In SPRINT cohort, HFpEF, HFrEF outcomes similar after initial HF event
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Aggressive BP lowering reduced acute decompensated HF events in SPRINT, but subsequent HF readmission and mortality did not differ between patients with reduced or preserved ejection fraction, researchers reported.
As Healio previously reported, an aggressive systolic BP target of less than 120 mm Hg was associated with lower rates of MI, other ACS, stroke, HF and death from CV causes, in addition to lower all-cause mortality, compared with a more standard target of less than 140 mm Hg.
Final results of the SPRINT trial published in The New England Journal of Medicine in 2021, which were based on more than 3 years of follow-up, confirmed that aggressive BP treatment lowering was associated with lower risk for the SPRINT primary outcome, including acute decompensated HF (HR = 0.73; 95% CI, 0.63-0.86).
“Because most hypertension trials have not examined HF cases by EF phenotype, there is relatively little information regarding the effect of BP lowering on incident HFpEF or subsequent outcomes after a new HFpEF diagnosis in patients with hypertension, particularly with intensive BP reduction. It is possible that lower BP treatment goals could have a differential impact on patients who develop HFpEF vs. HFrEF,” Bharathi Upadhya, MD, associate professor of cardiology at Wake Forest School of Medicine, and colleagues wrote in a new SPRINT analysis published in Circulation: Heart Failure. “This analysis seeks to understand the effects of intensive BP reduction on EF phenotype and clinical outcomes in middle-aged and older persons who experienced acute decompensated HF events during the SPRINT trial.”
Within the SPRINT cohort, 133 participants experienced acute decompensated HF, of whom 52% were adjudicated as having HFpEF and 48% as having HFrEF (P = .73).
Participants with HFpEF were older (P = .01), were less likely to be Black (P = .05) and had lower diastolic BP (P = .03), higher pulse pressure (P < .01) and lower glomerular filtration rate (P = .05). Researchers reported no intergroup differences for gender, BMI or systolic BP.
Although high among this group, the rates of 30-day HF readmission (OR = 1.01; 95% CI, 0.34-3; P = .99) and 30-day all-cause mortality (OR = 1.17; 95% CI, 0.17-7.96; P = .87) did not differ between HF subtypes after initial acute decompensated HF event.
Researchers also reported no significant difference between those with HFpEF and HFrEF regarding likelihood of long-term readmission for HF (HR = 0.74; 95% CI, 0.42-1.28; P = .28), all-cause mortality (HR = 1.37; 95% CI, 0.68-2.75; P = .38) or all-cause readmission (HR = 0.75; 0.44-1.3; P = .36) after initial acute decompensated HF event.
Subgroup analyses
In a multivariable analysis, researchers observed that older age was a modest predictor of all-cause mortality among participants with HFpEF (HR = 1.14; 95% CI, 1.05-1.23; P < .01).
Moreover, Black race (HR = 3.35; 95% CI, 1.29-8.75; P = .01) and history of HF at baseline (HR = 5.2; 95% CI, 1.89-14.21; P < .01) were both independent predictors of readmission among patients with HFpEF, but not HFrEF.
According to the study, Black race was also an independent predictor of all-cause readmission, but only among participants with HFpEF (HR = 2.61; 95% CI, 1.1-6.17; P = .03).
“Among participants who developed HFpEF but not HFrEF, age was an independent predictor of all-cause mortality, and Black race independently predicted long-term all-cause and HF readmission,” Upadhya and colleagues wrote. “Once HF develops in older hypertension patients, prognosis is poor, with rates of subsequent clinical events that are similarly high in HFpEF and HFrEF, and unaffected by the BP treatment group assignment. These data highlight the importance of optimal BP control in older patients with systolic hypertension to prevent new-onset acute HFpEF, particularly given the lack of evidence-based treatments for HFpEF and the poor prognosis once it is established.”
Remaining gaps in knowledge
In a related editorial, Leah Rethy, MD, a second-year resident in the department of medicine, and Jordana B. Cohen, MD, MSCE, assistant professor of epidemiology in biostatistics and epidemiology at the Perelman School of Medicine of the University of Pennsylvania, wrote: “While the current study provides important insights into the effects of BP lowering on acute decompensated HF in both HFpEF and HFrEF, there remain gaps in our knowledge of how BP lowering affects post-acute decompensated HF outcomes.
“The findings suggest that there is no difference in post-acute decompensated HF adverse events with intensive BP lowering in both HFpEF and HFrEF,” Rethy and Cohen wrote. “However, there was only a small number of post-acute decompensated HF adverse events across each HF subtype and randomization arm. It is possible that differences may have been observed in a larger study population of individuals with HF or with longer duration of follow-up in which to capture a higher number of events.”
References:
- Rethy L, et al. Circ Heart Fail. 2021;doi:10.1161/CIRCHEARTFAILURE.121.009277.
- SPRINT Research Group. N Engl J Med. 2021;doi:10.1056/NEJMoa1901281.
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