Is a higher blood pressure better in heart failure?

The past 25 years has witnessed a revolution in the therapeutic options for patients diagnosed with systolic heart failure (SHF) associated with modest reductions in mortality.1–3 The most recent heart failure guidelines advocate neurohormonal blockade as part of the strategy to treat patients with stage B, C and D heart failure.4 5 Individual drugs have target doses based on specific clinical trial design with baseline medical treatment usually reported by class, or less frequently, by specific drug formulation.5 Furthermore, clinical trials do not comment on whether background standard medical treatment was titrated to target doses throughout study duration. Likewise, a lack of reporting blood pressure measurements throughout the duration of clinical trials has left a void in heart failure guidelines and clinical practice. Therefore, we have no recommended target blood pressure for patients with chronic SHF. This lack of blood pressure data in the face of target doses for individual neurohormonal blocking agents has led many clinicians to drive down blood pressure relying on symptomatic hypotension as a threshold for titration. While inpatient databases have prospectively validated an inverse relationship between admission systolic blood pressure (SBP) and hospital mortality,6–11 this same …