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

Abstract

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.

Keywords: heart failure; outcomes; systolic blood pressure.

Central Illustration:. Kaplan Meier Plots by Systolic Blood Pressure <130 mmHg.

This study assessed the association of discharge systolic blood pressure (SBP) with outcomes in patients with heart failure with reduced ejection fraction (HFrEF) in a propensity score-matched cohort of 1,189 pairs of patients with an SBP of <130 versus ≥130 mmHg. During over 5 years of follow-up, SBP of <130 mmHg was associated with a significantly higher risk of death and readmission, compared with SBP of ≥130 mmHg.

Figure 1:. All-Cause Mortality by Systolic Blood Pressure: Restricted Cubic Spline Plots.

In cubic spline analysis, nonlinear relationship between discahrge systolic blood pressure and all-cause mortality was found in (a) 5615 pre-match patients, adjusted for demographics (age, sex, and race), (b) 5615 pre-match patients, adjusted for propensity scores, and (c) 2378 propensity score-matched patients balanced on 58 baseline characteristics (non-linearity p <0.001 for all three analyses). Spline curves excluded patients with systolic blood pressure values <80 mmHg (n=14) and >200 mmHg (n=2; none of the matched patients had systolic blood pressure values outside that range). Solid dark blue lines represent hazard ratios, and light blue shaded areas represent 95% CIs. CI = confidence interval.

Figure 2:. Forest Plots for Subgroup Analyses of Mortality by Hypertension.

In subgroups with (n=1666) and without (n=712) hypertension, patients with systolic blood pressure <130 mmHg had higher risk of mortality and readmission compared to patients with systolic blood pressure ≥130 mmHg. CI = confidence interval.