Systolic Blood Pressure and Outcomes in Older Patients with HFpEF and Hypertension

Abstract

Background: New hypertension and heart failure guidelines recommend that systolic blood pressure (SBP) in patients with heart failure with preserved ejection fraction (HFpEF) and hypertension be lowered to <130 mm Hg.

Methods: Of the 6778 hospitalized patients with HFpEF and a history of hypertension in the Medicare-linked OPTIMIZE-HF registry, 3111 had a discharge SBP <130 mm Hg. Using propensity scores for SBP <130 mm Hg, we assembled a matched cohort of 1979 pairs with SBP <130 versus ≥130 mm Hg, balanced on 66 baseline characteristics (mean age, 79 years; 69% women; 12% African American). We then assembled a second matched cohort of 1326 pairs with SBP <120 versus ≥130 mm Hg. Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes associated with SBP <130 and <120 mm Hg were separately estimated in the matched cohorts using SBP ≥130 mm Hg as the reference.

Results: HRs (95% CIs) for 30-day, 12-month, and 6-year all-cause mortality associated with SBP <130 mm Hg were 1.20 (0.91-1.59; P = 0.200), 1.11 (0.99-1.26; P = 0.080), and 1.05 (0.98-1.14; P = 0.186), respectively. Respective HRs (95% CIs) associated with SBP <120 mm Hg were 1.68 (1.21-2.34; P = 0.002), 1.28 (1.11-1.48; P = 0.001), and 1.11 (1.02-1.22; P = 0.022). There was no association with readmission.

Conclusions: Among older patients with HFpEF and hypertension, compared with SBP ≥130 mm Hg, the new target SBP <130 mm Hg had no association with outcomes but SBP <120 mm Hg was associated with a higher risk of death but not of readmission. Future prospective studies need to evaluate optimal SBP treatment goals in these patients.

Keywords: All-cause mortality; Heart failure with preserved ejection fraction (HFpEF), Readmission; Systolic blood pressure.

Figure 1.

Flow chart displaying assembly of propensity score matched cohorts of patients with HFpEF and a history of hypertension with discharge SBP ≥130 vs. <130 mm Hg (left panel) and discharge SBP ≥130 vs. <120 mmHg (right panel). HFpEF = heart failure and left ventricular ejection fraction; OPTIMIZE-HF = Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure; SBP = systolic blood pressure.

Figure 2.

Love plot displaying balance in 66 baseline characteristics in patients with HFpEF and hypertension between those with a discharge SBP≥130 vs. <130 mmHg (left panel) and those with a discharge SBP≥130 vs. <120 mmHg (right panel) before and after propensity score matching. HFpEF = heart failure and left ventricular ejection fraction; SBP = systolic blood pressure.

Figure 3.

Kaplan-Meier plots displaying associations of discharge SBP <130 versus ≥130 mm Hg (top panel) and <120 versus ≥130 mm Hg (bottom panel) with all-cause mortality in two separate propensity score-matched cohorts of patients with HFpEF and hypertension. CI = confidence interval; HFpEF = heart failure with preserved ejection fraction; HR = hazard ratio; SBP = systolic blood pressure.

Figure 4.

Restricted cubic spline plots for discharge SBP and 6-year all-cause mortality by in patients with HFpEF and hypertension, among 6,778 pre-match patients, adjusted for propensity scores (non-linearity p = 0.038; top), and among 3,958 propensity score-matched patients balanced on 66 baseline characteristics (non-linearity p = 0.336; bottom) Solid blue lines represent hazard ratios, and blue shaded areas represent 95% CIs. CI =confidence intervals; HFpEF = heart failure with preserved ejection fraction; SBP = systolic blood pressure.

Figure 5.

Forest plots displaying associations of SBP <120 (versus ≥130 mmHg) with 2-year all-cause mortality in subgroups of patients with HFpEF and hypertension. ACE = angiotensin-converting enzyme, ARB = angiotensin receptor blocker, CI = confidence interval; HFpEF = heart failure and left ventricular ejection fraction; SBP = systolic blood pressure. Note: Results of subgroup analyses need to be interpreted with caution as they may be false-positive due to multiple comparisons and false-negative due to inadequate power.