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Objective: To investigate the high-resolution CT (HRCT) imaging phenotypes, clinical characteristics and prognostic differences between emphysema-dominant (CPFE-E) and fibrosis-dominant (CPFE-F) subtypes of combined pulmonary fibrosis and emphysema (CPFE). Methods: A retrospective study of 383 CPFE patients was retrospectively enrolled. Based on quantitative HRCT analysis of emphysema and fibrosis proportions, patients were classified into CPFE-E group (emphysema proportion>fibrosis proportion, n=96; 90 men; median age 65 years) and CPFE-F group (fibrosis proportion>emphysema proportion, n=287; 230 men; median age 65 years). Clinical features, treatment regimens, and survival rates (Kaplan-Meier method) were compared, with Cox regression estimating Hazard ratio (HR) and 95%CI of emphysema/fibrosis subtypes on all-cause mortality. Results: The CPFE-E group had higher median emphysema proportion (12% vs. 1%, W=24 101.00, P<0.001), male predominance (93.8% vs. 80.1%, χ²=9.70, P=0.002), smoking index (650 vs. 400 pack-years, W=16 049.50, P=0.014), and bronchodilator use (39.6% vs. 22.0%, χ²=11.52, all P<0.001), but lower diabetes prevalence (6.3% vs. 18.5%, χ²=8.24, P=0.004). Survival analysis revealed lower 2-year survival in CPFE-E (18/96 vs. 51/287); however, the long-term survival trend over the entire follow-up period (median, 390 days) showed no significant difference between the two groups (21/96 vs. 58/287, log-rank P=0.594). Multivariate Cox regression showed that each 1% increase in emphysema proportion was associated with a 6% increase in mortality risk in the CPFE-E group (adjusted HR=1.06, 95%CI: 1.04-1.08, P<0.001), whereas fibrosis proportion significantly increased mortality risk only in CPFE-E (HR=1.24, 95%CI:1.15-1.33, P<0.001). Conclusion: CPFE imaging phenotypes can be classified into CPFE-E and CPFE-F, which show marked heterogeneity. Emphysema proportion is an independent risk factor for prognosis in CPFE-E group. Subtype-oriented individualized management may improve clinical outcomes.