Association of long-term SBP with clinical outcomes and quality of life in heart failure with preserved ejection fraction: an analysis of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist trial

Aims: To determine the associations of long-term SBP (LT-SBP) levels with clinical outcomes and health-related quality of life in heart failure with preserved ejection fraction (HFpEF).

Methods and results: We analyzed participants from the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) study with available different SBP measurements from different follow-ups (n = 3310). LT-SBP was the mean SBP value from 4-week measurement to the last one. The outcome measures are all-cause mortality and a composite of heart failure readmission or all-cause mortality and the Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary score. To determine the associations of LT-SBP and outcomes, we used adjusted Cox proportional hazards models and restricted cubic spline models. After multivariable adjustment, LT-SBP of 120-129 and 130-139 mmHg were associated with a lower risk of mortality (hazard ratio 0.66, 95% CI 0.51-0.87, P = 0.003; hazard ratio 0.68, 95% CI 0.51-0.90, P = 0.007, respectively); LT-SBP of 100-119 mmHg had similar risk of mortality (hazard ratio 0.96, 95% CI 0.72-1.28, P = 0.778) compared with LT-SBP of at least 140 mmHg. There was U-shaped relationship between LT-SBP and all-cause mortality (P < 0.001) with nadir risk occurring around 123 mmHg. Similar relationships were observed between LT-SBP and composite end point of heart failure readmission or all-cause mortality. The adjusted mean improvement in KCCQ score was significantly higher in the 120-129 mmHg group than in the at least 140 mmHg group beginning from the 12-month follow-up visit without significant differences in other groups.

Conclusion: Among patients with HFpEF, long-term control of SBP level at 120-129 mmHg is independently associated with the highest risk reduction of all-cause mortality and improvement of KCCQ score. Future randomized clinical trials need to specifically evaluate optimal SBP treatment goals in patients with HFpEF.