BackgroundHyperuricemia is a cardiometabolic risk factor among patients with hypertension. A high total cholesterol-to-high-density lipoprotein cholesterol ratio reflects atherogenic lipid imbalance and insulin resistance. This study investigated the association between a high total cholesterol-to-high-density lipoprotein cholesterol ratio and hyperuricemia among patients with hypertension at Uganda Heart Institute.MethodsWe conducted a cross-sectional study among 277 consecutively recruited patients with hypertension aged ≥18 years from 4 August 2025 to 20 October 2025 at Uganda Heart Institute. Hyperuricemia was defined as a serum uric acid level of ≥7 mg/dL in men and ≥6 mg/dL in women, whereas a high total cholesterol-to-high-density lipoprotein cholesterol ratio was defined as ≥5.ResultsAmong 277 participants, 89 had hyperuricemia, giving a proportion of 32.1% (95% confidence interval: 26.9-37.9). Hyperuricemia was significantly more common in participants with a total cholesterol-to-high-density lipoprotein cholesterol ratio of ≥5 (53.8%) than in those with a ratio of <5 (25.5%) (p < 0.001). After adjustment for confounders, a high total cholesterol-to-high-density lipoprotein cholesterol ratio remained independently associated with hyperuricemia (adjusted odds ratio = 2.83, 95% confidence interval: 1.31-6.09, p = 0.008). The total cholesterol-to-high-density lipoprotein cholesterol ratio demonstrated moderate predictive ability for hyperuricemia, with an optimal cutoff value of 4.33 (sensitivity, 58%; specificity, 71%) and an area under the curve of 0.68 (95% confidence interval: 0.61-0.75).ConclusionHyperuricemia is prevalent among patients with hypertension. A high total cholesterol-to-high-density lipoprotein cholesterol ratio is a potential predictor of hyperuricemia in this population.