Blood Pressure Paradox: Hypertension Associated with Survival in T2D and HF


Patients with comorbid T2D and heart failure may have a "distinct pathophysiology of the heart" say authors of a new study.

In some patients with type 2 diabetes (T2D) and acute heart failure, hypertension may be associated with decreased mortality but increased risk of hospitalization for heart failure, according to results from the Gulf-CARE (Gulf aCute heart failure rEgistry) study presented at the American College of Cardiology 66th Annual Scientific Session & Expo on March 17, 2017.1

“Current guidelines for patients with type 2 diabetes suggest that systolic blood pressure should be lower than 140 mmHg, and lower than 130 mmHg in some individuals. However, patients with both type 2 diabetes and acute heart failure have a distinct pathophysiology of the heart and may benefit from different guidelines,” lead author Charbel Abi Khalil, MD, PhD, said in a press release. Dr Khalil is assistant professor of medicine and genetic medicine at Weill Cornell Medicine and cardiology consultant at the heart hospital, Hamad Medical Corporation in Doha, Qatar.

The results are reminiscent of the “obesity paradox,” in which high body mass index-normally associated with worse health outcomes-has been associated with improved survival in patients with T2D and heart failure.

“We could be looking at a 'blood pressure paradox' if our findings are confirmed by future studies,” Dr Abi Khalil added.

While patients with T2D are not thought to benefit from tight blood pressure control, the optimal systolic blood pressure for patients with T2D remains unknown.

To evaluate the issue, researchers analyzed data from the Gulf-CARE registry for 2492 patients with T2D hospitalized for acute heart failure in seven Middle Eastern countries. They separated patients into the following categories based on systolic blood pressure recorded at discharge:

  < 120 mmHg (low blood pressure)

  120-129 mmHg (normal)

  130-149 mmHg (moderate)

  > 150 mmHg (high)

Then they evaluated mortality and hospitalizations for heart failure over the following year.   

Key results

Low BP: No increased risk of mortality (OR 1.11 [0.75-1.65]; p=0.61), or hospitalizations for heart failure (OR 1.2, [0.81-1.78], p=0.36), compared to normal blood pressure

Moderately elevated BP: Similar mortality risk as normal blood pressure

High BP: Significantly lower mortality risk (OR 0.55, [0.37-0.82], p=0.003)

  • Counteracted by increased heart failure hospitalizations (OR 1.53, 95% CI [1.07-2.21], p=0.02)

Among patients with high blood pressure, mortality remained significantly decreased (OR 0.67, 95% CI [0.47-0.97], p=0.04) and heart failure hospitalizations remained significantly increased (OR 1.51, 95% CI [1.02-2.25], p=0.04) in analyses adjusted for age, gender, smoking, dyslipidemia, left ventricular ejection fraction, heart rate, creatinine and medications at discharge.

Dr Abi Khalil, quoted in a press release, emphasized that further studies, including a randomized controlled trial, are needed to confirm the results, and to provide additional evidence for guidelines about blood pressure management in patients with T2D and acute heart failure.

Take Home Points

  • Prospective, observational study found that patients with T2D, acute heart failure and high blood pressure at discharge had decreased mortality in the following year, though readmissions for heart failure were increased

  • Patients with T2D and acute heart failure had similar mortality risk if they had low, normal, or moderately elevated blood pressure on discharge

  • Results bring up the idea of a “blood pressure” paradox in patients with T2D and heart failure, but more studies are needed 

The study was funded by Servier. Dr Abi Khalil reports funding by the Qatar Foundation, and grants from the Qatar National Research Fund.



Khalil CA, Sulaiman K, Singh R, et al. High blood pressure on discharge from acute decompensated heart failure in patients with type 2 diabetes is associated with decreased 12-month mortality: findings from the  Gulf-Care. Presented at American College of Cardiology 66th Scientific Sessions March 17, 2017. Accessed April 14 2017 at!/4223/presentation/37098

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