Belkin MN, Blair JE, Shah SJ, et al. - The TOPCAT Trial Score (TS) can help determine the likelihood of benefit from spironolactone in heart failure patients with preserved ejection fraction (HFpEF).

• A post-hoc analysis of the TOPCAT trial showed benefit of spironolactone in HFpEF patients from the Americas, but not Eastern Europe.

• The TOPCAT individual-level data were used to calculate a TS.

• A bimodal distribution of TS segregated American (n = 1766) and Eastern European (n = 1,677) participants.

• No significant response to spironolactone was seen in the presence of lower TS.

• Spironolactone's benefit increased with rising TS.

• In significantly more American participants, spironolactone’s benefit was evident based on higher TS (> 1.14), besides a higher probability of HFpEF based on higher H2 FPEF scores (≥3).

• Relative to American TOPCAT participants, even higher TS was present in real-world HFpEF patients.