Admission Systolic Blood Pressure Predicts Mortality Differently in Elderly and Young Patients Hospitalized with Acute Heart Failure

We read with great interest two recent articles published in the European Journal of Heart Failure exploring the paradoxical relationship between systolic blood pressure (SBP) and outcome in patients with heart failure (HF). Vidan et al.1 showed that higher SBP on admission is associated with significantly lower 30-day and 1-year mortality in patients older than 65 years hospitalized for HF; this association persisted even at very high SBP levels (>210 mmHg). Nunez et al.2 demonstrated in patients with ejection fraction (EF) <40% that SBP is linearly and inversely associated with 18-month mortality risk, whereas in patients with EF ≥50%, SBP followed a J-shaped curve. However, it is unknown whether the paradoxical relationship between blood pressure levels and mortality is age-dependent. Accordingly, we investigated the effect of blood pressure on outcome among 1721 patients enrolled in the Heart Failure Survey in Israel (HFSIS 2003). The design and methods of the HFSIS have been described previously.3 This analysis focused on 1721 patients hospitalized with acute HF who had echocardiographic data. For the purpose of the present study, we dichotomized age at the median value (75 years), and categorized admission SBP levels as follows: ≤95, 96–115, 116–125, 126–140, 141–160, 161–180, 181–200, and >200 mmHg. Cox proportional hazards regression analysis was performed adjusting for multiple clinical risk factors including EF and the above SBP categories. The endpoint of the study was all-cause mortality at 1 year of follow-up. Among elderly (>75 years) patients with acute HF, there was a consistent inverse relation between SBP levels and the risk of death at all levels of increasing blood pressure values (Figure Figure 1B). In contrast, in the young age-group (≤75 years), there was a J-shape curve for the relation between SBP and mortality demonstrating an inverse relation with increasing SBP values up to 161–180 mmHg, and a direct correlation among patients who exhibited higher SBP values on admission (Figure Figure 1A). Our findings suggest that the paradoxical relationship between blood pressure and mortality among high-risk cardiac patients is age-dependent. These differences in the prognostic effects of SBP between young and elderly patients were demonstrated in a cohort of patients with a wide age distribution and were independent of EF, therefore adding data to the recently published findings of Vidan et al.1 in patients older than 65 years and Nunez et al.2 in patients with systolic vs. diastolic dysfunction.