The impact of baseline systolic blood pressure (SBP) on outcomes in patients with advanced chronic systolic heart failure (HF) has not been studied using a propensity-matched design. Of the 2,706 participants in the Beta-Blocker Evaluation of Survival Trial (BEST) with chronic HF, New York Heart Association class III to IV symptoms and left ventricular ejection fraction ≤35%, 1,751 had SBP ≤120 mm Hg (median 108, range 70 to 120) and 955 had SBP >120 mm Hg (median 134, range 121 to 192). Propensity scores for SBP >120 mm Hg, calculated for each patient, were used to assemble a matched cohort of 545 pairs of patients with SBPs ≤120 and >120 mm Hg who were balanced in 65 baseline characteristics. Matched Cox regression models were used to estimate associations between SBP ≤120 mm Hg and outcomes over 4 years of follow-up. Matched participants had a mean age ± SD of 62 ± 12 years, 24% were women, and 24% were African-American. HF hospitalization occurred in 38% and 32% of patients with SBPs ≤120 and >120 mm Hg, respectively (hazard ratio 1.33 SBP ≤120 was compared to >120 mm Hg, 95% confidence interval 1.04 to 1.69, p = 0.023). All-cause mortality occurred in 28% and 30% of matched patients with SBPs ≤120 and >120 mm Hg, respectively (hazard ratio 1.13 SBP ≤120 compared to >120 mm Hg, 95% confidence interval 0.86 to 1.49, p = 0.369). In conclusion, in patients with advanced chronic systolic HF, baseline SBP ≤120 mm Hg is associated with increased risk of HF hospitalization, but had no association with all-cause mortality. © 2010 Elsevier Inc. All rights reserved.