Background

Hypertension is common in patients with heart failure with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF), and current guidelines recommend treating systolic blood pressure (SBP) to a target below 130 mmHg. However, data supporting treatment to this target is limited. Additionally, pulse pressure (PP), a marker of aortic stiffness, has been associated with increased risk of cardiovascular events, but its prognostic impact in HFpEF has not been extensively studied.

Objectives

This study aimed to explore the impact of baseline SBP and PP on cardiovascular outcomes in patients with HFmrEF or HFpEF.

Methods

I-PRESERVE, TOPCAT-Americas, PARAGON-HF and DELIVER were global, randomized clinical trials testing irbesartan, spironolactone, sacubitril/valsartan and dapagliflozin respectively, against either a placebo or an active comparator (valsartan, in PARAGON-HF), in patients with HF and a left ventricular ejection fraction ≥40% (in DELIVER) or ≥45% (in the other trials). The relationship between continuous baseline SBP and PP, and the primary endpoint (first HF hospitalization or cardiovascular death) was analyzed with restricted cubic splines. We further evaluated the prognostic impact of SBP categories (<120, 120-129, 130-139, ≥140 mmHg) and PP quartiles on the primary endpoint.

Results

A total of 16,950 patients (mean age 71±9 years, 49% male, mean SBP 131±15 mmHg, mean PP 55±14 mmHg) were included. The relationship between SBP and the primary endpoint was J-shaped, with the lowest risk at 120-130 mmHg. A similar pattern was found for PP, with the lowest risk at 50-60 mmHg. The highest SBP category (reference: 120-129 mmHg) and PP quartile (reference: 46-54 mmHg) were associated with a higher risk of the primary outcome (HR: 1.22; 95% CI: 1.10-1.34; HR: 1.22; 95% CI: 1.11-1.34, respectively). Higher PP was associated with greater cardiovascular risk, regardless of SBP.

Conclusions

Our analysis of a large pooled dataset from four clinical trials, including over 16,900 patients with HFmrEF/HFpEF, indicates a J-shaped relationship between both SBP and PP, and cardiovascular risk. The lowest risk was observed at SBP levels between 120 and 130 mmHg and PP values between 50 and 60 mmHg.

中文翻译：

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心力衰竭中的收缩压和脉压：四项试验的汇总参与者水平分析

 背景

高血压常见于射血分数轻度降低或保留的心力衰竭 （HFmrEF/HFpEF） 患者，目前的指南建议将收缩压 （SBP） 治疗至低于 130 mmHg 的目标值。然而，支持针对该目标进行治疗的数据有限。此外，脉压 （PP） 是主动脉僵硬的标志物，与心血管事件风险增加有关，但其对 HFpEF 的预后影响尚未得到广泛研究。

 目标

本研究旨在探讨基线 SBP 和 PP 对 HFmrEF 或 HFpEF 患者心血管结局的影响。

 方法

I-PRESERVE、TOPCAT-Americas、PARAGON-HF 和 DELIVER 是全球随机临床试验，分别测试了厄贝沙坦、螺内酯、沙库巴曲/缬沙坦和达格列净与安慰剂或活性对照剂（缬沙坦，在 PARAGON-HF 中）在左心室射血分数 ≥40%（DELIVER）或 ≥45%（在其他试验中）的 HF 患者中的疗效。使用限制性三次样条分析连续基线 SBP 和 PP 与主要终点 （首次 HF 住院或心血管死亡） 之间的关系。我们进一步评估了 SBP 类别 （<120、120-129、130-139、≥140 mmHg） 和 PP 四分位数对主要终点的预后影响。

 结果

共纳入 16,950 例患者 （平均年龄 71±9 岁，49% 为男性，平均 SBP 131±15 mmHg，平均 PP 55±14 mmHg）。SBP 与主要终点之间的关系呈 J 形，风险最低，为 120-130 mmHg。PP 也发现了类似的模式，风险最低，为 50-60 mmHg。最高 SBP 类别（参考：120-129 mmHg）和 PP 四分位数（参考：46-54 mmHg）与主要结果的较高风险相关（HR：1.22;95% CI：1.10-1.34;心率：1.22;95% CI：分别为 1.11-1.34）。无论 SBP 如何，较高的 PP 都与较高的心血管风险相关。

 结论

我们对来自四项临床试验（包括 16,900 多名 HFmrEF/HFpEF 患者）的大型汇总数据集的分析表明，SBP 和 PP 与心血管风险之间存在 J 形关系。在 120 至 130 mmHg 之间，PP 值在 50 至 60 mmHg 之间时观察到风险最低。