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Meta-Analysis
. 2025 Aug;48(8):2138-2151.
doi: 10.1038/s41440-025-02240-w. Epub 2025 May 23.

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

Chisa Matsumoto  1   2 , Michiaki Nagai  3   4 , Keisuke Shinohara  5 , Nagisa Morikawa  6   7 , Hisashi Kai  8 , Hisatomi Arima  9
Affiliations
Meta-Analysis

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

Chisa Matsumoto et al. Hypertens Res. 2025 Aug.

Abstract

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.

Keywords: HFpEF; JSH2025; meta-analysis; optimal blood pressure control.

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Conflict of interest statement

Compliance with ethical standards. Conflict of interest: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Flow chart of literature search of this study
Fig. 2
Fig. 2
A1. Forest plot of all-cause mortality, Fig. 2 A2. Funnel plot of all-cause mortality. B1. Forest plot of CVD mortality, Fig. 2 B2. Funnel plot of CVD mortality. C1. Forest plot of CVD, Fig. 2 C2. Funnel plot of CVD. D1. Forest plot of HF Hospitalization, Fig. 2 D2. Funnel plot of HF Hospitalization. E1. Forest plot of renal dysfunction, Fig. 2 E2. Funnel plot of renal dysfunction. F1. Forest plot of hypotension, Fig. 2 F2. Funnel plot of hypotension. G1. Forest plot of SAEs, Fig. 2 G2. Funnel plot of SAEs
Fig. 2
Fig. 2
A1. Forest plot of all-cause mortality, Fig. 2 A2. Funnel plot of all-cause mortality. B1. Forest plot of CVD mortality, Fig. 2 B2. Funnel plot of CVD mortality. C1. Forest plot of CVD, Fig. 2 C2. Funnel plot of CVD. D1. Forest plot of HF Hospitalization, Fig. 2 D2. Funnel plot of HF Hospitalization. E1. Forest plot of renal dysfunction, Fig. 2 E2. Funnel plot of renal dysfunction. F1. Forest plot of hypotension, Fig. 2 F2. Funnel plot of hypotension. G1. Forest plot of SAEs, Fig. 2 G2. Funnel plot of SAEs
Fig. 3
Fig. 3
Meta regression model of all-cause mortality by achieved SBP in the intervention group and the change in SBP from baseline in the intervention group
See this image and copyright information in PMC

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