Among hospitalized older patients who have heart failure with preserved ejection fraction (HFpEF), a systolic blood pressure (SBP) of less than 120 mm Hg — or even less than 130 mm Hg — at discharge is associated with poor outcomes, including death from any cause and hospital readmission, an observational study suggests.
“Findings from our study suggest that the optimal SBP target for HFpEF is far from clear, and aggressive control of SBP in older patients with HFpEF may need to be avoided,” senior authors, Gregg C. Fonarow, MD, University of California, Los Angeles, and Ali Ahmed, MD, MPH, George Washington University, Washington, DC, said in a joint email to theheart.org | Medscape Cardiology.
The study was published online February 14 in JAMA Cardiology.
The American College of Cardiology/American Heart Association/Heart Failure Society of America guideline for HF recommends that SBP be controlled in patients with HFpEF, and its 2017 update sets an optimal SBP target level of less than 130 mm Hg for patients with HFpEF and persistent hypertension.
“However, once patients develop HF, a lower SBP level may have a paradoxical association with a higher risk of cardiovascular morbidity and mortality,” the authors note in their paper, and less is known about this association in patients with HFpEF, they point out.
Using the national Medicare-linked OPTIMIZE-HF registry, the researchers did a propensity-matched observational study of hospitalized patients with HF and ejection fraction of 50% or greater.
A total of 901 patients with discharge SBP less than 120 mm Hg were matched on 58 baseline characteristics to 901 patients with discharge SBP of 120 mm Hg or greater. The 1802 matched patients had a mean age of 79 years, 1147 (63.7%) were women, and 134 (7.4%) were African American.
After propensity score–matching, a discharge SBP less than 120 mm Hg was associated with greater risks for all-cause mortality at 30 days, 1 year, and a median follow-up of 2.1 years (overall 6 years).
Table 1. All-Cause Mortality by SBP
| All-Cause Mortality | SBP < 120 mm Hg (%) | SBP ≥ 120 mm Hg (%) | Hazard Ratio (95% Confidence Interval) |
|---|---|---|---|
| 30 d | 10 | 5 | 2.07 (1.45 – 2.95) |
| 1 y | 39 | 31 | 1.36 (1.16 – 1.59) |
| Overall | 75 | 71 | 1.17 (1.05 – 1.30) |
Patients with a discharge SBP less than 120 mm Hg were also at increased risk for the combined endpoint of HF readmissions and all-cause mortality at all three time points.
Table 2. HF Readmission, All-Cause Mortality by SBP
| HF Readmission/All-Cause Mortality | SBP < 120 mm Hg (%) | SBP ≥ 120 mm Hg (%) | Hazard Ratio (95% Confidence Interval) |
|---|---|---|---|
| 30 d | 19 | 12 | 1.71 (1.34 – 2.18) |
| 1 y | 54 | 49 | 1.21 (1.07 – 1.38) |
| Overall | 85 | 83 | 1.12 (1.01 – 1.24) |
The observed associations were “essentially unchanged” when lower SBP was defined as SBP less than 130 mm Hg, the authors report.
“In addition to the sophisticated methodologies used, the consistency of the findings across multiple sensitivity cohorts as well as clinically important subgroups suggest that a lower SBP level is a marker of underlying pathophysiologic processes that is associated with poor outcomes in patients with HFpEF independent of over 50 baseline characteristics,” Fonarow and Ahmed commented.
Optimal SBP Target in HFpEF Still Unclear
“These findings point to the need for prospective randomized controlled trials to determine the optimal SBP target in HFpEF,” they said.
“The study is interesting because it challenges the guideline recommendation that HFpEF patients with hypertension have their blood pressure controlled to less than 130 mm Hg,” Sean Pinney, MD, Mount Sinai Health System, New York City, told theheart.org | Medscape Cardiology.
Why elderly, hospitalized patients with HFpEF who have SBP less than 120 mm Hg (as well as those with a pressure less than 130 mm Hg) faced a higher risk for dying at 30 days, 1 year, and 6 years is not entirely clear, said Pinney, who wasn’t involved in the study.
“Unfortunately, like most retrospective studies, this paper can only show association and not causation,” he said. “This happens to be a particularly selective group of patients, and the findings from this study may not necessarily apply to ambulatory HFpEF patients.
“Nonetheless, it is important to point out that regardless of blood pressure, hospitalized elderly patients with HFpEF face a high risk of death or re-hospitalization. One third will die within 1 year of discharge, giving them a prognosis which is worse than most forms of cancer,” Pinney said.
“We still have no real effective therapies for HFpEF. The search for treatments to improve HFpEF survival remains the greatest clinical challenge in the field of heart failure today,” he added.
Support for the study was provided by the National Institutes of Health. The OPTIMIZE-HF study was sponsored by GlaxoSmithKline. Fonarow reports consulting for Amgen, Novartis, Medtronic , and St Jude Medical and was the principal investigator in the OPTIMIZE-HF study. Ahmed and Pinney have no relevant disclosures.
JAMA Cardiol. Published online February 14, 2018. Abstract
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