Patients with heart failure with preserved ejection fraction (HFpEF) frequently exhibit widened pulse pressure (PP) and increased arterial stiffness, associated with impaired ventricular–arterial interaction and reduced functional capacity. Elevated PP has been associated with adverse outcomes in HFpEF, yet pharmacologic strategies have shown limited efficacy in modifying this hemodynamic feature. Blood pressure–adaptive atrial pacing (BPAP) dynamically adjusts atrial pacing rate in response to blood pressure measurements and has been shown to modify hemodynamics in drug-resistant hypertension and HFpEF. ,, In the randomized crossover RelieveHFpEF-II study, PP emerged as a responsive hemodynamic signal. We report the effects of BPAP on PP, diastolic blood pressure (DBP), and mean arterial pressure (MAP) in hypertensive HFpEF.
RelieveHFpEF-II was a prospective, double-blind, randomized crossover study enrolling 16 patients with hypertensive HFpEF (left ventricular ejection fraction ≥50%) and chronically implanted dual-chamber pacemakers. After a 7-day baseline period, participants underwent 3 weeks each of standard bradycardia pacing (STD) and BPAP in randomized sequence. During BPAP, a home-based tablet system transmitted twice-daily cuff BP measurements to a prespecified algorithm that adjusted atrial pacing rate upward or downward based on the difference between measured and target SBP; during STD, measurements were obtained identically without rate adjustment to preserve blinding. Twenty-four-hour ambulatory blood pressure monitoring (24hr ABPM) was performed at baseline and at the end of each treatment phase. prespecified outcomes were analyzed per the primary study’s within-group linear mixed model, accounting for learning and carryover effects. New hemodynamic analyses used paired comparisons of per-patient arm means.
Hemodynamic and functional outcomes are shown in Table 1 . Mean heart rate was higher during BPAP than STD (83.8 ± 8.3 vs 72.9 ± 12.0 bpm; p < 0.0001). Twice-daily readings demonstrated PP narrowing during BPAP (−3.19 mm Hg) and widening during STD (+3.89 mm Hg) (p = 0.0448), with arm-level PP of 51.3 ± 7.7 mm Hg (BPAP) versus 54.9 ± 9.1 mm Hg (STD) (p = 0.030). DBP increased during BPAP (86.6 ± 10.6 vs 83.7 ± 7.6 mm Hg; p = 0.041), with no change in SBP (137.5 ± 14.9 vs 138.6 ± 14.0 mm Hg; p = 0.68) or MAP (104.1 ± 9.5 vs 102.0 ± 7.2 mm Hg; p = 0.11). Findings were consistent on 24hr ABPM: PP narrowed by 4.2 mm Hg with BPAP versus a widening of 6.77 mm Hg with STD (p = 0.0254), driven by a rise in DBP (80.16 ± 9.3 vs 74.68 ± 9.98 mm Hg), while SBP and MAP remained unchanged. No adverse events occurred in either arm.
Table 1
Hemodynamic and functional responses to BPAP vs standard pacing
| Measure | BPAP | STD | p value |
|---|---|---|---|
| Twice-daily home blood pressure | |||
| Systolic BP (mm Hg) | 137.5 ± 14.9 | 138.6 ± 14.0 | 0.68 |
| Diastolic BP (mm Hg) | 86.6 ± 10.6 | 83.7 ± 7.6 | 0.041 |
| Mean Arterial Pressure (mm Hg) | 104.1 ± 9.5 | 102.0 ± 7.2 | 0.11 |
| Pulse Pressure, absolute (mm Hg) | 51.3 ± 7.7 | 54.9 ± 9.1 | 0.030 |
| Pulse Pressure, Δ baseline (mm Hg) | −3.19 | +3.89 | 0.0448 |
| 24-hour ambulatory blood pressure monitoring | |||
| Systolic BP (mm Hg) | 131.7 ± 15.4 | 131.5 ± 15.4 | 0.98 |
| Diastolic BP (mm Hg) | 80.16 ± 9.3 | 74.68 ± 9.98 | 0.024 |
| Mean Arterial Pressure (mm Hg) | 99.2 ± 9.3 | 96.6 ± 7.3 | 0.32 |
| Pulse Pressure, Δ baseline (mm Hg) | −4.2 | +6.77 | 0.0254 |
| Functional outcomes | |||
| 6-Minute Walk Distance (m) | +35.8 ± 29.9 | +8.2 ± 40.1 | 0.003 |
| Treadmill Duration (s) | +83.2 ± 55.6 | +70.8 ± 84.4 | 0.005 |
| MLWHF Score | −15% | +3% | 0.0288 |
| NYHA Class Improvement | 55.6% | 11% | 0.0455 |
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