Clinical characteristics were compared between hypertensive patients with and without heart failure in the absence of reduced ejection fraction (EF) to gain insights into the effects of renal insufficiency on the prevalence of diastolic heart failure. Study subjects consisted of 691 hypertensive patients with an EF>40%. Patients with serum creatinine >2.5 mg/dL were excluded from the study. The Framingham heart failure criteria were met by 198 patients, and competing risks of the prevalence of heart failure were analyzed. The multiple logistic regression analysis revealed that obesity, female gender, creatinine clearance (CCr), and a ratio of transmitral E velocity to early diastolic mitral annular velocity (E/ E')>15 were independently associated with the prevalence of heart failure with preserved EF. Patients with 60< or =CCr<90 mL/min represented higher E/E' ratio and lower E' velocity than the patients with CCr> or =90 mL/min, although there was no difference in the prevalence of heart failure between the two groups. These indices were not different between the patients with 60< or =CCr<90 mL/min and CCr<60 mL/min, although the prevalence of heart failure was higher in the patients with CCr<60 mL/min. The hemoglobin concentration was significantly decreased and the brachial-ankle pulse wave velocity was significantly elevated in patients with CCr<60 mL/min. Thus, progressive left ventricular diastolic dysfunction and renal insufficiency are competing risks of the prevalence of diastolic heart failure in hypertensive patients. Renal insufficiency may exert its effects through the modulation of extracardiac factors such as anemia and arterial stiffening rather than through the promotion of diastolic dysfunction.