Key result
SBP ≥130 mmHg in HFrEF is linked to ~9% lower mortality but higher kidney failure risk.
Why the study?
Elevated systolic blood pressure is paradoxically associated with lower mortality in HFrEF, but it is uncertain if this reflects pathophysiology or residual confounding, especially given its known risk for kidney failure.
Does systolic blood pressure ≥130 mmHg alter the risk of mortality and incident kidney failure in patients with HFrEF compared to SBP <130 mmHg?
Cohort (n=59,834)
Does systolic blood pressure ≥130 mmHg alter the risk of mortality and incident kidney failure in patients with HFrEF compared to SBP <130 mmHg?
In patients with HFrEF, elevated SBP (≥130 mmHg) is associated with paradoxically lower all-cause mortality but a significantly higher risk of incident kidney failure.
Answers are grounded in this paper and cite their sources.
Supports pathophysiological basis for SBP-mortality paradox in HFrEF; leaves open whether BP targets warrant adjustment in this population.
BACKGROUND Elevated systolic blood pressure (SBP) is associated with paradoxically lower mortality in heart failure with reduced ejection fraction (HFrEF), but whether this reflects underlying pathophysiology or residual confounding remains uncertain. Because higher SBP is also a risk factor for kidney failure, we tested the hypothesis that a higher risk of kidney failure despite lower mortality would support a pathophysiological explanation for this mortality paradox. METHODS We assembled a propensity score-matched cohort of 59,834 patients with HFrEF, hypertension, and no baseline kidney failure. The 29,917 pairs with SBP ≥130 versus <130 mmHg were balanced on 77 baseline characteristics. Outcomes were two-year all-cause mortality and incident kidney failure. Cox regression estimated associations of SBP ≥130 mmHg with outcomes, and restricted cubic splines assessed nonlinearity across the SBP continuum. RESULTS All-cause mortality occurred in 24.9% of patients with SBP <130 mmHg and 23.0% of patients with SBP ≥130 mmHg (HR associated with SBP ≥130 mmHg, 0.91; 95% CI, 0.88-0.94). Corresponding rates for kidney failure were 1.0% and 1.5% (HR, 1.44; 95% CI, 1.24-1.66). SBP had a nonlinear association with mortality (P<0.001 for nonlinearity), with progressively higher risk at SBP below 130 mmHg but no higher risk above 130 mmHg. The association with kidney failure was linear (P=0.68 for nonlinearity) with progressively higher risk above 130 mmHg. CONCLUSIONS In patients with HFrEF, elevated SBP is associated with lower mortality but a higher risk of kidney failure. These opposing cardiac and renal associations support a pathophysiological explanation for the inverse relationship between SBP and mortality in HFrEF.
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Sheriff et al. (2026) conducted a cohort in Heart failure with reduced ejection fraction (HFrEF) (n=59,834). Systolic blood pressure (SBP) ≥130 mmHg vs. SBP <130 mmHg was evaluated on All-cause mortality (HR 0.91, 95% CI 0.88-0.94). In patients with HFrEF, SBP ≥130 mmHg was associated with lower all-cause mortality but higher risk of incident kidney failure.
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