Aims To examine the clinical effectiveness of angiotensin receptor blockers (ARBs) in older patients with heart failure and preserved ejection fraction (HF-PEF).Methods and results Of the 10 570 hospitalized HF-PEF patients, aged ≤65 years, EF ≥40%, in OPTIMIZE-HF (20032004), linked to Medicare data (up to 31 December 2008), 3806 were not receiving angiotensin-converting enzyme inhibitors or prior ARB therapy. Of these, 303 (8%) patients received new discharge prescriptions for ARBs. Propensity scores for the receipt of ARBs, estimated for each of the 3806 patients, were used to assemble a cohort of 296 pairs of patients receiving and not receiving ARBs, who were balanced on 114 baseline characteristics. Patients had a mean age of 80 years, mean EF of 55%, 69% were women, and 12% were African American. During 6 years of follow-up, the primary composite endpoint of all-cause mortality or HF hospitalization occurred in 79% (235/296) and 81% (241/296) of patients receiving and not receiving ARBs, respectively [hazard ratio (HR) associated with ARB use 0.88, 95% confidence interval (CI) 0.74-1.06; P=0.179]. ARB use had no association with individual endpoints of all-cause mortality (HR 0.93, 95% CI 0.76-1.14; P=0.509), HF hospitalization (HR 0.90, 95% CI, 0.72-1.14; P=0.389), or all-cause hospitalization (HR 0.91, 95% CI 0.77-1.08; P=0.265). These associations remained unchanged when we compared any (prevalent and new prescriptions) ARB use vs. non-use in a separately assembled propensity-matched cohort of 1137 pairs of HF-PEF patients.ConclusionsIn real-world older HF-PEF patients, ARB use was not associated with improved clinical outcomes. © 2012 The Author.