Lower SBP linked to worse outcomes in older HF patients with reduced ejection fraction and hypertension

Clinicians should focus on preventing heart failure (HF) in patients with hypertension and providing optimal therapy in those with symptomatic disease, rather than on a specific blood pressure target, an editorial said.

Older patients who have heart failure (HF) with reduced ejection fraction may have worse outcomes after hospital discharge if their systolic blood pressure (SBP) is lower than 110 mm Hg, according to a recent study.

According to national guidelines, HF patients with reduced ejection fraction and hypertension should maintain SBP below 130 mm Hg. Researchers linked data from the OPTIMIZE-HF registry to Medicare to examine the association of SBP below 130 mm Hg with outcomes in hospitalized patients who had HF with reduced ejection fraction. Propensity scores for this SBP value were estimated for 5,615 patients in the registry who had stable SBP and were used to develop a matched cohort of 1,189 patient pairs with an SBP below 130 mm Hg versus an SBP of 130 mm Hg or higher. Another matched cohort included 1,099 patient pairs with an SBP of 110 to 129 mm Hg versus 130 mm Hg or higher. Primary outcomes were all-cause mortality, all-cause readmission, and HF readmission at 30 days, one year, and during overall follow-up of six years to Dec. 31, 2008. Secondary outcomes were combined endpoints of all-cause readmission or all-cause mortality and HF readmission or all-cause mortality. The study results were published in the June 25 Journal of the American College of Cardiology.

Overall, in the matched cohort of 2,378 patients, whose mean age was 76 years, 30-day all-cause mortality rates were 7% with an SBP below 130 mm Hg versus 4% with an SBP of 130 mm Hg or higher (hazard ratio [HR], 1.76; 95% CI, 1.24 to 2.48; P=0.001). For all-cause mortality, all-cause readmission, and HF readmission at one year, hazard ratios were increased with an SBP less than 130 mm Hg: 1.32 (95% CI, 1.15 to 1.53; P<0.001), 1.11 (95% CI, 1.01 to 1.23; P=0.030), and 1.24 (95% CI, 1.09 to 1.42; P=0.001), respectively. For 30-day and one-year all-cause mortality associated with an SBP of 110 to 129 mm Hg versus 130 mm Hg or higher, the HRs were 1.50 (95% CI, 1.03 to 2.19; P=0.035) and 1.19 (95% CI, 1.02 to 1.39; P=0.029).

The authors urged caution when interpreting their findings of higher adverse outcomes with lower SBP and noted that they cannot be extrapolated to patients with HF and reduced ejection fraction but without hypertension. They also pointed out that no data were available on dosages of HF drugs, among other limitations. Nevertheless, they concluded that in hospitalized older adults with HF and reduced ejection fraction, an SBP below 130 mm Hg is associated with poor outcomes versus an SBP of 130 mm Hg or higher, even after patients whose SBP is below 110 mm Hg are excluded.

“Clinicians need to exercise caution in lowering SBP with agents other than guideline-recommended neurohormonal antagonists in patients with HF [and reduced ejection fraction] who have SBP ≥130 mm Hg and are already receiving [guideline-directed medical therapy] in optimal doses,” the authors wrote. They called for future studies to examine optimal goals for SBP reduction in this population.

An accompanying editorial called the data “provocative” and said they make it clear that there are two questions to consider: “for the patient with heart failure and hypertension, what is the goal blood pressure treatment threshold; and for the patient with HF [and reduced ejection fraction], what is the acceptable nadir of blood pressure that optimizes benefit and minimizes harm?” They also noted that there is a need to determine how to target doses or therapeutic response to guideline-directed medical therapy.

While research involving precision medicine and mobile health devices will eventually help to address these questions, the editorialists said, physicians managing patients with HF should now focus on improving both blood pressure control and initiation and titration of medical therapy. “In summary, targeting blood pressure per se is not the goal; the emphasis should be on prevention of HF in those with hypertension and on optimal medical therapy and optimized clinical outcomes in those with symptomatic HF,” the editorialists wrote. “That is where the pressure should reside.”