High normal blood pressure (130-139/85-89 mmHg) was associated with a lower risk of new-onset heart failure compared to Normal blood pressure in treated hypertension (HR 0.89; 95% CI 0.82-0.97).
Cohort (n=211,624)
Yes
Does blood pressure level affect the risk of new-onset heart failure in primary care patients with treated hypertension?
In real-world primary care patients with hypertension, there is a U-shaped relationship between blood pressure and new-onset heart failure, with the lowest risk observed at 130-135 mmHg SBP, challenging trial data that supports targets <130 mmHg.
Effect estimate: HR 0.89 (95% CI 0.82-0.97)
Abstract Background Hypertension is a major risk factor for heart failure (HF). Randomized trials have shown that treatment to a systolic blood pressure (SBP) 130 mmHg decreases the risk of HF. Less is known about the relationship between blood pressure (BP) level and new-onset HF in patients with treated hypertension under real-world conditions. Purpose To determine the risk of new-onset HF in different BP categories, as defined by SBP and diastolic blood pressure (DBP) in HTN guidelines, and at continuous SBP levels in a real-world population of patients with hypertension in primary care. Methods Observational cohort study of patients with hypertension from a large Swedish primary care-register with data linked from national and regional registers. Patients with known HF or loop diuretics were excluded. The index date was the day of the first BP measurement at least a year after a diagnosis of hypertension and patients were included from 2011 to 2017. The risk of new-onset HF, defined as the occurrence of a HF diagnosis after the index date, was estimated with Cox regression models, for BP categories as well as for continuous SBP. The BP categories were Optimal (120 mmHg SBP and 80 mmHg DBP), Normal (120 – 129 mmHg SBP and/or 80 – 84 mmHg DBP), High normal (130 – 139 mmHgSBP and/or 85 – 89 mmHg DBP), Grade 1 hypertension (140 – 159 mmHg SBP and/or 90 – 99 mmHg DBP), Grade 2 hypertension (160 – 179 mmHg SBP and/or 100 – 109 mmHg DBP) and Grade 3 hypertension (≥180 mmHg SBP or ≥110 mmHg DBP). Normal BP was the reference in the categorical analysis. The models were adjusted for age, sex and cardiovascular comorbidities. A restricted cubic spline with four knots was used to plot the hazard ratios (HR) from the analysis of SBP. Results In all, 211 624 patients with hypertension were included (mean age 66.9 years, 50.7% female). The largest proportion of patients had Grade 1 hypertension (36.9%) and the mean SBP was 139.4 mmHg. During a median follow-up of 5.0 years (interquartile range 3.0 – 6.1), 6 520 patients were diagnosed with HF. The cumulative incidence of HF was highest in patients with Optimal BP (3.7%) and lowest in those with High normal BP (2.6%). The adjusted hazard ratio for HF was highest in the patients with Grade 3 hypertension (HR 1.42, 95% confidence interval (CI) 1.23 – 1.64). Only patients in the High normal category had a lower risk of HF (HR 0.89, 95% CI 0.82 – 0.97) than the reference Normal category. See figure 1. There was a U-shaped relationship between HF and continuous SBP, with a nadir in risk around 130 mmHg. See figure 2. Conclusions The lowest risk of HF in treated hypertension was observed in patients in the High normal category (130 – 139 mmHg SBP and/or 85-89 mmHg DBP), and at continuous SBP at around 130 – 135 mmHg. Patients with lower BP had higher risk of new-onset HF. This contrasts to findings from randomized trials, where treatment to SBP levels lower than 130 mmHg was associated with lower risk of HF.Risk of heart failure by BP category Risk of heart failure by continuous SBP
Bager et al. (Sat,) conducted a cohort in hypertension (n=211,624). High normal blood pressure vs. Normal blood pressure was evaluated on new-onset heart failure (HR 0.89, 95% CI 0.82-0.97). High normal blood pressure (130-139/85-89 mmHg) was associated with a lower risk of new-onset heart failure compared to Normal blood pressure in treated hypertension (HR 0.89; 95% CI 0.82-0.97).