Impact of changes in blood pressure during the treatment of acute decompensated heart failure on renal and clinical outcomes

Abstract

Aims: One of the primary determinants of blood flow in regional vascular beds is perfusion pressure. Our aim was to investigate if reduction in blood pressure during the treatment of decompensated heart failure would be associated with worsening renal function (WRF). Our secondary aim was to evaluate the prognostic significance of this potentially treatment-induced form of WRF.

Methods and results: Subjects included in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial limited data were studied (386 patients). Reduction in systolic blood pressure (SBP) was greater in patients experiencing WRF (-10.3 ± 18.5 vs. -2.8 ± 16.0 mmHg, P < 0.001) with larger reductions associated with greater odds for WRF (odds ratio = 1.3 per 10 mmHg reduction, P < 0.001). Systolic blood pressure reduction (relative change > median) was associated with greater doses of in-hospital oral vasodilators (P ≤ 0.017), thiazide diuretic use (P = 0.035), and greater weight reduction (P = 0.023). In patients with SBP-reduction, WRF was not associated with worsened survival [adjusted hazard ratio (HR) = 0.76, P = 0.58]. However, in patients without SBP-reduction, WRF was strongly associated with increased mortality (adjusted HR = 5.3, P < 0.001, P interaction = 0.001).

Conclusion: During the treatment of decompensated heart failure, significant blood pressure reduction is strongly associated with WRF. However, WRF that occurs in the setting of SBP-reduction is not associated with an adverse prognosis, whereas WRF in the absence of this provocation is strongly associated with increased mortality. These data suggest that WRF may represent the final common pathway of several mechanistically distinct processes, each with potentially different prognostic implications.

Figure 1

Kaplan–Meier plots for total survival grouped by degree of admission to discharge systolic blood pressure reduction and worsening renal function status. Systolic blood pressure reduction dichotomized about the median.

Figure 2

Incidence of worsening renal function and 6-month mortality grouped in patients with and without a systolic blood pressure reduction below the median. SBP, systolic blood pressure; WRF, worsening renal function. Interaction P value derived from Cox proportional hazards modelling.

Figure 3

Kaplan–Meier plots for total survival grouped by haemoconcentration and worsening renal function status. Haemoconcentration is defined as admission to discharge increase in haematocrit in the top tertile.