Abstract Body: Introduction:
Hypertension (HTN) is a cmorbidity and a contributor to both systolic and diastolic heart failure (HF). However, limited research exists comparing HTN outcome in patient with systolic versus diastolic HF.

Hypothesis:
This study aims to compare the impact of HTN on cardiovascular (CV) outcomes in patients with systolic HF versus those with diastolic HF.

Methods:
This retrospective cohort study utilized the Trinetx to analyze data from patients aged ≥18 between January 2007-May 2025. Cohort 1: patients with systolic HF and HTN, Cohort 2: patients with diastolic HF and HTN. Propensity matching was employed to balance demographics, comorbidities, and medications between the two cohorts, each containing 914,494 patients. The mean age at diagnosis was 70 years, with 54% males, 41% females, and the remaining having an unknown gender. The primary outcomes were all-cause mortality, HF events, atrial fibrillation/flutter (AF), ventricular tachycardia (VT), and ventricular fibrillation (VF). Risk ratios (RR), hazard ratios (HR), confidence intervals (CI), and p-values were used to assess the relationships between heart conditions and outcomes.

Results:
Cohort 1 (systolic HF and HTN) had a higher all-cause mortality rate (29.36%) compared to Cohort 2 (27.36%), with a RR of 1.073 (95% CI: 1.068–1.078), p < 0.0001, and HR of 1.109 (95% CI: 1.103–1.115), p < 0.0001. Regarding HF events, Cohort 1 had a higher incidence (79.78%) than Cohort 2 (74.71%), with a RR of 1.068 (95% CI: 1.066–1.070), p < 0.0001, and HR of 1.228 (95% CI: 1.224–1.232), p < 0.0001. AF was observed in 45.05% of Cohort 1 and 43.22% of Cohort 2, with a RR of 1.042 (95% CI: 1.039–1.046), p < 0.0001, and HR for AF of 1.085 (95% CI: 1.08–1.09), p < 0.0001. VT occurred in 13.18% of Cohort 1 compared to 7.93% in Cohort 2, with a RR of 1.663 (95% CI: 1.649–1.678), and HR for VT of 1.785 (95% CI: 1.769–1.802), p < 0.0001. Lastly, VF occurred in 2.47% of Cohort 1 and 1.23% of Cohort 2, with a RR of 2.013 (95% CI: 1.968–2.059), and HR for VF of 2.084 (95% CI: 2.037–2.132), p < 0.0001.

Conclusion:
This study shows that patients with systolic HF and HTN face significantly higher risks of all-cause mortality, CV mortality, and CV events, including future HF, VT, and VF, compared to those with diastolic HF and HTN. These results are consistent with the understanding that systolic HF is associated with reduced ejection fraction and impaired myocardial viability, leading to greater afterload stress.