What is the blood pressure target for a patient with dilated cardiomyopathy and reduced ejection fraction heart failure?

Blood Pressure Target in Dilated Cardiomyopathy with Reduced Ejection Fraction

For patients with dilated cardiomyopathy and reduced ejection fraction (HFrEF), target systolic blood pressure should be <130/80 mm Hg but maintained above 120/70 mm Hg. 1

Guideline-Recommended Blood Pressure Targets

The 2020 International Society of Hypertension guidelines provide explicit targets for hypertensive patients with heart failure:

• Target BP is <130/80 mm Hg with a lower safety threshold of >120/70 mm Hg in patients with hypertension and heart failure with reduced ejection fraction. 1

• This target applies specifically to patients with HFrEF, where hypertension is a major risk factor for both development and progression of heart failure. 1

• For elderly patients (typically >65-70 years), a slightly less aggressive target of <140/80 mm Hg may be acceptable, though the <130/80 mm Hg target remains preferred when tolerated. 1

Evidence Supporting This Target Range

Recent pooled analysis of over 16,900 patients with heart failure demonstrates:

• The relationship between systolic BP and cardiovascular outcomes follows a J-shaped curve, with the lowest risk observed at SBP between 120-130 mm Hg. 2

• SBP categories ≥140 mm Hg were associated with 22% higher risk of heart failure hospitalization or cardiovascular death compared to the 120-129 mm Hg reference range (HR 1.22,95% CI 1.10-1.34). 2

• Importantly, SBP <120 mm Hg was also associated with increased risk, confirming the lower safety threshold recommended in guidelines. 2

Critical Context: Low Blood Pressure Should Not Prevent GDMT Optimization

A common pitfall is withholding or down-titrating guideline-directed medical therapy (GDMT) due to blood pressure concerns:

• Never discontinue or reduce GDMT for asymptomatic hypotension with adequate perfusion, as GDMT medications maintain efficacy and safety even in patients with baseline SBP <110 mm Hg. 1, 3

• In the CHAMP-HF registry, fewer than 20% of HFrEF patients achieved target doses of foundational therapies, with low blood pressure cited as a major barrier—yet this represents clinical inertia rather than true contraindication. 4

• GDMT provides approximately 73% mortality reduction over 2 years when all four medication classes (ARNI/ACEi/ARB, beta-blocker, MRA, SGLT2 inhibitor) are optimized, far outweighing concerns about modest BP reductions. 3

Practical Management Algorithm for BP in DCMP

Step 1: Assess Current Blood Pressure Status

• If SBP is 130-160 mm Hg: Initiate or optimize all four GDMT medication classes simultaneously (SGLT2 inhibitor, MRA, beta-blocker, ARNI). 3, 5

• If SBP is 110-129 mm Hg: Still initiate GDMT, prioritizing SGLT2 inhibitor and MRA first (minimal BP effects), then add beta-blocker and ARNI. 1, 3

• If SBP is 90-109 mm Hg: Start SGLT2 inhibitor (causes only -1.5 mm Hg decrease) and MRA, then cautiously add low-dose beta-blocker or ARNI while monitoring symptoms. 1, 3

• If SBP is <90 mm Hg or patient has symptomatic hypotension: Address reversible causes first (stop alpha-blockers, reduce diuretics if euvolemic, treat infection/dehydration), then initiate GDMT starting with SGLT2 inhibitor. 1, 3

Step 2: Medication Selection Based on BP

For patients with BP in the 110-130 mm Hg range (common in DCMP):

• SGLT2 inhibitors (dapagliflozin 10 mg or empagliflozin 10 mg once daily) cause minimal BP reduction (average -1.5 mm Hg, diminishing to <1 mm Hg after 4 months) and should be started immediately. 1, 3

• Mineralocorticoid receptor antagonists (spironolactone 12.5-25 mg or eplerenone 25 mg daily) also have minimal BP effects and provide 20% mortality reduction. 1, 3

• Beta-blockers (carvedilol, metoprolol succinate, or bisoprolol) provide 34% mortality reduction—the highest relative risk reduction among GDMT classes—and should not be withheld for BP 100-130 mm Hg. 3

• ARNI (sacubitril/valsartan) provides 20% mortality reduction superior to ACE inhibitors and should be titrated to target dose of 97/103 mg twice daily even in patients with SBP 100-130 mm Hg. 3

Step 3: Diuretic Management

• Reassess loop diuretic dose based on volume status, as excessive diuresis contributes to hypotension without mortality benefit. 3

• Once euvolemia is achieved (no edema, no orthopnea, no jugular venous distension), use the lowest diuretic dose that maintains this state. 3

• Serial natriuretic peptide monitoring can guide diuretic titration to ensure congestion does not worsen during dose reduction. 3

Special Consideration: "Decapitated Hypertension"

• In advanced dilated cardiomyopathy, blood pressure may paradoxically decrease as pump function deteriorates—a phenomenon termed "decapitated hypertension." 6

• This represents worsening cardiac output rather than improved BP control, and should prompt intensification of GDMT rather than dose reduction. 6

• Systolic BP was independently predictive of mortality in DCMP patients, with lower BP associated with worse prognosis—yet this association is weakened by optimal GDMT, highlighting the ongoing benefit of therapy even at lower BP levels. 1, 7

Monitoring Requirements During BP Optimization

• Check BP, heart rate, renal function, and electrolytes at 1-2 weeks after each GDMT dose increment. 3

• Modest increases in creatinine (up to 30% above baseline) are acceptable and should not prompt discontinuation. 3

• Discontinuing RAAS inhibitors after hypotension is associated with two- to fourfold higher risk of adverse events compared to continuing therapy. 1, 3

Common Pitfalls to Avoid

• Accepting suboptimal GDMT doses due to BP 100-130 mm Hg: This range is safe and should not prevent titration to target doses, as clinical trials demonstrated benefits at target doses, not low doses. 3, 4

• Stopping GDMT for asymptomatic hypotension: Adverse events occur in 75-85% of HFrEF patients regardless of treatment, with no substantial difference between GDMT and placebo arms. 3

• Using non-evidence-based antihypertensives: Diltiazem and verapamil are absolutely contraindicated in HFrEF as they worsen outcomes; alpha-blockers should be discontinued as they interfere with GDMT optimization. 3, 5

• Delaying SGLT2 inhibitor initiation: This medication provides substantial mortality benefit with minimal BP effect and should be started immediately regardless of BP level. 1, 3