Deepak K. Gupta, MD

HFpEF is a challenging syndrome in both the acute hospitalized and chronic ambulatory clinical settings. The high morbidity and mortality of this syndrome coupled with the lack of clearly efficacious therapies proven in clinical trials warrants deeper investigation into the pathophysiology and drivers of prognosis. In this regard, the current paper provides meaningful insights into the importance of systolic BP among patients hospitalized with HFpEF, by demonstrating that prognosis substantially varies according to systolic BP. This reinforces the concept of the heterogeneity of HFpEF and suggests we cannot simply approach all patients with HFpEF as hypertensives just because it is the most common comorbidity in HFpEF. A hospitalized patient with HFpEF with relatively low to “normal” systolic BP or without a history of hypertension may be a different phenotype than the typical hypertensive HFpEF patient. 

The overall finding that HFpEF patients with lower BP are at greater risk for death and HF readmissions is expected, as this has been seen among patients with HF. However, this had not previously been specifically evaluated among older hospitalized patients with HFpEF. In this regard, these findings provide an important addition to the literature. 

Clinicians usually think about diagnosis, etiology/pathophysiology, therapy and prognosis. The findings of this study may influence clinical practice regarding two of these, etiology and prognosis. For prognosis, the data suggest that clinicians should have a heightened awareness that older (Medicare-eligible) hospitalized patients with HFpEF with relatively lower admission or discharge BPs are at greater risk. For etiology, clinicians who see a patient with HFpEF with relatively lower BP in the absence of a history of hypertension should consider what other factors may be contributing to HFpEF in that patient. 

We have to be cautious about drawing inferences about therapeutic implications for patients with HFpEF. More specifically, this study does not answer whether lowering (or raising) BP in hospitalized patients with HFpEF to achieve a specific BP range is detrimental or associated with adverse outcomes.  No. 1, this was not a randomized trial targeting a specific BP range in hospitalized patients with HFpEF. No. 2, the primary analysis and results were among patients with stable BPs from admission to discharge. In the secondary analysis of patients whose BP varied substantially, with most having a marked reduction in systolic BP from admission to discharge, the association of lower discharge systolic BP with adverse outcomes was less clear. In other words, in those presenting with “hypertensive HFpEF,” lower discharge BP was not consistently associated with worse outcomes. As the authors conclude, prospective randomized trials targeting specific BP ranges for hospitalized patients with HFpEF are needed to address this question. 

Optimal BP for individual patients with HF, in both the acute and chronic settings, is a critical question that remains to be answered. From this study, it is uncertain whether BP is a modifiable target that would alter prognosis or simply a marker of risk. To address this question, one could envision a clinical trial targeting a specific BP range among patients with HF, examining both the acute and non-acute settings. The question of optimal BP for patients with HFpEF, and with HF in general, also extends outside of the Medicare cohort studied in this paper.

The authors should be congratulated on moving the discussion and science forward on BP in HFpEF.