48-hour BPRI trajectories and 28-day mortality in vasoactive-supported hypertensive heart disease with heart failure

Hypertensive heart disease (HHD) complicated by heart failure is associated with high mortality in intensive care units. The Blood Pressure Response Index (BPRI), the ratio of mean arterial pressure to vasoactive-inotropic score, integrates hemodynamic targets and treatment intensity, yet the prognostic value of its dynamic trajectories in this population remains unclear. This retrospective cohort study used MIMIC-IV v3.1 as the development cohort and eICU-CRD v2.0 as an independent replication cohort for trajectory patterns and trajectory–outcome associations. We included critically ill adults with a primary discharge code for hypertensive heart disease with heart failure who received vasoactive support during the first 48 h after ICU admission. Log-transformed BPRI values per 4-h window over 48 h were analyzed via group-based trajectory modeling. The primary outcome was 28-day all-cause mortality, assessed with multivariable Cox regression, logistic regression, and restricted cubic spline analysis. 1,078 patients from MIMIC-IV and 260 from eICU-CRD were analyzed. Five distinct BPRI trajectories were identified in both cohorts. The Persistently low BPRI group had the highest 28-day mortality (37.58% in MIMIC-IV; 37.21% in eICU-CRD). The fully adjusted hazard ratio for this high-risk group was 3.01 (95% CI 1.71–5.30) in the MIMIC-IV cohort, and the corresponding adjusted odds ratio was 2.37 (95% CI 1.13–4.56) in the eICU-CRD replication cohort. The 48-h mean log-BPRI showed a near-linear inverse association with mortality, with no significant subgroup interactions. In incremental predictive analyses, the 48-h BPRI trajectory model showed the highest apparent and optimism-corrected discrimination among the evaluated models. Among vasoactive-supported critically ill patients with discharge-coded hypertensive heart disease and heart failure, persistently low BPRI was associated with higher 28-day mortality.