Synergistic Impact of Systolic Blood Pressure and Perfusion Status on Mortality in Acute Heart Failure

Abstract

Background: Physical examination remains the cornerstone in the assessment of acute heart failure. There is a lack of adequately powered studies assessing the combined impact of both systolic blood pressure (SBP) and hypoperfusion on short-term mortality. Methods: Patients with acute heart failure from 41 Spanish emergency departments were recruited consecutively in 3 time periods between 2011 and 2016. Logistic regression models were used to assess the association of 30-day mortality with SBP (<90, 90–109, 110–129, and ≥130 mm Hg) and with manifestations of hypoperfusion (cold skin, cutaneous pallor, delayed capillary refill, livedo reticularis, and mental confusion) at admission. Results: Among 10 979 patients, 1143 died within the first 30 days (10.2%). There was an inverse association between 30-day mortality and initial SBP (35.4%, 18.9%, 12.4%, and 7.5% for SBP<90, SBP 90–109, SBP 110–129, and SBP≥130 mm Hg, respectively; P <0.001) and a positive association with hypoperfusion (8.0%, 14.8%, and 27.6% for those with none, 1, ≥2 signs/symptoms of hypoperfusion, respectively; P <0.001). After adjustment for 11 risk factors, the prognostic impact of hypoperfusion on 30-day mortality varied across SBP categories: SBP≥130 mm Hg (odds ratio [OR]=1.03 [95% CI, 0.77–1.36] and OR=1.18 [95% CI, 0.86–1.62] for 1 and ≥2 compared with 0 manifestations of hypoperfusion), SBP 110 to 129 mm Hg (OR=1.23 [95% CI, 0.86–1.77] and OR=2.18 [95% CI, 1.44–3.31], respectively), SBP 90 to 109 mm Hg (OR=1.29 [95% CI, 0.79–2.10] and OR=2.24 [95% CI, 1.36–3.66], respectively), and SBP<90 mm Hg (OR=1.34 [95% CI, 0.45–4.01] and OR=3.22 [95% CI, 1.30–7.97], respectively); P -for-interaction =0.043. Conclusions: Hypoperfusion confers an incremental risk of 30-day all-cause mortality not only in patients with low SBP but also in normotensive patients. On admission, physical examination plays a major role in determining prognosis in patients with acute heart failure.

Evaluation of the effect of intravenous nitroglycerine on short-term survival of patients with acute heart failure according to congestion and perfusion status at emergency department arrival

“…Indeed, many cases of acute pulmonary oedema are usually associated with systemic hypoperfusion and hypertensive crisis, as our data also suggest: median SBP on patients treated with IV-NTG was 153 mmHg (IQR, 135–178), with similar values in treated patients that exhibited severe clinical hypoperfusion (157 mmHg; IQR, 131–186). A recent study described that hypoperfusion confers an incremental risk of 30-day all-cause mortality not only in patients with low SBP but also in normotensive patients [19]. Therefore, this finding could, to some extent, be linked to this fact.…”

Hemodynamics for the Heart Failure Clinician: A State-of-the-Art Review

“…Most clinical investigations have used 90 mmHg for systolic BP (SBP) and 60 mmHg for mean arterial pressure (MAP) for at least 30 minutes. Concomitant presence of hypoperfusion is required, assessed by exam 38 or simple measures of hypoperfusion, such as decreased urine output or increased lactate. It should be recognized that tissue hypoperfusion can be present without hypotension if CO has significantly fallen but endogenous vasoconstrictor responses are maintaining BP.…”

SBP Is Superior to MAP to Reflect Tissue Perfusion and Hemodynamic Abnormality Perioperatively

“…A study on 41 Spanish emergency departments among 10,979 patients suffering from acute heart failure demonstrated that 30-day mortality was negatively correlated with initial SBP. After adjustment for the risk factors, the prognostic impacts of hypo-perfusion on 30-day mortality varied across SBP categories ( Rossello et al, 2021 ). Another clinical trial also indicated that SBP may be more related to patients’ tissue perfusion and outcomes perioperatively ( Futier et al, 2017 ).…”