Clinical profile and prognosis of hypertensive heart failure: a distinct, yet high-risk acute hf phenotype

Abstract Background Long-standing hypertension is a common contributor to cardiac remodeling and the development of heart failure with preserved ejection fraction (HFpEF). Among patients admitted for acute heart failure (AHF), those with hypertensive heart failure (HHF) may represent a distinct clinical phenotype. Clarifying their characteristics and outcomes is essential for risk stratification and preventive management. Purpose To characterize the clinical, biomarker, and echocardiographic features of HHF in AHF and assess its prognostic implications at 3 and 6 months. Materials-Methods We prospectively included 436 consecutive AHF patients (February 2023–January 2025). HHF was defined as HF occurring in the context of long-standing hypertension with echocardiographic features of hypertensive heart disease (concentric remodeling/hypertrophy) and preserved or mildly reduced LVEF. Clinical variables, admission biomarkers, imaging parameters, and outcomes (mortality and rehospitalization) were compared with those of HF due to other causes. Results HHF was identified in 119 patients (27.3%). Compared with HF of other causes, the HHF group was older (83 vs 79 years, p=0.001), more frequently female (63.9% vs 40.4%, p0.001), and presented with significantly higher systolic blood pressure (160 vs 140 mmHg, p0.001). Atrial fibrillation (AF) was more frequent in HHF, driven mainly by a higher prevalence of chronic AF (46.2% vs 31.9%, p=0.001). HHF patients had preserved ejection fraction, accompanied by a more favorable hemodynamic profile, including lower E/E′ ratio (p=0.001) and higher tricuspid S′ velocity (p=0.02). They also exhibited lower NT-proBNP levels (p0.001), and CRP levels (p0.001), while renal function did not differ. Outcome analyses showed that HHF was associated with lower mortality at 3 and 6 months and reduced 6-month AHF rehospitalization, despite similar in-hospital outcomes. Conclusions Hypertensive heart failure delineates a distinct clinical phenotype within AHF, characterized by older age, higher atrial fibrillation burden, preserved ejection fraction and a more favorable imaging and laboratory profile. However, these patients still face a meaningful burden of adverse events during follow-up, highlighting the need for intensive blood pressure management, optimization of guideline-directed therapy, and systematic post-discharge care. Early identification of HHF supports more focused preventive strategies and individualized management.Demographics and comorbiditesFor image description, please refer to the figure legend and surrounding text. Laboratory and imaging parametersFor image description, please refer to the figure legend and surrounding text.