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IMPORTANCE: Lower systolic blood pressure (SBP) levels are associated with poor outcomes in patients with heart failure. Less is known about this association in heart failure with preserved ejection fraction (HFpEF). OBJECTIVE: To determine the associations of SBP levels with mortality and other outcomes in HFpEF. DESIGN, SETTING, AND PARTICIPANTS: A propensity score–matched observational study of the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry included 25 354 patients who were discharged alive; 8873 (35.0%) had an ejection fraction of at least 50%, and of these, 3915 (44.1%) had stable SBP levels (≤20 mm Hg admission to discharge variation). Data were collected from 259 hospitals in 48 states between March 1, 2003, and December 31, 2004. Data were analyzed from March 1, 2003, to December 31, 2008. EXPOSURE: Discharge SBP levels less than 120 mm Hg. A total of 1076 of 3915 (27.5%) had SBP levels less than 120 mm Hg, of whom 901 (83.7%) were matched by propensity scores with 901 patients with SBP levels of 120 mm Hg or greater who were balanced on 58 baseline characteristics. MAIN OUTCOMES AND MEASURES: Thirty-day, 1-year, and overall all-cause mortality and heart failure readmission through December 31, 2008. RESULTS: The 1802 matched patients had a mean (SD) age of 79 (10) years; 1147 (63.7%) were women, and 134 (7.4%) were African American. Thirty-day all-cause mortality occurred in 91 (10%) and 45 (5%) of matched patients with discharge SBP of less than 120 mm Hg vs 120 mm Hg or greater, respectively (hazard ratio [HR], 2.07; 95% CI, 1.45-2.95; P < .001). Systolic blood pressure level less than 120 mm Hg was also associated with a higher risk of mortality at 1 year (39% vs 31%; HR, 1.36; 95% CI, 1.16-1.59; P < .001) and during a median follow-up of 2.1 (overall 6) years (HR, 1.17; 95% CI, 1.05-1.30; P = .005). Systolic blood pressure level less than 120 mm Hg was associated with a higher risk of heart failure readmission at 30 days (HR, 1.47; 95% CI, 1.08-2.01; P = .02) but not at 1 or 6 years. Hazard ratios for the combined end point of heart failure readmission or all-cause mortality associated with SBP level less than 120 mm at 30 days, 1 year, and overall were 1.71 (95% CI, 1.34-2.18; P < .001), 1.21 (95% CI, 1.07-1.38; P = .004), and 1.12 (95% CI, 1.01-1.24; P = .03), respectively. CONCLUSIONS AND RELEVANCE: Among hospitalized patients with HFpEF, an SBP level less than 120 mm Hg is significantly associated with poor outcomes. Future studies need to prospectively evaluate optimal SBP treatment goals in patients with HFpEF.

Positive inotropic drugs have long been studied for their potential benefits in patients with heart failure and reduced ejection fraction (HFrEF). Although there has been an extensive amount of research about the clinical effects of these drugs in general, few studies examined their effect in older patients. Therefore, there is little or no evidence to guide the use of positive inotropes in older patients with HFrEF. However, recommendations from national heart failure guidelines may be generalized to older HFrEF patients on an individual basis, taking into consideration the basic geriatric principles of pharmacotherapy: start low and go slow.

Heart failure is a disease of poor prognosis marked by frequent hospitalizations, premature death, and impaired quality of life. Despite advances in medical therapy for patients with heart failure and reduced ejection fraction, mortality and hospitalizations with advanced disease are still increased and the quality of life continues to be poor in this population. The advent of cardiac resynchronization therapy has led to a significant improvement in both survival and symptom management in patients with heart failure and reduced ejection fraction. Its beneficial effects in the elderly population, however, are not well-defined.

Thrombosis complicating the rupture of an atherosclerotic plaque can lead to arterial occlusion. Tissue factor, a membrane-bound glycoprotein, is expressed to a greater extent in atherosclerotic plaques and may be a key mediator of microthrombosis and macrothrombosis. This pilot study was designed to determine whether the angiographic presence or the extent of atherosclerosis was correlated with the activity of coagulation factors in blood. A novel computational model was used to predict whether differences in the activity of coagulation factors would alter the generation of thrombin.

Introduction:Prevalent heart failure (HF) is considered a risk factor for incident stroke. We examined this association in community-dwelling older adults in the Cardiovascular Health Study (CHS).Methods:Of the 5795 CHS participants ?65 years (mean age, 73 years; 58% women; 15% African American), 5448 were free of baseline stroke/transient ischemic attack, of whom 229 had baseline HF. Incident stroke was centrally adjudicated and occurred in 1049 patients. Cox regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for incident stroke associated with HF.Results:Stroke incidence rates were similar at 23 years (18.8% for HF and 19.3% for non-HF), but not at 5 years (11.4% for HF and 5.4% for non-HF). Age-sex-race-adjusted HR (95% CI) for 23-year stroke was 1.65 (1.21-2.25; p=0.001; Figure). HRs (95% CIs) for 23-year stroke risk, after added adjustments for 4 cardiovascular (CVD: hypertension, diabetes mellitus, acute myocardial infarction, atrial fibrillation), 10 non-CVD (including tobacco and physical activity), and all 14 risk factors were 1.27 (0.92-1.74; p=0.14), 1.48 (1.08-2.02; p=0.01) and 1.17 (0.85-1.61; p=0.33), respectively.Conclusion:The proportion of community-dwelling older adults who had a new stroke over 23 years was similar for HF and non-HF, though they seem to occur earlier in those with HF. The relative risk of stroke was higher in those with HF, which was mostly explained by 4 baseline CVD, but not by modifiable risk factors. These findings suggest that HF and stroke share similar risk factors and highlight the importance of primary prevention of CVD for both conditions.

Introduction:Heart failure (HF) and breast cancer are highly prevalent and are two of the leading causes of death in postmenopausal women. Few studies to date have examined the impact of HF and breast cancer on outcomes in postmenopausal women.Objectives:We seek to examine the impact of incident breast cancer and incident HF on survival in patients with background prevalent HF and breast cancer, respectively.Methods:We studied postmenopausal women within the 40 participating centers of the Women?s Health Initiative (WHI) who were enrolled between 1993 and 1998. All incident hospitalized HF, breast cancer, and survival outcomes were centrally adjudicated through 2017. Cox proportional hazards model adjusting for age was performed.Results:Among a cohort of 44,174 (mean age: 63?7 years) within the 161,808 women in the WHI, 2,688 participants developed incident breast cancer (of which 2,188 were invasive) and 2,417 developed incident HF (median follow-up: 14 years and 15 years, respectively). Prognosis of incident HF was worse than that of incident invasive breast cancer (median survival: 5.3 and 18.5 years, respectively). In patients with incident invasive breast cancer, prevalent HF was associated with an increased risk of all-cause mortality [adjusted hazard ratio (HR) 2.32; 95% CI 1.34-4.02]. In patients with incident HF, prevalent breast cancer was associated with an increased risk of all-cause mortality (adjusted HR 1.66; 95% CI 1.03-2.68).Conclusions:Among a large cohort of postmenopausal women, the presence of incident invasive breast cancer or incident HF in those with prevalent HF or prevalent breast cancer, respectively, was associated with an increased risk of all-cause mortality. Importantly, mortality after incident HF was much higher compared with mortality after incident invasive breast cancer.

Introduction:Heart failure (HF) and breast cancer are two of the leading causes of death in postmenopausal women. The temporal association between HF and breast cancer in a cohort of postmenopausal women has not been described.Objectives:We seek to examine the temporal association between HF and breast cancer incidencesMethods:We studied postmenopausal women within the 40 participating centers of the Women?s Health Initiative (WHI) who were enrolled between 1993 and 1998. All incident hospitalized HF and breast cancer outcomes were centrally adjudicated through 2017. The associations between prevalent HF and incident breast cancer and prevalent breast cancer and incident HF were determined using the Kaplan Meier estimate and Cox proportional hazards model.Results:Among a cohort of 44,174 (mean age, 63?7 years) within the 161,808 women in the WHI, 2,688 participants developed incident breast cancer (of which 2,188 were invasive) and 2,417 developed incident HF (median follow-up 14 years and 15 years, respectively). When compared to a breast cancer- and HF-free cohort, there was no association between prevalent HF and incident breast cancer (p=0.98) or incident invasive breast cancer (p=0.27). Similarly, there was no association between prevalent breast cancer and incident HF (p=0.46). Shared risk factors for breast cancer and HF include age, obesity, alcohol use, physical inactivity, and elevated resting heart rate.Conclusions:Among a large cohort of post-menopausal women, prevalent HF was not associated with a higher incidence of breast cancer and similarly, prevalent breast cancer was not associated with a higher incidence of incident HF. The lack of association suggests a distinct pathophysiology that defines each condition.