Heart failure and uncontrolled hypertension: recent evidence of routine care in Germany

Background Hypertension (HTN) is the leading global cause of premature mortality and a major risk factor for renal and cardiovascular disease, including heart failure (HF). 6 Achieving guideline blood pressure (BP) targets yields meaningful benefits: lowering systolic BP by 10 mmHg reduces the risk of heart failure by 27% and cardiovascular mortality by 13%. 7 As contemporary real-world data from Germany are scarce, the MapHTN study leverages electronic medical records (EMR) to characterize patients with controlled (cHTN), uncontrolled (uHTN), and resistant hypertension (rHTN) in routine care, including patients with key comorbidities such as HF. Methods We performed a retrospective secondary analysis of EMR data from general practitioners, cardiologists, and internists across Germany. Adults (≥18 years) with a documented diagnosis of HTN were included. Patients were categorised into cHTN and uHTN cohorts based on their mean documented office BP value, using a target of ≤140/90 mmHg. Within the uHTN cohort, patients receiving ≥3 antihypertensive agents were classified as resistant hypertension (rHTN). Across all three cohorts, blood pressure parameters, medication profiles, and relevant comorbidities -including HF- were assessed annually. Medication exposure was identified via Anatomical Therapeutic Chemical (ATC) codes, and eligible patients were identified using ICD-10-GM codes. Results Of the 663,650 patients with a HTN diagnosis 11.3% (n=74,680) also had a diagnosis of HF. Among these, 30.9% (n=23,084) had evaluable BP measurements and were classified as cHTN (56.9%, 13,135) or uHTN (43.1%, 9,949). In the cHTN cohort, 5,525 (42.1%) and 4,585 (46.1%) in the uHTN cohort received zero or one antihypertensive agent; 2,597 (19,8%) cHTN and 1,670 (16,8%) uHTN patients received two and 5,013 (38.2%) cHTN / 3,694 (37.1%) uHTN patients ≥3 antihypertensive drug classes. The three most prescribed antihypertensive drug classes in the cHTN cohort were beta-blockers (49.8%), diuretics (48.9%) and ACEi/ARB (45.9%), and in the uHTN cohort ACEi/ARB (49.9%), beta-blockers (42.6%) and diuretics (41.2%). Most common combination therapies in cHTN and uHTN were ACEi/ARB + beta-blockers (31.1% and 31.0%, respectively), ACEi/ARB + Diuretics (28.2% and 29.3%, respectively) followed by a triple therapy in cHTN (ACEi/ARB + Diuretics + beta-blockers in 20.2%) and ACEi/ARB + calcium channel blockers in uHTN (25.0%). Conclusion This real-world analysis highlights the high prevalence (nearly half of the population) of uncontrolled and resistant hypertension among patients with concomitant heart failure in Germany. Despite the availability of multiple effective therapies, BP control remains suboptimal. Given the proven benefits of achieving BP targets in this high-risk population, these findings underscore the urgent need for intensified guideline-based management to improve outcomes and reduce cardiovascular events.