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CLINICAL RESEARCH: HEART FAILURE

Influence of Blood Pressure on the Effectiveness of a Fixed-Dose Combination of Isosorbide Dinitrate and Hydralazine in the African-American Heart Failure Trial

Inder S. Anand, MD, FACC, FRCP, DPhil (Oxon)^_*,,_*, S. William Tam, PhD^,1, Thomas S. Rector, PhD^_*,3, Anne L. Taylor, MD, FACC, Michael L. Sabolinski, MD^,1, W. Tad Archambault, PhD, Kirkwood F. Adams, MD^||, Adeoye Y. Olukotun, MD^,¶, Manuel Worcel, MD^,1 and Jay N. Cohn, MD, FACC^,2

^_* VA Medical Center, Minneapolis, Minnesota
University of Minnesota, Minneapolis, Minnesota
NitroMed, Inc., Lexington, Massachusetts
Virtu Stat, Ltd., North Wales, Pennsylvania
^|| University of North Carolina, Chapel Hill, North Carolina
^¶ CR Strategies, LLC, Princeton, New Jersey.

Manuscript received March 3, 2006; revised manuscript received April 12, 2006, accepted April 17, 2006.

^_* Reprint requests and correspondence: Dr. Inder S. Anand, VA Medical Center, Cardiology 111-C, One Veterans Drive, Minneapolis, Minnesota 55417. (Email: anand001{at}umn.edu).

OBJECTIVES: This study sought to assess the effect of baseline systolic blood pressure (SBP) and changes in SBP on the effectiveness of treatment with fixed-dose combination of isosorbide dinitrate and hydralazine (FDC I/H) in patients with heart failure (HF).

BACKGROUND: Low SBP is a risk factor for adverse outcomes in patients with HF. However, FDC I/H lowered SBP in the A-HeFT (African-American Heart Failure Trial) and yet prolonged survival. Whether blood pressure (BP) lowering is critical to the efficacy of FDC I/H and whether a low BP limits its effectiveness is unclear.

METHODS: The effects of FDC I/H on SBP and on mortality and hospitalization were compared in patients with a low or high baseline SBP using multivariable Cox regression models. The interaction between the effect of treatment and baseline SBP was examined.

RESULTS: Mean ± SD baseline SBP in all of the patients was 126 ± 18 mm Hg. Patients with baseline SBP equal to or below the median (126 mm Hg) had features of more severe HF. Baseline SBP equal to or below the median was an independent risk factor for death (hazard ratio [HR] 2.09; 95% confidence interval [CI] 1.02 to 4.29) or first hospitalization for HF (HR 1.66; 95% CI 1.18 to 2.34). The FDC I/H treatment reduced BP in patients with SBP above the median but not in patients with SBP below 126 mm Hg. The FDC I/H treatment was associated with a similar decrease in mortality or hospitalization for HF in patients with SBP below the median and above the median. The effects of FDC I/H on mortality alone were also similar.

CONCLUSIONS: In A-HeFT, patients with lower SBP had a greater risk but a similar relative benefit from the use of FDC I/H as those with higher SBP. The FDC I/H treatment did not reduce SBP in patients with low SBP. An asymptomatic low SBP should not be considered a contraindication to use of FDC I/H in patients with HF.

Abbreviations and Acronyms   ACE-I = angiotensin-converting enzyme inhibitor   ARB = angiotensin receptor blocker   CI = confidence interval   FDC I/H = fixed-dose combination of isosorbide dinitrate and hydralazine   HF = heart failure   HR = hazard ratio   LVEF = left ventricular ejection fraction   SBP = systolic blood pressure

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Blood Pressure in Heart Failure: A Love-Hate Relationship

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JACC 2007 49: 40-42. [Full Text]  

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