Hypotension at heart failure discharge: Should it be a limiting factor for drug titration?

• Published in: International journal of cardiology Vol. 386; pp. 59 - 64
• Main Authors: Melendo-Viu, Maria, Dobarro, David, Marchán López, Álvaro, Domínguez, Luis Manuel, Raposeiras-Roubín, Sergio, Abu-Assi, Emad, Cardero-González, Carmen, Pérez-Expósito, Lucía, Cespón Fernández, María, Parada Barcia, Jose Antonio, Barreiro Pérez, Manuel, García, Enrique, Íñiguez Romo, Andrés
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier B.V 01-09-2023
• Subjects: HFrEF treatment; Hypotension; Mortality; Prognosis; Uptitration; BB; Prognosis; PS; AoS; LR; LVEF; NHB; HR; HFrEF; BP; Uptitration; ARNi; CKD; NYHA; SBP; OR; MR; Mortality; CI; HFrEF treatment; Hypotension; ARB; ACEi; MRA; SGLT2i; HF
• ISSN: 0167-5273; 1874-1754; 1874-1754
• DOI: 10.1016/j.ijcard.2023.05.007

Medical treatment in Heart Failure (HF) with reduced ejection fraction (HFrEF; LVEF ≤40%) has shifted towards quadruple therapy. Maximum tolerated dose is the goal, yet no hypotension's cut-off point has been specified. In this work, we analyze the impact of intensive drug titration in clinical events, focusing on low blood pressure (BP) patients at hospital discharge.
Retrospective analysis of 713 patients with HFrEF discharged after an acute HF event (mean LVEF 30 ± 5%). Mean SBP was 112.4 ± 16.5 mmHg and 50.6% were discharged on triple therapy. We considered hypotension as a Systolic blood pressure (SBP) <100 mmHg (21.7% of patients, mean SBP was 112.4 ± 16.5 mmHg) and codified the intensity of drug therapy in 5 stages from untreated to very high therapy intensity. The impact of the intensity of treatment was analysed with a propensity score and increasing the intensity was associated in the whole cohort with a reduction of the composite outcome of all-cause mortality and HF readmission, (HR 0.69; CI95% 0.57–0.85, p < 0.001) and benefit in mortality was maintained for SBP < 100 mmHg (HR 0.42; CI95% 0.22–0.82; p = 0.011). Moreover, therapy intensity was clearly associated with lower risk of HF-hospitalization and death after the additional regression, considering SBP as a covariate, in the whole cohort (HR 0.70; CI95% 0.57–0.85; p < 0.001).
In this retrospective cohort analysis, patients with HFrEF and an acute-HF admission, intensive drug dose titration was related to better outcomes, even in patients with low blood pressure at hospital discharge. Therefore, hypotension is not a contraindication for NHB uptitration.
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•Hypotensive patients were traditionally excluded from pivotal trials in HFrEF.•Quadruple neurohormonal blockade titration is usually limited by low blood pressure.•This is a real-life HFrEF cohort where the intensity of treatment vs blood pressure is analysed.•Intensify treatment to maximum tolerated dose reduces mortality and hospitalizations.•Intensify treatment despite systolic blood pressure < 100 mmHg reduces mortality by 30%.