The Prognostic Impact of Pulse Pressure in Acute Heart Failure: Insights from the HEARTS Registry

Abstract

Background: Low pulse pressure predicts long-term mortality in chronic heart failure, but its prognostic value in acute heart failure is less understood. The present study was designed to examine the prognostic value of pulse pressure in acute heart failure.

Methods: Pulse pressure was tested for its impact on short- and long-term mortality in all patients admitted with acute heart failure from October 2009 to December 2010 in eighteen tertiary centers in Saudi Arabia (n = 2609). All comparisons were based on the median value (50 mmHg). Heart failure with reduced ejection fraction was defined as less than 40%.

Results: Low pulse pressure was associated with increased short-term mortality in the overall population (OR = 1.61; 95 CI 1.17, 2.22; P 0.004 and OR = 1.51; 95% CI 1.13, 2.01; P = 0.005, for hospital and thirty-day mortality, respectively), and short-term and two-year mortality in the reduced ejection fraction group (OR = 1.81; 95% CI 1.19, 2.74; P = 0.005, OR = 1.69; 95% CI 1.17, 2.45; P = 0.006, and OR = 1.29; 95% CI 1.02, 1.61; P = 0.030 for hospital, thirty-day, and two-year mortality, respectively). This effect remained after adjustment for relevant clinical variables; however, pulse pressure lost its predictive power both for short-term and long-term mortality after the incorporation of systolic blood pressure in the model. Conversely, low pulse pressure was an independent predictor of improved survival at two and three years in heart failure with preserved ejection fraction (OR = 0.43; 95% CI 0.24, 0.78, P = 0.005 and OR = 0.49; 95% CI 0.28, 0.88; P = 0.016, respectively).

Conclusion: In acute heart failure with reduced ejection fraction, the prognostic value of low pulse pressure was dependent on systolic blood pressure. However, it inversely correlated with long-term survival in heart failure with preserved ejection fraction.

Keywords: Acute heart failure; Mortality; Pulse pressure; Saudi Arabia.

Fig. 1

Differences in evidence-based medical therapies used before admission (A), during hospital stay (B), and at discharge (C) based on pulse pressure median value. Abbreviations: AA: aldosterone antagonists, ACEI: angiotensin converting enzyme inhibitors, ARB: angiotensin receptor blockers, BB: β-blockers, PP: pulse pressure. * P-value < 0.05. ** P-value < 0.01. *** P-value < 0.001.

Fig. 2

Kaplan-Meier plot for all-cause mortality in all acute heart failure patients (A), heart failure with reduced ejection fraction (B), and heart failure with preserved ejection fraction (C) based on pulse pressure median value. Abbreviations: PP: pulse pressure.