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Current management and future directions for the treatment of patients hospitalized for heart failure with low blood pressure

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Abstract

Although patients hospitalized with heart failure have relatively low in-hospital mortality, the post-discharge rehospitalization and mortality rates remain high despite advances in treatment. Most patients admitted for heart failure have normal or high blood pressure, but 15–25 % have low systolic blood pressure with or without signs and/or symptoms of hypoperfusion. All pharmacological agents known to improve the prognosis of patients with heart failure also reduce blood pressure, and this limits their use in patients with heart failure and low blood pressure (HF-LBP). However, patients with HF-LBP have much higher in-hospital and post-discharge mortality. In these patients, a conceptually important therapeutic target is to improve cardiac output in order to alleviate signs of hypoperfusion. Accordingly, the majority of these patients will require an inotrope as cardiac dysfunction is the cause of their low cardiac output. However, the short-term use of currently available inotropes has been associated with further decreases in blood pressure and increases in heart rate, myocardial oxygen consumption and arrhythmias. Agents that improve cardiac contractility without this undesirable effects should be developed. To the best of our knowledge, the epidemiology, pathophysiology and therapy of patients with HF-LBP have not been addressed thoroughly. In June 2010, a workshop that included scientists and clinicians was held in Rome, Italy. The objectives of this meeting were to (1) develop a working definition for HF-LBP, (2) describe its clinical characteristics and pathophysiology, (3) review current therapies and their limitations, (4) discuss novel agents in development and (5) create a framework for the design and conduct of future clinical trials.

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Abbreviations

ACE:

Angiotensin-converting enzyme

HF:

Heart failure

LBP:

Low blood pressure

ARB:

Angiotensin receptor blocker

BMI:

Body mass index

BUN:

Blood urea nitrogen

CABG:

Coronary artery bypass graft

CAD:

Coronary artery disease

CO:

Cardiac output

DBP:

Diastolic blood pressure

IV:

Intravenous

LOS:

Length of stay

LVEF:

Left ventricular ejection fraction

LVSD:

Left ventricular systolic dysfunction

NYHA:

New York Heart Association

PCWP:

Pulmonary capillary wedge pressure

PCI:

Percutaneous coronary intervention

RAAS:

Renin-angiotensin-aldosterone system

SBP:

Systolic blood pressure

WRF:

Worsening renal function

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Acknowledgments

Scientific meeting in June 2010 in Rome, Italy, was funded by an unrestricted educational grant from Sigma Tau (not present at meeting and was not involved in the preparation of this manuscript).

Conflict of interest

Mihai Gheorghiade MD: consultant—Abbott Laboratories (modest), Astellas (modest), Astra Zeneca (modest), Bayer Schering Pharma AG (significant), CorThera, Inc. (modest), Cytokinetics, Inc. (modest), DebioPharm SA (significant), Errekappa Terapeutici (Milan, Italy) (modest), GlaxoSmithKline (modest), Johnson & Johnson (modest), Medtronic (significant), Merck (modest), Novartis Pharma AG (significant), Otsuka Pharmaceuticals (significant), Pericor Therapeutics (significant), Protein Design Laboratories (modest), Sanofi-Aventis (modest), Sigma Tau (significant), Solvay Pharmaceuticals (significant); Muthiah Vaduganathan MD MPH: none; Andrew Ambrosy MD: none; Michael Boehm MD PhD: support by Boehringer-Ingelheim, Servier, Pfizer, Medtronic; Umberto Campia MD: supported by a National Institutes of Health grant (K12-HL083790); John GF Cleland MD: received an honorarium from Bayer for an advisory board. Funding level modest; Francesco Fedele MD: none; Gregg C. Fonarow MD: consultant for Novartis, Medtronic and Takeda; Aldo P. Maggioni MD: none; Alexandre Mebazaa MD: honoraria from Orion, Alere, Thermofisher and Bayer and consultant for Bayer Pharma; Mandeep Mehra MD: consultant for Johnson & Johnson, Medtronics, St. Judes Inc. Research support, National Heart Lung and Blood Institute, National Institutes of Health; Marco Metra MD: honoraria and advisory board from Bayer and Novartis. Modest funding level; Savina Nodari MD: none; Peter S. Pang MD: consultant for Bayer, Medtronic, Novartis, Otsuka, Sigma Tau, Trevena, honoraria from Johnson & Johnson, the Medicines Company and Corthera, and research support from Abbott; Piotr Ponikowski MD: consultant to Bayer Schering AG, Corthera, Amgen, Johnson & Johnson; Hani N. Sabbah PhD: research grants from Bayer Healthcare AG, Johnson & Johnson, Stealth Peptides, Sigma Tau. Consultant to Bayer Healthcare AG and Johnson and Johnson; Michel Komajda MD: none; Javed Butler MD MPH: consultant to Cardiomems, Trevena, Bayer Healthcare, Takeda and Amgen. Events Committee for WorldHeart and Corthera. Research support by GE Healthcare, Medtronic, National Heart Lung and Blood Institute, National Institutes of Health.

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Authors and Affiliations

  1. Center of Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, 645 North Michigan Ave, Suite 1006, Chicago, IL, 60611, USA

    Mihai Gheorghiade, Umberto Campia & Peter S. Pang

  2. Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

    Muthiah Vaduganathan

  3. Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA

    Andrew Ambrosy

  4. Department of Internal Medicine III, University Hospital of Saarland, Homburg/Saar, Germany

    Michael Böhm

  5. Department of Cardiology, Castle Hill Hospital, Hull York Medical School, University of Hull, Kingston-upon-Hull, UK

    John G. F. Cleland

  6. Department of Cardiovascular, Respiratory and Morphological Sciences, Sapienza University, Rome, Italy

    Francesco Fedele

  7. Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA

    Gregg C. Fonarow

  8. ANMCO Research Center, Florence, Italy

    Aldo P. Maggioni

  9. Department of Anesthesia and Intensive Care, Lariboisiere Hospital, University of Paris, Paris, France

    Alexandre Mebazaa

  10. Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Mandeep Mehra

  11. Cardiology, Department of Experimental and Applied Medicine, University and Civil Hospital of Brescia, Brescia, Italy

    Marco Metra & Savina Nodari

  12. Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

    Peter S. Pang

  13. Department of Cardiology, Wroclaw Medical University, Wroclaw, Poland

    Piotr Ponikowski

  14. Department of Medicine, Henry Ford Hospital, Detroit, MI, USA

    Hani N. Sabbah

  15. Assistance Publique Hopitaux de Paris, University Pierre et Marie Curie Paris, Paris, France

    Michel Komajda

  16. Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA

    Javed Butler

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  1. Mihai Gheorghiade
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Correspondence to Mihai Gheorghiade.

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Gheorghiade, M., Vaduganathan, M., Ambrosy, A. et al. Current management and future directions for the treatment of patients hospitalized for heart failure with low blood pressure. Heart Fail Rev 18, 107–122 (2013). https://doi.org/10.1007/s10741-012-9315-1

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