Determinants of significant day-time systolic hypotension in patients with chronic heart failure

Background

Low BP is common in HF patients due to a number of underlying mechanisms such as impaired cardiac function, hypovolaemia and altered vasoreactivity secondary to co-morbidities characterised by autonomic dysfunction. However, it most commonly results from the effect of the HF disease modifying therapy itself.

Low blood pressure is associated with increased incidence of dementia, faster progression of cognitive decline, confusion, dizziness, fatigue, low mood, eGFR decline, AKI, electrolyte imbalance, reduced autonomy in daily living, reduced quality of life, increased risk of falls and fall-related injuries, increased risk of hospitalization and all-cause mortality.

Thorough hypotension assessment is not only based on single clinic readings or average BP but also on whether BP drops are present on continuous assessments such 24-h ambulatory blood pressure monitors. Day-time SBP < 90mmHg represents significant systolic hypotension and predicts syncope with high specificity.

Purpose

The aim of this study is to assess the association of significant systolic hypotension to HF medications combination, co-morbidities and heart failure aetiology in order to provide new significant knowledge in the field of hypotension and chronic heart failure.

Methods

Our study is an ongoing observational prospective study that focuses on ambulatory patients with chronic heart failure.

To date, a total of 275 patients with chronic stable heart failure have been recruited.

All patients underwent assessment through 24-h ambulatory blood pressure monitors.

Patients that showed even a single reading of SBP < 90mmHg were labelled as day-time dippers.

Demographic and clinical characteristics such as heart failure aetiology (ischaemic/non ischaemic), gender, age, co-morbidities, NT-pro-BNP level and frailty score (Rockwood classification), were recorded.

Results

Patients with co-morbidities including CKD stage IV/V, neurological conditions (CVA – stroke/TIA, and peripheral neuropathy mainly) and/or use of a walking aid were more likely to exhibit diurnal dipping compared with those without these co-morbidities. Patients receiving at least three pillars, with or without loop diuretics, were also more likely to develop diurnal dips. Aetiology (ischaemic vs non-ischaemic) did not influence the likelihood of diurnal dipping. These results are illustrated in Graph 2.

Conclusions

In summary, co-morbidities and medication combinations should be considered important risk factors for day-time blood pressure dipping and should prompt further evaluation. Future studies should focus on developing structured, safe symptom assessment pathways and clear de-escalation algorithms where clinically indicated.Baseline characteristicsFor image description, please refer to the figure legend and surrounding text.ResultsFor image description, please refer to the figure legend and surrounding text.