Hypotension in heart failure is less harmful if associated with high or increasing doses of heart failure medication: Insights from the Swedish Heart Failure Registry

• Published in: European journal of heart failure 2024-02, Vol.26 (2), p.359-369
• Main Authors: Girerd, Nicolas, Coiro, Stefano, Benson, Lina, Savarese, Gianluigi, Dahlström, Ulf, Rossignol, Patrick, Lund, Lars H.
• Format: Article
• Language: English
• Subjects: Blood pressure; Cardiovascular diseases; Dose; Heart failure; Heart failure with reduced ejection fraction; Life Sciences; Medication
• ISSN: 1388-9842; 1879-0844; 1879-0844
• DOI: 10.1002/ejhf.3066

Aims Heart failure (HF) medication may reduce blood pressure (BP). Low BP is associated with worse outcomes but how this association is modified by HF medication has not been studied. We evaluated the association between BP and outcomes according to HF medication dose in HF with reduced ejection fraction (HFrEF). Methods and results We studied HFrEF patients from the Swedish HF registry (2000–2018). Associations between systolic BP (SBP) and cardiovascular death (CVD) and/or HF hospitalization (HFH) were analysed according to doses of renin–angiotensin system (RAS) inhibitors, beta‐blockers and mineralocorticoid receptor antagonists (MRA). Among 42 040 patients (median age 74.0), lower baseline SBP was associated with higher risk of CVD/HFH (adjusted hazard ratio [HR] per 10 mmHg higher SBP: 0.92, 95% confidence interval [CI] 0.92–0.93), which was less high risk under optimized RAS inhibitor and beta‐blocker doses (10% decrease in event rates per 10 mmHg SBP increase in untreated patients vs. 7% decrease in patients at maximum dose, both adjusted p 10 mmHg when HF medication doses were increased, whereas 24.6% reported a SBP decrease >10 mmHg with stable/decreasing doses. Decreasing SBP was associated with higher risk of CVD/HFH in patients with stable (HR 1.10, 95% CI 1.04–1.17) or decreasing (HR 1.29, 95% CI 1.18–1.42) HF medication dose but not in patients with an increase in doses (HR 0.94, 95% CI 0.86–1.02). Conclusions The association of lower SBP with higher risk of CVD/HFH is attenuated in patients with optimized HF medication. These results suggest that low or declining SBP should not limit HF medication optimization. Low blood pressure and heart failure in SwedeHF: The heightened risk associated with lower systolic blood pressure (SBP) is reduced when higher doses of heart failure medications are used. Increasing medication doses, even when leading to a decrease in SBP, does not correlate with an elevated risk, indicating that low SBP should not inhibit the optimization of heart failure therapy. BB, beta‐blocker; BP, blood pressure; CV, cardiovascular; CVD, cardiovascular death; HF, heart failure; HFH, heart failure hospitalization; HFrEF, heart failure with reduced ejection fraction; MRA, mineralocorticoid receptor antagonist; RAS, renin‐angiotensin system; SBP, systolic blood pressure.