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Original Investigation
April 2018

Systolic Blood Pressure and Outcomes in Patients With Heart Failure With Preserved Ejection Fraction

Author Affiliations
  • 1Veterans Affairs Medical Center, Washington, DC
  • 2Georgetown University, Washington, DC
  • 3MedStar Washington Hospital Center, Washington, DC
  • 4George Washington University, Washington, DC
  • 5University of Alabama at Birmingham, Birmingham
  • 6University of California-San Francisco, Fresno
  • 7Stony Brook University, Stony Brook, New York
  • 8University of Mississippi, Jackson
  • 9Westchester Medical Center, Valhalla, New York
  • 10New York Medical College, Valhalla
  • 11Northwestern University, Chicago, Illinois
  • 12Deputy Editor, JAMA Cardiology
  • 13Ahmanson-UCLA Cardiomyopathy Center, Division of Cardiology, University of California, Los Angeles
  • 14Associate Editor for Health Care Quality and Guidelines, JAMA Cardiology
JAMA Cardiol. 2018;3(4):288-297. doi:10.1001/jamacardio.2017.5365
Key Points

Question  How is systolic blood pressure associated with outcomes in patients with heart failure with preserved ejection fraction?

Findings  In a propensity score–matched observational study of hospitalized patients with HF and ejection fraction 50% or greater in the national Medicare-linked OPTIMIZE-HF registry, a discharge systolic blood pressure level of less than 120 mm Hg was associated with a significantly higher risk of 30-day, 1-year, and long-term all-cause mortality.

Meaning  A systolic blood pressure level of less than 120 mm Hg identifies patients with heart failure with preserved ejection fraction at higher risk for short- and long-term mortality and emphasizes the need for future prospective studies to evaluate optimal systolic blood pressure treatment goals in this patient population.

Abstract

Importance  Lower systolic blood pressure (SBP) levels are associated with poor outcomes in patients with heart failure. Less is known about this association in heart failure with preserved ejection fraction (HFpEF).

Objective  To determine the associations of SBP levels with mortality and other outcomes in HFpEF.

Design, Setting, and Participants  A propensity score–matched observational study of the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry included 25 354 patients who were discharged alive; 8873 (35.0%) had an ejection fraction of at least 50%, and of these, 3915 (44.1%) had stable SBP levels (≤20 mm Hg admission to discharge variation). Data were collected from 259 hospitals in 48 states between March 1, 2003, and December 31, 2004. Data were analyzed from March 1, 2003, to December 31, 2008.

Exposure  Discharge SBP levels less than 120 mm Hg. A total of 1076 of 3915 (27.5%) had SBP levels less than 120 mm Hg, of whom 901 (83.7%) were matched by propensity scores with 901 patients with SBP levels of 120 mm Hg or greater who were balanced on 58 baseline characteristics.

Main Outcomes and Measures  Thirty-day, 1-year, and overall all-cause mortality and heart failure readmission through December 31, 2008.

Results  The 1802 matched patients had a mean (SD) age of 79 (10) years; 1147 (63.7%) were women, and 134 (7.4%) were African American. Thirty-day all-cause mortality occurred in 91 (10%) and 45 (5%) of matched patients with discharge SBP of less than 120 mm Hg vs 120 mm Hg or greater, respectively (hazard ratio [HR], 2.07; 95% CI, 1.45-2.95; P < .001). Systolic blood pressure level less than 120 mm Hg was also associated with a higher risk of mortality at 1 year (39% vs 31%; HR, 1.36; 95% CI, 1.16-1.59; P < .001) and during a median follow-up of 2.1 (overall 6) years (HR, 1.17; 95% CI, 1.05-1.30; P = .005). Systolic blood pressure level less than 120 mm Hg was associated with a higher risk of heart failure readmission at 30 days (HR, 1.47; 95% CI, 1.08-2.01; P = .02) but not at 1 or 6 years. Hazard ratios for the combined end point of heart failure readmission or all-cause mortality associated with SBP level less than 120 mm at 30 days, 1 year, and overall were 1.71 (95% CI, 1.34-2.18; P < .001), 1.21 (95% CI, 1.07-1.38; P = .004), and 1.12 (95% CI, 1.01-1.24; P = .03), respectively.

Conclusions and Relevance  Among hospitalized patients with HFpEF, an SBP level less than 120 mm Hg is significantly associated with poor outcomes. Future studies need to prospectively evaluate optimal SBP treatment goals in patients with HFpEF.

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