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Hypertension is the most common risk factor for systolic and diastolic heart failure. Based on population-attributable risks, hypertension has the greatest impact on the development of heart failure, accounting for 39% of HF events in men and 59% in women. Higher blood pressure, longer duration of hypertension and older age are associated with higher incidence of heart failure however, long term control of hypertension reduces the risk of heart failure. Thus current guideline pointed the hypertension as the single most important modifiable risk factor for heart failure. Although a number of studies have done regarding the hypertension and the development of heart failure, the prognostic value of the hypertension in established systolic heart failure setting has not been well evaluated. Since the hypertension is associated with other cardiovascular risk factors including diabetes and chronic kidney disease, the patients with preexisting hypertension might have worse prognosis. On the contrary, higher dosage and more combinations of heart failure medication which have mortality benefits could be tolerable in patients with hypertension.

Admission systolic blood pressure is known as a predictor of mortality in previous studies. However the initial blood pressure on admission could be easily affected by high sympathetic tone rather than the preexisting hypertension. The concept of “reactive hypertension” which means functional cardiac reserve in acute physiologic stress was applied to explain this phenomenon. The patients with lower functional cardiac reserve have lower blood pressure even in acute stressful condition (ie, pulmonary congestion) and these patients are at higher risk of mortality. We believe the benefits of the medical treatment are more appropriate to explain the lower mortality of hypertension group. While a history of hypertension is very common in heart failure, the high blood pressure can disappear when left ventricular systolic dysfunction develops. Unfortunately, that doesn’t mean spontaneous resolution of high blood pressure but exhausted heart. In a meta analysis of 10 observational heart failure study, 10 mmHg higher systolic blood pressure was associated with 13% reduced mortality rate regardless the etiology of heart failure and the use of the ACEi or Beta blocker. On the other hand high blood pressure is also related to the left ventricular reverse remodeling which is considered as the strongest factor for long term prognosis in idiopathic dilated cardiomyopathy. Thus the high blood pressure is being regarded as a credible predictor for better prognosis after development of heart failure, even though it has contributed the development of heart failure before.

The purpose of this presentation is to focus on prognostic impact of reactive hypertension and preexisting hypertension in established heart failure.

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