Systolic blood pressure lower than 130 mmHg in heart failure with preserved ejection fraction: a systematic review and meta-analysis of clinical outcomes

The optimal blood pressure (BP) management level for patients with heart failure (HF) with preserved ejection fraction (HFpEF) remains unclear. In conjunction with the upcoming the Japanese Society of Hypertension Guidelines for the Management of Hypertension 2025 (JSH2025), we conducted a systematic review and meta-analysis to evaluate whether managing systolic BP (SBP) < 130 mmHg improves outcomes in HFpEF patients. We searched PubMed, Cochrane and Ichishi for randomized controlled trials (RCTs) published since 2012 that targeted HFpEF patients; used strict BP control, antihypertensive medications, or intensive HF management as interventions; demonstrated significant BP reduction with achieved SBP < 130 mmHg in intervention groups; and had follow-up periods ≥6 months. Six studies were included, evaluating mineralocorticoid receptor antagonists (n = 2), angiotensin receptor-neprilysin inhibitors (n = 2), intensive BP control (n = 1), and intensive HF management (n = 1). Meta-analysis showed that achieving SBP < 130 mmHg significantly reduced HF hospitalizations (relative risk RR 95% confidence interval (CI) 0.80 0.69-0.93, p = 0.005) and demonstrated a trend toward reduced all-cause mortality (RR 95% CI 0.74 0.53-1.04, p = 0.083). While hypotension increased (RR 95% CI 1.35 1.03-1.79, p = 0.03), there was no significant increase in renal dysfunction or serious adverse events. Despite limitations from indirectness (no RCTs specifically targeted SBP < 130 mmHg as primary intervention), our findings suggest that achieving SBP < 130 mmHg in HFpEF patients may improve clinical outcomes. We recommend managing HFpEF patients to achieve SBP < 130 mmHg, while carefully monitoring for hypotension.