Directionality of blood pressure response to standing may determine development of heart failure: prospective cohort study

Aims To study the prospective relationship of blood pressure response during orthostatic challenge with incidence of heart failure (HF). Methods and results In a Swedish prospective cohort study (the Malmo Preventive Project), we followed up 32 669 individuals (68.2% men; mean age, 46 years) over a period of 24 years. Incidence of first hospitalization due to new-onset HF was related to early (60-120 s) postural changes in systolic and diastolic blood pressure (Delta SBP and. Delta BP), and mean arterial pressure (Delta MAP), using Cox proportional hazards models. Hazard ratio of incident HF increased across descending quartiles of Delta SBP from the first (and reference) quartile (+8.5 +/- 4.9 mmHg), through the second (neutral response), to the third and fourth quartiles (-5.0 +/- 0.1 and -13.7 +/- 6.1 mmHg, respectively; P for linear trend=0.009). A pronounced hypotensive SBP response (fourth quartile) conferred the highest risk of new-onset HF [ hazard ratio (HR), 1.31; 95% confidence interval (CI), 1.11-1.53]. A similar pattern was observed with regard to DMAP, where the first (and reference) quartile with a marked positive MAP response (+7.7 +/- 3.1 mmHg) had the lowest, and the fourth quartile with a hypotensive MAP response (-5.2 +/- 3.4 mmHg) had the highest HF risk (HR for fourth vs. first quartile: 1.37; 95% CI, 1.17-1.62). In a continuous model, the risk of incident HF conferred by negative DSBP matched that of resting SBP (HR per 10 mmHg difference: 1.17; 95% CI, 1.11-1.23, and 1.17, 1.14-1.20, respectively), whereas MAP drop was the strongest individual predictor of HF development (HR 1.26, 95% CI, 1.21-1.31). Conclusion Early increase of blood pressure in response to orthostatic challenge signals reduced the risk of HF development.