Impact of guideline‐directed medical therapy on systolic blood pressure and cardiovascular outcomes in patients with heart failure and low blood pressure: A systematic review and meta‐analysis

Abstract Aims Existing research indicates that patients with heart failure (HF) may have restricted access to guideline‐directed medical therapy (GDMT) when their blood pressure (BP) is comparatively low. However, recent clinical trials suggest that HF patients with low BP could still benefit from certain HF medications, which have a minimal impact on BP. This systematic review and meta‐analysis was conducted to determine whether this applies to all GDMT. Methods and results A systematic search of MEDLINE and EMBASE was conducted for studies published from inception to 10 January 2024. Randomized controlled trials were selected if they reported on the longitudinal change of systolic BP (SBP) due to GDMT, or the risks of cardiovascular events in HF patients based on SBP categories. Weighted mean difference (WMD), hazard ratio or relative risk, and corresponding 95% confidence intervals (CI) were pooled for meta‐analysis where possible. Data from 20 studies, encompassing information on 84 782 individuals, were analysed. Overall, GDMT is associated with lower SBP (WMD, −2.16; 95% CI −2.86 to −1.46), with no significant difference between baseline low and non‐low BP subgroups (interaction p = 0.810). However, SBP of the treatment group increased by 5.8 mmHg from baseline in the low SBP subgroup during follow‐up, while it decreased by 4.0 mmHg in the baseline non‐low SBP subgroup. GDMT demonstrated similar cardiovascular benefits and risk of hypotension between low and non‐low SBP subgroups (interaction p = 0.318 and 0.903, respectively). Conclusions Guideline‐directed medical therapy is associated with a negligible decrease in SBP, but can provide similar cardiovascular benefits in both low and non‐low SBP HF patients, with no significant interaction with SBP as to hypotension. Therefore, GDMT should be initiated and maintained in HF patients with low BP.