ESC Congress 2026 Abstract · Oct 26, 2026

Time in blood pressure range and cardiovascular outcomes in HFmrEF/HFpEF: a pooled participant-level analysis of four large-scale trials

By Lu H, Claggett BL, Ostrominski JW et al.

Background: Hypertension is prevalent in patients with heart failure with preserved ejection fraction (HFpEF) and blood pressure (BP) control is one of the only Class I recommendations for the management of HFpEF in the latest AHA/ACC/HFSA guidelines; however, evidence supporting specific systolic BP (SBP) targets in patients with HFpEF remains limited. Aim: We investigated the association between BP control and subsequent cardiovascular (CV) outcomes in contemporary trials including patients with HF with mildly reduced EF (HFmrEF)/HFpEF. Methods: TOPCAT-Americas, PARAGON-HF, DELIVER, and FINEARTS-HF were randomized clinical trials testing spironolactone, sacubitril/valsartan, dapagliflozin, and finerenone, respectively, versus placebo or an active control (valsartan in PARAGON-HF), in patients with HF and a LVEF >40% (DELIVER), ≥40% (FINEARTS-HF), or ≥45% (TOPCAT-Americas, PARAGON-HF). For each participant, daily BPs were estimated by interpolation from standardized office measurements obtained at prespecified study visits: randomization and 1, 2, 4, 8, and 12 months (TOPCAT-Americas); randomization and 1, 4, 8, and 12 months (PARAGON-HF); randomization and 1 and 12 months (DELIVER); and randomization and 1, 3, 6, 9, and 12 months (FINEARTS-HF). The percentage of time spent within the target SBP range (110–<130mmHg) during the first year after randomization was then estimated. The continuous association between individual-level time-in-target range (TIR) during the first year post-randomization and subsequent risk of the primary outcome of first HF hospitalization (HFH) or CV death, its individual components, and all-cause death was assessed using landmark Cox proportional hazards models with linear splines, adjusted for baseline CV risk factors. Results: Among 18,823 patients (mean age 72±9 years; 47% men; mean baseline SBP 129±15 mmHg), the mean percentage of TIR during the first year was 42%, corresponding to ≈153 days. Randomization to active therapies increased the percentage of TIR across trials, by 3% (95%CI −1 to 7%) with spironolactone, 7% (5 to 9%) with sacubitril/valsartan, 2% (0 to 4%) with dapagliflozin, and 4% (2 to 5%) with finerenone. There was a significant association between higher percentage of TIR and lower subsequent risk of the composite outcome (P=0.021). This association was primarily driven by a lower risk of HFH (P=0.007), whereas no significant associations were observed with CV death or all-cause death. Sensitivity analyses applying a stricter range (120-130mmHg) and more liberal ranges (100-130mmHg, 120-140mmHg) produced qualitatively similar findings. TIR accounted for only a limited proportion of mediation of the treatment effects of spironolactone, dapagliflozin, and finerenone on the composite outcome (all less than 5%). Conclusions: In patients with HFmrEF/HFpEF, BP control during the first year was associated with a lower subsequent risk of HFH, supporting current guideline recommendations.

doi.org/10.1093/eurheartj/ehag785.1095 Open access Interventions