Synergistic Impact of Systolic Blood Pressure and Perfusion Status on Mortality in Acute Heart Failure
Xavier Rosselló, Héctor Bueno, Víctor Gil, Javier Jacob, Francisco Javier Martín‐Sánchez, Pere Llorens, Pablo Herrero, Aitor Alquézar‐Arbé, Begoña Espinosa, Sergio Raposeiras‐Roubín, Christian Müller, Alexandre Mebazaa, Aldo P. Maggioni, Stuart Pocock, Ovidiu Chioncel, Òscar Miró, Marta Fuentes, Cristina Gil, Héctor Alonso, Enrique Pérez‐Llantada, Guillermo García, Mar Suárez Cadenas, Rosa Escoda, Carolina Xipell, Carolina Sánchez, María José Pérez‐Durá, Eva Salvo, José Pavón, Antonio Noval, José Manuel Torres, María Luisa López‐Grima, Amparo Valero, María Ángeles Juan, Alfons Aguirre, María Àngels Pedragosa, Silvia Mínguez Masó, María Isabel Alonso, Francisco Ruiz, José Miguel Franco, Ana Belén Mecina, Josep Tost, Marta Berenguer, Ruxandra Donea, Susana Sánchez Ramón, Virginia Carbajosa Rodríguez, Pascual Piñera, José Andrés Sánchez Nicolás, Raquel Torres Gárate, Miguel Alberto Rizzi, Sergio Herrera, Álex Roset, Irene Cabello, Antonio Haro, Fernando Richard, José María Álvarez Pérez, María Pilar López Díez, Pablo Herrero, Joaquín Vázquez Álvarez, Belén Prieto García, María García García, Marta Sánchez González, Patricia Javaloyes, Víctor Marquina, Inmaculada Mora-Jiménez, Néstor Hernández, Benjamín Brouzet, Juan Antonio Andueza, Rodolfo Romero, Martín Ruíz, Roberto Calvache, María Teresa Lorca Serralta, Luis Ernesto Calderón Jave, Beatriz Amores Arriaga, Beatriz Sierra Bergua, Enrique Martín Mojarro, Brigitte Silvana Alarcón Jiménez, LisetteTravería Bécquer, Guillermo Burillo, Lluís Llauger Garcia, Gerard Corominas LaSalle, Carmen Agüera Urbano, Ana Belén García Soto, Elisa Delgado Padial, Ester Soy Ferrer, José Manuel Garrido, Francisco Javier Lucas-Imbernón, Rut Gaya, Carlos Bibiano, María Mir, Beatriz L. Rodríguez, José Luís Carballo, Esther Rodríguez‐Adrada, Belén Rodríguez Miranda
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.