Effects of pharmacological blood pressure lowering in heart failure with mildly reduced or preserved ejection fraction: a meta-analysis
In brief
Blood-pressure drugs cut heart-failure death or hospitalization by 14% in HFpEF/mrEF
A meta-analysis of 18 randomized trials involving 39,452 patients with mildly reduced or preserved-ejection-fraction heart failure found that pharmacologic BP lowering reduced the combined risk of cardiovascular death and HF hospitalization by about 14%, driven mainly by SGLT2 inhibitors, MR antagonists, ARNI and GLP-1 agonists. The benefit did not correlate with the amount of BP drop, suggesting effects are drug-specific rather than due solely to lower pressure.
- Journal
- Heart (British Cardiac Society) (Q1)
- Published
- 7 August 2026
- Study design
- Systematic review of cohort studies
- Evidence level
- Level 2, Moderate (CEBM 2a)
- Authors
- Samuel Jay Jackson Pack, Sonia Sawant, Christian Abhayaratna, Nelson Wang
- PMID
- 42571647
- DOI
- 10.1136/heartjnl-2026-327872
Why clinicians should know about it
- Picked for Cardiology and Cardiovascular Medicine (paper of the day, 10 August 2026): Meta‑analysis of BP‑lowering drugs in HFmrEF/HFpEF outcomes
Abstract
BACKGROUND: The role of blood pressure (BP) lowering in patients with heart failure (HF) with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF) remains uncertain, and it is unclear to what extent the existing benefits of therapies are mediated by BP reduction. METHODS AND RESULTS: A systematic review and meta-analysis of randomised clinical trials was conducted, comparing any BP lowering treatment to placebo, usual care or another drug class in patients with HFmrEF/HFpEF. The primary endpoint was a composite of cardiovascular death and HF hospitalisation. Data were pooled using a random effects meta-analysis and meta-regression with inverse variance weighting expressed as a risk ratio (RR) and its 95% CI. 18 studies were identified totalling 39 452 patients. Pharmacological BP lowering led to a significant reduction in the primary composite endpoint (RR 0.86, 95% CI 0.83 to 0.89; p≤0.001), but there were significant differences between drug classes (p value=0.018), with evidence of benefit with sodium-glucose cotransporter 2 inhibitor, mineralocorticoid receptor antagonist, angiotensin-receptor neprilysin inhibitor and glucagon-like peptide-1 receptor agonists but not other drug classes. Meta-regressions found no significant association between the degree of BP reduction and treatment effects (coefficient slope=-0.0125, p=0.304). Similarly, pharmacological BP lowering was associated with a reduction in HF hospitalisations (RR 0.83, 95% CI 0.79 to 0.86; p≤0.001), but treatment effects were not related to degree of BP reduction (coefficient slope=-0.0121, p=0.528). CONCLUSION: In patients with HFmrEF/HFpEF, there was no significant association between pharmacological BP lowering and clinical outcomes, suggesting that BP lowering alone is unlikely to explain all the benefits observed with the use of recently established HF therapies. PROSPERO REGISTRATION NUMBER: CRD42025631539.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.