Visit-to-visit blood pressure variation and outcomes in heart failure with reduced ejection fraction: findings from the Eplerenone in Patients with Systolic Heart Failure and Mild Symptoms trial
Abstract
Background: Visit-to-visit office blood pressure variability (BPV) has been associated with morbidity and mortality outcomes in several cardiovascular conditions. The aim of this study was to evaluate the association between BPV and outcomes in patients with heart failure and reduced ejection fraction (HFrEF) and the effect of eplerenone on BPV. Methods and Results: We evaluated the associations between BPV, calculated as systolic blood pressure coefficient of variation (SBP-CoV=SD/mean*100%), and the primary composite endpoint of cardiovascular mortality or HF hospitalization, and its components, in 2549 patients from the EMPHASIS-HF trial. Lower SBP-CoV was independently associated with a higher risk of all the studied outcomes, while higher as well as lower SBP-CoV were associated with a higher risk of cardiovascular death. After a median follow-up period of 21 months the risk of the composite outcome of cardiovascular death or HF hospitalization was almost double in the lower SBP-CoV tertile as compared to the intermediate tertile (adjusted HR: 2.01, 95%CI [1.62-2.51], p<0.001). The relationship between SBP-CoV and outcomes was not modified by eplerenone (p-value for interaction=0.48). An interaction was detected between mean SBP and SBP-CoV for the primary outcome (p=0.048) and for HF hospitalization (p=0.018). The effect modification was slight, but lower SBP-CoV was associated with worse outcomes in patients with both low and high SBP, while this interaction was less clear for patients with SBP in the "normal" range. Conclusions: In our patients with HFrEF and mild symptoms, both a lower and higher SBP-CoV were associated with worse outcomes. SBP-CoV did not modify the benefit of eplerenone. Further studies are warranted to clarify the role of BPV in HF.
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