Differing prognostic value of pulse pressure in patients with heart failure with reduced or preserved ejection fraction: results from the MAGGIC individual patient meta-analysis

Implications of pulse wave velocity and central pulse pressure in heart failure with reduced ejection fraction

BACKGROUND

Carotid-femoral pulse wave velocity (cfPWV) and central pulse pressure (PP) are recognised as significant indicators of vascular health and predictors of cardiovascular outcomes. In this study, associations between central hemodynamics and left ventricular (LV) echocardiographic parameters were investigated in subjects with heart failure with reduced ejection fraction (HFrEF), comparing the results to healthy individuals.

METHODS AND RESULTS

This cross-sectional prospective controlled study included 50 subjects with HFrEF [mean LV ejection fraction (EF) 26 ± 6.5%] and 30 healthy controls (mean LVEF 65.9 ± 5.3%). Pulse wave analysis (PWA) and carotid-femoral pulse wave velocity (cfPWV) were used to measure central hemodynamics and arterial stiffness. The HFrEF group displayed higher cfPWV (8.2 vs. 7.2 m/s, p = 0.007) and lower central (111.3 vs. 121.7 mmHg, p = 0.001) and peripheral (120.1 vs. 131.5 mmHg, p = 0.002) systolic blood pressure. Central pulse pressure (PP) was comparable between the two groups (37.6 vs. 40.4 mmHg, p = 0.169). In the HFrEF group, cfPWV significantly correlated with left ventricular end-diastolic volume (LVEDV) index (mL/m2) and LVEF, with LVEDV index being a significant independent predictor of cfPWV (R2 = 0.42, p = 0.003). Central PP was significantly associated with heart rate, LVEF and LVEDV index, with the latter being a significant independent predictor of central PP (R2 = 0.41, p < 0.001). These correlations were not observed in healthy controls.

CONCLUSIONS

Significant associations between central hemodynamic measures and LV echocardiographic parameters were identified, suggesting the potential to use PWA and cfPWV as possible tools for managing HFrEF.

Prognostic utility of pulse pressure in patients with heart failure with preserved ejection fraction: The RICA Registry

BACKGROUND AND AIMS

The prognostic role of pulse pressure (PP) in heart failure (HF) patients with preserved left ventricular ejection fraction (LVEF) is not well understood. Our aim was to evaluate it in acute and stable HF.

MATERIAL AND METHODS

This work is a retrospective observational study of patients included in the RICA registry between 2008 and 2021. Blood pressure was collected on admission (decompensation) and 3 months later on an outpatient basis (stability). Patients were categorized according to whether the PP was greater or less than 50 mmHg. All-cause mortality was assessed at 1 year after admission.

RESULTS

A total of 2291 patients were included, with mean age 80.1 ± 7.7 years. 62.9% were women and 16.7% had a history of coronary heart disease. In the acute phase, there was no difference in mortality according to PP values, but in the stable phase PP < 50 mmHg was independently associated with all-cause mortality at 1-year follow-up (HR 1.57, 95% CI 1.21-2.05, p = 0.001), after adjusting for age, sex, New York Heart Association functional class, previous HF, chronic kidney disease, valvular heart disease, cerebrovascular disease, score on the Barthel and Pfeiffer scales, haemoglobin and sodium levels.

CONCLUSIONS

Low stable-phase PP was associated with increased all-cause mortality in HF patients with preserved LVEF. However, PP was not useful as a prognostic marker of mortality in acute HF. Further studies are needed to assess the relationship of this variable with mortality in HF patients.

Prognostic Implication of Admission Mean and Pulse Pressure in Acute Decompensated Heart Failure With Different Phenotypes

BACKGROUND

It remains unknown whether admission mean (MAP) and pulse pressure (PP) pressure are associated with short- and long-term mortality in Chinese patients with heart failure with preserved (HFpEF), mid-range (HFmrEF), and reduced (HFrEF) ejection fraction.

METHODS

In 2,706 acute decompensated heart failure (HF) patients, we assessed the risk of 30-day, 1-year, and long-term (>1 year) mortality with 1-SD increment in MAP and PP, using multivariable logistic and Cox regression, respectively.

RESULTS

During a median follow-up of 4.1 years, 1,341 patients died. The 30-day, 1-year, and long-term mortality were 3.5%, 16.7%, and 39.4%, respectively. A lower MAP was associated with a higher risk of 30-day mortality in women (P = 0.023) and a higher risk of 30-day and 1-year mortality in men (P ≤ 0.006), while higher PP predicted long-term mortality in men (P ≤ 0.014) with no relationship observed in women. In adjusted analyses additionally accounted for PP, 1-SD increment in MAP was associated with 30-day mortality in HFpEF (odds ratio [OR], 0.63; 95% CI, 0.43 to 0.92; P = 0.018), with 1-year mortality in HFmrEF (OR, 0.46; 95% CI, 0.32 to 0.66; P < 0.001) and HFrEF (OR, 0.54; 95% CI, 0.40 to 0.72; P < 0.001). In the adjusted model additionally accounted for MAP, 1-SD increment in PP was associated with long-term mortality in HFpEF (hazard ratio, 1.16; 95% CI, 1.05 to 1.28; P = 0.003).

CONCLUSIONS

A lower MAP was associated with a higher risk of short-term mortality in all HF subtypes, while a higher PP predicted a higher risk of long-term mortality in men and in HFpEF. Our observations highlight the clinical importance of admission blood pressure for risk stratification in HF subtypes.

Pulse pressure and all-cause mortality in ischaemic heart failure patients: a prospective cohort study

BACKGROUND

Whether the association between pulse pressure (PP) and mortality varies with systolic blood pressure (SBP) in ischaemic heart failure (HF) with left ventricular systolic dysfunction (LVSD) is unknown.

OBJECTIVE

To evaluate the association between PP and all-cause mortality in ischaemic HF patients with SBP status at admission.

PATIENTS AND METHODS

This prospective cohort study included 1581 ischaemic HF patients with LVSD. A total of 23.3% (n = 368) and 22.2% (n = 351) of the participants had SBP <110 mmHg and SBP >140 mmHg, respectively, with more than 80% of participants being male. Restricted cubic spline was performed to determine whether a nonlinear relationship existed between PP and all-cause mortality risk. A multivariable Cox proportional hazards model was used to assess the association between PP and all-cause mortality.

RESULTS

After a median of follow-up of 3.0 years, 257 events (16.4%) were observed in the cohort. There was a J-shaped relationship between PP and all-cause mortality (P value for nonlinearity = 0.020), with a risk nadir of approximately 46-49 mmHg. All-cause mortality risk varied with SBP status. Higher PP was associated with worse prognosis when the SBP was ≥110 mmHg, whereas the relationship did not reach statistical significance when the SBP was <110 mmHg.

CONCLUSION

A J-shaped relationship between PP and all-cause mortality was observed in ischaemic HF patients with LVSD, and higher PP was associated with worse prognosis only in those with SBP ≥110 mmHg. Further studies are needed to corroborate these findings.KEY MESSAGESA J-shaped relationship between pulse pressure and all-cause mortality was observed in ischaemic heart failure patients with left ventricular systolic dysfunction, with a risk nadir of approximately 46-49 mmHg.All-cause mortality risk varied with systolic blood pressure status, and higher pulse pressure was associated with worse prognosis when systolic blood pressure was above 110 mmHg.

The Analysis of Arterial Stiffness in Heart Failure Patients: The Prognostic Role of Pulse Wave Velocity, Augmentation Index and Stiffness Index

Background: The role of arterial stiffness in the pathogenesis and clinical outcome of heart failure (HF) patients has to be clarified. The aim of this study was to evaluate the prognostic role of arterial stiffness in HF patients discharged after acute episode of decompensation by evaluating cut-off values for clinical assessment. Methods: Patients admitted for decompensated heart failure (ADHF) underwent pre-discharge evaluation. Arterial stiffness was measured by aortic pulse wave velocity (aPWV), augmentation index (AIx75) and stiffness index (β0). Patients were also evaluated after discharge for a variable follow-up time. Results: We observed 199 patients (male 61.3%, age 76.2 ± 10.7 years) after discharge for a median of 437 days (IQR 247-903), 69 (34.7%) patients suffered HF with preserved ejection fraction (HFpEF), 45 (22.6%) patients experienced HF with mid-range ejection fraction (HFmEF) and 85 (42.7%) reported an HF with reduced ejection fraction (HFrEF). After the adjustment for principal confounders, aPWV, AIx75 and β0 were inversely correlated with free-event survival (p = 0.006, p < 0.001, p = 0.001): only β0 was inversely correlated with overall survival (p = 0.03). Analysing the threshold, overall survival was inversely correlated with β0 ≥3 (HR 2.1, p = 0.04) and free-event survival was inversely correlated with aPWV ≥10 m/s (HR 1.7, p = 0.03), AIx75 ≥ 25 (HR 2.4, p < 0.001), and β0 ≥ 3 (HR 2.0, p = 0.009). Dividing HF patients for LV ejection fraction, β0 and AIx75 appeared to be accurate prognostic predictors among the three different classes according to free-event survival. Conclusions: The non-invasive measurements of arterial stiffness proved to be strong prognostic parameters in HF patients discharged after an acute HF decompensation.

Clinical Significance of Mean and Pulse Pressure in Patients With Heart Failure With Preserved Ejection Fraction

It remains debated whether pulse pressure is associated with left ventricular traits and adverse outcomes over and beyond mean arterial pressure (MAP) in patients with heart failure (HF) with preserved ejection fraction. We investigated these associations in 3428 patients with HF with preserved ejection fraction (51.5% women; mean age, 68.6 years) enrolled in the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist). We computed association sizes and hazards ratios with 1-SD increase in MAP and pulse pressure. In multivariable-adjusted analyses, association sizes (P≤0.039) for MAP were 0.016 cm and 0.014 cm for septal and posterior wall thickness, -0.15 for E/A ratio, -0.66 for E/e', and -0.64% for ejection fraction, independent of pulse pressure. With adjustment additionally applied for MAP, E/A ratio and longitudinal strain increased with higher pulse pressure with association sizes amounting to 0.067 (P=0.026) and 0.40% (P=0.023). In multivariable-adjusted analyses of both placebo and spironolactone groups, lower MAP and higher pulse pressure predicted the primary composite end point (P≤0.028) and hospitalized HF (P≤0.002), whereas MAP was also significantly associated with total mortality (P≤0.007). Sensitivity analyses stratified by sex, median age, and region generated confirmatory results with exception for the association of adverse outcomes with pulse pressure in patients with age ≥69 years. In conclusion, the clinical application of MAP and pulse pressure may refine risk estimates in patients with HF with preserved ejection fraction. This finding may help further investigation for the development of HF with preserved ejection fraction preventive strategies targeting pulsatility and blood pressure control.

The U-shape relationship between pulse pressure level on inpatient admission and long-term mortality in acute coronary syndrome patients undergoing percutaneous coronary intervention

The association between pulse pressure and long-term mortality was investigated among acute coronary syndrome (ACS) patients who received percutaneous coronary intervention (PCI). The study population included 5055 ACS patients in the Department of Cardiology of Beijing Friendship Hospital who were enrolled from January 2013 to July 2019. The median duration of follow-up was 24 months. Multivariate Cox regression was used to analyze the relationships between PP on inpatient admission and mortalities. Non-linear associations were studied by restricted cubic splines. Considering the heart function, the analyses were performed in the whole cohort and the LVEF > = 0.5 cohort separately. Subgroup analyses were performed according to the different diagnosis (the myocardial infarction subgroup and the unstable angina pectoris subgroup). When PP was used as categorical variable, the high PP group (≥61 mm Hg) significantly increased the risk of death compared with the intermediate PP group (50-60 mm Hg) in the both cohorts. When PP was used as continuous variable, a U-shape relationship were found between PP and mortalities in the whole cohort (p (for nonlinearity) = .005 and .003, respectively), with reference PP level of 55 mm Hg. However, this U-shape relationship disappeared in the LVEF > 0.5 cohort (p (for nonlinearity) = .111 and .117, respectively). The similar results were obtained in MI subgroup. From this study, the U-shape relationships between PP level and all-cause and cardiac mortalities were found in ACS patients who underwent PCI. The U-shape relationships disappeared in the LVEF > 0.5 cohort. The reference PP level was 55 mm Hg.

Prediction of HF-Related Mortality Risk Using Genetic Risk Score Alone and in Combination With Traditional Risk Factors

Background: Common variants may contribute to the variation of prognosis of heart failure (HF) among individual patients, but no systematical analysis was conducted using transcriptomic and whole exome sequencing (WES) data. We aimed to construct a genetic risk score (GRS) and estimate its potential as a predictive tool for HF-related mortality risk alone and in combination with traditional risk factors (TRFs). Methods and Results: We reanalyzed the transcriptomic data of 177 failing hearts and 136 healthy donors. Differentially expressed genes (fold change >1.5 or <0.68 and adjusted P < 0.05) were selected for prognosis analysis using our whole exome sequencing and follow-up data with 998 HF patients. Statistically significant variants in these genes were prepared for GRS construction. Traditional risk variables were in combination with GRS for the construct of the composite risk score. Kaplan-Meier curves and receiver operating characteristic (ROC) analysis were used to assess the effect of GRS and the composite risk score on the prognosis of HF and discriminant power, respectively. We found 157 upregulated and 173 downregulated genes. In these genes, 31 variants that were associated with the prognosis of HF were finally identified to develop GRS. Compared with individuals with low risk score, patients with medium- and high-risk score showed 2.78 (95%CI = 1.82-4.24, P = 2 × 10^-6) and 6.54 (95%CI = 4.42-9.71, P = 6 × 10^-21) -fold mortality risk, respectively. The composite risk score combining GRS and TRF predicted mortality risk with an HR = 5.41 (95% CI = 2.72-10.64, P = 1 × 10^-6) for medium vs. low risk and HR = 22.72 (95% CI = 11.9-43.48, P = 5 × 10^-21) for high vs. low risk. The discriminant power of GRS is excellent with a C statistic of 0.739, which is comparable to that of TRF (C statistic = 0.791). The combination of GRS and TRF could significantly increase the predictive ability (C statistic = 0.853). Conclusions: The 31-SNP GRS could well distinguish those HF patients with poor prognosis from those with better prognosis and provide clinician with reference for the intensive therapy, especially when combined with TRF. Clinical Trial Registration: https://www.clinicaltrials.gov/, identifier: NCT03461107.

The impact of exercise training for chronic heart failure patients with cardiac resynchronization therapy: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Systematically review the current published literature on the impact of exercise training (ET) in chronic heart failure (CHF) patients who were conducted cardiac resynchronization therapy (CRT).

METHODS

PubMed, EMBASE, and the Cochrane Library of Controlled Trails databases were searched for trials comparing the additional effects of ET in CHF patients after CRT implantation with no exercise or usual care control up until 2020.03.07. We independently screened the literature, extracted data, employed the tool for the assEssment of Study qualiTy and reporting in EXercise (TESTEX) to evaluate study quality and risk of bias, and performed meta-analysis with Revman 5.3 software.

RESULTS

Eight trials were identified for qualitative analysis and 7 randomized controlled trails (RCTs) included 235 participants (120 ET; 115 controls) for quantitative analysis. The results showed that the maximal workload (mean difference [MD] 26.32 W, 95% CI 19.41-33.23; P < .00001, I2 = 0%) and the exercise duration (MD 68.95 seconds, 95% CI 15.41-122.48; P = .01, I2 = 76%) had significant improvement in the ET group versus control. Subgroup analysis showed that compared with control, the change in peak oxygen uptake (VO2) (MD 3.05 ml/kg/minute, 95% CI 2.53-3.56; P < .00001, I2 = 0%), left ventricular ejection fraction (LVEF) (MD 4.97%, 95% CI 1.44-8.49; P = .006, I2 = 59%), and health related quality of life (HRQoL) (the change in Minnesota living with heart failure questionnaire [MLHFQ]: MD -19.96, 95% CI -21.57 to -18.34; P < .00001, I2 = 0%) were significantly improved in the light to moderate intensity training (non-HIT) group, while there seemed no statistical difference of above endpoints in the high intensity training (HIT) group.

CONCLUSION

During the short term (up to 6 months), non-HIT could improve exercise capacity, cardiac function, and HRQoL in CHF patients with CRT. However, due to the small number of participants, a high-quality large-sample multicenter trial is demanded.

Acute Hemodynamic Index Predicts In-Hospital Mortality in Acute Decompensated Heart Failure

Fundamento

O exame físico permite a avaliação prognóstica de pacientes com insuficiência cardíaca (IC) descompensada, porém não é suficientemente confiável e depende da experiência clínica do profissional. Considerando as respostas hemodinâmicas a situações do tipo “luta ou fuga” tais como a admissão no serviço de emergência, foi proposto o índice hemodinâmico agudo (IHA), calculado a partir da frequência cardíaca e pressão de pulso.

Objetivo

avaliar a capacidade prognóstica intra-hospitalar do IHA na IC descompensada.

Métodos

estudo prospectivo, multicêntrico e observacional baseado no registro BREATHE, incluindo dados de hospitais públicos e privados no Brasil. Foram utilizadas análises ROC ( Receiver Operating Characteristic ), de estatística c e de regressão multivariada, assim como o critério de informação de Akaike, para testar a capacidade prognóstica do IHA. O valor-p < 0,05 foi considerado estatisticamente significativo.

Resultados

Foram analisados dados de 463 pacientes com IC com fração de ejeção reduzida a partir do registro BREATHE. A mortalidade intra-hospitalar foi de 9%. A mediana do IHA foi considerada o valor de corte (4 mmHg⋅bpm). Um baixo IHA (≤ 4 mmHg⋅bpm) foi encontrado em 80% dos pacientes falecidos. O risco de mortalidade intra-hospitalar em pacientes com baixo IHA foi 2,5 vezes maior que aquele para pacientes com IHA > 4 mmHg⋅bpm. O IHA foi capaz de predizer independentemente a mortalidade intra-hospitalar na IC aguda descompensada [sensibilidade: 0,786; especificidade: 0,429; AUC (área sob a curva): 0,607 (0,540-0,674), p = 0,010] mesmo depois dos ajustes para comorbidades e uso de medicamentos [razão de chances (RC): 0,061 (0,007-0,114), p = 0,025].

Conclusões

O IHA é capaz de predizer independentemente a mortalidade intra-hospitalar na IC aguda descompensada. Esse índice simples e realizado à beira do leito pode se mostrar útil em serviços de emergência. (Arq Bras Cardiol. 2021; 116(1):77-86)

Reliability of the blood pressure response during performance of bedside Valsalva maneuver and association with NT-pBNP levels

BACKGROUND

Heart failure (HF) is common in older people. The diagnosis of HF, however, is difficult in older subjects, especially in settings without direct access to further diagnostics. The type of blood pressure response during the performance of a Valsalva maneuver has been suggested as an easily applicable bedside test to detect HF; however, the reliability of this maneuver and the association with HF is unknown in geriatric patients.

METHODS

This study included 89 patients admitted for geriatric rehabilitation. Systolic blood pressure was taken while the patient performed a Valsalva maneuver. The systolic blood pressure response was classified as sinusoidal (type A), absent overshoot (type B) or square pattern (type C). To test interrater reliability systolic blood pressure response was evaluated independently by two investigators. The procedure was repeated after 1h to estimate test-retest reliability. Both investigators were blinded to the results of the other. Interrater reliability and test-retest reliability were calculated using Cohen's kappa. Blood samples for N‑terminal pro brain natriuretic peptide (NT-pBNP) were obtained on the morning the Valsalva maneuver was performed.

RESULTS

Blood pressure response was sinusoidal in 37 (42%), showed an absent overshoot in 17 (19%) and had a square wave pattern in 34 (38%) patients. Cohen's kappa was 0.911 (95% CI 0.837-0.985) for interrater reliability and 0.929 (95% CI 0. 0.862-0.996) for test-retest reliability. The interrater and test-retest agreement were 94% and 96%, respectively. The mean NT-pBNP plasma levels and the interquartile ranges (IQR) in subjects with types A, B and C blood pressure response pattern were 213 (153-324) pg/ml, 805 (622-1332) pg/ml and 3964 (2595-5906) pg/ml, respectively (p < 0.001).

CONCLUSION

The blood pressure response during a Valsalva maneuver shows an excellent reliability in older subjects. The type of response is associated with the NT-pBNP plasma level.

Pulse Pressure, Prognosis, and Influence of Sacubitril/Valsartan in Heart Failure With Preserved Ejection Fraction

Arterial stiffness is increased with increasing age, and pulse pressure (PP), a marker of arterial stiffness, is a predictor of incident cardiovascular disease and mortality. However, the prognostic relevance of PP in heart failure (HF) with preserved ejection fraction has not been fully understood. We studied 4796 patients with HF with preserved ejection fraction from the PARAGON-HF trial. All patients underwent sequential run-in phases of valsartan and sacubitril/valsartan before randomization. We categorized patients by PP quartile and evaluated the influence of baseline PP on the PARAGON-HF primary end point (total HF hospitalizations and cardiovascular death). At screening, the median PP was 58 mm Hg (interquartile range, 50-69 mm Hg). There was a nonlinear, J-shaped association between PP and outcomes. Multivariable Cox proportional hazards models showed that patients in the highest PP quartile had a higher risk of the primary end point (adjusted hazard ratio, 1.39 [95% CI, 1.14-1.69]; P=0.001), total HF hospitalizations (adjusted hazard ratio, 1.43 [95% CI, 1.15-1.79]; P=0.001), and myocardial infarction (adjusted hazard ratio, 1.54 [95% CI, 1.06-2.23]; P=0.022) compared with those in the second (lowest risk) PP quartile. Reductions in PP during sacubitril/valsartan run-in were associated with a decreased risk of the primary end point and total HF hospitalizations. One year after randomization, PP was significantly lower in the sacubitril/valsartan group compared with the valsartan group (3.0 mm Hg decrease [95% CI, 2.4-3.5]; P<0.001). In conclusion, PP was an independent predictor of cardiovascular events in patients with HF with preserved ejection fraction enrolled in PARAGON-HF. Sacubitril/valsartan lowered PP compared with valsartan.

Management of low blood pressure in ambulatory heart failure with reduced ejection fraction patients

Low blood pressure is common in patients with heart failure and reduced ejection fraction (HFrEF). While spontaneous hypotension predicts risk in HFrEF, there is only limited evidence regarding the relationship between hypotension observed during heart failure (HF) drug titration and outcome. Nevertheless, hypotension (especially orthostatic hypotension) is an important factor limiting the titration of HFrEF treatments in routine practice. In patients with signs of shock and/or severe congestion, hospitalization is advised. However, in the very frequent cases of non-severe and asymptomatic hypotension observed while taking drugs with a class I indication in HFrEF, European and US guidelines recommend maintaining the same drug dosage. In instances of symptomatic or severe persistent hypotension (systolic blood pressure < 90 mmHg), it is recommended to first decrease blood pressure reducing drugs not indicated in HFrEF as well as the loop diuretic dose in the absence of associated signs of congestion. Unless the management of hypotension appears urgent, a HF specialist should then be sought rather than stopping or decreasing drugs with a class I indication in HFrEF. If symptoms or severe hypotension persist, no recommendations exist. Our HF group reviewed available evidence and proposes certain steps to follow in such situations in order to improve the pharmacological management of these patients.

The Role of Arterial Stiffness and Central Hemodynamics in Heart Failure

Whereas traditional understanding of left ventricular afterload was focused on a steady-state circulation model with continuous pressures and flow, a more realistic concept is emerging, taking the pulsatile nature of the heart and the arterial system into account. The most simple measure of pulsatility is brachial pulse pressure, representing the pulsatility fluctuating around the mean blood pressure level. Brachial pulse pressure is widely available, fundamentally associated with the development and treatment of heart failure (HF), but its analysis is often confounded in patients with established HF. The next step of analysis consists of arterial stiffness, central (rather than brachial) pressures, and of wave reflections. The latter are closely related to left ventricular late systolic afterload, ventricular remodeling, diastolic dysfunction, exercise capacity, and, in the long term, the risk of new-onset HF. Wave reflection may also evolve as a suitable therapeutic target for HF with preserved and reduced ejection fraction. A full understanding of ventricular-arterial coupling, however, requires dedicated analysis of time-resolved pressure and flow signals. This review provides a summary of current understanding of pulsatile hemodynamics in HF.

Brachial pulse pressure in acute heart failure. Results of the Heart Failure Registry

Aims

To investigate the still uncertain independent prognostic impact of pulse pressure (PP) in acute heart failure (HF), in particular across the left ventricular ejection fraction (EF) phenotypes, and the potential contribution of PP in outlining the individual phenotypes.

Methods and results

We prospectively evaluated 1‐year death and rehospitalization in 4314 patients admitted for acute HF grouped by EF and stratified by their PP level on admission. In HF with reduced (< 40%) EF (HFrEF), the highest quartiles of PP had the lowest unadjusted [hazard ratio (HR) 0.77, 95% confidence interval (CI) 0.61–0.98] and adjusted (HR 0.64 0.50–0.82) risk of 1 year all cause death compared to the lowest quartile. Its prognostic impact was partially mediated by systolic blood pressure (SBP). In HF with preserved (≥ 50%) EF (HFpEF), the intermediate quartile of PP showed the lowest 1 year all cause mortality in unadjusted (HR 0.598, CI 0.416–0.858) and adjusted (HR 0.55, 95% CI 0.388‐0.801) models with no relationship with SBP. In a receiver operating characteristic analysis, a combination of PP > 60 mmHg and SBP > 140 mmHg was associated to a preserved EF with a high performance value. No prognostic significance of PP was found in the HF with mid‐range EF subgroup.

Conclusions

In acute HFrEF, there is an almost linear inverse relation between mortality and PP, partly mediated by SBP. In HFpEF, a J‐shaped relationship between mortality and PP was present with a better prognosis at the nadir. A combination of PP > 60 mmHg with SBP > 140 mmHg may be clinically helpful as marker of a preserved left ventricular EF.

Integrated UPLC-Q/TOF-MS Technique and MALDI-MS to Study of the Efficacy of YiXinshu Capsules Against Heart Failure in a Rat Model

Background: Yixinshu Capsules (YXSC) are widely used in Chinese medicine for the treatment of cardiovascular diseases. However, the therapeutic mechanisms of action are not well understood. Method: In this study, a metabonomic approach based on integrated UPLC-Q/TOF-MS technique and MALDI-MS was utilized to explore potential metabolic biomarkers that may help increase the understanding of heart failure (HF) and in order to assess the potential mechanisms of YXSC against HF. Plasma metabolic profiles were analyzed by UPLC-Q/TOF-MS with complementary hydrophilic interaction chromatography and reversed-phase liquid chromatography. Moreover, time-course analysis at the 2nd, 4th, and 10th week after permanent occlusion was conducted. In an effort to identify a more reliable potential metabolic marker, common metabolic markers of the 2nd, 4th, and 10th week were selected through multivariate data analysis. Furthermore, MALDI-MS was applied to identify metabolic biomarkers in the blood at apoptotic positions of heart tissues. Results: The results showed that HF appeared at the fourth week after permanent occlusion based on echocardiographic assessment. Clear separations were observed between the sham and model group by loading plots of orthogonal projection to latent structure discrimination analysis (OPLS-DA) at different time points after permanent occlusion. Potential markers of interest were extracted from the combining S-plots, variable importance for the projections values (VIP > 1), and t-test (p < 0.05). Twenty-one common metabolic markers over the course of the development and progression of HF after permanent occlusion were identified. These were determined to be mainly related to disturbances in fatty acids, phosphatidylcholine, bile acids, amino acid metabolism, and pyruvate metabolism. Of the metabolic markers, 16 metabolites such as palmitoleic acid, arachidonic acid, and lactic acid showed obvious changes (p < 0.05) and a tendency for returning to baseline values in YXSC-treated HF rats at the 10th week. Moreover, four biomarkers, including palmitoleic acid, palmitic acid, arachidonic, acid and lactic acid, were further validated at the apoptotic position of heart tissue using MALDI-MS, consistent to the variation trends in the plasma. Conclusions: Taken in concert, our proposed strategy may contribute to the understanding of the complex pathogenesis of ischemia-induced HF and the potential mechanism of YXSC.

Preoperative Pulse Pressure and Adverse Postoperative Outcomes: A Meta-Analysis

OBJECTIVE

To evaluate the association between preoperative pulse pressure (PP) and the incidences of renal, neurologic, cardiac, and mortality outcomes after surgery.

DESIGN

Systematic review and meta-analysis of cohort studies.

SETTING

Hospitals.

PARTICIPANTS

Patients who underwent cardiac or noncardiac surgeries.

INTERVENTION

The preoperative PP was measured.

MEASUREMENT AND MAIN RESULTS

Relevant cohort studies were obtained by systematic search of PubMed and Embase databases. A randomized effect model was used to pool the results. The multivariate adjusted risk ratio (RR) and its 95% confidence intervals (CI) were calculated to reflect the association between preoperative PP and adverse postoperative outcomes. Twelve cohort studies that included 40,143 patients who had undergone cardiac, vascular, or noncardiac surgery were included in the meta-analysis. The results showed that above a threshold of 40 mmHg, an increase in preoperative PP of 10 mmHg was independently associated with increased risk for renal events (adjusted RR: 1.13, 95% CI 1.08-1.19, p < 0.001; I² = 0%), neurologic events (adjusted RR: 1.75, 95% CI 1.01-3.02, p = 0.04; I² = 70%), cardiac events (adjusted RR: 1.19, 95% CI 1.03-1.37, p = 0.01; I² = 0%), major cardiovascular adverse events (adjusted RR: 1.62, 95% CI 1.10-2.41, p = 0.02; I² = 0%), and overall mortality (adjusted RR: 1.13, 95% CI 1.07-1.20, p < 0.001; I² = 0%) after surgery.

CONCLUSIONS

Patients with higher-than-normal preoperative PP are at increased risk for adverse postoperative outcomes.

Pulse pressure and prognosis in patients with heart failure with reduced ejection fraction

BACKGROUND

A high pulse pressure (PP) is associated with adverse cardiovascular (CV) outcomes; however, this relationship may be reversed in patients with heart failure with reduced ejection fraction (HFREF).

METHODS

Patients from the WARCEF trial with left ventricular ejection fraction ≤35% were included. PP was divided into tertiles: ≤42, 42-54 and >54 mm Hg. Age and ejection fraction adjusted Kaplan-Meier curves were generated to evaluate the relationship between PP and outcomes [mortality, CV mortality, stroke and HF hospitalizations (HFH)]. Cox proportional hazards models were created incorporating PP as a continuous variable. The interaction of PP with New York Heart Association (NYHA) functional class was examined. Linear and restricted cubic splines were used to study nonlinear association between PP and outcomes.

RESULTS

We included 2,299 patients with a mean(±SD) follow-up of 3.5 ± 1.8 years. The lowest tertile of PP (≤42 mm Hg) was associated with significantly higher CV mortality and HFH. Cox proportional hazards models showed a reduction in CV death and HFH with higher PP, with adjusted hazard ratios (HR) of 0.91 (P = 0.02) and 0.93 (P = 0.04) per 10 mm Hg increase in PP. This relationship was more pronounced in subjects with NYHA functional class III-IV. Spline analysis showed that the association between PP and CV mortality and HFH was only seen at PP values lower than 40 mm Hg.

CONCLUSIONS

In patients with advanced HFREF, a low PP (<40 mm Hg) portends a worse prognosis, whereas a high PP (>50 mm Hg) predicts a relatively favourable prognosis.

Differential Effect of APOE ɛ4 Status and Elevated Pulse Pressure on Functional Decline in Cognitively Normal Older Adults

BACKGROUND/OBJECTIVE

The APOE ɛ4 allele and increased vascular risk have both been independently linked to cognitive impairment and dementia. Since few studies have characterized how these risk factors affect everyday functioning, we investigated the relationship between APOE ɛ4 genotype and elevated pulse pressure (PP) on functional change in cognitively normal participants from the Alzheimer's Disease Neuroimaging Initiative (ADNI).

METHODS

738 normally aging participants underwent APOE genotyping, and baseline PP was calculated from blood pressure indices. The Functional Activities Questionnaire (FAQ) was completed by participants' informant at baseline and 6, 12, 24, 36, and 48-month follow-up visits. Multiple linear regression and multilevel modeling were used to examine the effects of PP and APOE ɛ4 genotype on cross-sectional and longitudinal FAQ scores, respectively.

RESULTS

Adjusting for demographic and clinical covariates, results showed that both APOE ɛ4 status and elevated PP predicted greater functional difficulty trajectories across four years of follow-up. Interestingly, however, elevated PP was associated with greater functional decline over time in ɛ4 non-carriers versus carriers.

CONCLUSION

Results show that, although APOE ɛ4 status is the prominent predictor of functional difficulty for ɛ4 carriers, an effect of arterial stiffening on functional difficulty was observed in non-carriers. Future studies are needed in order to clarify the etiology of the association between PP and different brain aging processes, and further explore its utility as a marker of dementia risk. The present study underscores the importance of targeting modifiable risk factors such as elevated PP to prevent or slow functional decline and pathological brain aging.

Clinical significance of brachial-ankle pulse-wave velocity in patients with heart failure with preserved left ventricular ejection fraction

BACKGROUND

Although pulse-wave velocity (PWV) is a recognized risk predictor for cardiovascular diseases, its association with cardiovascular outcomes in heart failure with preserved left ventricular ejection fraction (HFpEF) is unclear.

METHODS AND RESULTS

The 502 patients with HFpEF finally enrolled in this study (mean follow-up duration: 1017 days) were divided into those with or without peripheral artery disease (PAD). The latter were further grouped according to brachial-ankle PWV (baPWV) quintiles using an ankle-brachial pressure index device. Kaplan-Meier analysis revealed a significantly higher risk of all-cause mortality and total cardiovascular events (both P = 0.01) in HFpEF patients with than without PAD. Multivariate Cox hazard analysis, including predictors identified as significant by simple Cox hazard analysis, identified PAD as a significant and independent predictor of cardiovascular events (hazard ratio: 1.85; 95% confidence interval: 1.01-3.39; P = 0.04). In an analysis of HFpEF patients without PAD grouped according to baPWV quintiles, estimated glomerular filtration rate (r = 0.21, P < 0.01) and hemoglobin (r = 0.18, P = 0.01) levels correlated negatively with baPWV. In the Kaplan-Meier analysis, patients with a baPWV more than 1900 cm/s and those with the lowest baPWV (<1300 cm/s) had a significantly higher frequency of total cardiovascular events than patients with 1300 baPWV or less which is less than 1900, indicating a J-shaped association between baPWV and total cardiovascular events as well as similarities to HFpEF patients with PAD. By contrast, the lowest baPWV group had the highest risk of heart failure-related events, accompanied by the highest brain natriuretic peptide levels.

CONCLUSION

Identifying complications of PAD and measuring baPWV values in HFpEF patients can improve risk stratification.

U-shaped association of central pulse pressure with long-term prognosis after ST-segment elevation myocardial infarction

The relationship between central pulse pressure (CPP) measured at the time of primary percutaneous coronary intervention (PPCI) and long-term prognosis after ST-segment elevation myocardial infarction (STEMI) has not been investigated. CPP measurements were performed in 1348 patients with STEMI (327 women; mean age 62.5 ± 12.1 years) undergoing PPCI. Aortic systolic and diastolic blood pressure was measured before intervention. The primary outcome was 8-year all-cause mortality. The median [25-75th percentile] CPP value was 55.0 [43.0-70.0] mmHg. CPP correlated negatively with heart rate (P < 0.001), body mass index (P = 0.007), Killip class (P < 0.001) and initial area at risk (P < 0.001) and positively with age (P < 0.001), female sex (P < 0.001), diabetes (P = 0.012), arterial hypertension (P < 0.001) and glomerular filtration rate (P = 0.004). There were 181 deaths over the follow-up. In patients with CPP within the 1st, 2nd and 3rd tertiles, the Kaplan-Meier estimates of mortality were 17.3%, 10.8% and 24.2%, respectively; univariable hazard ratio [HR] =1.52, 95% confidence interval [CI] 0.99 to 2.32; P = 0.055 for tertile 1 vs. tertile 2 and HR =2.09 [1.36-3.21]; P < 0.001 for tertile 3 vs. tertile 2. For CPP values lower than 35 mmHg and higher than 71 mmHg, the association between CPP and all-cause mortality was significant (HR =1.276 [1.004-1.621] for the 35 mmHg value and HR =1.289 [1.003-1.657] for the 71 mmHg value) compared with the CPP reference value (54 mmHg). After adjustment, the association between CPP and all-cause mortality was attenuated (P = 0.304). In patients with STEMI undergoing PPCI there is a U-shaped association between CPP and mortality up to 8 years after PPCI.

Baroreflex activation therapy: a new approach to the management of advanced heart failure with reduced ejection fraction

Chronic heart failure is a common clinical condition characterized by persistent excessive sympathetic nervous system activation. The derangement of the sympathetic activity has relevant implications for disease progression and patient survival. Aiming to positively impact patient outcome, autonomic nervous system modulatory therapies have been developed and tested in animal and clinical studies. As a general gross assumption, direct vagal stimulation and baroreflex activation are considered equivalent. This assumption does not take into account the fact that direct cervical vagal nerve stimulation involves activation of both afferent and efferent fibers innervating not only the heart, but the entire visceral system, leading to undesired responses to and from this compartment. The different action of baroreflex activation is based on generating a centrally mediated reduction of sympathetic outflow and increasing parasympathetic activity to the heart via a physiological reflex pathway. Thus, baroreflex activation rebalances the unbalanced autonomic nervous system via a specific path. Independent and complementary investigations have shown that sympathetic nerve activity can be rebalanced via control of the arterial baroreflex in heart failure patients.

Results from recent pioneering research studies support the hypothesis that baroreflex activation can add significant therapeutic benefit on top of guideline-directed medical therapy in patients with advanced heart failure. In the present review, baroreflex activation therapy results are discussed, focusing on critical aspects like patient selection rationale to support clinician orientation in opting for baroreflex activation therapy when, on top of current guideline-directed medical treatment, other therapies are to be considered.

Pulsatile operation of a continuous-flow right ventricular assist device (RVAD) to improve vascular pulsatility

Despite the widespread acceptance of rotary blood pump (RBP) in clinical use over the past decades, the diminished flow pulsatility generated by a fixed speed RBP has been regarded as a potential factor that may lead to adverse events such as vasculature stiffening and hemorrhagic strokes. In this study, we investigate the feasibility of generating physiological pulse pressure in the pulmonary circulation by modulating the speed of a right ventricular assist device (RVAD) in a mock circulation loop. A rectangular pulse profile with predetermined pulse width has been implemented as the pump speed pattern with two different phase shifts (0% and 50%) with respect to the ventricular contraction. In addition, the performance of the speed modulation strategy has been assessed under different cardiovascular states, including variation in ventricular contractility and pulmonary arterial compliance. Our results indicated that the proposed pulse profile with optimised parameters (A_pulse = 10000 rpm and ω_min = 3000 rpm) was able to generate pulmonary arterial pulse pressure within the physiological range (9–15 mmHg) while avoiding undesirable pump backflow under both co- and counter-pulsation modes. As compared to co-pulsation, stroke work was reduced by over 44% under counter-pulsation, suggesting that mechanical workload of the right ventricle can be efficiently mitigated through counter-pulsing the pump speed. Furthermore, our results showed that improved ventricular contractility could potentially lead to higher risk of ventricular suction and pump backflow, while stiffening of the pulmonary artery resulted in increased pulse pressure. In conclusion, the proposed speed modulation strategy produces pulsatile hemodynamics, which is more physiologic than continuous blood flow. The findings also provide valuable insight into the interaction between RVAD speed modulation and the pulmonary circulation under various cardiovascular states.

Mining telemonitored physiological data and patient-reported outcomes of congestive heart failure patients

This paper addresses patient-reported outcomes (PROs) and telemonitoring in congestive heart failure (CHF), both increasingly important topics. The interest in CHF trials is shifting from hard end-points such as hospitalization and mortality, to softer end-points such health-related quality of life. However, the relation of these softer end-points to objective parameters is not well studied. Telemonitoring is suitable for collecting both patient-reported outcomes and objective parameters. Most telemonitoring studies, however, do not take full advantage of the available sensor technology and intelligent data analysis. The Chiron clinical observational study was performed among 24 CHF patients (17 men and 7 women, age 62.9 ± 9.4 years, 15 NYHA class II and 9 class III, 10 of ishaemic, aetiology, 6 dilated, 2 valvular, and 6 of multiple aetiologies or cardiomyopathy) in Italy and UK. A large number of physiological and ambient parameters were collected by wearable and other devices, together with PROs describing how well the patients felt, over 1,086 days of observation. The resulting data were mined for relations between the objective parameters and the PROs. The objective parameters (humidity, ambient temperature, blood pressure, SpO2, and sweeting intensity) could predict the PROs with accuracies up to 86% and AUC up to 0.83, making this the first report providing evidence for ambient and physiological parameters to be objectively related to PROs in CHF patients. We also analyzed the relations in the predictive models, gaining some insights into what affects the feeling of health, which was also generally not attempted in previous investigations. The paper strongly points to the possibility of using PROs as primary end-points in future trials.

Association between sleep-disordered breathing and arterial stiffness in heart failure patients with reduced or preserved ejection fraction

AIMS

Sleep-disordered breathing (SDB) is associated with arterial stiffness, which may be one of the factors that lead to heart failure (HF). We examined the relationship between pulse wave velocity (PWV) and SDB in patients who have HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF).

METHODS AND RESULTS

We measured the apnoea-hypopnoea index (AHI) by polysomnography, echocardiographic parameters, and PWV in 221 HF patients. Age, blood pressure, and PWV were higher in HFpEF (ejection fraction > 50%, n = 70) patients than in HFrEF (ejection fraction < 50%, n = 151) patients. All HF patients were divided into three groups according to AHI: none-to-mild SDB group (AHI < 15 times/h, n = 77), moderate SDB group (15 < AHI < 30 times/h, n = 59), and severe SDB group (AHI > 30 times/h, n = 85). Although blood pressure and echocardiographic parameters did not differ among the three groups, PWV was significantly higher in the severe SDB group than in the none-to-mild and moderate SDB groups (P = 0.002). When the HFrEF and HFpEF patients were analysed separately, PWV was significantly higher in the severe SDB group than in the none-to-mild and moderate SDB groups in patients with HFpEF (P = 0.002), but not in those with HFrEF (P = 0.068). In the multiple regression analysis to determine PWV, the presence of severe SDB was found to be an independent predictor of high PWV in HFpEF (β = 0.234, P = 0.005), but not in HFrEF patients.

CONCLUSIONS

Severe SDB is associated with elevated arterial stiffness and may be related to the pathophysiology of HF, especially in HFpEF patients.

Arterial pulse pressure and postoperative morbidity in high-risk surgical patients

BACKGROUND

Systemic arterial pulse pressure (systolic minus diastolic pressure) ≤53 mm Hg in patients with cardiac failure is correlated with reduced stroke volume and is independently associated with accelerated morbidity and mortality. Given that deconditioned surgical and heart failure patients share similar cardiopulmonary physiology, we examined whether lower pulse pressure is associated with excess morbidity after major surgery.

METHODS

This was a prospective observational cohort study of patients deemed by their preoperative assessors to be at higher risk of postoperative morbidity. Preoperative pulse pressure was calculated before cardiopulmonary exercise testing. The primary outcome was any morbidity (PostOperative Morbidity Survey) occurring within 5 days of surgery, stratified by pulse pressure threshold ≤53 mm Hg. The relationship between pulse pressure, postoperative morbidity, and oxygen pulse (a robust surrogate for left ventricular stroke volume) was examined using logistic regression analysis (accounting for age, sex, BMI, cardiometabolic co-morbidity, and operation type).

RESULTS

The primary outcome occurred in 578/660 (87.6%) patients, but postoperative morbidity was more common in 243/ 660 patients with preoperative pulse pressure ≤53 mm Hg{odds ratio (OR): 2.24 [95% confidence interval (CI): 1.29-3.38]; P<0.001). Pulse pressure ≤53 mm Hg [OR:1.23 (95% CI: 1.03-1.46); P=0.02] and type of surgery were independently associated with all-cause postoperative morbidity (multivariate analysis). Oxygen pulse <90% of population-predicted normal values was associated with pulse pressure ≤ 53 mm Hg [OR: 1.93 (95% CI: 1.32-2.84); P=0.007].

CONCLUSIONS

In deconditioned surgical patients, lower preoperative systemic arterial pulse pressure is associated with excess morbidity. These data are strikingly similar to meta-analyses identifying low pulse pressure as an independent risk factor for adverse outcomes in cardiac failure. Low preoperative pulse pressure is a readily available measure, indicating that detailed physiological assessment may be warranted.

CLINICAL TRIAL REGISTRATION

ISRCT registry, ISRCTN88456378.

Proportional pulse pressure relates to cardiac index in stabilized acute heart failure patients

AIMS

In chronic heart failure, proportional pulse pressure (PPP) is suggested as an estimate of cardiac index (CI). The association between CI and PPP in acute heart failure (AHF) has not been described.

METHODS

This was examined using hemodynamic measurements (from a trial using serelaxin) in 63 stabilized AHF patients.

RESULTS

Mean (SD) age was 68 (11), 74% male, mean (SD) ejection fraction (EF) was 33.4% (13.7), mean (SD) CI (L/min/m²) was 2.3 (0.6). CI correlated with PPP (Pearson R = 0.42; p < 0.0001) based on a linear mixed-effects model analysis of 171 pairs of measurements from 47 patients (out of 63) where CI and PPP were measured within 3 min of each other during. Serelaxin treatment did not modify the established correlation between CI and PPP. Time-weighted average CI correlated with time-weighted average PPP (Spearman Rank R = 0.35; p = 0.0051) over the -4 h to 24 h time interval. In a multivariable regression analysis, low PPP was an independent predictor of low CI (p < 0.0001).

CONCLUSIONS

In patients with AHF after initial clinical stabilization, both baseline and post-baseline CI measurements are positively related to PPP. This was the most closely related non-invasive blood pressure variable to CI.

Characteristics, treatments and 1-year prognosis of hospitalized and ambulatory heart failure patients with chronic obstructive pulmonary disease in the European Society of Cardiology Heart Failure Long-Term Registry

AIMS

To describe the characteristics and assess the 1-year outcomes of hospitalized (HHF) and chronic (CHF) heart failure patients with chronic obstructive pulmonary disease (COPD) enrolled in a large European registry between May 2011 and April 2013.

METHODS AND RESULTS

Overall, 1334/6920 (19.3%) HHF patients and 1322/9409 (14.1%) CHF patients were diagnosed with COPD. In both groups, patients with COPD were older, more frequently men, had a worse clinical presentation and a higher prevalence of co-morbidities. In HHF, the increase in the use of heart failure (HF) medications at hospital discharge was greater in non-COPD than in COPD for angiotensin-converting enzyme inhibitors (+13.7% vs. +7.2%), beta-blockers (+20.6% vs. +11.8%) and mineralocorticoid receptor antagonists (+20.9% vs. +17.3%), thus widening the gap in HF treatment already existing between the two groups at admission. In CHF patients, there was a similar increase in the use of these medications after enrollment visit in the two groups, leaving a significant difference of 8.2% for beta-blockers in favour of non-COPD patients (89.8% vs. 81.6%, P < 0.001). At 1-year follow-up, the hazard ratios for COPD in multivariable analysis confirmed its independent association with hospitalizations both in HHF [all-cause: 1.16 (1.04-1.29), for HF: 1.22 (1.05-1.42)] and CHF patients [all-cause: 1.26 (1.13-1.41), for HF: 1.37 (1.17-1.60)]. The association between COPD and all-cause mortality was not confirmed in both groups after adjustments.

CONCLUSIONS

COPD frequently coexists in HHF and CHF, worsens the clinical course of the disease, and significantly impacts its therapeutic management and prognosis. The matter should deserve greater attention from the cardiology community.

[Non-device-based telemonitoring : Toy or tool?]

Non-device-based telemedical management can be useful to prevent decompensation and death in patients suffering from easily disequilibrated conditions like diabetes mellitus, chronic obstructive pulmonary disease and heart failure (HF). This article summarizes current knowledge on non-device-based telemedical care for patients with HF. Several parameters (heart rate, heart rate variability, systolic blood pressure, pulse pressure, body weight, physical activity as derived from accelerometry, and occurrence of atrial and ventricular arrhythmias) have been identified as being associated with imminent clinical deterioration of HF patients. Structured telephone-based support and noninvasive telemonitoring with integrated electronic transfer of physiological data have been applied to care for HF patients and have been evaluated in multiple studies. The impact of telemedical care on clinical outcome appears to depend on the applied telemedical configuration and on the disease severity of targeted populations. The exclusive use of an automated telephone response system has not been successful. In patients with optimal medical therapy and relatively low decompensation risk noninvasive telemonitoring did not significantly reduce mortality. Nevertheless meta-analyses of structured telephone support and of noninvasive telemonitoring combining knowledge from available randomized trials suggest that both of these telemedical approaches may reduce the mortality risk of HF patients by 13-20%. The results of the Telemedical Interventional Management in Heart Failure II (TIM-HF II) trial on noninvasive telemonitoring versus usual care in 1500 high-risk HF patients are awaited in 2018 and will further clarify the usefulness of telemedical care in this field.

Pulse pressure in acute coronary syndromes: Comparative prognostic significance with systolic blood pressure

Background:

Pulse pressure is a readily available vital sign that has been shown to independently predict outcomes in several cardiovascular disease states. We investigated the prognostic significance of pulse pressure (PP) and systolic blood pressure (SBP) among patients with acute coronary syndromes (ACS).

Methods:

A total of 14,514 patients with ACS in the prospective, multicentre Global Registry of Acute Coronary Events (GRACE), expanded GRACE (GRACE-2) and Canadian Registry of Acute Coronary Events (CANRACE) were stratified by initial PP on presentation. Patient characteristics and in-hospital outcomes were compared by PP quartiles and the independent prognostic significance of PP for in-hospital mortality was quantified. We compared the discriminative ability (c-statistic) of models incorporating either PP or SBP.

Results:

Patients with higher PPs were older, more frequently female and had higher prevalence rates of conventional cardiovascular risk factors (all p < 0.01). Lower PP was associated with ST-segment elevation myocardial infarction presentation, higher GRACE risk scores and higher rates of adverse in-hospital outcomes ( p < 0.001). PP was strongly correlated with SBP (Pearson’s correlation coefficient = 0.79, p < 0.001). After adjustment for other GRACE risk model predictors, lower PP was independently associated with in-hospital mortality (first vs. fourth quartile [reference]: adjusted odds ratio 2.57, 95% confidence interval 1.80–3.67). The c-statistic was slightly higher for the multivariable model incorporating SBP as compared to the model with PP (0.868 vs. 0.864, respectively, p = 0.028) for in-hospital mortality.

Conclusion:

Higher presenting PP is associated with increased age and more prevalent cardiovascular risk factors, whereas patients with lower PP present with worse clinical characteristics and in-hospital outcomes. Lower PP is an independent adverse prognosticator in ACS. However, PP did not improve the discriminatory performance of the GRACE risk score compared with SBP.