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Hypertensive Heart Failure with Preserved Ejection Fraction: Guidelines vs. Randomized Controlled Trials Evidence
Georgios Mavraganis1,2, Christos Fragoulis1, Georgios Georgiopoulos2
1First Cardiology Clinic, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece.
Medicina (Kaunas, Lithuania)
|July 28, 2026
Summary
Hypertension significantly contributes to heart failure with preserved ejection fraction (HFpEF). While sodium-glucose co-transporter 2 inhibitors (SGLT2i) show promise in reducing HF events, dedicated trials and optimized blood pressure management are needed for hypertensive HFpEF patients.
Area of Science:
- Cardiology and Cardiovascular Research
- Hypertension and Heart Failure Pathophysiology
- Pharmacological Interventions in Cardiovascular Disease
Background:
- Hypertension is a critical modifiable risk factor for heart failure with preserved ejection fraction (HFpEF) development and progression.
- Current guideline-directed blood pressure targets and therapies like sodium-glucose co-transporter 2 inhibitors (SGLT2i) lack dedicated randomized controlled trials (RCTs) specifically for the HFpEF population.
Purpose of the Study:
- To synthesize current evidence on hypertension management in HFpEF, addressing pathophysiological links, therapeutic efficacy, and evidence gaps.
- To discuss the role of SGLT2 inhibitors and blood pressure targets in hypertensive HFpEF patients.
- To advocate for future research and precision medicine approaches for optimized patient-centered care.
Main Methods:
- Narrative review synthesizing recent meta-analyses (ESC/ESH 2024, JSH 2025) and landmark trial post hoc analyses (EMPEROR-Preserved, DELIVER).
- Discussion of pathophysiological frameworks, biomarker utility (sST2, NT-proBNP), and device therapy data (renal denervation).
- Analysis of real-world implementation barriers and Hellenic HF Registry data on frailty.
Main Results:
- SGLT2 inhibitors demonstrated consistent heart failure event reductions (pooled HR 0.79) with modest systolic blood pressure lowering (-2.3 mmHg).
- Biomarkers like sST2 and NT-proBNP aid risk stratification but are not specific to hypertension-mediated remodeling.
- Significant evidence gaps exist regarding optimal BP thresholds, device therapies, and real-world adherence in elderly/comorbid populations.
Conclusions:
- Dedicated RCTs are crucial to evaluate intensive versus standard BP targets and SGLT2i sequencing in hypertensive HFpEF.
- Precision medicine approaches, including phenomapping and multi-biomarker panels, can address phenotype-specific challenges.
- European real-world registries are needed to bridge the translational gap and optimize care for the growing hypertensive HFpEF population.
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