Synergistic Impact of Systolic Blood Pressure and Perfusion Status on Mortality in Acute Heart Failure
Authors: Rossello Xavier , Bueno Héctor , Gil Víctor , Jacob Javier , Martín-Sánchez Francisco Javier , Llorens Pere , Herrero Puente Pablo , Alquézar-Arbé Aitor , Espinosa Begoña , Raposeiras-Roubín Sergio , Müller Christian E. , Mebazaa Alexandre , Maggioni Aldo P. , Pocock Stuart , Chioncel Ovidiu , Miró Òscar , Fuentes Marta , Gil Cristina , Alonso Héctor , Pérez-Llantada Enrique , García Guillermo Llopis , Cadenas Mar Suárez , Escoda Rosa , Xipell Carolina , Sánchez Carolina , Pérez-Durá María José , Salvo Eva , Pavón José , Noval Antonio , Torres José Manuel , López-Grima María Luisa , Valero Amparo , Juan María Ángeles , Aguirre Alfons , Pedragosa Maria Àngels , Masó Silvia Mínguez , Alonso María Isabel , Ruiz Francisco , Franco José Miguel , Mecina Ana Belén , Tost Josep , Berenguer Marta , Donea Ruxandra , Ramón Susana Sánchez , Rodríguez Virginia Carbajosa , Piñera Pascual , Sánchez Nicolás José Andrés , Garate Raquel Torres , Rizzi Miguel Alberto , Herrera Sergio , Roset Alex , Cabello Irene , Haro Antonio , Richard Fernando , Álvarez Pérez José María , López Diez María Pilar , Puente Pablo Herrero , Álvarez Joaquín Vázquez , García Belén Prieto , García María García , González Marta Sánchez , Javaloyes Patricia , Marquina Víctor , Jiménez Inmaculada , Hernández Néstor , Brouzet Benjamín , Andueza Juan Antonio , Romero Rodolfo , Ruíz Martín , Calvache Roberto , Lorca Serralta María Teresa , Calderón Jave Luis Ernesto , Arriaga Beatriz Amores , Bergua Beatriz Sierra , Mojarro Enrique Martín , Alarcón Jiménez Brigitte Silvana , Bécquer LisetteTravería , Burillo Guillermo , García Lluís Llauger , LaSalle Gerard Corominas , Urbano Carmen Agüera , García Soto Ana Belén , Padial Elisa Delgado , Ferrer Ester Soy , Garrido José Manuel , Lucas-Imbernón Francisco Javier , Gaya Rut , Bibiano Carlos , Mir María , Rodríguez Beatriz , Carballo José Luis , Rodríguez-Adrada Esther , Miranda Belén Rodríguez 
Published: March 2021

Background:
Physical examination remains the cornerstone in the assessment of acute heart failure. There is a lack of adequately powered studies assessing the combined impact of both systolic blood pressure (SBP) and hypoperfusion on short-term mortality.

Methods:
Patients with acute heart failure from 41 Spanish emergency departments were recruited consecutively in 3 time periods between 2011 and 2016. Logistic regression models were used to assess the association of 30-day mortality with SBP (<90, 90–109, 110–129, and ≥130 mm Hg) and with manifestations of hypoperfusion (cold skin, cutaneous pallor, delayed capillary refill, livedo reticularis, and mental confusion) at admission.

Results:

Among 10 979 patients, 1143 died within the first 30 days (10.2%). There was an inverse association between 30-day mortality and initial SBP (35.4%, 18.9%, 12.4%, and 7.5% for SBP<90, SBP 90–109, SBP 110–129, and SBP≥130 mm Hg, respectively;
P
<0.001) and a positive association with hypoperfusion (8.0%, 14.8%, and 27.6% for those with none, 1, ≥2 signs/symptoms of hypoperfusion, respectively;
P
<0.001). After adjustment for 11 risk factors, the prognostic impact of hypoperfusion on 30-day mortality varied across SBP categories: SBP≥130 mm Hg (odds ratio [OR]=1.03 [95% CI, 0.77–1.36] and OR=1.18 [95% CI, 0.86–1.62] for 1 and ≥2 compared with 0 manifestations of hypoperfusion), SBP 110 to 129 mm Hg (OR=1.23 [95% CI, 0.86–1.77] and OR=2.18 [95% CI, 1.44–3.31], respectively), SBP 90 to 109 mm Hg (OR=1.29 [95% CI, 0.79–2.10] and OR=2.24 [95% CI, 1.36–3.66], respectively), and SBP<90 mm Hg (OR=1.34 [95% CI, 0.45–4.01] and OR=3.22 [95% CI, 1.30–7.97], respectively);
P
-for-interaction =0.043.

Conclusions:
Hypoperfusion confers an incremental risk of 30-day all-cause mortality not only in patients with low SBP but also in normotensive patients. On admission, physical examination plays a major role in determining prognosis in patients with acute heart failure.