Low pulse pressure is independently related to elevated natriuretic peptides and increased mortality in advanced chronic heart failure

AIMS: An increased pulse pressure (PP) has consistently predicted increased cardiovascular morbidity and mortality in cardiovascular risk patients and mild chronic heart failure (CHF). In contrast, a decreased PP was related to increased mortality in patients with acute decompensated heart failure. However, the predictive value of PP in patients with advanced CHF is not known. METHODS AND RESULTS: PP was analysed for its effect on mortality, adjusting for other modifiers of risk, using Cox proportional hazards regression analysis of data collected from 1901 patients with New York Heart Association Class III or IV CHF (mean age 65 and mean ejection fraction 0.26). Natriuretic peptides were measured in a subgroup. Multivariable Cox-regression analysis demonstrated that lower PP was associated with an increased mortality hazard ratio (HR) 0.91 per 10 mmHg; 0.93-0.99, independent of mean arterial pressure (MAP) and other well known prognostic markers. In patients with a PP below the median value of 45 mmHg, PP was a stronger predictor of mortality than MAP (HR for PP 0.80 per 10 mmHg; 0.64-0.99). In patients with a PP above the median value of 45 mmHg, MAP was a stronger predictor of mortality than PP (HR for MAP 0.83 per 10 mmHg increase; 0.72-0.95). In addition, lower PP was independently related to increased atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP). CONCLUSION: In patients with advanced CHF, low PP is an independent predictor of mortality. In addition, low PP was related to increased levels of ANP and BNP.