History of hypertension is associated with improved survival in patients with nonischemic etiology of heart failure and reduced ejection fraction.

Background

Hypertension (HTN) is a common comorbidity in patients with heart failure with reduced ejection fraction (HFrEF), yet its prognostic significance remains complex.

Objective

To evaluate the association between HTN and all-cause mortality in patients with HFrEF, stratified by ischemic and nonischemic etiologies.

Methods

This retrospective cohort study included 11 242 patients with HFrEF treated between January 2009 and October 2025 at a national tertiary referral center. Patients were categorized according to ischemic vs. nonischemic etiology. The primary outcome was all-cause mortality. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox proportional hazards models, with multivariable adjustment for baseline characteristics.

Results

HTN was present in 6992 patients (62%), and 6963 (63%) had ischemic heart disease (IHD). During a median follow-up of 5.0 years, 4952 patients (44%) died. Crude mortality was higher among hypertensive patients (46% vs. 41%, P < 0.001). In univariate analysis, HTN was associated with increased mortality risk (HR 1.24, 95% CI 1.17-1.30, P < 0.001). However, after multivariable adjustment, HTN was associated with a reduction in mortality (HR 0.92, 95% CI 0.87-0.97, P = 0.004). Stratified analysis demonstrated that this protective association was confined to patients without IHD (HR 0.84, 95% CI 0.77-0.92, P < 0.001), while no significant association was observed in those with IHD (HR 0.99, 95% CI 0.92-1.06).

Conclusion

In patients with HFrEF, HTN is associated with reduced mortality only in those with nonischemic etiology.