Patients with heart failure and low systolic blood pressure at hospital admission are more likely to have poor outcomes including higher mortality rates and increased rates of rehospitalization, despite medical treatment, according to a study in the November 8 issue of JAMA.
Acute heart failure is a major public health concern because of its prevalence and associated illness and death. In 2003, 1.1 million patients were discharged from the hospital for heart failure, making this the most common discharge diagnosis among patients older than 65 years, according to background information in the article. Recent studies have indicated that the majority of patients hospitalized for heart failure are admitted with low or normal systolic blood pressure (SBP; the peak pressure in the arteries during the cardiac cycle). Elevated SBP may identify patients with certain clinical characteristics that are unique from those in patients with low SBP.
Mihai Gheorghiade, M.D., of the Feinberg School of Medicine, Northwestern University, Chicago, and colleagues evaluated the relationship between SBP at admission, patient clinical data, and outcomes in patients hospitalized for acute heart failure. The researchers analyzed data from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry and performance-improvement program, which included patients hospitalized with heart failure at 259 U.S. hospitals between March 2003 and December 2004. Patients were divided into quartiles by SBP at hospital admission (<120, 120-139, 140-161, and >161 mm Hg).
In-hospital outcomes were based on 48,612 patients age 18 years or older with heart failure. Of the 41,267 patients who had left ventricular function assessed, 21,149 (51 percent) had preserved left ventricular function. Outcomes following discharge from the hospital were based on a prespecified subgroup (n = 5,791, approximately 10 percent of patients) with follow-up data for between 60 and 90 days.
The researchers found that lower SBP at admission was associated with substantially increased in-hospital risk of death: 7.2 percent (for blood pressure <120 mm Hg), 3.6 percent (120-139 mm Hg), 2.5 percent (140-161 mm Hg), and 1.7 percent (>161 mm Hg). The odds of in-hospital death increased 21 percent for each 10-mm Hg decrease in SBP below 160 mm Hg. In the follow-up group, higher SBP at admission was also associated with lower risk of 60- to 90-day death.
Patients with higher SBP were more likely to be female and black. Fifty percent of the patients had SBP higher than 140 mm Hg at admission.
"… this analysis demonstrates that SBP at hospital admission, a readily accessible vital sign, is an important and independent predictor of morbidity and mortality in patients with heart failure, including patients with reduced or relatively preserved systolic function. Systolic blood pressure at hospital admission can effectively identify groups of patients that differ with respect to clinical characteristics, prognosis, and perhaps underlying pathophysiology. Accordingly, the therapeutic approach may vary among patients with high, normal, or low SBP," the authors write.
(JAMA. 2006;296:2217-2226. Available pre-embargo to the media at www.jamamedia.org.)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Editorial: Systolic and Nonsystolic Heart Failure - Equally Serious Threats
In an accompanying editorial, Per Hildebrandt, M.D., D.M.Sc., of Roskilde University Hospital, Roskilde, Denmark, comments on the two studies on heart failure in this week's issue of JAMA.
"The findings … that approximately half of patients with heart failure, whether observed in the community or in the hospital, have preserved systolic function and that mortality in these patients is similar to that for patients with heart failure and reduced systolic function have important implications. Just as heart failure with reduced LVEF [left ventricular ejection fraction] has long been recognized as a common and serious disease and has been the subject of a number large-scale clinical trials, the entities of heart failure with preserved LVEF and diastolic dysfunction equally deserve attention. Deciphering the mechanisms and developing evidence-based treatments for these major public threats deserve the highest priority."
(JAMA. 2006;296:2259-2260. Available pre-embargo to the media at www.jamamedia.org.)
Editor's Note: Financial disclosures: Dr. Hildebrandt reported receiving honoraria from AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, Merck, Novartis, Pfizer, Sanofi-Aventis, Servier, and Takeda.
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