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Association of orthostatic blood pressure response with incident heart failure: The Framingham Heart Study
Tara A Shrout1,2, Stephanie Pan3, Gary F Mitchell4
1Department of Internal Medicine, Residency Program, Boston Medical Center, Boston, MA, United States of America.
Insights
Orthostatic hypotension (OH), a drop in blood pressure upon standing, is linked to increased heart failure (HF) risk, particularly HF with reduced ejection fraction (HFrEF). Orthostatic hypertension (OHT) showed no association with HF risk.
Area of Science:
- Cardiology
- Hypertension Research
- Heart Failure Studies
Background:
- Orthostatic hypotension (OH) and orthostatic hypertension (OHT) are abnormal blood pressure (BP) regulation conditions.
- These conditions are associated with increased cardiovascular disease risk.
- The relationship between OH, OHT, and heart failure (HF) risk, including its subtypes (HF with reduced ejection fraction [HFrEF] and HF with preserved ejection fraction [HFpEF]), is not well-established in community settings.
Purpose of the Study:
- To investigate the association between OH and OHT and the risk of developing HF.
- To examine the relationship between OH and OHT with specific HF subtypes: HFrEF and HFpEF.
- To determine if orthostatic BP responses can serve as an early indicator for HF risk.
Main Methods:
- A prospective observational cohort study was conducted using community-based individuals from the Framingham Heart Study Original Cohort.
- 1,914 participants were followed from examination cycle 17 (1981-1984) until December 31, 2017, for incident HF or death.
- OH and OHT were defined by specific BP changes upon standing; Cox proportional hazards regression models were used to analyze the associations, adjusting for multiple covariates.
Main Results:
- During a median follow-up of 13 years, 492 HF events were observed.
- Participants with OH exhibited a significantly higher risk of HF (Hazard Ratio [HR] 1.47, 95% CI 1.13-1.91) compared to those with normal BP response.
- OH was specifically associated with an increased risk of HFrEF (HR 2.21, 95% CI 1.34-3.67), while OHT was not significantly associated with HF risk.
Conclusions:
- Orthostatic hypotension may serve as an early warning sign for heart failure risk.
- The findings suggest a potential shared pathophysiology between abnormal BP regulation (specifically OH) and the development of HF, including HFrEF.
- Further research into the mechanisms linking orthostatic BP dysregulation and HF is warranted.
Importance:
Orthostatic hypotension (OH) and hypertension (OHT) are aberrant blood pressure (BP) regulation conditions associated with higher cardiovascular disease risk. The relations of OH and OHT with heart failure (HF) risk in the community are unclear and there remains a paucity of data on the relations with HF subtypes [HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF)].
Objective:
Relate OH and OHT with HF risk and its subtypes.
Design:
Prospective observational cohort.
Setting:
Community-based individuals in the Framingham Heart Study Original Cohort.
Participants:
1,914 participants (mean age 72 years; 1159 women) attending examination cycle 17 (1981-1984) followed until December 31, 2017 for incident HF or death.
Exposures:
OH or OHT, defined as a decrease or increase, respectively, of ≥20/10 mmHg in systolic/diastolic BP upon standing from supine position.
Outcomes And Measures:
At baseline, 1,241 participants had a normal BP response (749 women), 274 had OH (181 women), and 399 had OHT (229 women). Using Cox proportional hazards regression models, we related OH and OHT to risk of HF, HFrEF, and HFpEF compared to the absence of OH and OHT (reference), adjusting for age, sex, body mass index, systolic and diastolic BP, hypertension treatment, smoking, diabetes, and total cholesterol/high-density lipoprotein.
Results:
On follow-up (median 13 years) we observed 492 HF events (292 in women; 134 HFrEF, 116 HFpEF, 242 HF indeterminate EF). Compared to the referent, participants with OH [n = 84/274 (31%) HF events] had a higher HF risk (Hazards Ratio [HR] 1.47, 95% CI 1.13-1.91). Moreover, OH was associated with a higher HFrEF risk (HR 2.21, 95% CI 1.34-3.67). OHT was not associated with HF risk.
Conclusions And Relevance:
Orthostatic BP response may serve as an early marker of HF risk. Findings suggest shared pathophysiology of BP regulation and HF, including HFrEF.
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