Association of Blood Pressure and Its Evolving Changes With the Survival of Patients With Heart Failure LILIAN GRIGORIAN-SHAMAGIAN, MD, PhD, 1 JOSE RAMON GONZALEZ-JUANATEY, MD, PhD, 1 RAFAEL VAZQUEZ, MD, PhD, 2 JUAN CINCA, MD, PhD, 3 ANTONI BAYES-GENIS, MD, PhD, 3 DOMINGO PASCUAL, MD, 4 CARLOS FERNANDEZ-PALOMEQUE, MD, PhD, 5 ALFREDO BARDAJI, MD, PhD, 6 JESUS ALMENDRAL, MD, PhD, 7 VICENTE NIETO, MD, 8 CARLOS MACAYA, MD, PhD, 9 RICARDO PAVON JIMENEZ, MD, 2 AND ANTONI BAYES DE LUNA, MD, PhD, 3 ON BEHALF OF THE MUERTE SUBITA EN LA INSUFICIENCIA CARDIACA (MUSIC) GROUP * Santiago de Compostela, Sevilla, Barcelona, Murcia, Palma de Mallorca, Tarragona, Madrid, and Las Palmas, Spain ABSTRACT Objective: The association between low blood pressure (BP) levels and increased mortality has been estab- lished in several studies of heart failure (HF). Although many drugs administered to these patients decrease BP, the relationship between changes in BP and survival has not been investigated. Nor have previous anal- yses distinguished among different forms of death. We investigated the influence of baseline BP and changes in BP during a 1-year period on the survival of patients with HF, distinguishing among sudden cardiac death, nonsudden cardiac death, and noncardiac death. We also identified the possible relationship with the baseline values of and changes in other clinical and treatment variables, including pharmacologic treatments. Method and Results: A total of 1062 patients with chronic HF included in the Spanish National Registry of Sudden Death (mean age of 64.5 6 11.8 years, 72% were men, and 21% were in New York Heart Asso- ciation class III with a mean left ventricular ejection fraction of 36.7% 6 14.2%) were prospectively inves- tigated for a mean of 1.9 6 0.6 years. A multivariable Cox proportional hazards model adjusting for clinical and therapeutic variables showed an independent association between low baseline systolic blood pressure (SBP) and nonsudden cardiac death (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.93e0.98), but changes in SBP during the following year did not influence survival, regardless of the baseline SBP level (P 5 .55). Contrariwise, baseline diastolic BP was not associated with mortality, but an increase in diastolic BP during the following year showed a borderline independent significant association with lower nonsudden cardiac death (HR 0.90, 95% CI 0.82e1.00). Treatment with angiotensin-converting enzyme inhibitors or beta-blockers at baseline was also associated with lower nonsudden cardiac mortality, as was an increase in left ventricular ejection fraction during the following year (HR 0.69, 95% CI 0.51e0.93; P 5 .015). Conclusion: Among patients with stable HF, low SBP is associated with a greater risk of nonsudden cardiac death. The change in SBP during a 1-year period has no prognostic value. Because the beneficial effects of drugs associated with increased survival (in this study, angiotensin-converting enzyme inhibitors and beta- blockers) thus seem to be independent of their effects on BP, changes in BP should probably not influence the decision to use such drugs or continue their administration. (J Cardiac Fail 2008;14:561e568) Key Words: Blood pressure, heart failure, prognosis. In recent decades, a large number of demographic, clini- cal, and other variables (eg, biochemical and hemodynamic) have been identified as codeterminants of outcome among patients with congestive heart failure (HF). Nevertheless, it is difficult to assess the individual influences of these vari- ables on outcome in clinical practice (as opposed to clinical trials) or the prognostic value of treatment-induced changes in these variables. Such knowledge would aid the design of From the 1 Hospital Clinico, Santiago de Compostela; 2 Hospital de Valme, Sevilla; 3 Hospital Sant Pau, Barcelona; 4 Hospital Virgen de la Arrixaca, Murcia; 5 Hospital Son Dureta, Palma de Mallorca; 6 Hospital Joan XXIII, Tarragona; 7 Hospital Gregorio Maran ˜o ´n, Madrid; 8 Hospital Insular de las Palmas, Las Palmas and 9 Clı ´nico de San Carlos, Madrid, Spain. Manuscript received October 22, 2006; revised manuscript received March 12, 2008; revised manuscript accepted March 14, 2008. Reprint requests: Jose Ramon Gonzalez-Juanatey, MD, PhD, Servicio de Cardiologia, Hospital Clinico Universitario de Santiago de Compostela, Travesia Choupana s/n, 15706 Santiago de Compostela, Spain. The MUSIC study is supported by the Spanish Ministry of Health through the Instituto de Salud Carlos III, the Spanish National Health Foundation. 1071-9164/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.cardfail.2008.03.006 * MUSIC subinvestigators: Ramon de Castro, Antonio Fernandez Romero, Miguel Fiol, Dolores Garcia Medina, Ricardo Huerta Blanco, Os- car Hugo Conde, Juan Leal del Ojo, Efren Martinez Quintana, Pilar Mazon Ramos, Jose Antonio Mora Pardo, Luis Pastor Torres, Margarita Reina Sanchez, and Pilar Valdovinos. 561 Journal of Cardiac Failure Vol. 14 No. 7 2008