Systolic Blood Pressure and Pulse Pressure in Heart Failure
Key result
Baseline systolic blood pressure ≥140 mm Hg was associated with a higher risk of heart failure hospitalization or cardiovascular death compared to 120-129 mm Hg (HR 1.22; 95% CI 1.10-1.34).
Journal of the American College of Cardiology published a graphical abstract
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Why the study?
Data supporting the recommended target SBP of <130 mm Hg in HFmrEF/HFpEF are limited, and the prognostic impact of pulse pressure has not been extensively studied.
What is the prognostic impact of baseline systolic blood pressure and pulse pressure on cardiovascular outcomes in patients with HFmrEF or HFpEF?
Key Points
- This study aimed to examine how baseline systolic blood pressure and pulse pressure affect cardiovascular outcomes in patients with heart failure with mildly reduced or preserved ejection fraction.
- Data pooled from I-PRESERVE, TOPCAT, PARAGON-HF, and DELIVER trials involving patients with heart failure and left ventricular ejection fraction ≥40%.
- Analyzed continuous baseline systolic blood pressure and pulse pressure concerning the primary endpoint using restricted cubic splines.
- Categorized systolic blood pressure into four groups and pulse pressure into quartiles to evaluate their prognostic impact on cardiovascular events.
- A total of 16,950 patients were included with mean systolic blood pressure of 131 mm Hg and mean pulse pressure of 55 mm Hg.
- A J-shaped relationship was identified between systolic blood pressure and cardiovascular risk, with the lowest risk at levels 120-130 mm Hg (HR: 1.22; 95% CI: 1.10-1.34).
- Similarly, pulse pressure showed a J-shaped association with the lowest risk at 50-60 mm Hg (HR: 1.22; 95% CI: 1.11-1.34).
Study Design
Type
Meta-Analysis (n=16,950)
Multicenter
Yes
Structured PICO
What is the prognostic impact of baseline systolic blood pressure and pulse pressure on cardiovascular outcomes in patients with HFmrEF or HFpEF?
P
Population
16,950 patients with HFmrEF or HFpEF from 4 global clinical trials, analyzed to determine the prognostic impact of baseline systolic blood pressure and pulse pressure.
E
Exposure
Baseline systolic blood pressure (SBP) and pulse pressure (PP) levels
C
Comparator
Reference categories: SBP 120-129 mm Hg and PP 46-54 mm Hg
O
Outcome
Composite of first heart failure hospitalization or cardiovascular deathcomposite
Main Result
Hazard Ratio: 1.22 (95% CI 1.1–1.34)
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“In a pooled analysis of 16,950 patients with chronic HFmrEF or HFpEF enrolled from 4 global randomized clinical trials, a J-shaped relationship was observed between SBP and the risk of adverse CV events, with the lowest risk occurring at SBP values between 120.”
Implication
In patients with HFmrEF/HFpEF, both systolic blood pressure and pulse pressure exhibit a J-shaped relationship with cardiovascular risk, with the lowest risk observed at SBP 120-130 mm Hg and PP 50-60 mm Hg, supporting current guideline targets.
Abstract
BACKGROUND Hypertension is common in patients with heart failure with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF), and current guidelines recommend treating systolic blood pressure (SBP) to a target <130 mm Hg. However, data supporting treatment to this target are limited. Additionally, pulse pressure (PP), a marker of aortic stiffness, has been associated with increased risk of cardiovascular events, but its prognostic impact in HFpEF has not been extensively studied. OBJECTIVES This study aimed to explore the impact of baseline SBP and PP on cardiovascular outcomes in patients with HFmrEF or HFpEF. METHODS The I-PRESERVE (Irbesartan in Heart Failure With Preserved Ejection Fraction), TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist)-Americas, PARAGON-HF (Prospective Comparison of Angiotensin Receptor-Neprilysin Inhibitor With Angiotensin-Receptor Blocker Global Outcomes in HF With Preserved Ejection Fraction), and DELIVER (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure) trials were global, randomized clinical trials testing irbesartan, spironolactone, sacubitril/valsartan, and dapagliflozin, respectively, against either a placebo or an active comparator (valsartan, in PARAGON-HF), in patients with heart failure and a left ventricular ejection fraction ≥40% (in DELIVER) or ≥45% (in the other trials). The relationship between continuous baseline SBP and PP, and the primary endpoint (first heart failure hospitalization or cardiovascular death) was analyzed with restricted cubic splines. We further evaluated the prognostic impact of SBP categories (<120, 120-129, 130-139, and ≥140 mm Hg) and PP quartiles on the primary endpoint. RESULTS A total of 16,950 patients (mean age 71 ± 9 years; 49% male; mean SBP 131 ± 15 mm Hg; mean PP 55 ± 14 mm Hg) were included. The relationship between SBP and the primary endpoint was J-shaped, with the lowest risk at 120 to 130 mm Hg. A similar pattern was found for PP, with the lowest risk at 50 to 60 mm Hg. The highest SBP category (reference: 120-129 mm Hg) and PP quartile (reference: 46-54 mm Hg) were associated with a higher risk of the primary outcome (HR: 1.22; 95% CI: 1.10-1.34 and HR: 1.22; 95% CI: 1.11-1.34, respectively). Higher PP was associated with greater cardiovascular risk, regardless of SBP. CONCLUSIONS Our analysis of a large pooled dataset from 4 clinical trials, including >16,900 patients with HFmrEF/HFpEF, indicates a J-shaped relationship between both SBP and PP and cardiovascular risk. The lowest risk was observed at SBP levels between 120 and 130 mm Hg and PP values between 50 and 60 mm Hg (I-PRESERVE [Irbesartan in Heart Failure With Preserved Systolic Function], NCT00095238; TOPCAT [Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist], NCT00094302; PARAGON-HF [Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction], NCT01920711; DELIVER [Dapagliflozin Evaluation to Improve the LIVEs of Patients With PReserved Ejection Fraction Heart Failure], NCT03619213).
Discussion
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Cite This Study
Lu et al. (2024) conducted a meta-analysis in Heart failure with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF) (n=16,950). Highest systolic blood pressure category (≥140 mm Hg) vs. Systolic blood pressure 120-129 mm Hg was evaluated on First heart failure hospitalization or cardiovascular death (HR 1.22, 95% CI 1.10-1.34). Baseline systolic blood pressure ≥140 mm Hg was associated with a higher risk of heart failure hospitalization or cardiovascular death compared to 120-129 mm Hg (HR 1.22; 95% CI 1.10-1.34).