Burden of Heart Failure Among Patients with Hypertension: A Systematic Review and Meta-Analysis (2026)

Introduction: Persistent raise of blood pressure brings structural and functional changes in the cardiovascular system, including left ventricular hypertrophy, myocardial fibrosis, vascular remodeling, and impaired cardiac function, ultimately increasing the risk of developing heart failure. Despite advances in antihypertensive therapy and cardiovascular risk reduction strategies, heart failure remains a common complication among patients with hypertension. Therefore, this review is aimed to estimate burden of heart failure among patients with hypertension. 

Methods and Materials: Both manual and electronic searches were used to extract studies for this meta-analysis from PubMed, Google Scholar, Scopus, and Web of Science. The quality of studies was assessed by using the Joanna Briggs Institute (JBI) quality appraisal tool for prevalence. Meta-analysis was carried out using a random-effects method using the STATA™ Version 14 software.

Result: Eighteen studies with a total of 44,249 participants included in this study. Most studies were conducted in Africa regions. From the included studies, the prevalence of heart failure among patients with hypertension ranged from 1.3- 55.6%. The pooled proportion of heart failure with random effect model was found to be 19.21% (95% CI: 14.2-24.2): with the highest prevalence of heart failure 25.7 % (95% CI: 15.4-36.0) was seen in African region and the lowest 6.79 % (95% CI: 2.0-11.5) was seen in Asia region. 

Conclusion: Despite considerable global efforts to reduce the burden of cardiovascular diseases through improved prevention, early diagnosis, and advances in the management of heart failure, the condition remains a major public health challenge. The present meta-analysis found that the pooled prevalence of heart failure among patients with hypertension was significant indicating that nearly one in five individuals in the studied populations is affected. Therefore, strong and context-specific interventions are essential.

Hypertension remains one of the prevalent cardiovascular risk factors worldwide and a leading contributor to morbidity, mortality, and healthcare expenditure [1]. According to global estimates, over one billion adults are affected by hypertension, with the burden continuing to rise [2,3]. The burden of hypertension is increasing, as are disparities between high-income countries and low- and middle-income countries [4].

Persistent raise of blood pressure brings structural and functional changes in the cardiovascular system, including left ventricular hypertrophy, myocardial fibrosis, vascular remodeling, and impaired cardiac function, ultimately increasing the risk of developing heart failure [5]. Heart failure (HF) is a multifaceted clinical syndrome characterized by the inability of the heart to pump sufficient blood to meet the body metabolic demands or to do so only at elevated filling pressures [6]. Patients with HF exert a high health care burden, with a much higher risk of cardiovascular, all‐cause, and non-cardiovascular events, and nearly 4 times as many days spent in hospital [7].

Heart failure represents a major public health challenge due to its high prevalence, poor prognosis, frequent hospitalizations, and substantial economic burden and associated with high mortality, morbidity, poor quality of life and functional capacity [8].

Hypertension is one of the most important modifiable risk factors for heart failure, contributing to heart failure with preserved ejection fraction (HFpEF) and with reduced ejection fraction (HFrEF) [9-11]. Arterial hypertension is the cause of HF in 64% of patients and it is the second leading cause of heart failure through pathologic left ventricular hypertrophy (LVH) and diastolic dysfunction [12-14]. Study also shows that those individuals with hypertension are at a significantly higher risk of developing heart failure compared with normotensive individuals [15,16].

The relationship between hypertension and heart failure is particularly important because hypertension often precedes the onset of symptomatic cardiac dysfunction by several years. Achieving lower blood pressure targets yields significant cardiovascular benefits, particularly in reducing MACE, cardiovascular mortality, stroke, and heart failure [17-20]. Despite advances in antihypertensive therapy and cardiovascular risk reduction strategies, heart failure remains a common complication among patients with hypertension [21].

Different studies have reported varying estimates of the prevalence of heart failure among patients with hypertension in several regions, healthcare settings, and patient demographics. These variations may be attributed to differences in study design, diagnostic criteria, population characteristics, duration and severity of hypertension, and access to healthcare services. Consequently, the true burden of heart failure among individuals with hypertension remains incompletely understood.

A comprehensive synthesis of available evidence is essential to quantify the burden of heart failure in hypertensive patients and to identify potential sources of heterogeneity across studies. Such evidence can support healthcare planning, inform clinical practice, and guide future research efforts aimed at preventing the progression from hypertension to heart failure. Therefore, this systematic review and meta-analysis aim to estimate the pooled burden of heart failure among patients with hypertension.

Objective of the review

To identify the pooled global burden of heart failure among patients with hypertension.

The systematic review and meta-analysis were conducted based on the Preferred Reporting Items for Systematic and Meta-analysis (PRISMA) [22].

Inclusion and exclusion criteria

Those studies which are conducted among adults, globally, cross-sectional observational studies, both published and unpublished studies, and published at any time were included in this study.  Articles were excluded if they were: those studies with no clear report of the outcome, and case reports.

Searching strategy

The search strategy was used to explore all relevant published and unpublished studies on the burden of heart failure among patients with hypertension in the following databases; PubMed, Scopus, web of science, and Google Scholar were searched. The following core search terms or phrases were used; burden, prevalence, proportion, epidemiology, heart failure, congestive heart failure, CHF, hypertension, high blood pressure, hypertensive, hypertensive heart disease and global. MeSH (Medical Subject Headings) and Boolean operators were used to search in the advanced Pub Med search engine.

Study selection criteria

The retrieved articles were exported to the reference manager software, EndNote x8, and removed duplicate studies. All reviewers screened the title and abstract based on selection criteria. The full text of potentially eligible studies was retrieved and assessed in detail against the inclusion criteria. All reviewers independently appraised the quality of the studies by using the Joanna Briggs Institute (JBI) quality appraisal tool for prevalence study [23].  If the quality assessment indicator score was 50% or higher, then the study was considered low risk. Any disagreements that arose between the reviewers were resolved through discussion.

Data Extraction

Data were independently extracted by all authors using a standardized data extraction format; including first authors’ name, publication year, study setting, study design, sample size, and the prevalence of heart failure. Articles that fulfilled the predefined criteria were used as a source of data for the final analysis. The reviewers were cross-checked it to ensure consistency. Any discrepancy was solved through discussion with other authors.

Data analysis

The STATA V. 14 statistical software was used for all statistical analysis. The pooled prevalence of the heart failure was determined with a random effect model. The Heterogeneity among the included studies was checked with forest plot, I2 test, and the p-values. Heterogeneity among the included studies was investigated with subgroup analysis. Publication bias was checked with a funnel plot. Subgroup analysis was done by region of the study conducted. Additionally, meta-regression model was applied by taking sample size and publication year investigate the sources of heterogeneity.

Study selection

Initially, 9761 articles were retrieved: 6427 from PubMed, 1987 from Scopus, 302 Google Scholar, and 1045 web of science. Five thousand and four hundred three remained after removing duplicates.  3860 articles were screened based on their title and abstracts and removed. Then 1140 articles were screened by using the eligibility criteria. Finally, 18 articles met the eligibility criteria and were included in the analysis (Figure 1).

Figure 1: PRISMA flow diagram of study selection for pooled global burden of Heart Failure among Patients with Hypertension.

Characteristics of study

The eighteen studies [24-41] included 44,249 participants. Majority of studies were cross-sectional. The sample size ranged from 54 [28] to 22158 [33]. Most studies were conducted in Africa regions. From the included studies, the prevalence of heart failure ranged from 1.3[33] to 55.6 [28] (Table 1).

Table 1: characteristics of the study included in systematic review and meta-analysis.

Burden of heart failure among patients with hypertension

The pooled proportion of heart failure among patients with hypertension with random effect model was found to be 19.21% (95% CI: 14.2-24.2) with a heterogeneity index of 99.6%, with a P-value of less than 0.001(Figure 2). The Egger test yielded a statistically significant result with a P-value of less than 0.001. So trim and fill analysis was conducted but is not significant.

Figure 2: Forest plot showing the pooled global burden of Heart Failure among Patients with Hypertension.

Sub-group analysis

The subgroup analysis was conducted based on region of the studies conducted. The highest prevalence of heart failure 25.7 % (95% CI: 15.4- 36.0, I2 = 99.2%) was seen in African region, and the lowest 6.79 % (95% CI: 2.0.-11.5, I2 = 94.7%) was seen in Asia region (Figure 3). 

Figure 3: Subgroup analysis of pooled global burden of Heart Failure among Patients with Hypertension by region.

Meta-regression and publication bias

The heterogeneity index values (99.6%) indicated that the studies were heterogeneous. Therefore, meta-regression was conducted using year of publication and sample size as a covariate. The analysis showed that year of publication and sample size didn’t have a significant effect on heterogeneity between studies, with a P- value of 0.299 and 0.294. Publication bias was assessed using a funnel plot and the Egger regression test with a significance threshold of less than 0.05.  The funnel plot displayed asymmetrical distribution (Figure 4) and the Egger test yielded a statistically significant result with a P-value of less than 0.001. The funnel plot adjusted by trim and fills analysis and appeared symmetrical (Figure 5).

Figure 4: Funnel plot to test publication bias in 18 studies with 95% confidence limits.

Figure 5: Funnel plot to test publication bias in 18 studies with 95% confidence limits by trim and fill analysis.

Sensitivity analysis

Sensitivity analysis was performed to determine how various sources of uncertainty contribute to the overall uncertainty among the studies, but the results indicated that uncertainty has an insignificant influence on pooled prevalence (Figure 6).

Figure 6: Sensitivity analysis of pooled global burden of Heart Failure among Patients with Hypertension for each study being removed one at a time.

Uncontrolled hypertension is the leading risk factor for various cardiovascular diseases, including stroke, coronary artery disease, atrial fibrillation, and peripheral vascular disease. Based on study findings about 90% of the patients with HF had hypertension. The mechanism hypertension in development of heart failure is primarily related to chronic left ventricular pressure overload and increased intravascular volume, affecting the ventricular structure and function through different molecular mechanisms [42-45]. This meta-analysis found that the pooled prevalence of heart failure among patients with hypertension was 19.21% (95% CI: 14.2-24.2), indicating that nearly one in five individuals in the included populations experienced heart failure. Similar variability in heart failure burden has been reported globally, which shows that Hypertensive heart disease significantly contributes to global morbidity and mortality, worsened by rising hypertension rates [46].

The subgroup analysis demonstrated marked regional variation in heart failure prevalence. The highest prevalence was observed in the African region (25.7%, 95% CI: 15.4-36.0), whereas the lowest prevalence was found in the Asian region (6.79%, 95% CI: 2.0-11.5). The higher prevalence in Africa may be attributable to the increasing burden of cardiac diseases, and limited access to early cardiovascular screening and treatment [47-49]. In contrast, the lower prevalence observed in Asia might be due to implementation of effective cardiovascular disease prevention and management strategies, leading to improved control of risk factors such as hypertension and diabetes [50-52]. Furthermore, variation in demographic characteristics of the study population, health care infrastructure, availability of diagnostic technologies, sample size, and prioritization will lead to variation.

Despite considerable global efforts to reduce the burden of cardiovascular diseases through improved prevention, early diagnosis, and advances in the management of heart failure, the condition remains a major public health challenge. The present meta-analysis found that the pooled prevalence of heart failure among patients with hypertension was significant indicating that nearly one in five individuals in the studied populations is affected. Therefore, strong and context-specific interventions, including strengthened prevention programs, effective control of hypertension and other modifiable risk factors, improved access to diagnostic services, and timely initiation of evidence-based therapies is essential. Future researchers should focus on identifying the underlying drivers of regional disparities and evaluating interventions that can effectively reduce the prevalence and consequences of heart failure.

Limitation of the study

This systematic review and meta-analysis have certain limitations to be considered. First due to significant heterogeneity of studies, result should be interpreted with caution. Secondly, we encountered difficulties when comparing our findings due to the absence of systematic reviews and meta-analyses done previously.

Ethics approval and consent to participant

Not applicable.

Consent for publication

Not applicable.

Availability of data and materials

All the data analyzed during the current systematic review and meta-analysis is fully available with request from corresponding author.

Competing interests

all the authors declare that they have no competing interests.

Funding
Not applicable.

Acknowledgment
We would like to thank all authors of studies included in this systematic review and meta-analysis.