Longitudinal Blood Pressure and Cardiovascular Outcomes in Heart Failure: An Individual Patient Data Pooling Analysis of Clinical Trials

Jing‐Wei Li; Jiang Wang; Yunlong Chen; Hao Yang; Yi Wang; Xia Wang; Ying Wang; Dehui Qian; Shiyong Yu; Xiaohui Zhao; Tan H; Jun Jin; Xin Du; Craig S. Anderson

doi:10.1002/ejhf.3706

May 24, 2025European Journal of Heart FailureOpen Access

Longitudinal Blood Pressure and Cardiovascular Outcomes in Heart Failure: An Individual Patient Data Pooling Analysis of Clinical Trials

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Why the study?

Previous analyses of blood pressure and heart failure outcomes primarily used baseline values rather than longitudinal measurements across HFrEF, HFmrEF, and HFpEF.

Does longitudinal blood pressure level affect the risk of cardiovascular death or HF hospitalization in patients with heart failure?

Structured PICO

Does longitudinal blood pressure level affect the risk of cardiovascular death or HF hospitalization in patients with heart failure?

P

Population

28,406 patients with heart failure (HFrEF, HFmrEF, and HFpEF) pooled from eight clinical trials

I

Intervention

Longitudinal blood pressure (time-dependent BP categorized by tertiles and per 10 mmHg increments)

C

Comparator

Middle-level systolic blood pressure (SBP)

O

Outcome

Time to the first occurrence of a composite endpoint comprising cardiovascular death or HF hospitalizationcomposite

Longitudinal blood pressure exhibits a J-shaped relationship with outcomes in HFrEF and a U-shaped relationship in HFmrEF/HFpEF, highlighting the need for ejection fraction-specific blood pressure management strategies.

Implication

Longitudinal BP assessment may refine HF risk stratification; leaves open whether targets should vary by EF subtype.

Abstract

AIMS: Previous analyses of the relationship between blood pressure (BP) and heart failure (HF) outcomes have primarily used baseline values rather than longitudinal measurements. We aimed to elucidate associations between longitudinal BP and clinical outcomes in patients with HF with reduced ejection fraction (HFrEF), mildly reduced ejection fraction (HFmrEF), and preserved ejection fraction (HFpEF). METHODS AND RESULTS: We conducted a comprehensive analysis of 28 406 patients from eight trials, evaluating time-dependent BP categorized by tertiles and per 10 mmHg increments in BP on outcomes. The primary endpoint was the time to the first occurrence of a composite endpoint comprising cardiovascular death or HF hospitalization. Multivariate Cox regression analysis revealed a J-shaped relationship between BP and the composite outcome in HFrEF. Specifically, compared with the middle-level systolic BP (SBP), low SBP was associated with a higher risk of the composite endpoint (hazard ratio [HR] 1.71, 95% confidence interval [CI] 1.60-1.82; p < 0.001) and high SBP showed a non-significant change in risk (HR 1.07, 95% CI 0.97-1.18; p = 0.187). Conversely, a U-shaped relationship was observed in HFmrEF and HFpEF. Low SBP was linked to a higher risk of the composite endpoint (HR 1.74, 95% CI 1.47-2.07; p < 0.001), and high SBP similarly increased the risk (HR 1.77, 95% CI 1.45-2.17; p < 0.001). CONCLUSIONS: The relationship between BP and HF outcomes is non-linear and closely tied to left ventricular ejection fraction. Low SBP consistently predicts a poor prognosis, whereas high SBP is associated with an increased risk in HFmrEF and HFpEF but not in HFrEF.