Diastolic Blood Pressure and Adverse Outcomes in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) Trial

BACKGROUND: Although diastolic blood pressure (DBP) is independently associated with an increased risk of adverse cardiovascular outcomes in the general population, it is unclear if a similar relationship exists in patients with heart failure with preserved ejection fraction. METHODS AND RESULTS: This analysis included 1703 (mean age, 72±10 years; 50% men; 78% white) patients with heart failure with preserved ejection fraction enrolled in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) Trial from the Americas who were treated for hypertension. Multivariable Cox regression was used to examine the risk of hospitalization for heart failure, death, and cardiovascular death associated with DBP. The relationship between hospitalization for heart failure and DBP was linear, with an increased risk observed with decreasing DBP values (≥90 mm Hg: referent; 80–89 mm Hg: hazard ratio [HR], 1.44; 95% confidence interval [CI], 0.85–2.44; 70–79 mm Hg: HR, 1.18; 95% CI, 0.69–2.01; 60–69 mm Hg: HR, 1.54; 95% CI, 0.90–2.63; <60 mm Hg: HR, 2.12; 95% CI, 1.20–3.74; P=0.0055 for trend). The associations of DBP with death (≥90 mm Hg: HR, 1.86; 95% CI, 1.12–3.06; 80–89 mm Hg: HR, 1.23; 95% CI, 0.89–1.70; 70–79 mm Hg: referent; 60–69 mm Hg: HR, 1.20; 95% CI, 0.90–1.59; <60 mm Hg: HR, 1.68; 95% CI, 1.21–2.33) and cardiovascular death (≥90 mm Hg: HR, 2.02; 95% CI, 1.10–3.71; 80–89 mm Hg: HR, 1.17; 95% CI, 0.77–1.79; 70–79 mm Hg: referent; 60–69 mm Hg: HR, 1.16; 95% CI, 0.80–1.70; <60 mm Hg: HR, 1.85; 95% CI, 1.21–2.82) were nonlinear, with a greater risk of each outcome observed with DBP values ≥90 and <60 mm Hg. CONCLUSIONS: DBP values ≥90 and <60 mm Hg are associated with a significant risk of adverse outcomes in patients with heart failure with preserved ejection fraction who are treated for hypertension. Further research is needed to determine optimal DBP targets to reduce the risk of adverse events in patients with heart failure with preserved ejection fraction.