Systolic Blood Pressure <130 mmHg is Linked to Poor Outcomes in Heart Failure
WASHINGTON (June 19, 2019) — Physician researchers from the Washington DC Veterans Affairs Medical Center published an original research paper in the current issue of Journal of the American College of Cardiology that indicates patients with heart failure who have a systolic blood pressure less than 130 mmHg are at a higher risk of worse outcomes. According to recent changes in national blood pressure and heart failure guidelines, systolic blood pressure in patients with heart failure and high blood pressure or hypertension should be maintained below 130 mmHg.
“Results of this research are important for Veterans as both high blood pressure and heart failure are common among Veteran patients,” said Charles Faselis, MD, chief of staff at the Washington DC VA Medical Center and professor of medicine at the George Washington University. “The sociodemographic and health status of Veterans are different from those of the general population, and it would be important to replicate these results in Veterans with heart failure. DC VA Medical Center now has the capabilities to use innovative advanced machine learning techniques to leverage our robust longitudinal national electronic health record data to shed light on some of the underlying causes of this paradoxical relationship – why high blood pressure causes heart failure but is linked to patients with heart failure living longer and staying out of the hospital.”
“Findings from our study show that hospitalized patients with heart failure and low ejection fraction whose systolic blood pressure was less than 130 mm Hg before discharge from the hospital were more likely to die or be re-hospitalized than those whose systolic blood pressure was 130 mmHg or higher,” said Cherinne Arundel, MD, chief of Hospitalist Section at the Washington DC VA Medical Center and associate professor of medicine at the George Washington University, who was the co-lead investigator of the study with Phillip Lam, MD.
“These results suggest that there is an urgent need for randomized controlled trials to determine optimal goals for blood pressure in patients with heart failure”, added Lam, who was a cardiology fellow at Georgetown University and the DC VA Medical Center when the research for this study began, and is currently an advanced heart failure fellow at the Brigham and Women's Hospital and Harvard Medical School.
Arundel, Lam and their colleagues also found that when patients with systolic blood pressure less than 110 mmHg were excluded, those with systolic blood pressure between 110 and 130 mmHg, which would be considered normal by any standard, was also linked with a higher risk of poor outcomes.
“Clinicians need to interpret the results of this study very carefully and not withhold guideline-directed heart failure drugs for fear of lowering blood pressure as drugs such as ACE inhibitors and beta-blockers lower the risk of death and hospitalization despite lowering blood pressure,” said Ali Ahmed, MD, MPH, associate chief of staff for health and aging at Washington DC VA Medical Center and professor of medicine at the George Washington University and Georgetown University and the study’s senior investigator.
“If I have a heart failure patient with an ejection fraction of 25% and a systolic blood pressure of 120 mmHg, I will not hesitate to initiate therapy with an ACE inhibitor and a beta-blocker,” said Ahmed. “However, if I have a patient who is on optimal doses of these drugs and had a systolic blood pressure of 140 mmHg, I will not add a calcium channel blocker or an alpha blocker to lower it below 130 mmHg. And, if a patient on optimal doses of heart failure drugs had a systolic blood pressure of 120 mmHg and was also on a calcium channel blocker, I will not hesitate to lower the dose or even discontinue it to get the systolic blood pressure above 130 mmHg.”
Another Medical Center study published last year in the Journal of the American Medical Association Cardiology demonstrated a similar link between systolic blood pressure less than 130 mmHg and a higher risk of death or re-hospitalization in patients with heart failure with normal ejection fraction. Clinicians and scientists are intrigued by these results as individuals with systolic blood pressure higher than 130 mmHg are at a higher risk of developing heart failure than those with a lower systolic blood pressure. However, once heart failure has developed, those with a higher systolic blood pressure are at a lower risk of death and hospitalization.
The heart is a pump that supplies oxygen-rich blood to the whole body and the term “heart failure” means that the heart is unable to pump enough blood to meet the oxygen requirement of the body. The left ventricle is the main pumping chamber of the heart and the term “ejection fraction” indicates the fraction of blood the left ventricle pumps out with each contraction. According to the American Heart Association, a normal heart’s ejection fraction is 50 percent or higher and ejection fraction of 40 percent or lower is considered abnormal.
Arundel, Lam and their colleagues studied 2,378 patients with heart failure with reduced ejection fraction – 1,189 with systolic blood pressure less than 130 mmHg and 1,189 with systolic blood pressure 130 mmHg or higher. Patients in the two groups were similar on 58 baseline characteristics including ejection fraction.
These patients were enrolled in OPTIMIZE-HF – a large national heart failure registry based on 259 hospitals from 48 lower states during 2003 and 2004. The study was funded by GlaxoSmithKline to Gregg Fonarow, MD of the University of California, Los Angeles, who is also an investigator in the study. GlaxoSmithKline played no role in the design or analysis of this study.
Other coauthors in the study are Gauravpal S. Gill, MD from the MedStar Washington Hospital Center, Washington, D.C.; Samir Patel, MD and Steven N. Singh, MD from the Washington DC VA Medical Center; Gurusher Panjrath, MD and Richard M. Allman, MD from the George Washington University; Michel White, MD from the University of Montreal and Montreal Heart Institute, Montreal, Quebec, Canada; Charity J. Morgan, PhD from the University of Alabama at Birmingham, Birmingham, Alabama; and Wilbert S. Aronow, MD from the New York Medical College and Westchester Medical Center, Valhalla, New York.
This release is posted courtesy of the Washington DC Veterans Affairs Medical Center. For more news, visit va.gov/opa/pressrel/.