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This retrospective study of 98 patients assessed whether hypertensive heart disease (HHD) is associated with angiographic coronary artery disease (CAD) burden, quantified by the Duke CAD Index, and whether HHD or CAD burden influenced revascularization strategy. HHD was independently associated with higher Duke CAD Index values in linear regression (B = 10.33, p = 0.038) and with greater odds of more severe CAD categories in ordinal regression (OR = 3.19, p = 0.015). However, revascularization choice did not differ by HHD status or CAD severity (p = 0.95). A model incorporating age, sex, diabetes mellitus, and HHD demonstrated moderate discriminative ability for predicting severe CAD (AUC = 0.753). These findings suggest that HHD identifies a high-risk coronary atherosclerotic phenotype, but they are hypothesis-generating and require confirmation in larger prospective studies before clinical application.