Does hypertension cause heart failure with preserved ejection fraction (HFpEF) or heart failure with reduced ejection fraction (HFrEF)?

Hypertension Causes Both HFrEF and HFpEF, But Predominantly HFpEF

Hypertension is a major risk factor for both types of heart failure, but it more commonly leads to heart failure with preserved ejection fraction (HFpEF) through chronic pressure overload causing left ventricular hypertrophy and diastolic dysfunction, while it causes HFrEF primarily indirectly through ischemic heart disease and atherosclerosis. 1, 2

Pathophysiologic Mechanisms Differ by HF Type

HFpEF Pathway (More Direct)

• Chronic pressure overload from sustained hypertension causes:
  • Left ventricular hypertrophy
  • Diastolic dysfunction
  • Atrial dysfunction and enlargement
  • Coronary microvascular disease
  • Myocardial fibrosis
  • Endothelial dysfunction 3, 4

Hypertension is the most common comorbidity in HFpEF patients, present in the vast majority of cases 5, 4. The direct mechanical stress from elevated blood pressure on the left ventricle drives structural remodeling that preserves systolic function while impairing diastolic filling.

HFrEF Pathway (More Indirect)

Hypertension causes HFrEF through two main mechanisms 1, 2:

1. Direct pathway: Chronic pressure overload leading to adverse cardiac remodeling and eventual systolic dysfunction
2. Indirect pathway (more common): Accelerated atherosclerosis causing:
   • Ischemic heart disease
   • Myocardial infarction
   • Progressive myocardial damage

The prevalence of hypertension among HFrEF patients continues to rise, though it remains less directly causative than in HFpEF 1.

Clinical Implications

For HFrEF with hypertension: Target SBP <130 mm Hg using guideline-directed medical therapy (GDMT) for heart failure—ARNI/ACEi/ARB, beta-blockers, MRA, and SGLT2i—which simultaneously treats both conditions 1. Add dihydropyridine calcium channel blockers if additional BP control needed; avoid non-dihydropyridine CCBs due to negative inotropic effects 1.

For HFpEF with hypertension: Rigorous BP control is central to prevention and management, though optimal targets remain undefined from dedicated RCTs 3, 5. Use RAS blockers as backbone therapy, with SGLT2i now having Class I evidence for reducing hospitalizations 5, 6.

Important Caveat

One outlier study 7 controversially suggests hypertensive heart disease rarely progresses to either HF type and that cardiovascular consequences are primarily atherosclerotic. However, this contradicts the overwhelming consensus from major guidelines 1, 8 and multiple research studies 2, 3, 5, 4 establishing hypertension as a leading, well-established cause of both HF phenotypes through documented pathophysiologic mechanisms.