS

Mortality rates at 30 days, 180 days, 1 year, and 3 years were higher in patients with discharge SBP <130 mmHg (6.9 %, 21.1 %, 29.1 %, and 45.1 %) vs. SBP ≥130 mmHg (4.8 %, 16.0 %, 23.6 %, and 40.3 %). Hazard ratios (HR) for mortality were consistently higher in patients with discharge SBP <130 at 1.30 (95 % CI, 1.11-1.52), 1.45 (95 % CI, 1.33-1.58), 1.40 (95 % CI, 1.30-1.51), 1.31 (95 % CI, 1.23-1.38) at these intervals. The average YLL per deceased individual was 1-2 years greater in the discharge SBP <130 group (incidence rate ratios, 1.004 to 1.230). Restricted cubic spline analysis showed that HR for mortality shifted toward better outcomes at discharge SBP ≥130 Sensitivity analysis supported these findings.

CONCLUSION

In hospitalized ADHF patients, SBP <130 mmHg at discharge or within 30 days post-discharge was linked to higher mortality and YLL, while SBP ≥130 mmHg or improvement to ≥130 mmHg post-discharge led to better short and long-term outcomes. Further research is needed to understand the mechanisms and benefits of SBP optimization.

The Impact of Preprocedural Blood Pressure on Outcome After M-TEER: The Paradox or Something Else?

OBJECTIVE

The aim of this study was to investigate the influence of systolic blood pressure (SBP) values on admission on the outcome of mitral transcatheter edge-to-edge repair (M-TEER).

METHODOLOGY

We included all patients who underwent interventional MV repair in our institution between January 2010 and October 2020. All data are obtained from the MiTra ULM registry. Based on SBP values measured on admission, all patients were divided into four groups: < 120, 120-129, 130-139, and ≥ 140 mmHg.

RESULTS

Eight hundred and fifty-eight patients were included in this study. There were no major differences in demographic and clinical characteristics between the four observed groups. The patients with SBP on admission ≥ 140 mmHg had the lowest prevalence of functional MR and the highest LVEF. Higher SBP at admission (HR 0.74, 95% CI: 0.63-0.87) and preprocedural LVEF values (HR 0.99, 95% CI: 0.97-0.99) were predictors of lower 1-year mortality but did not impact 1-year hospitalization rate or MACE in the whole study population. When patients were separated into two groups according to the mechanisms of MR (functional and structural), the results showed that higher SBP on admission and better preprocedural LVEF were associated with significantly lower 1-year CV mortality in both groups of patients, with functional and structural MR. Higher SBP at admission was also associated with lower 1-year CV mortality (HR 0.73, 95% CI: 0.55-0.96) in patients with preserved ejection fraction (LVEF > 50%), but not with 1-year rehospitalization and MACE.

CONCLUSION

Higher SBP on admission (> 140 mmHg) is an independent predictor of a better 1-year outcome in patients treated with M-TEER. The effect of higher SBP on outcome after M-TEER should be further investigated.

A Systematic Review of Metabolic Syndrome: Key Correlated Pathologies and Non-Invasive Diagnostic Approaches

Background and Objectives: Metabolic syndrome (MetS) is a condition marked by a complex array of physiological, biochemical, and metabolic abnormalities, including central obesity, insulin resistance, high blood pressure, and dyslipidemia (characterized by elevated triglycerides and reduced levels of high-density lipoproteins). The pathogenesis develops from the accumulation of lipid droplets in the hepatocyte (steatosis). This accumulation, in genetically predisposed subjects and with other external stimuli (intestinal dysbiosis, high caloric diet, physical inactivity, stress), activates the production of pro-inflammatory molecules, alter autophagy, and turn on the activity of hepatic stellate cells (HSCs), provoking the low grade chronic inflammation and the fibrosis. This syndrome is associated with a significantly increased risk of developing type 2 diabetes mellitus (T2D), cardiovascular diseases (CVD), vascular, renal, pneumologic, rheumatological, sexual, cutaneous syndromes and overall mortality, with the risk rising five- to seven-fold for T2DM, three-fold for CVD, and one and a half-fold for all-cause mortality. The purpose of this narrative review is to examine metabolic syndrome as a "systemic disease" and its interaction with major internal medicine conditions such as CVD, diabetes, renal failure, and respiratory failure. It is essential for internal medicine practitioners to approach this widespread condition in a "holistic" rather than a fragmented manner, particularly in Western countries. Additionally, it is important to be aware of the non-invasive tools available for assessing this condition. Materials and Methods: We conducted an exhaustive search on PubMed up to July 2024, focusing on terms related to metabolic syndrome and other pathologies (heart, Lung (COPD, asthma, pulmonary hypertension, OSAS) and kidney failure, vascular, rheumatological (osteoarthritis, rheumatoid arthritis), endocrinological, sexual pathologies and neoplastic risks. The review was managed in accordance with the PRISMA statement. Finally, we selected 300 studies (233 papers for the first search strategy and 67 for the second one). Our review included studies that provided insights into metabolic syndrome and non-invasive techniques for evaluating liver fibrosis and steatosis. Studies that were not conducted on humans, were published in languages other than English, or did not assess changes related to heart failure were excluded. Results: The findings revealed a clear correlation between metabolic syndrome and all the pathologies above described, indicating that non-invasive assessments of hepatic fibrosis and steatosis could potentially serve as markers for the severity and progression of the diseases. Conclusions: Metabolic syndrome is a multisystem disorder that impacts organs beyond the liver and disrupts the functioning of various organs. Notably, it is linked to a higher incidence of cardiovascular diseases, independent of traditional cardiovascular risk factors. Non-invasive assessments of hepatic fibrosis and fibrosis allow clinicians to evaluate cardiovascular risk. Additionally, the ability to assess liver steatosis may open new diagnostic, therapeutic, and prognostic avenues for managing metabolic syndrome and its complications, particularly cardiovascular disease, which is the leading cause of death in these patients.

Effect of low blood pressure on prognosis of acute heart failure

Low blood pressure (BP) is associated with poor outcomes in patients with heart failure (HF). We investigated the influence of initial BP on the prognosis of HF patients at admission, and prescribing patterns of HF medications, such as angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB), and beta-blockers (BB). Data were sourced from a multicentre cohort of patients admitted for acute HF. Patients were grouped into heart failure reduced ejection fraction (HFrEF) and HF mildly reduced/preserved ejection fraction (HFmrEF/HFpEF) groups. Initial systolic and diastolic BPs were categorized into specific ranges. Among 2778 patients, those with HFrEF were prescribed ACEi, ARB, or BB at discharge, regardless of their initial BP. However, medication use in HFmrEF/HFpEF patients tended to decrease as BP decreased. Lower initial BP in HFrEF patients correlated with an increased incidence of all-cause death and composite clinical events, including HF readmission or all-cause death. However, no significant differences in clinical outcomes were observed in HFmrEF/HFpEF patients according to BP. Initial systolic (< 120 mmHg) and diastolic (< 80 mmHg) BPs were independently associated with a 1.81-fold (odds ratio [OR] 1.81, 95% confidence interval [CI] 1.349-2.417, p < 0.001) and 2.24-fold (OR 2.24, 95% CI 1.645-3.053, p < 0.001) increased risk of long-term mortality in HFrEF patients, respectively. In conclusion, low initial BP in HFrEF patients correlated with adverse clinical outcomes, and BP < 120/80 mmHg independently increased mortality. However, this relationship was not observed in HFmrEF/HFpEF patients.

Blood pressure levels and adverse cardiovascular outcomes in heart failure: A systematic review and meta-analysis

AIM

Existing data on the association between blood pressure levels and adverse cardiovascular outcomes in patients with heart failure (HF) are inconsistent. The optimal blood pressure targets for patients with HF remain uncertain. This study sought to assess the associations between blood pressure (systolic [SBP] and diastolic blood pressure [DBP]) levels and adverse cardiovascular disease (CVD) outcomes in patients with HF.

METHODS AND RESULTS

A systematic review and meta-analysis were conducted using MEDLINE, Embase, the Cochrane Library, and Web of Science databases up to 5 May 2023. The outcomes of interest included adverse cardiovascular events and all-cause mortality. Pooled relative risks (RRs) with corresponding 95% confidence intervals (CIs) were calculated. Forty-three unique observational cohort studies, comprising 120 643 participants with HF, were included. The pooled RRs (95% CIs) for SBP thresholds of ≥140 mmHg versus <140 mmHg were 0.92 (0.83-1.01) for all-cause mortality, 0.83 (0.67-1.04) for CVD death, and 0.98 (0.80-1.21) for HF hospitalization. The pooled RR (95% CI) for SBP thresholds of ≥160 mmHg versus <160 mmHg and all-cause mortality was 0.67 (0.62-0.74). SBP levels below <130, <120, and <110 mmHg were each associated with an increased risk of various cardiovascular endpoints and all-cause mortality. The pooled RR (95% CI) for DBP thresholds of ≥80 mmHg versus <80 mmHg and all-cause mortality was 0.86 (0.67-1.10). A 10 mmHg increase in SBP or DBP was associated with a reduction in all-cause mortality and other cardiovascular endpoints.

CONCLUSIONS

The findings suggest that lower and normal baseline SBP levels (<130, <120, and <110 mmHg) may be associated with future risk of worse outcomes in patients with HF. Optimal baseline blood pressure levels for these patients may lie within the range of ≥140 mmHg for SBP. In the absence of observational studies with repeated blood pressure measurements or definitive trials evaluating optimal blood pressure targets, individualized blood pressure targets based on patients' unique circumstances are warranted in HF management.

Hypotension in heart failure is less harmful if associated with high or increasing doses of heart failure medication: Insights from the Swedish Heart Failure Registry

AIMS

Heart failure (HF) medication may reduce blood pressure (BP). Low BP is associated with worse outcomes but how this association is modified by HF medication has not been studied. We evaluated the association between BP and outcomes according to HF medication dose in HF with reduced ejection fraction (HFrEF).

METHODS AND RESULTS

We studied HFrEF patients from the Swedish HF registry (2000-2018). Associations between systolic BP (SBP) and cardiovascular death (CVD) and/or HF hospitalization (HFH) were analysed according to doses of renin-angiotensin system (RAS) inhibitors, beta-blockers and mineralocorticoid receptor antagonists (MRA). Among 42 040 patients (median age 74.0), lower baseline SBP was associated with higher risk of CVD/HFH (adjusted hazard ratio [HR] per 10 mmHg higher SBP: 0.92, 95% confidence interval [CI] 0.92-0.93), which was less high risk under optimized RAS inhibitor and beta-blocker doses (10% decrease in event rates per 10 mmHg SBP increase in untreated patients vs. 7% decrease in patients at maximum dose, both adjusted p < 0.02). Among the 13 761 patients with repeated measurements, 9.9% reported a SBP decrease >10 mmHg when HF medication doses were increased, whereas 24.6% reported a SBP decrease >10 mmHg with stable/decreasing doses. Decreasing SBP was associated with higher risk of CVD/HFH in patients with stable (HR 1.10, 95% CI 1.04-1.17) or decreasing (HR 1.29, 95% CI 1.18-1.42) HF medication dose but not in patients with an increase in doses (HR 0.94, 95% CI 0.86-1.02).

CONCLUSIONS

The association of lower SBP with higher risk of CVD/HFH is attenuated in patients with optimized HF medication. These results suggest that low or declining SBP should not limit HF medication optimization.

Novel Pulse Waveform Index by Ambulatory Blood Pressure Monitoring and Cardiac Function: A Pilot Study

Background

A simple ambulatory measure of cardiac function could be helpful for monitoring heart failure patients.

Objectives

The purpose of this paper was to determine whether a novel pulse waveform analysis using data obtained by our developed multisensor-ambulatory blood pressure monitoring (ABPM) device, the 'Sf/Am' ratio, is associated with echocardiographic left ventricular ejection fraction (LVEF).

Methods

Multisensor-ABPM was conducted twice at baseline in 20 heart failure (HF) patients with HF-reduced LVEF or HF-preserved LVEF (median age 66 years, male 65%) and over a 6- to 12-month follow-up after patient-tailored treatment. We assessed the changes in the pulse waveform index Sf/Am and LVEF that occurred between the baseline and follow-up. The Sf/Am consists of the area of the ejection part in the square forward wave (Sf) and the amplitude of the measured wave (Am). We divided the patients into the recovered (n = 11) and not-recovered (n = 9) groups defined by a ≥10% increase in LVEF.

Results

Although the ambulatory BP levels and variabilities did not change in either group, the Sf/Am increased significantly in the recovered group (baseline 21.4 ± 4.5; follow-up, 25.6 ± 3.7, P = 0.004). The not-recovered group showed no difference between the baseline and follow-up. The follow-up/baseline Sf/Am ratio was significantly associated with the LVEF ratio (r = 0.469, P = 0.037). The Sf/Am was significantly correlated with the LVEF in overall measurements (n = 40, r = 0.491, P = 0.001).

Conclusions

These results demonstrated that a novel noninvasive pulse waveform index, the Sf/Am measured by multisensor-ABPM is associated with LVEF. The Sf/Am may be useful for estimating cardiac function.

Effect of blood pressure index on clinical outcomes in patients with heart failure and chronic kidney disease

AIMS

This study aimed to assess the effect of blood pressure (BP) index, in terms of level and variability, on the progression of cardiovascular and renal diseases in patients with both heart failure (HF) and chronic kidney disease (CKD).

METHODS AND RESULTS

The study involved patients with HF and CKD from the database of the Chronic Renal Insufficiency Cohort (CRIC) study. The study endpoint includes the following: (i) primary endpoint, including cardiovascular disease (CVD) events, renal events, and all-cause death; (ii) CVD events; (iii) renal events; and (iv) all-cause death. Among 3939 participants in the CRIC study, a total of 382 patients were included. The duration of the follow-up was 6.3 ± 2.7 years, the age was 60.2 ± 8.9 years, and 57.6% were male. BP index included 20 indicators in relation to BP level and variability, 4 of which were analysed including baseline systolic BP (SBP), standard deviation of SBP, coefficient of variation of diastolic BP (DBP CV), and average real variability of pulse pressure. In the Cox regression analysis after adjustment, baseline SBP was significant for the risk of primary endpoint [hazard ratio (HR) 1.22, 95% confidence interval (CI) 1.03-1.44, P = 0.02] and renal events (HR 1.54, 95% CI 1.22-1.95, P < 0.001), and DBP CV was significant for the risk of primary endpoint (HR 1.03, 95% CI 1.01-1.06, P = 0.02) and CVD events (HR 1.04, 95% CI 1.02-1.07, P < 0.01). The result of the forest plot depicted that baseline SBP had a linear association with the risk of CVD and renal events (P = 0.04 and 0.001, respectively) and DBP CV with CVD events (P = 0.02). As the restricted cubic spline models displayed, DBP CV featured a J- or L-curved association with the primary endpoint, renal events, and all-cause death (P for nonlinearity = 0.01, <0.001, and 0.01, respectively).

CONCLUSIONS

The baseline SBP and DBP CV may remain significant for clinical outcomes in patients with both HF and CKD. The increase in baseline SBP is associated with a higher risk of primary endpoint, CVD events, and renal events, and the increase in DBP CV with a higher risk of CVD events. Concerning nonlinear association, DBP CV features a J- or L-curved relationship with the primary endpoint, renal events, and all-cause death, with a higher risk at both low and high values.

TRIAL REGISTRATION

https://www.

CLINICALTRIALS

gov; unique identifier: NCT00304148.

Blood pressure control and its associated factors among patients with heart failure in Jordan

Uncontrolled blood pressure (BP) has been associated with increased risk of cardiovascular events including heart failure. This study aimed to explore the factors associated with poor BP control among patients with heart failure at two major outpatient cardiology clinics in Jordan. Variables including socio-demographics, biomedical variables, in addition to disease and medication characteristics were collected using medical records and custom-designed questionnaire. The validated 4-item Medication Adherence Scale was used to assess medication adherence. Binary logistic regression analysis was conducted to explore the significant and independent predictors of poor BP control. Regression analysis results revealed that being not satisfied with the prescribed medication (OR = 2.882; 95% CI: 1.458-5.695; P < 0.01), reporting moderate medication adherence (OR = 0.203; 95% CI: 22 0.048-0.863; P < 0.05), not receiving digoxin (OR = 3.423; 95% CI: 1.346-8.707; P < 0.05), and not receiving aldosterone antagonist (OR = 2.044; 95% CI: 1.038-4.025; P < 0.05) were associated with poor BP control. Future interventions should focus on increasing medication satisfaction and enhancing medication adherence, in order to improve BP control among patients with heart failure.

Clinical Outcomes in Patients on Hemodialysis with Congestive Heart Failure

Introduction

Congestive heart failure (CHF) is one of the common complications in patients with end-stage kidney disease. In the general population, CHF increases the risk of the death. However, there is no well-designed relevant study in the Chinese hemodialysis (HD) population addressing the risks associated with CHF. The aim of this study was to explore the impact of CHF on clinical outcomes in HD patients.

Methods

Data from a prospective cohort study, the China Dialysis Outcomes and Practice Patterns Study (DOPPS) 5 (2012-2015), were analyzed. Demographic data, comorbidities, lab data, and death records were extracted. CHF was defined by the diagnosis records upon study inclusion. Our primary outcome was all-cause and cardiovascular (CV) mortality; secondary outcomes were all-cause and cause-specific hospitalization risk. Associations between CHF and outcomes were evaluated using Cox regression models. Stepwise multivariate logistic regression was used to identify the related risk factors, and subgroup analyses were carried out.

Results

Of 1,411 patients without missing CHF history information, 24.1% (340) had CHF diagnosis at enrollment. The overall mortality rates were 21.8% versus 12.0% (p < 0.001) in patients with and without CHF during follow-up, respectively. CHF was associated with higher all-cause mortality (adjusted HR: 1.72, 95% confidence interval [CI]: 1.17-2.53, p = 0.006), and the association with CV death was of similar magnitude (HR: 1.60, 95% CI: 0.91-2.81, p = 0.105). CHF patients had more episodes of hospitalization due to heart failure (HR: 2.93, 95% CI: 1.49-5.76, p < 0.01). However, compared with patients without CHF, the all-cause hospitalization risk was not much higher in CHF patients (HR: 1.09, 95% CI: 0.90-1.33, p = 0.39). Subgroup analysis found that the effect of CHF on all-cause mortality was stronger for male patients, patients with residual renal function, the elderly (≥60 years of age), patients with arteriovenous fistulae vascular accesses, nondiabetic patients, low-flux dialyzer users, and inadequately dialyzed patients (standardized Kt/V <2).

Conclusion

In HD patients, CHF was found to be associated with a higher risk of all-cause mortality and cause-specific hospitalization risk. Further research is needed to identify opportunities to improve care for HD patients combined with CHF.

Systolic blood pressure time in target range and long-term outcomes in patients with ischemic cardiomyopathy

BACKGROUND

The relationship between the degree of systolic blood pressure (SBP) control and outcomes remains unclear in patients with ischemic cardiomyopathy (ICM). Current control metrics may not take into account the potential effects of SBP fluctuations over time on patients.

METHODS

This study was a post-hoc analysis of the surgical treatment of ischemic heart failure trial which enrolled 2,136 participants with ICM. Our SBP target range was defined as 110 to 130 mm Hg and the time in target range (TTR) was calculated by linear interpolation.

RESULTS

A total of 1,194 patients were included. Compared with the quartile 4 group (TTR 77.87%-100%), the adjusted hazard ratios and 95% confidence intervals of all-cause mortality were 1.32 (0.98-1.78) for quartile 3 group (TTR 54.81%-77.63%), 1.40 (1.03-1.90) for quartile 2 group (TTR 32.59%-54.67%), and 1.53 (1.14-2.04) for quartile 1 group (TTR 0%-32.56%). Per 29.28% (1-SD) decrement in TTR significantly increased the risk of all-cause mortality (1.15 [1.04-1.26]). Similar results were observed in the cardiovascular (CV) mortality and the composite outcome of all-cause mortality plus CV rehospitalization, and in the subgroup analyses of either coronary artery bypass grafting or medical therapy, and different baseline SBP.

CONCLUSIONS

In patients with ICM, the higher TTR was significantly associated with decreased risk of all-cause mortality, CV mortality and the composite outcome of all-cause mortality plus CV rehospitalization, regardless of whether the patient received coronary artery bypass grafting or medical therapy, and the level of baseline SBP. TTR may be a surrogate metric of long-term SBP control in patients with ICM.

Effect of different blood pressure levels on short-term outcomes in hospitalized heart failure patients

Background

To investigate the influence of blood pressure (BP) level on short-term prognosis of heart failure (HF), the effect of the BP level on clinical end point events 3 months after discharge was observed.

Methods

A retrospective cohort study was performed on 1492 hospitalized HF patients. All patients were divided according to systolic blood pressure (SBP) per 20 mmHg and diastolic blood pressure (DBP) per 10 mmHg. Logistic regression analysis was used to analyze the relationship between BP level and heart failure rehospitalization, cardiac death, all-cause death and a composite end point of heart failure rehospitalization/all-cause death at 3 month follow-up after discharge.

Results

After multivariable adjustment, the relationship between SBP and DBP levels and outcomes followed an inverted J curve relationship. Compared with the reference group (110 < SBP≤130 mmHg), the risk of all end point events significantly increased in the SBP≤90 mmHg group included heart failure rehospitalization (OR 8.16, 95%CI 2.88-23.11, P < 0.001), cardiac death (OR 5.43, 95%CI 1.97-14.96, P = 0.001), all-cause death (OR 4.85, 95%CI 1.76-13.36, P = 0.002), and composite end point (OR 2.76, 95%CI 1.03-7.41, P = 0.044). SBP>150 mmHg significantly increased the risk of heart failure rehospitalization (OR 2.67, 95%CI 1.15-6.18, P = 0.022). Compared with.the reference group (65 < DBP≤75 mmHg), cardiac death (OR 2.64, 95%CI 1.15-6.05, P = 0.022) and all-cause death (OR 2.67, 95%CI 1.20-5.93, P = 0.016) was significantly increased in DBP≤55 mmHg group. There was no significant difference among subgroups according to left ventricular ejection fraction (P > 0.05).

Conclusions

There is a significant difference in the short-term prognosis 3 months after discharge in HF patients with different BP levels at discharge. There was an inverted J curve relationship between BP levels and prognosis.

Hypotension on cardiopulmonary stress test predicts 90 day mortality after LVAD implantation in INTERMACS 3-6 patients

AIMS

Cardiopulmonary stress test (CPX) is routinely performed when evaluating patient candidacy for left ventricular assist device (LVAD) implantation. The predictive value of hypotensive systolic blood pressure (SBP) response during CPX on clinical outcomes is unknown. This study aims to determine the effect of hypotensive SBP response during to clinical outcomes among patients who underwent LVAD implantation.

METHODS AND RESULTS

This was a retrospective single center study enrolling consecutive patients implanted with a continuous flow LVAD between 2011 and 2022. Hypotensive SBP response was defined as peak exercise SBP below the resting value. Multivariable Cox-regression analysis was performed to evaluate the relationship between hypotensive SBP response and all-cause mortality within 30 and 90 days of LVAD implantation. A subgroup analysis was performed for patients implanted with a HeartMate III (HM III) device. Four hundred thirty-two patients underwent LVAD implantation during the pre-defined period and 156 with INTERMACS profiles 3-6 met our inclusion criteria. The median age was 63 years (IQR 54-69), and 52% had ischaemic cardiomyopathy. Hypotensive SBP response was present in 35% of patients and was associated with increased 90 day all-cause mortality (unadjusted HR 9.16, 95% CI 1.98-42; P = 0.0046). Hazard ratio remained significant after adjusting for age, INTERMACS profile, serum creatinine, and total bilirubin. Findings were similar in the HM III subgroup.

CONCLUSIONS

Hypotensive SBP response on pre-LVAD CPX is associated with increased perioperative and 90 day mortality after LVAD implantation. Additional studies are needed to determine the mechanism of increased mortality observed.

Effect of sodium-glucose cotransporter-2 inhibitors on blood pressure in patients with heart failure: a systematic review and meta-analysis

Background

Recent studies have shown that sodium-glucose cotransporter-2 inhibitors (SGLT2i) can achieve significant improvement in blood pressure in people with diabetes. Furthermore, randomized controlled trials (RCTs) have established that SGLT2i have a cardioprotective effect in adults with heart failure (HF). Therefore, we performed this systematic review an meta-analysis to determine the effect of SGLT2i on blood pressure in patients with HF.

Methods

We used the Medline, Cochrane Library, Embase, and PubMed databases to identify RCTs (published through to April 29, 2022) that evaluated the effect of SGLT2i on HF. The primary endpoint was defined as change in blood pressure. Secondary composite outcomes were heart rate, hematocrit, body weight, and glycated hemoglobin. The N-terminal pro-brain natriuretic peptide level, Kansas City Cardiomyopathy Questionnaire scores, and estimated glomerular filtration rate were also evaluated.

Results

After a literature search and detailed evaluation, 16 RCTs were included in the quantitative analysis. Pooled analyses showed that SGLT2i were associated with a statistically significant reduction in systolic blood pressure of 1.68 mmHg (95% confidence interval [CI] − 2.7, − 0.66; P = 0.001; I² = 45%) but not diastolic blood pressure (mean difference [MD] −1.06 mmHg; 95% CI −3.20, 1.08; P = 0.33; I² = 43%) in comparison with controls. Furthermore, SGLT2i decreased body weight (MD − 1.36 kg, 95% CI − 1.68, − 1.03; P < 0.001; I² = 61%) and the glycated hemoglobin level (MD − 0.16%, 95% CI − 0.28, −0.04, P = 0.007; I² = 91%) but increased hematocrit (MD 1.63%, 95% CI 0.63, 2.62, P = 0.001; I² = 100%). There was no significant between-group difference in heart rate (MD − 0.35; 95% CI − 2.05, 1.35, P = 0.69; I² = 0).

Conclusions

SGLT2i decreased systolic blood pressure in patients with HF but had no effect on diastolic blood pressure. These inhibitors may have numerous potentially beneficial clinical effects in patients with HF.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01574-w.

Initiation of anti-hypertensive drugs and outcomes in patients with heart failure with preserved ejection fraction and persistent hypertension

BACKGROUND

National heart failure (HF) guidelines recommend that in patients with HF with preserved ejection fraction (EF;HFpEF) and hypertension, systolic blood pressure (SBP) should be maintained below 130 mmHg. The objective of the study is to examine the association between initiation of anti-hypertensive drugs and outcomes in patients with HFpEF with persistent hypertension.

METHODS

Of the 8873 hospitalized patients with HFpEF (EF ≥50%) with a history of hypertension without renal failure in Medicare-linked OPTIMIZE-HF, 3315 had a discharge SBP ≥130 mmHg, of whom 1971 were not receiving anti-hypertensive drugs, thiazides and calcium channel blockers, before hospitalization. Of these, 366 received discharge prescriptions for those drugs. We assembled a propensity score-matched cohort of 365 pairs of patients initiated and not initiated on anti-hypertensive drugs, balanced on 37 baseline characteristics. Hazard ratios (HR) and 95% confidence intervals (CI) for outcomes associated with anti-hypertensive drug initiation were estimated in the matched cohort.

RESULTS

Matched patients (n = 730) had a mean age of 78 years; 67% were women and 17% African Americans. During 6 (median 2.5) years of follow-up, 66% of the patients died and 45% had HF readmission. HRs (95% CIs) for all-cause mortality at 30 days, 12 months and 6 years associated with anti-hypertensive drug initiation were 0.64 (0.30-1.36), 0.70 (0.51-0.97), and 0.95 (0.79-1.13), respectively. Respective HRs (95% CIs) for HF readmission were 1.65 (0.97-2.80), 1.18 (0.90-1.56) and 1.09 (0.88-1.35).

CONCLUSIONS

Among hospitalized older patients with HFpEF with uncontrolled hypertension, the initiation of therapy with anti-hypertensive drugs was not associated with all-cause mortality or hospital readmission.

Prognostic Value of Time in Blood Pressure Target Range Among Patients With Heart Failure

BACKGROUND

Blood pressure (BP) is a continuous and dynamic measure. However, standard BP control metrics may not reflect the variability in BP over time.

OBJECTIVES

This study assessed the prognostic value of time in BP target range among hypertensive patients with heart failure (HF).

METHODS

The authors performed a post hoc analysis of data from the TOPCAT (Treatment of Preserved Cardiac Function HF with an Aldosterone Antagonist) trial and the BEST (Beta-Blocker Evaluation of Survival Trial). Time in target range (TTR) for each patient was calculated using linear interpolation across the study period with the target range of systolic BP between 120 and 130 mm Hg.

RESULTS

A total of 4,789 hypertensive patients (n = 1,654 from BEST and n = 3,135 from TOPCAT) were included. The cumulative incidences of primary endpoint (ie, cardiovascular death or HF hospitalization) were highest among the top quartile of TTR with a dose-dependent manner across quartiles (P_trend <0.005). The top quartile of TTR was significantly associated with a lower risk of primary outcome using adjusted Cox regression model (HR: 0.71; 95% CI: 0.60-0.82), cardiovascular mortality (HR: 0.68; 95% CI: 0.55-0.84), HF hospitalization (HR: 0.70; 95% CI: 0.58-0.85), all-cause mortality (HR: 0.69; 95% CI: 0.58-0.83), and any hospitalization (HR: 0.76; 95% CI: 0.67-0.85). Further analyses using restricted cubic spline indicated a linear relationship between TTR and primary outcome. Similar patterns were observed in the individual trial. Sensitivity analyses generated consistent results while redefining target range as 110 to 130 mm Hg for systolic BP or 70 to 80 mm Hg for diastolic BP.

CONCLUSIONS

TTR could independently predict major adverse cardiovascular events in hypertensive patients with HF.

Predictive value of <i>QRS</i> complex duration in patients with chronic heart failure and atrial fibrillation: retrospective study

Aim. To study of the features of the clinical course and prognosis in patients with chronic heart failure with low ejection fraction (HFrEF) and atrial fibrillation (AF) depending on the width of the QRS complex. Materials and methods. We studied the case histories of 514 patients (aged 60.213.84 years, 78% men) with HFrEF, hospitalized at the Chazov National Medical Research Center of Cardiology (Moscow) for the period from Jan 1, 2017 to Dec 31, 2018. Patients were divided into 2 groups depending on the duration of the QRS complex. Results. Clinical and statistical retrospective analysis of the medical histories of patients with HFrEF, depending on the QRS duration, showed the predominance of patients with a QRS complex size of less than 130 ms (60.7%). In HFrEF, the expansion of the QRS complex is accompanied by an increase in the rate of readmission in patients with sinus rhythm (p=0.004). In patients with AF, the rehospitalization rate is significantly higher than in sinus rhythm and does not depend on the QRS duration (p=0.001). The incidence of unfavorable outcomes increases in connection with the addition of AF, which is most likely a more significant risk factor than QRS width. Conclusion. These results highlight that patients with AF and a narrow QRS complex have the same poor prognosis as those with a wide QRS complex and require the close attention of cardiologists.

Comorbid Hypertension Reduces the Risk of Ventricular Arrhythmia in Chronic Heart Failure Patients with Implantable Cardioverter-Defibrillators

AIMS

Low blood pressure (BP) has been shown to be associated with increased mortality in patients with chronic heart failure. This study was designed to evaluate the relationships between diagnosed hypertension and the risk of ventricular arrhythmia (VA) and all-cause death in chronic heart failure (CHF) patients with implantable cardioverter-defibrillators (ICD), including those with preserved left ventricular ejection fraction (HFpEF) and indication for ICD secondary prevention. We hypothesized that a stable hypertension status, along with an increasing BP level, is associated with a reduction in the risk of VA in this population, thereby limiting ICD efficacy.

METHODS

We retrospectively enrolled 964 CHF patients, with hypertension diagnosis and hospitalized BP measurements obtained before ICD implantation. The primary outcome measure was defined as the composite of SCD, appropriate ICD therapy, and sustained VT. The secondary endpoint was time to death or heart transplantation (HTx). We performed multivariable Cox proportional hazard regression and entropy balancing to calculate weights to control for baseline imbalances with or without hypertension. The Fine-Gray subdistribution hazard model was used to confirm the results. The effect of random BP measurements on the primary outcome was illustrated in the Cox model with inverse probability weighting.

RESULTS

The 964 patients had a mean (SD) age of 58.9 (13.1) years; 762 (79.0%) were men. During the interrogation follow-up [median 2.81 years (interquartile range: 1.32-5.27 years)], 380 patients (39.4%) reached the primary outcome. A total of 244 (45.2%) VA events in non-hypertension patients and 136 (32.1%) in hypertension patients were observed. A total of 202 (21.0%) patients died, and 31 (3.2%) patients underwent heart transplantation (incidence 5.89 per 100 person-years; 95% CI: 5.16-6.70 per 100 person-years) during a median survival follow-up of 4.5 (IQR 2.8-6.8) years. A lower cumulative incidence of VA events was observed in hypertension patients in the initial unadjusted Kaplan-Meier time-to-event analysis [hazard ratio (HR): 0.65, 95% confidence interval (CI): 0.53-0.80]. The protective effect was robust after entropy balancing (HR: 0.71, 95% CI: 0.56-0.89) and counting death as a competing risk (HR: 0.71, 95% CI: 0.51-1.00). Hypertension diagnosis did not associate with all-cause mortality in this population. Random systolic blood pressure was negatively associated with VA outcomes (p = 0.065).

CONCLUSIONS

In hospitalized chronic heart failure patients with implantable cardioverter-defibrillators, the hypertension status and higher systolic blood pressure measurements are independently associated with a lower risk of combined endpoints of ventricular arrhythmia and sudden cardiac death but not with all-cause mortality. Randomized controlled trials are needed to confirm the protective effect of hypertension on ventricular arrhythmia in chronic heart failure patients.

Prognostic value of blood pressure in ambulatory heart failure: a meta-analysis and systematic review. Ambulatory blood pressure predicts heart failure prognosis

Previous primary studies have explored the association between blood pressure (BP) and mortality in ambulatory heart failure (HF) patients reporting varying and contrasting associations. The aim is to determine the pooled BP prognostic value and explore potential reasons for between-study inconsistency. We searched Medline, Cochrane, EMBASE and CINAHL from January 2005 to October 2018 for studies with ≥ 50 events (mortality and/or hospitalization) and included BP in a multivariable model in ambulatory HF patients. We pooled hazard ratios (random effects model) for systolic BP (SBP) or diastolic BP (DBP) effect on mortality and/or hospitalization risk. We used a priori defined sub-group analyses to explore heterogeneity and GRADE approach to assess the certainty of the evidence. Seventy-one eligible articles (239,467 screened) at low to moderate risk of bias included 235,752 participants. Higher SBP was associated with reduced all-cause mortality (HR 0.93, 95%CI 0.91-0.95, I2 = 87.13%, moderate certainty), all-cause hospitalization events (HR 0.91, 95%CI 0.88-0.93, I2 = 44.4%, high certainty) and their composite endpoint (HR 0.93 per 10 mmHg, 95%CI 0.91-0.94, I2 = 86.3%, high certainty). DBP did not demonstrate a statistically significant effect for all outcomes. The association strength was significantly weaker in studies following patients with either LVEF > 40%, higher average SBP (> 130 mmHg), increasing age and diabetes. All other a priori subgroup hypotheses did not explain between study differences. Higher ambulatory SBP is associated with reduced risk of all-cause mortality and hospitalization. Patients with lower BP and reduced LVEF are in a high-risk group of developing adverse events with moderate certainty of evidence.

Clinical Predictors of Mortality in Prehospital Distress Calls by Emergency Medical Service Subscribers

(1) Introduction: Most studies rely on in-hospital data to predict cardiovascular risk and do not include prehospital information that is substantially important for early decision making. The aim of the study was to define clinical parameters in the prehospital setting, which may affect clinical outcomes. (2) Methods: In this population-based study, we performed a retrospective analysis of emergency calls that were made by patients to the largest private emergency medical services (EMS) in Israel, SHL Telemedicine Ltd., who were treated on-site by the EMS team. Demographics, clinical characteristics, and clinical outcomes were analyzed. Mortality was evaluated at three time points: 1, 3, and 12 months’ follow-up. The first EMS prehospital measurements of the systolic blood pressure (SBP) were recorded and analyzed. Logistic regression analyses were performed. (3) Results: A total of 64,320 emergency calls were included with a follow-up of 12 months post index EMS call. Fifty-five percent of patients were men and the mean age was 70.2 ± 13.1 years. During follow-up of 12 months, 7.6% of patients died. Age above 80 years (OR 3.34; 95% CI 3.03–3.69, p < 0.005), first EMS SBP ≤ 130 mm Hg (OR 2.61; 95% CI 2.36–2.88, p < 0.005), dyspnea at presentation (OR 2.55; 95% CI 2.29–2.83, p < 0001), and chest pain with ischemic ECG changes (OR 1.95; 95% CI 1.71–2.23, p < 0.001) were the highest predictors of 1 month mortality and remained so for mortality at 3 and 12 months. In contrast, history of hypertension and first EMS prehospital SBP ≥ 160 mm Hg were significantly associated with decreased mortality at 1, 3 and 12 months. (4) Conclusions: We identified risk predictors for all-cause mortality in a large cohort of patients during prehospital EMS calls. Age over 80 years, first EMS-documented prehospital SBP < 130 mm Hg, and dyspnea at presentation were the most profound risk predictors for short- and long-term mortality. The current study demonstrates that in prehospital EMS call settings, several parameters can be used to improve prioritization and management of high-risk patients.

Distinctive prognostic factor of heart failure with preserved ejection fraction stratified with admission blood pressure

Aims

The prognostic importance of admission systolic blood pressure (SBP) in heart failure with preserved ejection fraction (HFpEF) is elusive. We aimed to clarify the pathophysiological differences between patients categorized with admission SBP among HFpEF patients.

Methods and results

We studied 1008 inpatients from PURSUIT‐HFpEF, a multicentre prospective observational registry. We classified patients as having elevated (>140 mmHg), preserved (90–140 mmHg), or low (<90 mmHg) admission SBP. Most cases had elevated (n = 584) or preserved (n = 420) SBP; the four cases with low SBP were excluded. Univariable Cox regression testing revealed that preserved SBP patients had a higher risk of a composite of cardiac death and heart failure re‐hospitalization [hazard ratio (HR) 1.48, 95% confidence interval (CI) 1.14–1.92, P = 0.0035] than elevated SBP patients. In multivariable Cox regression models, while prior heart failure hospitalization (HR 1.36, 95% CI 1.01–2.84, P = 0.0453), atrial fibrillation (HR 1.82, 95% CI 1.10–2.99, P = 0.0209), and N‐terminal pro‐B‐type natriuretic peptide (HR 1.94, 95% CI 1.10–3.43, P = 0.0229) at discharge were significantly associated with adverse outcomes in elevated SBP patients, N‐terminal pro‐B‐type natriuretic peptide (HR 2.06, 95% CI 1.04–4.07, P = 0.0373) and right ventricular‐pulmonary artery uncoupling reflected by the tricuspid annular plane systolic excursion/pulmonary artery systolic pressure ratio (HR 0.19, 95% CI 0.05–0.65, P = 0.0075) at discharge were significant prognostic factors in preserved SBP patients.

Conclusions

Patients with preserved admission SBP had significant higher risks for adverse outcomes than those with elevated SBP in HFpEF. Tricuspid annular plane systolic excursion/pulmonary artery systolic pressure was the distinctive prognostic factor between the two groups.

Sex-specific temporal trends in ambulatory heart failure incidence, mortality and hospitalisation in Ontario, Canada from 1994 to 2013: a population-based cohort study

OBJECTIVES

To examine the temporal trends in mortality and heart failure (HF) hospitalisation in ambulatory patients following a new diagnosis of HF.

DESIGN

Retrospective cohort study SETTING: Outpatient PARTICIPANTS: Ontario residents who were diagnosed with HF in an outpatient setting between 1994 and 2013.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was all-cause mortality within 1 year of diagnosis and the secondary outcome was HF hospitalisation within 1 year. Risks of mortality and hospitalisation were calculated using the Kaplan-Meier method and the relative hazard of death was assessed using multivariable Cox proportional hazard models.

RESULTS

A total of 352 329 patients were studied (50% female). During the study period, there was a greater decline in age standardised 1-year mortality rates (AMR) in men (33%) than in women (19%). Specifically, female AMR at 1 year was 10.4% (95% CI 9.1% to 12.0%) in 1994 and 8.5% (95% CI 7.5% to 9.5%) in 2013, and male AMR at 1 year was 12.3% (95% CI 11.1% to 13.7%) in 1994 and 8.3% (95% CI 7.5% to 9.1%) in 2013. Conversely, age standardised HF hospitalisation rates declined in men (11.4% (95% CI 10.1% to 12.9%) in 1994 and 9.1% (95% CI 8.2% to 10.1%) in 2013) but remained unchanged in women (9.7% (95% CI 8.3% to 11.3%) in 1994 and 9.8% (95% CI 8.6% to 11.0%) in 2013).

CONCLUSION

Among patients with HF over a 20-year period, there was a greater improvement in the prognosis of men compared with women. Further research should focus on the determinants of this disparity and ways to reduce this gap in outcomes.

Within-patient comparison of His-bundle pacing, right ventricular pacing, and right ventricular pacing avoidance algorithms in patients with PR prolongation: Acute hemodynamic study

AIMS

A prolonged PR interval may adversely affect ventricular filling and, therefore, cardiac function. AV delay can be corrected using right ventricular pacing (RVP), but this induces ventricular dyssynchrony, itself harmful. Therefore, in intermittent heart block, pacing avoidance algorithms are often implemented. We tested His-bundle pacing (HBP) as an alternative.

METHODS

Outpatients with a long PR interval (>200 ms) and intermittent need for ventricular pacing were recruited. We measured within-patient differences in high-precision hemodynamics between AV-optimized RVP and HBP, as well as a pacing avoidance algorithm (Managed Ventricular Pacing [MVP]).

RESULTS

We recruited 18 patients. Mean left ventricular ejection fraction was 44.3 ± 9%. Mean intrinsic PR interval was 266 ± 42 ms and QRS duration was 123 ± 29 ms. RVP lengthened QRS duration (+54 ms, 95% CI 42-67 ms, p < .0001) while HBP delivered a shorter QRS duration than RVP (-56 ms, 95% CI -67 to -46 ms, p < .0001). HBP did not increase QRS duration (-2 ms, 95% CI -8 to 13 ms, p = .6). HBP improved acute systolic blood pressure by mean of 5.0 mmHg (95% CI 2.8-7.1 mmHg, p < .0001) compared to RVP and by 3.5 mmHg (95% CI 1.9-5.0 mmHg, p = .0002) compared to the pacing avoidance algorithm. There was no significant difference in hemodynamics between RVP and ventricular pacing avoidance (p = .055).

CONCLUSIONS

HBP provides better acute cardiac function than pacing avoidance algorithms and RVP, in patients with prolonged PR intervals. HBP allows normalization of prolonged AV delays (unlike pacing avoidance) and does not cause ventricular dyssynchrony (unlike RVP). Clinical trials may be justified to assess whether these acute improvements translate into longer term clinical benefits in patients with bradycardia indications for pacing.

Effect of dapagliflozin according to baseline systolic blood pressure in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial (DAPA-HF)

AIMS

Concern about hypotension often leads to withholding of beneficial therapy in patients with heart failure and reduced ejection fraction (HFrEF). We evaluated the efficacy and safety of dapagliflozin, which lowers systolic blood pressure (SBP),according to baseline SBP in Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial (DAPA-HF).

METHODS AND RESULTS

Key inclusion criteria were: New York Heart Association Class II-IV, left ventricular ejection fraction ≤ 40%, elevated N-terminal pro-B-type natriuretic peptide level, and SBP ≥95 mmHg. The primary outcome was a composite of worsening heart failure or cardiovascular death. The efficacy and safety of dapagliflozin were examined using SBP as both a categorical and continuous variable. A total of 1205 patients had a baseline SBP <110 mmHg; 981 ≥ 110 < 120; 1149 ≥ 120 < 130; and 1409 ≥ 130 mmHg. The placebo-corrected reduction in SBP from baseline to 2 weeks with dapagliflozin was -2.54 (-3.33 to -1.76) mmHg (P < 0.001), with a smaller between-treatment difference in patients in the lowest compared to highest SBP category. Patients in the lowest SBP category had a much higher rate (per 100 person-years) of the primary outcome [20.6, 95% confidence interval (95% CI) 17.6-24.2] than those in the highest SBP category (13.8, 11.7-16.4). The benefit and safety of dapagliflozin was consistent across the range of SBP; hazard ratio (95% CI) in each SBP group, lowest to highest: 0.76 (0.60-0.97), 0.76 (0.57-1.02), 0.81 (0.61-1.08), and 0.67 (0.51-0.87), P interaction = 0.78. Study drug discontinuation did not differ between dapagliflozin and placebo across the SBP categories examined.

CONCLUSION

Dapagliflozin had a small effect on SBP in patients with HFrEF and was superior to placebo in improving outcomes, and well tolerated, across the range of SBP included in DAPA-HF.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT03036124.

Coexisting Morbidities in Heart Failure: No Robust Interaction with the Left Ventricular Ejection Fraction

PURPOSE OF REVIEW

Heart failure (HF) patients often present with multiple coexisting morbidities. In this review, we contend that coexisting morbidities are highly prevalent and clinically important regardless of the left ventricular ejection fraction (LVEF).

RECENT FINDINGS

Multimorbidity is prevalent in the ambulatory subjects of the community and increases with age. Differences in the prevalence of coexisting morbidities between HF with preserved LVEF (> 50%), mid-range LVEF (40-50%), and reduced LVEF (< 40%) are either not demonstrable or whenever present are small and unrelated to morbidity and mortality. The constellation of coexisting morbidities together with the disease modifiers (age, sex, genes, other) defines the HF phenotype and outcome. There is no robust evidence supporting an interaction in HF patients between the prevalence and clinical significance of coexisting morbidities and the LVEF.

Managing hypertension in patients with heart failure: an ongoing quandary

PURPOSE OF REVIEW

Hypertension (HTN) is one of the strongest risk factors for heart failure and is prevalent in up to 91% of patients with newly diagnosed heart failure. This article offers a practical approach to HTN in patients with heart failure.

RECENT FINDINGS

To date, no randomized trials comparing specific antihypertensive regimens have been conducted in the heart failure population. Management of heart failure with reduced ejection fraction patients with elevated blood pressure (BP) should include guideline-directed medical therapy [angiotensin-converting-enzyme inhibitors (ACEis), aldosterone receptor blockers, AT1 neprilysin-inhibitors, beta blockers and aldosterone blockers] titrated to maximal tolerated doses regardless of BP. Despite the lack of survival benefit current available data suggest the use of ACEis, aldosterone receptor blockers as first-line therapy for HTN in patients with heart failure with preserved ejection fraction.

SUMMARY

Management of HTN in heart failure patients should be based on left ventricular function. Recent findings suggest that AT1 neprilysin-inhibitors offer better BP control when compared with ACEi, or aldosterone receptor blockers and therefore should be used as first-line therapy in hypertensive patients with heart failure with reduced ejection fraction. Their role as antihypertensive agents in heart failure with preserved ejection fraction seems promising but remains under investigation.

Blood pressure and heart failure

Background

Hypertension is a leading cause of cardiovascular disease, stroke, and death. It affects a substantial proportion of the population worldwide, and remains underdiagnosed and undertreated.

Body

Long-standing high blood pressure leads to left ventricular hypertrophy and diastolic dysfunction that cause an increase in myocardial rigidity, which renders the myocardium less compliant to changes in the preload, afterload, and sympathetic tone. Adequate blood pressure control must be achieved in patients with hypertension to prevent progression to overt heart failure. Controlling blood pressure is also important in patients with established heart failure, especially among those with preserved ejection fractions. However, aggressive blood pressure lowering can cause adverse outcomes, because a reverse J-curve association may exist between the blood pressure and the outcomes of patients with heart failure. Little robust evidence exists regarding the optimal blood pressure target for patients with heart failure, but a value near 130/80 mmHg seems to be adequate according to the current guidelines.

Conclusion

Prospective studies are required to further investigate the optimal blood pressure target for patients with heart failure.

The association between blood pressure and long-term outcomes of patients with ischaemic cardiomyopathy with and without surgical revascularization: an analysis of the STICH trial

Aims

Hypertension (HTN) is a well-known contributor to cardiovascular disease, including heart failure (HF) and coronary artery disease, and is the leading risk factor for premature death world-wide. A J- or U-shaped relationship has been suggested between blood pressure (BP) and clinical outcomes in different studies. However, there is little information about the significance of BP on the outcomes of patients with coronary artery disease and left ventricular dysfunction. This study aimed to determine the relationship between BP and mortality outcomes in patients with ischaemic cardiomyopathy.

Methods and results

The influence of BP during a median follow-up of 9.8 years was studied in a total of 1212 patients with ejection fraction ≤35% and coronary disease amenable to coronary artery bypass grafting (CABG) who were randomized to CABG or medical therapy alone (MED) in the STICH (Surgical Treatment for Ischaemic Heart Failure) trial. Landmark analyses were performed starting at 1, 2, 3, 4, and 5 years after randomization, in which previous systolic BP values were averaged and related to subsequent mortality through the end of follow-up with a median of 9.8 years. Neither a previous history of HTN nor baseline BP had any significant influence on long-term mortality outcomes, nor did they have a significant interaction with MED or CABG treatment. The landmark analyses showed a progressive U-shaped relationship that became strongest at 5 years (χ2 and P-values: 7.08, P = 0.069; 8.72, P = 0.033; 9.86; P = 0.020; 8.31, P = 0.040; 14.52, P = 0.002; at 1, 2, 3, 4, and 5-year landmark analyses, respectively). The relationship between diastolic BP (DBP) and outcomes was similar. The most favourable outcomes were observed in the SBP range 120-130, and DBP 75-85 mmHg, whereas lower and higher BP were associated with worse outcomes. There were no differences in BP-lowering medications between groups.

Conclusion

A strong U-shaped relationship between BP and mortality outcomes was evident in ischaemic HF patients. The results imply that the optimal SBP might be in the range 120-130 mmHg after intervention, and possibly be subject to pharmacologic action regarding high BP. Further, low BP was a marker of poor outcomes that might require other interactions and treatment strategies.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.

Comparison of Hemodynamic Factors Predicting Prognosis in Heart Failure: A Systematic Review

Objectives: We systematically reviewed the literature to address the question of which of the three hemodynamic factors predicts prognosis best in heart failure patients when directly compared to each other: cardiac output, preload or afterload. Methods: Prognostic studies in heart failure (HF) were searched that included at least two of the three hemodynamic variables: (1) cardiac output or cardiac index (CI), (2) preload represented by pulmonary capillary wedge pressure (PCWP) and (3) afterload simplified to systolic blood pressure (SBP). Critical appraisal was done according to the QUIPS format for prognostic studies. The main endpoint was all-cause mortality, which could be combined with other endpoints. We report the number of studies in which CI, PCWP and SBP remained significant prognostic predictors in multivariate analysis. We also assessed whether hemodynamic predictors of prognosis varied in four different HF-populations. Results: Included were 18 studies containing a multivariate analysis. PCWP was an independent predictor of prognosis in 10 of 18 studies, SBP in 3 of 14 studies and CI in none of 18 studies. Results were not specific for any of the HF-populations. Conclusions: A higher PCWP and lower SBP are independent predictors of poor prognosis in HF. In spite of the frequently used concept behind HF, this review demonstrates that CI is not an independent predictor of prognosis in HF.

The cholesterol paradox may be attenuated in heart failure patients with diabetes

BACKGROUND

In heart failure (HF) patients, a lower total cholesterol (TC) appears to portend an ominous prognosis. We studied if the prognostic impact of TC was different according to diabetes mellitus (DM) status in a chronic HF population.

METHODS

Patients with systolic HF under optimized and stable evidence-based therapy were prospectively recruited from our HF clinic. We excluded patients on renal replacement therapy and those hospitalized in the previous 2 months. A venous blood sample was collected. Patients were followed for up to 5 years and all-cause mortality was the endpoint under analysis. The prognostic impact of TC was analyzed using a Cox-regression analysis. Analysis was stratified according to coexistence of DM.

RESULTS

We studied 262 chronic HF patients, 182 males, mean age 69 years, 98 (37.4%) diabetic and 62.2% with severe left ventricular systolic dysfunction. Median B-type natriuretic peptide: 237.8 pg/mL; median TC: 169 mg/dL. During follow-up 121 (46.2%) patients died. Patients with TC>200 mg/dL had better survival than those with lower TC; however, this protective effect was mostly observed in non-diabetic HF patients. In non-diabetics the multivariate adjusted 5-year mortality hazard ratio (HR) was 0.36 (95% CI: 0.16-0.79) for those with TC>200 mg/dL. In diabetic HF patients, there was a non-significant survival benefit of TC>200 mg/dL; HR 0.51 (95% CI: 0.20-1.30).

CONCLUSIONS

Non-diabetic chronic HF patients with TC>200 mg/dL have a 64% lower risk of 5-year death. In diabetics, there is a non-significant 49% protective effect of elevated TC. The cholesterol paradox may be attenuated in diabetic HF patients.

Sex differences in outcomes of heart failure in an ambulatory, population-based cohort from 2009 to 2013

BACKGROUND

Heart failure remains a substantial cause of morbidity and mortality in women. We examined the sex differences in heart failure incidence, mortality and hospital admission in a population-based cohort.

METHODS

All Ontario residents who were diagnosed with heart failure in an ambulatory setting between Apr. 1, 2009, and Mar. 31, 2014, were included in this study. Incident cases of heart failure were captured through physician billing using a validated algorithm. Outcomes were mortality and hospital admission for heart failure within 1 year of the diagnosis. Probability of death and hospital admission were calculated using the Kaplan-Meier method. The hazard of death was assessed using a multivariable Cox proportional hazard model.

RESULTS

A total of 90 707 diagnoses of heart failure were made in an ambulatory setting during the study period (47% women). Women were more likely to be older and more frail, and had different comorbidities than men. The incidence of heart failure decreased during the study period in both sexes. The mortality rate decreased in both sexes, but remained higher in women than men. The female age-standardized mortality rate was 89 (95% confidence interval [CI] 80-100) per 1000 in 2009 and 85 (95% CI 75-95) in 2013, versus male age-standardized mortality rates of 88 (95% CI 80-97) in 2009 and 83 (95% CI 75-91) in 2013. Conversely, the rates of incident heart failure hospital admissions after heart failure diagnosis decreased in men and increased in women.

INTERPRETATION

Despite decreases in overall heart failure incidence and mortality in ambulatory patients, mortality rates remain higher in women than in men, and rates of hospital admission for heart failure increased in women and declined in men. Further studies should focus on sex differences in health-seeking behaviour, medical therapy and response to therapy to provide guidance for personalized care.

Sodium-Glucose Cotransporter-2 Inhibitors, Reverse J-Curve Pattern, and Mortality in Heart Failure

The prevalence of diabetes mellitus and heart failure is increasing. The novel sodium-glucose cotransporters 2 inhibitors offer multidimensional ameliorating effects on cardiovascular and heart failure risk factors. Several studies have assessed the impact on cardiovascular events, with data suggesting beneficial effects on cardiovascular events in high-risk patients with diabetes in patients with heart failure. The reverse J-curve pattern between blood pressure levels and mortality has emerged as an important topic in the field of heart failure. There is no significant evidence to propose any potential effect of sodium-glucose co-transporter 2 inhibitors on the J-shape-suggested mortality in patients with heart failure.

Risk Factors Before Dialysis Predominate as Mortality Predictors in Diabetic Maintenance Dialysis patients

Diabetic patients undergoing maintenance dialysis (MD) have a particularly high mortality rate. Many of the risk factors for mortality have been identified in diabetics who die before reaching end stage renal disease (ESRD), i.e. before dialysis (BD). In addition, many risk factors for mortality have been identified in diabetics after dialysis onset (AD). However, whether in the BD period there are long-term risk factors for AD mortality in diabetics is unknown. We therefore investigated a new concept, i.e. that clinical and biochemical risk factors during the BD stage affect long-term AD mortality. We performed a population based retrospective cohort study, in diabetic CKD patients in a single center in south Israel who initiated MD between the years 2003 and 2015. Clinical and biochemical data 12 months BD and 6 months AD were collected and evaluated for association with mortality AD using Cox’s proportional-hazards model. BD parameters that were found to be significant were adjusted for significant parameters AD, thus generating a “combined” regression model in order to isolate the contribution of BD factors on long term mortality. Six hundred and fifty two diabetic MD patients were included in the final analysis. Four independent BD parameters were found in the multivariate model to significantly predict AD mortality: age, BMI (inversely), pulse pressure (U-shaped) and cardiovascular comorbidity. AD independent risk factors for mortality were age, BMI (inversely) and albumin (inversely). Of note, BD factors remained dominantly significant even after additionally adjusting for AD factors. No association was found between either BD HbA1C levels or BD proteinuria and AD mortality. In diabetics who reach ESRD, BD parameters can predict long term AD mortality. Thus, some of the factors affecting the poor survival of diabetic MD patients appear to begin already in the BD period.

Relation of Systolic Blood Pressure on the Following Day with Post-Discharge Mortality in Hospitalized Heart Failure Patients with Preserved Ejection Fraction

The clinical scenario, which is based on systolic blood pressure (SBP) upon admission, is useful for classifying and determining initial treatment for acute heart failure (HF). However, the prognostic significance of SBP following the initial treatment is unclear.The Japanese Heart Failure Syndrome with Preserved Ejection Fraction (JASPER) registry is a nationwide, observational, and prospective registration of consecutive Japanese patients hospitalized with HF with preserved ejection fraction (HFpEF) and left ventricular ejection fraction ≥ 50%. We divided 525 patients into three groups based on their SBP on the day following hospitalization: high (SBP > 140 mmHg, n = 72, 13.7%); normal (100 ≤ SBP ≤ 140 mmHg, n = 379, 72.2%); and low (SBP < 100 mmHg, n = 74, 14.1%) groups. This analysis had two primary endpoints: (1) all-cause death and (2) all-cause death or rehospitalization for HF. In the Kaplan-Meier analysis, both of the endpoints were the highest in the low group (Log-Rank < 0.05, respectively). Compared to the normal and high groups, the low group demonstrated a higher prevalence of atrial fibrillation (67.1%, 63.9%, and 47.8%, P = 0.026) and the lowest left ventricular outflow tract velocity time integral determined by echocardiography (16.4 cm, 19.4 cm, and 23.3 cm, P = 0.001). In the multivariable Cox proportional hazard analysis, low SBP on the day following hospitalization was an independent predictor of all-cause death (hazard ratio 1.868, 95% confidence interval 1.024-3.407, P = 0.042) and the composite endpoint (hazard ratio 1.660, 95% confidence interval 1.103-2.500, P = 0.015).Classification based on SBP on the day following initial treatment predicts post-discharge prognosis in hospitalized patients with HFpEF.

Systolic Blood Pressure and Outcomes in Patients With Heart Failure With Reduced Ejection Fraction

BACKGROUND

National guidelines recommend that systolic blood pressure (SBP) in patients with heart failure with reduced ejection fraction (HFrEF) and hypertension be maintained below 130 mm Hg.

OBJECTIVES

This study sought to determine associations of SBP <130 mm Hg with outcomes in patients with HFrEF.

METHODS

Of the 25,345 patients in the Medicare-linked OPTIMIZE-HF registry, 10,535 had an ejection fraction (EF) ≤40%. Of these, 5,615 had stable SBP (≤20 mm Hg admission to discharge variation), and 3,805 (68%) had a discharge SBP <130 mm Hg. Propensity scores for SBP <130 mm Hg, estimated for each of the 5,615 patients, were used to assemble a matched cohort of 1,189 pairs of patients with SBP <130 versus ≥130 mm Hg, balanced on 58 baseline characteristics (mean age 76 years; mean EF 28%, 45% women, 13% African American). This process was repeated in 3,946 patients, after excluding 1,669 patients (30% of 5,615) with a discharge SBP <110 mm Hg and assembled a second matched balanced cohort of 1,099 pairs of patients with SBP 110 to 129 mm Hg versus ≥130 mm Hg.

RESULTS

Thirty-day all-cause mortality occurred in 7% and 4% of matched patients with SBP <130 mm Hg versus ≥130 mm Hg, respectively (hazard ratio [HR]: 1.76; 95% confidence interval [CI]: 1.24 to 2.48; p = 0.001). HRs (95% CIs) for all-cause mortality, all-cause readmission, and HF readmission at 1 year, associated with SBP <130 mm Hg, were 1.32 (1.15 to 1.53; p < 0.001), 1.11 (1.01 to 1.23; p = 0.030), and 1.24 (1.09 to 1.42; p = 0.001), respectively. HRs (95% CIs) for 30-day and 1-year all-cause mortality associated with SBP 110 to 129 mm Hg (vs. ≥130 mm Hg) were 1.50 (1.03 to 2.19; p = 0.035), and 1.19 (1.02 to 1.39; p = 0.029), respectively.

CONCLUSIONS

Among hospitalized older patients with HFrEF, SBP <130 mm Hg is associated with poor outcomes. This association persisted when the analyses were repeated after excluding patients with SBP <110 mm Hg. There is an urgent need for randomized controlled trials to evaluate optimal SBP reduction goals in patients with HFrEF.

Sacubitril/valsartan in heart failure with reduced ejection fraction patients: Real world experience on advanced chronic kidney disease, hypotension, and dose escalation

BACKGROUND

Angiotensin receptor and neprilysin inhibition (ARNI) has been shown to reduce cardiovascular mortality by 20% as compared with enalapril in a randomized controlled trial. However, there is a paucity of real-world data on the effects of ARNI in heart failure patients with reduced ejection fraction (HFrEF), especially those with concurrent renal impairment or hypotension.

METHODS

Between 2016 and 2017, we recruited 466 HFrEF patients treated with sacubitril/valsartan (Group A) and 466 patients managed with standard HF treatment without ARNI (Group B) in a HF referral center. Baseline characteristics and clinical outcomes were collected between both groups.

RESULTS

Baseline characteristics were comparable between the two groups. During a follow-up period of 15 months, death from cardiovascular causes or first unplanned hospitalization for HF occurred in 100 patients in Group A (21.5%) and 144 in Group B (30.9%, hazard ratio 0.66; 95% CI 0.51-0.85; p=0.001). The incidences of deaths from any causes, cardiovascular death, sudden death, and HF re-hospitalization were all significantly lower in Group A than Group B patients. Among patients with different chronic kidney disease stages and normotensive patients, treatment with sacubitril/valsartan showed more favorable outcomes than treatment with standard HF care without ARNI. However, in patients with baseline systolic blood pressure lower than 100mmHg, there were no significant differences of outcomes in both groups. Among Group A patients, escalation of sacubitril/valsartan was associated with better outcomes.

CONCLUSIONS

Our study demonstrated the effectiveness of sacubitril/valsartan on HFrEF patients in real world practice, including those with advanced renal impairment.

Metabolic Syndrome in Heart Failure: Friend or Foe?

The interplay between metabolic syndrome (MetS) and heart failure (HF) is intricate. Population studies show that MetS confers an increased risk to develop HF and this effect is mediated by insulin resistance (IR). However, obesity, a key component in MetS and common partner of IR, is protective in patients with established HF, although IR confers an increased risk of dying by HF. Such phenomenon, known as "obesity paradox," accounts for the complexity of the HF-MetS relationship. Because IR impacts more on outcomes than MetS itself, the former may be considered the actual target for MetS in HF patients.

Association of Ambulatory Blood Pressure with All-Cause and Cardiovascular Mortality in Hemodialysis Patients: Effects of Heart Failure and Atrial Fibrillation

BACKGROUND

Evidence on the utility of ambulatory BP monitoring for risk prediction has been scarce and inconclusive in patients on hemodialysis. In addition, in cardiac diseases such as heart failure and atrial fibrillation (common among patients on hemodialysis), studies have found that parameters such as systolic BP (SBP) and pulse pressure (PP) have inverse or nonlinear (U-shaped) associations with mortality.

METHODS

In total, 344 patients on hemodialysis (105 with atrial fibrillation, heart failure, or both) underwent ambulatory BP monitoring for 24 hours, starting before a dialysis session. The primary end point was all-cause mortality; the prespecified secondary end point was cardiovascular mortality. We performed linear and nonlinear Cox regression analyses for risk prediction to determine the associations between BP and study end points.

RESULTS

During the mean 37.6-month follow-up, 115 patients died (47 from a cardiovascular cause). SBP and PP showed a U-shaped association with all-cause and cardiovascular mortality in the cohort. In linear subgroup analysis, SBP and PP were independent risk predictors and showed a significant inverse relationship to all-cause and cardiovascular mortality in patients with atrial fibrillation or heart failure. In patients without these conditions, these associations were in the opposite direction. SBP and PP were significant independent risk predictors for cardiovascular mortality; PP was a significant independent risk predictor for all-cause mortality.

CONCLUSIONS

This study provides evidence for the U-shaped association between peripheral ambulatory SBP or PP and mortality in patients on hemodialysis. Furthermore, it suggests that underlying cardiac disease can explain the opposite direction of associations.

Reverse J-Curve Relationship Between On-Treatment Blood Pressure and Mortality in Patients With Heart Failure

OBJECTIVES

This study aimed to assess the relationship between on-treatment blood pressure (BP) and clinical outcomes of patients with heart failure (HF).

BACKGROUND

Lower BP has been reported to be related to increased mortality in various cardiovascular diseases. The optimal BP level for patients already experiencing HF is contentious.

METHODS

The Korean Acute Heart Failure registry prospectively enrolled a total of 5,625 consecutive patients hospitalized for acute HF in 10 tertiary university hospitals in Korea between March 2011 and February 2014. Clinical profiles including BP were collected at admission, discharge, and during outpatient follow-up. Mean on-treatment BP was calculated from BP at discharge and at each follow-up visit. We evaluated the effects of mean on-treatment BP on the clinical outcomes of patients.

RESULTS

Patients were followed up for a median 2.2 years. One-year mortality after discharge was 18.2%. The relationship between on-treatment BP and all-cause mortality followed a reversed J-curve relationship. A nonlinear, multivariable Cox proportional hazard model identified a nadir of systolic and diastolic BPs of 132.4/74.2 mm Hg in patients, for whom the mortality rate was lowest (p < 0.0001). The relationship with increased mortality above and below the reference BP was more definitive for diastolic BP and for HF with a preserved ejection fraction.

CONCLUSIONS

Systolic and diastolic BPs <130/70 mm Hg at discharge and during follow-up was associated with worse survival in HF patients. These data suggest that the lowest BP possible might not be an optimal target for HF patients. Further studies should establish a proper BP goal in HF patients. (Registry [Prospective Cohort] for Heart Failure in Korea [KorAHF]; NCT01389843).