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

Abstract

Importance: Lower systolic blood pressure (SBP) levels are associated with poor outcomes in patients with heart failure. Less is known about this association in heart failure with preserved ejection fraction (HFpEF).

Objective: To determine the associations of SBP levels with mortality and other outcomes in HFpEF.

Design, setting, and participants: A propensity score-matched observational study of the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry included 25 354 patients who were discharged alive; 8873 (35.0%) had an ejection fraction of at least 50%, and of these, 3915 (44.1%) had stable SBP levels (≤20 mm Hg admission to discharge variation). Data were collected from 259 hospitals in 48 states between March 1, 2003, and December 31, 2004. Data were analyzed from March 1, 2003, to December 31, 2008.

Exposure: Discharge SBP levels less than 120 mm Hg. A total of 1076 of 3915 (27.5%) had SBP levels less than 120 mm Hg, of whom 901 (83.7%) were matched by propensity scores with 901 patients with SBP levels of 120 mm Hg or greater who were balanced on 58 baseline characteristics.

Main outcomes and measures: Thirty-day, 1-year, and overall all-cause mortality and heart failure readmission through December 31, 2008.

Results: The 1802 matched patients had a mean (SD) age of 79 (10) years; 1147 (63.7%) were women, and 134 (7.4%) were African American. Thirty-day all-cause mortality occurred in 91 (10%) and 45 (5%) of matched patients with discharge SBP of less than 120 mm Hg vs 120 mm Hg or greater, respectively (hazard ratio [HR], 2.07; 95% CI, 1.45-2.95; P < .001). Systolic blood pressure level less than 120 mm Hg was also associated with a higher risk of mortality at 1 year (39% vs 31%; HR, 1.36; 95% CI, 1.16-1.59; P < .001) and during a median follow-up of 2.1 (overall 6) years (HR, 1.17; 95% CI, 1.05-1.30; P = .005). Systolic blood pressure level less than 120 mm Hg was associated with a higher risk of heart failure readmission at 30 days (HR, 1.47; 95% CI, 1.08-2.01; P = .02) but not at 1 or 6 years. Hazard ratios for the combined end point of heart failure readmission or all-cause mortality associated with SBP level less than 120 mm at 30 days, 1 year, and overall were 1.71 (95% CI, 1.34-2.18; P < .001), 1.21 (95% CI, 1.07-1.38; P = .004), and 1.12 (95% CI, 1.01-1.24; P = .03), respectively.

Conclusions and relevance: Among hospitalized patients with HFpEF, an SBP level less than 120 mm Hg is significantly associated with poor outcomes. Future studies need to prospectively evaluate optimal SBP treatment goals in patients with HFpEF.

Figure 1.. Kaplan-Meier Plots for All-Cause Mortality by Systolic Blood Pressure (SBP) Level

Kaplan-Meier plot for all-cause mortality in 901 pairs of propensity score–matched patients with heart failure and left ventricular ejection fraction of 50% or greater, by SBP level less than 120 vs 120 mm Hg or greater. Hazard ratios for all-cause mortality at 1 month, 1 year, and overall were 2.07 (95% CI, 1.45-2.95; P < .001), 1.36 (95% CI, 1.16-1.59; P < .001), and 1.17 (95% CI, 1.05-1.30; P = .005), respectively.

Figure 2.. Restricted Cubic Spline Plots for All-Cause Mortality by Systolic Blood Pressure

Hazard ratios and 95% confidence intervals for all-cause mortality by discharge systolic blood pressure level in 3915 patients with heart failure with preserved ejection fraction of 50% or greater according to restricted cubic spline regression models using 4 knots at blood pressures of 110 mm Hg, 120 mm Hg (reference), 140 mm Hg, and 150 mm Hg. Solid black lines indicate hazard ratios, and shaded areas indicate 95% CI. Plots on the left panel (A) are based on 3906 prematch patients (9 prematch patients had systolic blood pressure levels >200 mm Hg and were excluded), adjusting for propensity scores, and those on the right panel (B) are based on 1802 matched patients (none had systolic blood pressure levels >200 mm Hg) balanced on 58 baseline characteristics. Spline curves were truncated at a systolic blood pressure level of 200 mm Hg.

Figure 3.. Forest Plots for Subgroup Analyses of Mortality by Systolic Blood Pressure (SBP) Level

Forest plots displaying hazard ratios and 95% confidence intervals for all-cause mortality in subgroups of propensity score–matched patients with heart failure and a left ventricular ejection fraction of 50% or greater by discharge SBP level less than 120 vs 120 mm Hg or greater. ACE indicates angiotensin-converting enzyme; ARB, angiotensin II receptor blocker.