Neutrophil to high-density lipoprotein cholesterol ratio is positively associated with congestive heart failure among hypertensive adults: a population-based study

Background Congestive heart failure (CHF) continues to pose a substantial global health issue. The neutrophil-to-high-density lipoprotein cholesterol ratio (NHR), a novel biomarker reflecting systemic inflammatory balance, has been linked to cardiovascular outcomes, yet its relationship with CHF in hypertensive individuals is unclear. Methods A cross-sectional investigation was adopted using data obtained from the National Health and Nutrition Examination Survey (NHANES) spanning the years 1999 to 2018. Weighted multivariate logistic regression was used to evaluate the independent correlation between NHR and CHF. Weighted restricted cubic spline (RCS) curves were applied to explore possible nonlinearities in the overall population and across subgroups. Weighted stratified comparison and interaction tests were executed for robustness. Mediation analysis assessed potential intermediaries. Seven machine learning (ML) models were developed to forecast CHF probability, with performance measured by Receiver Operating Characteristic (ROC) analysis, among others. Results A total of 19,820 individuals with hypertension were included. Elevated NHR was correlated with higher CHF prevalence. After full adjustment, NHR remained independently associated with CHF (odds ratio [OR] = 1.15, 95% confidence interval [CI]: 1.10–1.21). Individuals in the highest quartile of NHR exhibited a 69% increased prevalence (OR = 1.69, 95% CI: 1.34–2.13) of CHF when benchmarked against the lowest quartile. Weighted subgroup analyses showed consistent associations without significant interactions. Mediation analysis indicated serum albumin mediated 4.18% of the NHR-CHF association. Among ML models, Extreme Gradient Boosting (XGBoost) showed the optimal predictive efficacy [validation set Area Under the Curve (AUC) = 0.781, 95% CI: 0.758–0.803]. Conclusions Among hypertensive adults, NHR was independently associated with CHF prevalence. These findings suggest that NHR may be a relevant inflammatory marker in this population. However, the findings should be interpreted cautiously because of the cross-sectional design and the reliance on self-reported CHF.