CONSENSUS DOCUMENTHypertension and heart failure with preserved ejection fraction: position paper by the European Society of HypertensionKasiakogias, Alexandrosa; Rosei, Enrico Agabitib; Camafort, Miguelc; Ehret, Georgd; Faconti, Lucae; Ferreira, João Pedrof,g,h; Brguljan, Janai; Januszewicz, Andrzejj; Kahan, Thomask; Manolis, Athanasiosl; Tsioufis, Konstantinosa; Weber, Thomasm; von Lueder, Thomas G.n; Smiseth, Otto A.o; Wachtell, Kristianp; Kjeldsen, Sverre E.q; Zannad, Faiezf,g,h; Mancia, Giusepper; Kreutz, Reinholds Author Information aFirst Department of Cardiology, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece bDepartment of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy cInternal Medicine Department, ICMID, Hospital Clínic, University of Barcelona, Barcelona, Spain dCardiology, Geneva University Hospitals, Geneva, Switzerland eKing's College London British Heart Foundation Centre, London, UK fUniversité de Lorraine, Centre d’Investigations Cliniques Plurithématique Inserm 1433 gCHRU de Nancy, Inserm U1116 hFCRIN INI-CRCT, Nancy, France iUniversity Medical Centre Ljubljana, Hypertension Department, Medical University Ljubljana, Ljubljana, Slovenia jDepartment of Hypertension, National Institute of Cardiology, Warsaw, Poland kKarolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Stockholm, Sweden lCardiology Department, Asklepeion General Hospital, Athens, Greece mCardiology Department, Klinikum Wels-Grieskirchen, Wels, Austria nØkern Heart Centre oInstitute for Surgical Research and Department of Cardiology, Oslo University Hospital, Rikshospitalet, and University of Oslo pDepartment of Cardiology, Oslo University Hospital qInstitute of Clinical Medicine, Medical Faculty, University of Oslo, and Departments of Cardiology and Nephrology, Oslo University Hospital, Ullevaal, Oslo, Norway rUniversità Milano-Bicocca, Milan; Policlinico di Monza, Monza, Italy sCharité - Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institut für Klinische Pharmakologie und Toxikologie, Berlin, Germany Correspondence to Reinhold Kreutz, Institute of Clinical Pharmacology and Toxicology, Charitéplatz 1, D-10117 Berlin, Germany. Tel: +49 30 450 525 112; e-mail: [email protected] Abbreviations: ABPM, ambulatory blood pressure monitoring; ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor neprilysin inhibitor; BNP, brain natriuretic peptide; BP, blood pressure; CCB, calcium channel blocker; CKD, chronic kidney disease; ESC, European Society of Cardiology; ESH, European Society of Hypertension; FDA, Food and Drug Administration; GDMT, guideline directed medical therapy; HF, heart failure; HFpEF, HF with preserved ejection fraction; HFrEF, HF with reduced ejection fraction; HMOD, hypertension mediated organ damage; HR, hazard ratio; LV, left ventricle, left ventricular; LVEF, left ventricular ejection fraction; LVH, left ventricular hypertrophy; MRA, mineralocorticoid-receptor antagonist; NYHA, New York Heart Association; RAS, Renin-angiotensin system; RCT, randomized controlled trial; RR, rate ratio; SGLT2, sodium-glucose co-transporter-2 Received 3 March, 2021 Revised 27 April, 2021 Accepted 8 May, 2021 Journal of Hypertension: August 2021 - Volume 39 - Issue 8 - p 1522-1545 doi: 10.1097/HJH.0000000000002910 Buy Metrics Abstract Hypertension constitutes a major risk factor for heart failure with preserved ejection fraction (HFpEF). HFpEF is a prevalent clinical syndrome with increased cardiovascular morbidity and mortality. Specific guideline-directed medical therapy (GDMT) for HFpEF is not established due to lack of positive outcome data from randomized controlled trials (RCTs) and limitations of available studies. Although available evidence is limited, control of blood pressure (BP) is widely regarded as central to the prevention and clinical care in HFpEF. Thus, in current guidelines including the 2018 European Society of Cardiology (ESC) and European Society of Hypertension (ESH) Guidelines, blockade of the renin-angiotensin system (RAS) with either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers provides the backbone of BP-lowering therapy in hypertensive patients. Although superiority of RAS blockers has not been clearly shown in dedicated RCTs designed for HFpEF, we propose that this core drug treatment strategy is also applicable for hypertensive patients with HFpEF with the addition of some modifications. The latter apply to the use of spironolactone apart from the treatment of resistant hypertension and the use of the angiotensin receptor neprilysin inhibitor. In addition, novel agents such as sodium-glucose co-transporter-2 inhibitors, currently already indicated for high-risk patients with diabetes to reduce heart failure hospitalizations, and finerenone represent promising therapies and results from ongoing RCTs are eagerly awaited. The development of an effective and practical classification of HFpEF phenotypes and GDMT through dedicated high-quality RCTs are major unmet needs in hypertension research and calls for action. Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.