European Journal of Heart Failure (2017) 19, 843–845 EDITORIAL COMMENT doi:10.1002/ejhf.818 Observations on the blood pressure paradox in heart failure Hector O. Ventura 1 *, Franz H. Messerli 2,3,4 , and Carl J. Lavie 1 1 The John Ochsner Heart and Vascular Institute, Ochsner Clinical School—The University of Queensland School of Medicine, New Orleans, LA, USA; 2 Department of Cardiology and Clinical Research, University Hospital, Bern, Freiburgstrasse, Bern, Switzerland; 3 Mount Sinai Health Medical Center, Icahn School of Medicine, New York, NY, USA; and 4 Jagiellonian University Krakow, Poland This article refers to ‘Prognostic value of long-term blood pressure changes in patients with chronic heart failure’ by F.A. Schmid et al., published in this issue on pages 837–842. In this issue of European Heart Failure Journal, Schmid et al. 1 report the infuence of long-term blood pressure (BP) changes on clinical outcomes in close to 1000 patients with heart failure (HF). The authors performed a retrospective analysis of patients with HF with either preserved or reduced ejection fraction (HFpEF and HFrEF, respectively) and demonstrated that patients with stable systolic blood pressure (SBP) over a year had the best survival. Systolic blood pressure changes with an increase or decrease of greater than ±10 mmHg/year were associated with a worse composite outcome (mortality or heart transplantation) and, importantly, the subgroup with the lowest SBP levels (<90 mmHg) had the worst survival. On the basis of these and related data, the authors conclude that a SBP <90 mmHg and increased long-term BP variability is associated with poor survival in HF. We will examine the relationship between BP, its variability and HF, focusing on the so-called ‘hypertension (HTN) paradox’ and ‘decapitated BP’ and its prognosis in patients with established HF, amplifying and corroborating the fndings of Schmid et al. 1 with those from other investigations. Hypertension and heart failure The morbidity and mortality associated with HTN relates, among other issues, to the development of hypertensive heart disease and ultimately of HF. Hypertensive heart disease is a assemblage of abnormalities that includes left ventricular (LV) hypertrophy, systolic and diastolic dysfunction, and their clinical manifestations, such as arrhythmias, coronary ischaemia and symptomatic HF. 2,3 Epidemiological data from the Framingham cohort have shown that a history of HTN can be documented in 91% of all newly The opinions expressed in this article are not necessarily those of the Editors of the European Journal of Heart Failure or of the European Society of Cardiology. doi: 10.1002/ejhf.805 *Corresponding author. Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121, USA. Tel: +1 504 842 5222, Fax: +1 504 842 5960, Email: HVentura@ ochsner.org .......................................................................................................... diagnosed HF patients during up to 20 years of follow-up. 1 . In addition, among patients with HTN, myocardial infarction, diabetes mellitus (DM), LV hypertrophy, and valvular heart disease also predicted an increased risk of HF in both sexes. 4 Not surprisingly, therefore, the prevention of HTN and other HF risk factors, such as obesity and DM in middle-aged subjects, portends HF-free survival. 5 Thus, the absence of HTN, obesity, and DM by ages 45 years and 55 years is associated with up to 86% lower risk for incident HF in men and women across the remaining life span. 5 Once HF is established and, especially, in patients with advanced HF, SBP is usually low, even in those who presented initially with HTN. This phenomenon has been called ‘decapitated hyperten- sion’, that is, patients who have had HTN at the outset, progres- sively develop normal and even low BP as HF worsens and becomes more severe. Blood pressure paradox in patients with heart failure A higher SBP in patients with HF is associated with a paradoxically protective effect on survival. Several studies, including the one published in this issue, have shown that in most HF populations, high and, not as one would expect, low SBP is associated with improved outcomes. 1,6 – 9 Similarly, a meta-analysis of 10 studies of patients with HF (n = 8088) by Raphael et al. 10 demonstrated that a higher SBP was a favourable prognostic marker in HF; per BP increase of 10 mmHg there was a decrease in mortality of 13.0% that was not related to HF therapy. In addition, a retrospective study from the Carvedilol Prospec- tive Randomized Cumulative Survival (COPERNICUS) 11 demon- strated that the lower the pretreatment SBP of patients in the cohort, the higher the risk of a major clinical event. For each © 2017 The Authors European Journal of Heart Failure © 2017 European Society of Cardiology