Background The proportion of elderly patients with hypertension and coronary artery disease (HT-CAD) is high. Cardiometabolic disease (CMD) has gradually become the most common coexistence mode of multiple diseases among elderly people in China. The epidemic trend and prognosis of CMD in elderly patients with HT-CAD is rarely studied. Objective To explore the clinical characteristics and prognosis of cardiometabolic disease in elderly patients with HT-CAD.Methods From 2008 to 2018, elderly inpatients (aged ≥ 65 years) with HT-CAD from Department of Cardiology, Chinese PLA General Hospital were included in the study. All patients were followed up until September 2023, and divided into four groups, including HT-CAD group, HT-CAD combined with stroke (HT-CAD-STR)group, HT-CAD combined with diabetes (HT-CAD-DM) group、 HT-CAD with stroke and diabetes (HT-CAD-STR-DM) group. Cox regression model was used to calculate the hazard ratio (HR) and 95%  confidence interval (CI) of all-cause mortality in each group.Results A total of 8 258 patients were included in this study, including 3 454 patients (41.83%) in the HT-CAD group, 884 patients (10.70%) in the HT-CAD-STR group, 3,054 patients (36.98%) in the HT-CAD-DM group and 866 patients (10.49%) in the HT-CAD-STR-DM group. From 2008 to 2018, the proportion of HT-CAD patients decreased (45.52% vs 38.88%), and the proportion of HT-CAD-STR-DM patients increased (8.38% vs 12.53%) (trend test P < 0.01). Compared with the other three groups, patients in the HT-CAD-STR-DM group had a faster heart rate, a higher body mass index and a lower level of high-density lipoprotein, and a higher proportion of heart failure (HF), chronic kidney disease (CKD) and acute myocardial infarction (AMI). After a median follow-up of 6.38 years, a total of 6 843 patients completed the follow-up, 1 281 cases of death were identified. The number of events and their incidence rates for the four groups of patients were as follows: HTCAD group: 435/2885, 23.55 per 1 000 person-years; HT-CAD-STR group: 125/743, 26.36 per 1 000 person-years; HT-CAD-DM group: 530/2499, 33.24 per 1 000 person-years; HT-CAD-STR-DM group: 191/716, 41.82 per 1 000 person-years. Multivariate Cox regression model showed that the HR (95% CI) of all-cause mortality were 1.38 (1.21-1.57) for the HT-CAD-DM patients and 1.73 (1.45-2.05) for the HT-CAD-STR-DM patients compared to those with HT-CAD, while the risk of all-cause mortality did not significantly increase in the HT-CAD-STR patients. Stratified analysis by diabetes showed that stroke was not associated with increased risk of all-cause death in elderly patients with HT-CAD, but increased the risk by 26% in elderly HT-CAD-DM patients. Moreover, stratified analysis by stroke showed that diabetes increased the risk of all-cause mortality by 39% in elderly HT-CAD, but increased the risk by 71% in elderly HT-CAD-STR patients.Conclusion The prevalence of cardiometabolic disease is high among elderly HT-CAD patients and it keeps increasing year by year. Elderly HT-CAD patients with diabetes have a higher risk of all-cause mortality. Diabetes and stroke show synergistic effects on the risk of all-cause death in elderly HT-CAD patients.