Aggressive Systolic Blood Pressure Control In Older Patients With HFpEF Should Be Avoided

“Doctors” by Tele Jane is licensed under CC BY Interview with:
Dr. Apostolos Tsimploulis, Chief Medical Resident
Dr. Phillip H. Lam, Chief Cardiology Fellow
The Washington, DC Veterans Affairs Medical Center, Georgetown University, and
MedStar Washington Hospital Center, Washington, DC What is the background for this study? What are the main findings?

Response: Hypertension is a major risk factor for the development of new heart failure (HF). Findings from multiple randomized controlled trials in hypertension have consistently demonstrated that controlling systolic blood pressure (SBP) to normal levels such as to SBP <120 mm Hg reduces the risk of developing new HF.

However, interestingly, once patients develop heart failure, those with a normal SBP value such as SBP <120 mm Hg tend to have poor outcomes. This paradoxical association – also called reverse epidemiology – although poorly understood – has been described with other HF risk factors such as smoking and obesity. Regarding poor outcomes associated with lower SBP in HF patients with reduced ejection fraction (HFrEF – pronounced Hef-ref), it has been suggested that it may be a marker of weak heart muscle that is unable to pump enough blood. However, less is known about this association in patients with HF and preserved ejection fraction (HFpEF – pronounced Hef-pef) –– the heart muscle is not weak in the traditional sense.

This is an important question for a number of reasons: nearly half of all heart failure patients have HFpEF which accounts for about 2.5 to 3 million Americans. These patients have a high mortality similar to those with HFrEF – but unlike in HFrEF few drugs have been shown to improve their outcomes. Thus, there is a great deal of interest in improving their outcomes. One of those approaches is to control . systolic blood pressure and the 2017 ACC/AHA/HFSA Focused Update of the HF guidelines recommend that SBP “should be controlled in patients with HFpEF in accordance with published clinical practice guidelines to prevent morbidity.”

Thus, our study was designed to answer that simple question: do patients with HFpEF and SBP <120 mmHg, which is considered to be normal SBP, have better outcomes than those with SBP ≥120 mmHg.

Using a sophisticated approach called propensity score matching we assembled two groups of patients with HFpEF – one group with SBP <120 mmHg and the other groups had SBP ≥120 mmHg – and patients in both groups were similar in terms of 58 key baseline characteristics. In this population of balanced patients with HFpEF, those with a normal systolic blood pressure had a higher risk of mortality – starting 30 days post-discharge up to about 6 years. Finding from our restricted cubic spline plots suggest that compared with SBP <120 mm Hg, SBP values ≥120 mm Hg (up to 200 mm Hg) was not associated with a higher risk of death. What should readers take away from your report? 

Response: The key take away message from our study is that the optimal systolic blood pressure target for HFpEF is far from clear and aggressive control of SBP in older patients with HFpEF should be avoided. The recent AHA/ACC hypertension guideline is primarily based on evidence from patients without HF and those recommendations may not be generalizable for HFpEF. Although our study is observational in nature, the sophisticated methodologies used and consistency of the findings across multiple sensitivity cohorts as well clinically important subgroups suggest that a lower SBP level is a marker of underlying pathophysiologic processes that is associated with poor outcomes in patients with HFpEF. What recommendations do you have for future research as a result of this work?

Response: Future prospective randomized trials are needed to examine the impact of various SBP target levels on outcomes in patients with HFpEF and to determine the optimal SBP target for these patients. Is there anything else you would like to add? 

Response: We wish to thank Drs. Ahmed and Fonarow, our co-lead senior authors, and all our co-authors, for their support and contribution to this important paper. We also want to thank our colleagues at the Center for Health and Aging of the Washington DC Veterans Affairs Medical Center for their continued support. Completed ICMJE Forms for Disclosure of Potential Conflicts of Interest are submitted by all authors and published online by the journal. 


 Tsimploulis A, Lam PH, Arundel C, Singh SN, Morgan CJ, Faselis C, Deedwania P, Butler J, Aronow WS, Yancy CW, Fonarow GC, Ahmed A. Systolic Blood Pressure and Outcomes in Patients With Heart Failure With Preserved Ejection Fraction. JAMA Cardiol. Published online February 14, 2018. doi:10.1001/jamacardio.2017.5365 

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