Key finding(s)

Among patients with heart failure with reduced ejection fraction, reduced systolic blood pressure in the context of medication doses being raised or maximised was not associated with higher risk of death or hospitalisation.

The researchers suggest that low or falling blood pressure may not be a reason to stop dose optimisation.

Conducted by researchers based in France, Italy, and Sweden, the study appeared in European Journal of Heart Failure.

Implications and/or background

Medications to treat heart failure can cause hypotension, and most patients receive suboptimal dosing. While low blood pressure in patients with heart failure is associated with worse outcomes, higher doses of heart failure medications are associated with better outcomes. How medications and blood pressure might be involved with each other has been unclear.

Study design

The researchers examined Swedish registry data from 2000 to 2018.

They compiled data on systolic blood pressure and doses of renin-angiotensin system inhibitors, beta-blockers, and mineralocorticoid receptor antagonists in 42,040 patients with heart failure with reduced ejection fraction.

They calculated optimal doses based on guidelines.

The outcome of interest was cardiovascular death and/or heart failure hospitalisation.

Results

About 1 in 5 patients were on optimal doses of all three heart failure medication types.

As expected, lower baseline systolic blood pressure was associated with higher rates of the primary outcome. In patients taking optimised doses of renin-angiotensin system inhibitors and beta-blockers, this risk was still elevated but significantly lower.

A subset of 13,761 patients underwent repeated measurements. Systolic blood pressure decreases were reported by 1 in 10 patients after dose increases and by 1 in 4 patients during stable or reduced dosing.

The latter group saw higher risk for the primary outcome, especially during dose reduction.

By contrast, patients whose blood pressure fell with rising medication dosages did not face higher risk for the primary outcome.

Limitations

The study was retrospective and observational, and there may have been residual confounders.

Funding

The study did not receive external financial support. Most of the authors report industry ties.

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