Hypertension heralds the diagnosis of heart failure (HF) with preserved ejection fraction (HFpEF) in 75–85% of cases and shares many of its adverse outcomes as well as its acute and chronic symptoms. This review provides important new data about the pathophysiology and mechanisms that connect hypertension and HFpEF as well as therapy used in both conditions. The traditional model of HFpEF pathophysiology emphasizes the role of hypertension causing increased afterload on the left ventricle (LV), leading to LV hypertrophy (LVH) and subsequent LV diastolic dysfunction. Recent work has provided valuable insights into the mechanisms underlying the transition from hypertension to HFpEF, showing that the pathophysiology extends beyond LVH and diastolic dysfunction. An evolving paradigm suggests that HFpEF is inflammatory in nature with multifactorial pathophysiology, affected by age-related changes and comorbidities. Hypertension shares many of the proinflammatory mechanisms of HFpEF. Furthermore, hypertension precedes HFpEF in the majority of cases. Because of its clinically heterogeneous nature, development of standardized therapies for HFpEF has been challenging. As there are standardized approaches to hypertension, we suggest that similar approaches be used for the treatment of HFpEF, including medical and non-medical therapies. With medical therapies, a treat-to-target blood pressure (BP) strategy could be employed, such as systolic BP < 130 mmHg. With non-medical therapies, approaches to deal with physical inactivity, obesity, and sleep apnea could be used. Due to its heterogeneity, delineation of standardized therapies for HFpEF has been challenging. Focusing on the tremendous overlap of hypertensive heart disease with HFpEF, it is proposed that approaches currently used to guide therapies for hypertension be applied to the treatment of HFpEF.

Hypertension as a Road to Treatment of Heart Failure with Preserved Ejection Fraction

Background: In the SPRINT (Systolic Blood Pressure Intervention Trial), intensive BP treatment reduced acute decompensated heart failure (ADHF) events. Here, we report the effect on HF with preserv...

Incidence and Outcomes of Acute Heart Failure With Preserved Versus Reduced Ejection Fraction in SPRINT.

The SPRINT (Systolic Blood Pressure Intervention Trial) results have influenced clinical practice but have also generated discussion regarding the validity, generalizability, and importance of the ...

https://www.ahajournals.org/doi/pdf/10.1161/HYPERTENSIONAHA.121.17682

SPRINT Revisited: Updated Results and Implications.

SPRINT (Systolic Blood Pressure Intervention Trial) showed that intensive lowering of systolic blood pressure to <120 mm Hg was beneficial, as compared with standard treatment in which systolic blood pressure is lowered to <140 mm Hg. The proposal that the results of SPRINT were mainly driven by the reduction of heart failure events has undermined the main conclusion of the study. Therefore, this study aimed to assess whether the intensive treatment group was also associated with a reduced risk of cardiovascular events when heart failure events were excluded from the primary composite end point. The SPRINT data were analyzed with a redefined composite end point including myocardial infarction, acute coronary syndrome other than myocardial infarction, stroke, and cardiovascular death (excluding heart failure events). The results show that intensive treatment (<120 mm Hg) is associated with a reduced risk for the redefined composite end point (hazard ratio, 0.79 [95% CI, 0.66-0.95]; P=0.012), as compared with the standard treatment (<140 mm Hg), and with results similar to the original SPRINT findings (hazard ratio, 0.75 [95% CI, 0.64-0.89]; P<0.001). Overall, the main results of SPRINT are not driven by a reduction in heart failure events. Moreover, this post hoc analysis supports the use of a more intensive treatment strategy for high-risk hypertensive patients. (Less)

Heart Failure Events in a Clinical Trial on Arterial Hypertension: New Insights Into the SPRINT Trial

The findings of randomized trials of neurohormonal modulation have been neutral in heart failure with preserved ejection fraction and consistently positive in heart failure with reduced ej...

Therapeutic Stalemate in Heart Failure With Preserved Ejection Fraction

Objectives This study assessed the potential role of differential diuretic drugs in preventing incident acute decompensated heart failure (ADHF) in the SPRINT (Systolic Blood Pressure Intervention Trial) study. Background SPRINT showed that intensive blood pressure reduction in older patients (50 to 97 years of age) resulted in 36% fewer incident cases of ADHF. However, some investigators have questioned whether this was due merely to intergroup differences in diuretic medications. Methods Detailed use of medication data prospectively collected throughout the trial were examined. Results ADHF events occurred in 173 of 9,361 participants. Diuretic medication increased in both arms from screening to baseline visit (from 45% to 50% in the standard arm; and from 43% to 63% in the intensive arm) and then remained steady. The lowest use of diuretic agents was among participants in the standard arm who never had an ADHF event. Withdrawal of diuretic agents at the baseline visit occurred in 6.1% (n = 284) of participants in the standard arm and 2.3% (n = 107) of participants in the intensive arm. Of these, only 11 developed ADHF during the trial (10 in the standard arm, 1 in the intensive arm), and only 1 occurred ≤1 month after diuretic withdrawal. The benefit of ADHF reduction remained significant even after excluding those 11 participants (hazard ratio [HR]: 0.69; 95% confidence interval [CI]: 0.5 to 0.94; p = 0.02). Most ADHF events occurred in participants who were taking prescribed diuretic therapy at the last visit, prior to the ADHF event. There was limited use of loop ( Conclusions No evidence was found to suggest that the reduction in new ADHF events in SPRINT was due to differential diuretic use. (Systolic Blood Pressure Intervention Trial [SPRINT]; NCT01206062 ).

Dalane W. Kitzman

Papers

Heart Failure Prevention in Older Patients Using Intensive Blood Pressure Reduction: Potential Role of Diuretics.