Differential impact of heart rate and blood pressure on outcome in patients with heart failure with reduced versus preserved left ventricular ejection fraction☆
Introduction
Several well validated prognostic models [1], [2] have been developed for the estimation of risk in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF; HFREF). Among the contributory parameters, simple hemodynamic indices, including lower systolic blood pressure (BP) [2] and a higher resting heart rate (HR) [3], have been shown to be associated with an increased mortality in these patients. Pathophysiologically, these two measures are reflective of reduced cardiac output and elevated cardiac adrenergic drive [4], which also correlate with survival in patients with HFREF [5]. In this context, renin–angiotensin system inhibition has been shown to improve cardiac output and β-antagonists to reduce HR in patients with HFREF, and both classes of agents are well known to improve prognosis in these patients [4].
By contrast, it remains uncertain whether a similar relationship exists between HR or BP and outcome in patients with HF and preserved LVEF (HFPEF). Similar to that for HFREF, the clarification of the nature and extent of an association between HR or BP and prognosis in these patients holds substantial importance, particularly given ongoing controversy about the pathophysiology of HFPEF and the relative failure of therapies with proven efficacy in HFREF [6], [7], [8], [9].
Accordingly, the aim of the present study was to compare the relationship between HR and BP with outcome in a large cohort of HFREF and HFPEF patients that contributed to the Digitalis Investigations Group (DIG) trial.
Section snippets
Participants
The present study is a post hoc analysis of the randomized DIG trial [10] performed using the study database obtained from the National Heart, Lung, and Blood Institute (NHLBI; website https://biolincc.nhlbi.nih.gov/studies/dig/). Patients with a clinical diagnosis of HF and LVEF ≤ 45% or > 45% and “probable diastolic HF” [11] recruited between January 1991 and August 1993 in the United States and Canada were included in the main or an ancillary trial parallel to the main trial. We labeled this
Clinical characteristics of patients with HFREF and HFPEF
Patients with HFREF and HFPEF differed substantially at baseline, as shown in Table 1. Besides other differences, patients with HFREF had higher HR, lower systolic and diastolic BP, and lower PP.
Outcome in HFREF and HFPEF
Patients with HFREF had higher all-cause mortality and a higher HF hospitalization risk than HFPEF patients, and cardiac and cardiovascular mortality was also higher in HFREF patients (p < 0.001 for all comparisons using log rank tests or χ2 tests, as shown in Table 1), while non-cardiovascular mortality
Discussion
The present study demonstrated substantial differences in the prognostic value of simple clinical parameters such as HR and BP in a large cohort of HF patients with either reduced or preserved LVEF. In HFREF, higher HR and lower systolic and diastolic BP and PP correlated with all-cause mortality. By contrast, however, these variables did not correlate in a similar way with mortality in HFPEF patients; rather, PP appeared to be related to outcome in a J-shaped manner in these patients.
Acknowledgement
We thank Dr. Christopher M. Reid for technical support. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [35].
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MONITORIA: The start of a new era of ambulatory heart failure monitoring? Part I – Theoretical Rationale
2021, Revista Portuguesa de CardiologiaCitation Excerpt :The prognostic value of blood pressure differs substantially between HF with reduced left ventricular ejection fraction (LVEF) and HF with preserved LVEF, as clearly reported in the literature. Low systolic blood pressure (SBP), probably as a surrogate marker of low stroke volume, has been demonstrated as a predictor of death and HF hospitalization in HF with reduced ejection fraction patients.54 By contrast, apparently, there is no relationship between SBP and outcome in HF with preserved ejection fraction patients.
Resting Heart Rate as an Important Predictor of Mortality and Morbidity in Ambulatory Patients With Heart Failure: A Systematic Review and Meta-Analysis
2021, Journal of Cardiac FailureCitation Excerpt :This report was prepared according to the PRISMA guidelines (see Supplementary Fig. S1 for full PRISMA checklist).23 The literature search yielded 239,467 citations, of which 62 studies reporting on 163,445 patients were eligible for inclusion (Fig. 1).4–13,17,24–74 Of the 62 included studies, there were 24 RCT cohorts (96,550 patients), 21 prospective cohort studies (46,034 patients), and 17 retrospective cohort studies (20,861 patients).
Acute decompensated heart failure (ADHF): A comprehensive contemporary review on preventing early readmissions and postdischarge death
2016, International Journal of CardiologyCitation Excerpt :An analysis of the CHARM program showed that patients with a previous HF admission were more likely to be women, to have a more symptomatically advanced and of longer duration HF, and to have higher rates of hypertension, diabetes mellitus, and AF [20]. Several studies (Table 1) have proposed resting heart rate as an easily measurable and potentially modifiable factor associated with higher overall and CV risk [27,30,32,36–41]. In another analysis of the CHARM program, which included 7599 patients with symptomatic chronic HF and any LVEF, it was shown that for each 5 bpm increment in heart rate there was a significantly higher all-cause mortality as well as HF hospitalization in any of the following situation: baseline heart rate (HR = 1.03; CI:1.01–1.05; p = 0.002; HR = 1.04; CI:1.02–1.06; p < 0.001, respectively); heart rate at any visit (HR = 1.09; CI:1.07–1.11; p < 0.001; HR = 1.07; CI: 1.05–1.09; p < 0.001; respectively); and heart rate variation (HR = 1.09; CI:1.07–1.11; p < 0.001; HR = 1.06; CI: 1.04–1,08; p < 0.001; respectively).
Review: Integration of exercise evaluation into the algorithm for evaluation of patients with suspected heart failure with preserved ejection fraction
2013, International Journal of CardiologyPositive airway pressure therapy in heart failure patients comorbid with obstructive sleep apnea: Cardiovascular outcomes and nighttime-duration effect
2022, European Journal of Clinical Investigation
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The randomized DIG trial was conducted and supported by the NHLBI in collaboration with the Department of Veterans Affairs Cooperative Studies Program. Dr. Maeder was supported by the Swiss National Science Foundation (Grant PBZHB-121007). Dr. Kaye is supported by a program grant from the National Health and Medical Research Council of Australia.