Associations of Left Ventricular Structure and Function With Blood Pressure in Heart Failure With Preserved Ejection Fraction: Analysis of the TOPCAT Trial

Abstract

Background Data on the association of systolic and diastolic blood pressure with the structure and function of failing hearts with preserved ejection fraction (EF) are sparse. Methods and Results This analysis included 935 patients with heart failure (49.4% women; mean age, 69.9 years) with preserved EF (≥45%) enrolled in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) Trial before initiation of randomized therapy. Left ventricular (LV) structure (dimensions, wall thickness, and mass index), diastolic function (left atrial volume index, transmitral blood flow, and mitral annular velocities), and systolic function (EF and longitudinal strain) were assessed echocardiographically. In multivariable-adjusted analyses, association sizes expressed per 1-SD (14.8-mm Hg) increment in systolic blood pressure were 0.020 cm (P=0.003) and 0.018 cm (P=0.004) for LV septal and posterior wall thickness, respectively, and 2.42 mg/m² (P=0.018) for LV mass index. The corresponding associations with diastolic blood pressure were nonsignificant (P≥0.067). In similarly adjusted analyses, the association sizes expressed per 1-SD (10.7-mm Hg) increment in diastolic blood pressure were -0.15 for E/A (P<0.001), -0.76 for E/e' (P=0.006), and -0.62% for EF (P=0.024). These findings were consistent, if models including systolic blood pressure were additionally adjusted for diastolic blood pressure and vice versa, albeit that the relation of EF with diastolic blood pressure weakened (-0.54%; P=0.10). Conclusions In diastolic heart failure, LV wall thickness and LV mass index increased with higher systolic blood pressure, but not with higher diastolic blood pressure, whereas functional measures reflecting diastolic LV function decreased with higher diastolic blood pressure, independent of systolic blood pressure. These observations highlight the importance of controlling both systolic and diastolic blood pressure as modifiable risk factors to reduce the risk of LV remodeling and diastolic LV dysfunction.

Keywords: blood pressure; diastolic heart failure; echocardiography; hypertension; left ventricle.

Figure 1. Multivariable‐adjusted associations of the left ventricular (LV) mass index (A) and E wave/peak early diastolic tissue velocity (E/e′) (B) with systolic (SBP) and diastolic (DBP) blood pressure in patients with heart failure with preserved ejection fraction.

The plane shows the independent associations of LV mass index and E/e′ with SBP and DBP. The plotted plane was standardized to the mean distribution in the whole study patients of sex, age, ethnicity, body mass index, heart rate, current smoking, dyslipidemia, diabetes mellitus, use of antihypertensive medications by drug class (ie, diuretics, β blockers, inhibitors of the renin‐angiotensin system, and calcium channel blockers), and intake of aspirin, lipid‐lowering drugs, other cardiovascular medications, and antidiabetic agents.