What is the target blood pressure for patients with heart failure?

Target Blood Pressure for Heart Failure

In patients with heart failure, target a blood pressure of less than 130/80 mmHg using guideline-directed medical therapy (GDMT) that includes ACE inhibitors or ARBs, beta-blockers, and aldosterone antagonists. 1

Blood Pressure Goals by Heart Failure Type

Heart Failure with Reduced Ejection Fraction (HFrEF)

• The target systolic blood pressure is <130 mmHg, established as a Class I recommendation by the 2017 ACC/AHA/HFSA guidelines based on cardiovascular risk reduction data. 2, 1
• Successful clinical trials consistently achieved systolic BP in the range of 110-130 mmHg, with some evidence suggesting targets around 120 mmHg may be beneficial in select patients. 1
• This target applies to patients with stable ischemic heart disease and hypertension as well. 2

Heart Failure with Preserved Ejection Fraction (HFpEF)

• Adults with HFpEF and persistent hypertension after management of volume overload should be prescribed ACE inhibitors or ARBs and beta-blockers titrated to attain SBP of less than 130 mmHg. 2
• Diuretics should be prescribed first to control hypertension in patients presenting with symptoms of volume overload. 2

Medication Selection Algorithm

First-Line Therapy

• ACE inhibitors or ARBs are the foundation of treatment, serving dual purposes of treating both hypertension and improving heart failure outcomes. 1
• If an ACE inhibitor is not tolerated, an ARB may be substituted. 2

Second-Line Therapy

• Beta-blockers (bisoprolol, carvedilol, or metoprolol succinate extended-release) are essential and should be titrated to target doses proven in clinical trials. 1
• Avoid beta blockers with intrinsic sympathomimetic activity, and do not use atenolol as it is less effective than placebo in reducing cardiovascular events. 2

Third-Line Therapy

• Aldosterone antagonists (spironolactone or eplerenone) provide additional BP control and mortality benefit and should be used in conjunction with ACE inhibitors or ARBs. 1

Special Population Considerations

Diabetic Patients with Heart Failure

• Target blood pressure of <130/80 mmHg, which represents a Class I recommendation with Level A evidence from the European Society of Cardiology. 2, 1
• This more aggressive target is justified by the high cardiovascular risk profile in this population. 2

Elderly Patients (≥65 years)

• Target systolic BP is 130-140 mmHg if tolerated, and systolic BP should not be lowered below 120 mmHg. 1
• Initiation of BP-lowering therapy, especially with 2 drugs, should be done with caution and careful monitoring for adverse effects, including orthostatic hypotension. 1

Patients with Chronic Kidney Disease

• Target BP <130/80 mmHg for adults with hypertension and CKD. 2
• ACE inhibitors are preferred to slow kidney disease progression in patients with CKD stage 3 or higher, or stage 1-2 with albuminuria ≥300 mg/d. 2

Critical Pitfalls to Avoid

Medications to Avoid

• Do not use nondihydropyridine calcium channel blockers, alpha-blockers, or clonidine in heart failure patients due to negative inotropic effects and increased risk of worsening heart failure. 1
• Never combine ACE inhibitor + ARB + direct renin inhibitor, as this increases adverse events without benefit. 1
• Class Ic antiarrhythmic agents should not be used in heart failure patients. 2

Overly Aggressive BP Lowering

• Low blood pressure should not deter uptitration of drugs otherwise indicated to improve prognosis in heart failure, provided that patients tolerate drugs without adverse events. 3
• Be aware that aggressive blood pressure lowering can cause hypotension, syncope, falls, acute kidney injury, and electrolyte abnormalities, particularly in elderly patients. 3, 4
• Research suggests that SBP <110 mm Hg may be associated with worse outcomes in hospitalized older patients with HFrEF, though this remains controversial. 5

Monitoring Parameters

Initial Monitoring

• Check BP, serum creatinine, and potassium within 2-4 weeks of initiating or increasing ACE inhibitor/ARB doses. 1
• Continue ACE inhibitor/ARB unless creatinine rises >30% within 4 weeks of initiation or dose increase. 1

Ongoing Monitoring

• Monthly evaluation of adherence and therapeutic response until control is achieved after initiation of drug therapy. 1
• Once target BP is achieved, laboratory monitoring and clinic follow-up should occur every 3 to 6 months, depending on medications utilized and patient stability. 1

Evidence Nuances

The relationship between blood pressure and outcomes in heart failure is complex. While guidelines consensually recommend a target of 130/80 mmHg, 2, 1 observational data from the OPTIMIZE-HF registry found that hospitalized older patients with HFrEF and SBP <130 mm Hg had higher 30-day and 1-year mortality compared to those with SBP ≥130 mm Hg. 5 However, this association may reflect reverse causality, where lower BP is a marker of more severe heart failure rather than a cause of poor outcomes. 3 The key clinical principle is that treatment with GDMT should not be withheld based on blood pressure alone, as these medications improve outcomes across the BP spectrum when tolerated. 3