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
Abstract
Abstract Background 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 We studied HFrEF patients from the Swedish HF registry (2000–2018). Associations between systolic BP (SBP) and cardiovascular death and/or HF hospitalization (CVD/HFH) were analyzed according to doses of renin‐angiotensin system (RAS) inhibitors, beta‐blockers and mineralocorticoid receptor antagonists (MRA). Results Among 42 040 patients (median age 74.0), lower baseline SBP was associated with higher risk of CVD/HFH (adjusted HR per 10 mmHg higher SBP: 0.92 [0.92–0.93]), which was less high risk under optimized RAS inhibitors and beta‐blockers doses (10% decrease in event rates per 10 mmHg SBP increase in untreated patients versus 7% decrease in patients at maximum dose, both adjusted p < 0.02). Among the 13 761 patients with repeated measurements, 9.9% reported a SBP decrease >10 mmHg when HF medications' 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 [1.04–1.17]) or decreasing (HR = 1.29 [1.18–1.42]) HF medication dose but not in patients with an increase in doses (HR = 0.94 [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. This article is protected by copyright. All rights reserved.
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