Chicago, IL - Systolic hypertension is not only common in patients hospitalized with acute heart failure, it may also help protect against death while in the hospital and for several months after discharge, regardless of LV systolic function at admission, suggest data from a huge multicenter registry [1]. The adjusted in-hospital mortality for more than 48 000 patients hospitalized with HF varied inversely with their admission systolic blood pressure (SBP) and was about four times higher when the SBP was <120 mm Hg as compared with >161 mm Hg.

"Hypertension is very frequent in patients hospitalized with heart failure, including those with reduced systolic function as well as those with preserved systolic function," Dr Gregg C Fonarow (University of California, Los Angeles Medical Center), a coauthor of the analysis, told heartwire. Half of the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry cohort—more than a third of patients with LV systolic dysfunction and more than half of those with preserved LV function—had an admission SBP >140 mm Hg.

The inverse relationship between admission SBP and in-hospital mortality, Fonarow observed, applied to both types of patients. Postdischarge mortality also rose significantly with declining admission SBP, regardless of any treatment with vasodilators or inotropic agents, in a subgroup of the cohort that was followed for two to three months.

The OPTIMIZE-HF analysis from Dr Mihai Gheorghiade (Northwestern University, Chicago, IL) and associates was published in the November 8, 2006 issue of the Journal of the American Medical Association.

We put so much emphasis on LV ejection fraction, and yet it's not a major determinant of clinical outcomes in these patients, whereas admission systolic blood pressure . . . is a much larger predictor of mortality.

The findings not only suggest that admission SBP is independently prognostic in patients hospitalized with HF, they have implications for therapy, observed Fonarow. They suggest, he said, that "with the characteristics and outcomes so different among the patients by varied SBP levels, management will need to vary. Rather than grouping all of these patients together, we'll potentially need to stratify them."

The report states, "Elevated SBP appears to signal specific pathophysiological processes that differ from the underlying processes in patients with low SBP. Because the characteristics and outcomes are different among patients with heart failure with varying SBP levels, management may need to vary according to SBP at admission."

The in-hospital outcomes analysis included patients admitted with HF at 259 academic and community-based US hospitals "of all sizes and from all regions of the country." In the overall cohort and the subgroup of 5791 patients followed after discharge, admission SBP was a significant predictor of mortality after a long list of demographic, hemodynamic, renal functional, clinical, and drug treatment criteria was controlled for.

For admission SBP readings <160 mm Hg, the hazard ratio (HR) for in-hospital death went up 21% (95% CI 1.17-1.25) for every 10-mm-Hg drop; the risk didn't vary for SBP values >160 mm Hg. Also, for every 10-mm-Hg decrease in SBP, the postdischarge-mortality HR climbed 18% (95% CI 1.10-1.26) and the HR for the composite of mortality or rehospitalization rose 5% (95% CI 1.03-1.07).

The average hospital length of stay also declined with rising admission SBP regardless of LV systolic functional status; in the overall group it fell from 6.5 days for patients with SBP <120 mm Hg to 5.1 days for those with pressures >161 mm Hg (p<0.001). The rate of rehospitalization 60 to 90 days after discharge did not vary significantly overall or in the two LV-systolic-function subgroups.

"Interestingly, we put so much emphasis on LV ejection fraction," Fonarow said, "and yet it's not a major determinant of clinical outcomes in these patients, whereas admission systolic blood pressure, which has not received a lot of focus, is a much larger predictor of mortality in these patients."