What should be the target blood pressure in heart failure patients with an implantable cardioverter defibrillator who already had ventricular tachycardia (VT), so as to prevent future VT and death?

We aim to conduct a clinical trial to test whether patients with heart failure who have had sustained VT need lenient or aggressive BP lowering to prevent future VT and death. Patients will either have an existing implantable cardioverter defibrillator or are scheduled to have one immediately as part of their routine clinical care. These patients will be then randomized into 2 arms- aggressive vs. lenient BP reduction. Medications will be adjusted so as to achieve predefined BP targets (systolic BP <120mmHg in aggressive BP reduction arm vs. 120-140mmHg in lenient BP reduction arm). The treatment algorithms for each group have been adapted from the SPRINT trial (NEJM 2015). Patients will be followed up for a minimum of 2 years for the primary outcome of time to recurrent VT or death from any cause. Lenient BP control arm (systolic BP goal 120-140mmHg) treatment decision tree: Screening period (4weeks): • Patient is expected to be on a combination of RAAS inhibitors (ACEI or ARB or ARNI along with an AldA). • Use of beta-blocker is encouraged, but loop/thiazide diuretics are discouraged. The dose of beta-blocker should be maximized. The loop and thiazide diuretic should either be discontinued or maintained when compelling reason in a least permissible stable dose. • At least one screening visit is required at the beginning of the 4-week period. • Expected length of screening visit: 30min. Run-in period (2 weeks): • Dose changes to all medications are discouraged. • Resting blood pressure readings are taken once. • Exercise stress (Treadmill) test is performed • At least one run-in visit is required at the beginning of the 2-week period. • Expected length of run-in visit with stress test: 45min Resting BP will be estimated by averaging weekly home blood pressure recordings for at least 2 weeks and at least one clinic recording during the run-in period. Randomization visit: • Randomization will be performed through a computerized central randomization scheme. • Resting blood pressure readings are taken once to decide treatment modulation. • RAAS-inhibitors dose will be adjusted so as to achieve systolic BP 120-140mmHg. • Expected length of randomization visit: 30min a) If systolic BP is not in 120-140mmHg range at the initial randomization visit, then titrate, remove or add RAAS inhibitor therapy not already in use as appropriate AND see participant monthly until Systolic BP 120-140mmHg if clinically safe to do so or until clinical decision made that therapy should not be changed further. b) If systolic BP is 120-140mmHg at the initial randomization visit, RAAS inhibitors are continued as it is, if clinically safe to do so, and patient is transitioned straight to the 3 month follow-up visits. Follow-up visit: • After systolic BP has been achieved to 120-140mmHg as above, patient will be followed 3- monthly to monitor Systolic BP 120-140mmHg at each visit. • Expected length of each follow-up visit: 30min a) Continue therapy, unless side effects warrant change in therapy. b) If systolic BP is not in 120-140mmHg titrate, remove or add RAAS inhibitor therapy not already in use as appropriate, if clinically safe to do so. c) Monitor every 3-months through follow-up for 2 years. Each component of the intervention will be administered by the research nurse in consultation with the cardiologist. Adherence to the treatment will be monitored prospectively throughout the trial by patient interview at each study visit, or contacting their pharmacy when compliance is considered doubtful.