| Background and objective:Heart failure(HF)is a global major public health problem and high blood pressure(BP)is an important risk factor for HF.More than 50%of patients admitted to hospital for HF have a medical history of hypertension.However,the association between BP and clinical outcomes in patients hospitalized for HF remains uncertain.Unlike the linear association between increased BP and increased risk of adverse events in the general population,previous studies found the association between higher BP and lower risk of adverse events in HF patients and the U curve association has been found in other studies.Additionally,BP could have a differential prognostic effect on clinical outcomes according to left ventricular ejection fraction status.Our study aims to examine the association between BP and long-term clinical outcomes in patients hospitalized for HF,and the associations in important subgroups as well.Methods:Based on the China Patient-centered Evaluative Assessment of Cardiac Events HF study,we enrolled patients who were aged?18 years and hospitalized primarily for HF from 52 hospitals located in 20 provinces between August 2016 and May 2018.We collected information on demographic characteristics,socioeconomic characteristics,clinical characteristics,comorbidities,and medications through questionnaire and medical record abstraction.We also collected information on physical examination and echocardiogram results and took blood and urine samples.All enrolled patients were followed up for one year and clinical outcomes were collected during follow up.The key variables in this study were systolic blood pressure(SBP),diastolic blood pressure(DBP),and pulse pressure(PP).Clinical outcomes in this study were all-cause death,cardiovascular death,all-cause readmission,and HF readmission.Patients were categorized into subgroups by BP levels.The cumulative incidence rates of clinical outcomes in subgroups by BP levels were depicted.Cox proportional hazards frailty models or competing risk models were used to estimate hazard ratios(HRs)and 95%confidence intervals(CIs)for risk of clinical outcomes in BP subgroups.Restricted cubic splines were used to explore the non-linear association between BP as a continuous variable and clinical outcomes.Subgroup analyses were conducted in subgroups of sex,age,left ventricular ejection fraction,HF type,comorbidities,and medications.Results:In the analysis of the association between admission BP and clinical outcomes,a total of 4895 patients were included.The mean age of patients was 65.2±13.5 years and 37.7%were female.During one year follow up.856 patients died,714 patients had cardiovascular death,1954 patients had all-cause readmission,and 1559 patients had HF readmission.After adjusting demographic characteristics.socioeconomic characteristics,clinical characteristics,medications,and quality of life index,compared to patients with admission SBP of 120-129 mmHg,patients with admission SBP<110 mmHg had higher risk of death(HR=1.54.95%CI:1.23.1.92),cardiovascular death(HR=1.59.95%CI:1.24.2.04).and HF readmission(HR=1.21,95%CI:1.01.1.45),and patients with admission SBP?150 mmHg had lower risk of death(HR=0.76,95%CI:0.59,0.97);compared to patients with admission DBP of 80-89 mmHg,patients with admission DBP<70 mmHg had higher risk of death(HR=1.37,95%CI:1.12,1.67)and cardiovascular death(HR=1.42,95%CI:1.14,1.77),and patients with admission DBP?100 mmHg had lower risk of death(HR=0.75,95%CI:0.57,0.98)and cardiovascular death(HR=0.72,95%CI:0.53.0.98):compared to patients with admission PP<40 mmHg,patients with admission PP of 40-49 mmHg(HR=0.68,95%CI:0.55,0.83),50-59 mmHg(HR=0.68,95%CI:0.55,0.84),60-69 mmHg(HR=0.77,95%CI:0.61,0.97),and?70 mmHg(HR=0.61,95%CI:0.48,0.77)had lower risk of death.The association between admission PP and cardiovascular death was similar as the association between admission PP and all-cause death.Our study did not find the U curve association between admission BP and clinical outcomes.The associations between admission BP and clinical outcomes were consistent across various subgroups.In the analysis of the association between stable BP and clinical outcomes,a total of 4564 patients were included.The mean age of patients was 65.3±13.5 years and 37.9%were female.During one year follow up.771 patients died.668 patients had cardiovascular death.1886 patients had all-cause readmission.and 1492 patients had HF readmission.After adjusting demographic characteristics.socioeconomic characteristics,clinical characteristics,medications,and quality of life index.compared to patients with stable SBP of 120-129 mmHg.patients with stable SBP<110 mmHg had higher risk of death(HR=1.59,95%CI:1.28.1.98).cardiovascular death(HR=1.63.95%CI:1.28.2.07).and HF readmission(HR=1.18,95%CI:1.01.1.38):compared to patients with stable DBP of 80-89 mmHg.patients with stable DBP of 60-69 mmHg had higher risk of death(HR=1.33.95%CI:1.04.1.68)and cardiovascular death(HR=1.44.95%CI:1.11.1.87).and patients with stable DBP of 70-79 mmHg had higher risk of cardiovascular death(HR=1.39.95%CI:1.07,1.81);compared to patients with stable PP<40 mmHg,patients with stable PP of 40-49 mmHg(HR=0.67,95%CI:0.55,0.82),50-59 mmHg(HR=0.71,95%CI:0.57,0.88),and?60 mmHg(HR=0.68,95%CI:0.54,0.85)had lower risk of death.The associations between stable PP and cardiovascular death and HF readmission were similar as the association between stable PP and all-cause death.Our study did not find the U curve association between stable BP and clinical outcomes.The associations between stable BP and clinical outcomes were consistent across various subgroups.Conclusion:Our study found that admission BP and stable BP were independent predictors for patients hospitalized for HF.Patients with lower admission SBP,DBP,and PP had significantly higher risk of all-cause death and tended to have higher risk of HF readmission.Lower stable SBP,DBP,and PP were significantly associated with higher risk of all-cause death and HF readmission.Intensive care should be provided to HF patients with low admission BP,which may improve their long-term survival.BP levels should be closely monitored during hospitalization and clinicians should be cautious about lowering BP,especially avoiding decreasing BP to a very low level. |
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