Prognostic significance of diastolic blood pressure in acute heart failure: insights from the SMILE-HF registry

Abstract Background Acute heart failure (AHF) is a critical condition associated with substantial morbidity and mortality. Blood pressure management, particularly diastolic blood pressure (DBP), may have important prognostic implications in these patients. However, the impact of discharge DBP on short-term clinical outcomes remains unclear. Purpose This study aims to examine the association between discharge DBP and clinical outcomes at 3 months in patients hospitalised with AHF, using data from the SMILE-HF registry. Methods The SMILE-HF registry is a multicentre observational study that enrolled 1,976 patients hospitalised for AHF between 2019 and 2024. After excluding patients with missing data, 1,957 were included in the analysis. Patients were categorised into two groups based on discharge DBP (70 mmHg vs. ≥70 mmHg). The primary outcomes were all-cause mortality and cardiovascular (CV) readmission at 3 months. As a secondary analysis, outcomes were further stratified by heart failure phenotype: heart failure with reduced ejection fraction (HFrEF), mid-range ejection fraction (HFmrEF), and preserved ejection fraction (HFpEF). Kaplan-Meier survival analysis and log-rank tests were used to compare outcomes between the DBP groups. Results In the overall cohort, patients with a higher discharge DBP (≥70 mmHg) had a significantly lower CV readmission rate compared to those with a DBP 70 mmHg (12.8% vs. 16.5%, p=0.027). However, all-cause mortality did not differ between the groups (1.6% vs. 1.6%, p=0.991). Among patients with HFrEF, the difference in CV readmission was more pronounced, with significantly fewer events in the higher DBP group (11.9% vs. 18.4%, p=0.006). No significant difference in all-cause mortality was observed in this subgroup (1.7% vs. 1.9%, p=0.849). In contrast, patients with HFmrEF or HFpEF showed no significant differences in either mortality or CV readmission across DBP categories. Conclusion Higher DBP at discharge is associated with a lower rate of CV readmission at 3 months, particularly in patients with HFrEF. These findings underscore the importance of blood pressure optimisation during acute care and the early post-discharge period to improve short-term outcomes in HFrEF patients.