Association between blood pressure response index and mortality in decompensated heart failure: A real-world study

Short-term pharmacological options for heart failure (HF) patients with hemodynamic instability remain limited, and vasoactive agents are frequently used as life-saving interventions. This study aims to investigate the association between Blood Pressure Response Index (BPRI) and mortality in decompensated HF patients.

We conducted a retrospective cohort study in the MIMIC-IV database including HF patients requiring vasoactive drugs. BPRI was calculated hourly as the ratio of the mean arterial pressure to vasoactive-inotropic score. Predictive performance for in-hospital mortality was assessed using receiver operating characteristic curves and the nonlinear relationship was examined with restricted cubic splines. The Cox proportional hazards regression model was applied to evaluate the association between BPRI and 1-year mortality.

Among 1871 patients, BPRI demonstrated superior prognostic value for in-hospital mortality (AUC up to 0.755). Restricted cubic splines revealed an L-shaped relationship between BPRI and in-hospital mortality with a cutoff value at 4.391. Below this value, each unit decrease in BPRI significantly increased in-hospital mortality risk (odds ratio = 1.705, 95% CI 1.447-2.021), whereas no significant association was observed above it. Similarly, an elevated BPRI was associated with a reduced 1-year mortality risk, but this protective effect gradually weakened over time. Additionally, a discharge landmark analysis revealed BPRI was not significantly associated with post-discharge mortality (HR = 1.000, 95% CI 0.991-1.009).

By estimating the hemodynamic compensatory threshold and identifying patients with poor responsiveness to vasoactive agents support, BPRI may contribute to earlier risk stratification and more individualized short-term management in decompensated HF.