Prognostic impact of heart failure guideline-directed medical therapy in patients with low blood pressure

BACKGROUND: Patients with hypotension have consistently been excluded from heart failure (HF) randomized controlled trials. AIMS: We aimed to study HF patients with hypotension. METHODS: Retrospective study of outpatients with HF with left ventricular systolic dysfunction followed from January 2012-December 2020. We defined hypotension as systolic blood pressure (SBP) <100 mm Hg. ENDPOINT: all-cause mortality. Patients were followed until January 2023. A Cox-regression analysis was used to study the prognostic impact of guideline-directed medical therapy separately in HF patients with SBP <100 mm Hg and those ≥ 100 mm Hg. Adjustments were made for confounders. RESULTS: We studied 1206 HF patients, mean age 71 years; 91.4% were on β-blockers (BB), 82.8% were on renin-angiotensin-system inhibitors (RASi); 29.6% on mineralocorticoid receptor antagonists. SBP was<100 mm Hg in 157 (13.0%) patients. Hypotensive patients more often presented atrial fibrillation and severe left ventricular systolic dysfunction; they had lower hemoglobin and higher B-type natriuretic peptide; they were less medicated with RASi, but more with mineralocorticoid receptor antagonists and diuretics. BB was similarly prescribed in both groups. During a median follow-up of 47 (27-85) months, 645 (53.5%) patients died, 61.1 vs. 52.3% in hypotensive and non-hypotensive, P = 0.04. RASi prescription is associated with survival-benefit in both hypotensive (hazard ratio HR, 0.49 0.29-0.83) and non-hypotensive (HR, 0.64 0.50-0.80). BB predicted better survival in non-hypotensive (HR, 0.61 0.46-0.81), but not in hypotensive patients. CONCLUSIONS: Hypotension was associated with poor prognosis in HF patients. In patients with SBP <100 mm Hg BB use was prognostic neutral, however RASi use portended survival benefit. Despite their exclusion from most HF therapy trials, hypotensive patients appear to benefit from RASi drugs.