Associations of antihypertensive medication class with liver fibrosis and mortality in US adults with MASLD

OBJECTIVE: Metabolic dysfunction-associated steatotic liver disease (MASLD) frequently coexists with hypertension, yet comparative data on antihypertensive medication classes remain limited. We examined associations between antihypertensive medication class and liver fibrosis and mortality in US adults with MASLD. METHODS: We conducted a prevalent-user analysis using National Health and Nutrition Examination Survey (NHANES) 1999-2018 data linked to mortality through 2019. Antihypertensive exposure was defined at baseline based on self-reported medication use, consistent with a prevalent-user design. Steatosis was defined by the US Fatty Liver Index (US-FLI). Fibrosis was assessed using FIB-4 and APRI within a model-based framework derived from vibration-controlled transient elastography. Analyses comparing antihypertensive classes were restricted to monotherapy users. Logistic regression and Cox models with inverse probability of treatment weighting and survey weights were applied. RESULTS: = 47; 15 deaths) (ACEIs: adjusted hazard ratio [aHR], 0.30; 95% CI, 0.11-0.82; ARBs: 0.25; 95% CI, 0.07-0.94). In cross-sectional analyses, antihypertensive medication use was associated with lower odds of liver fibrosis defined by FIB-4 and APRI within US-FLI-defined populations (MASLD: FIB-4 aOR 0.51 [0.29-0.91]; APRI aOR 0.49 [0.28-0.89]). Findings were broadly consistent across sensitivity analyses, including alternative model specifications and expanded covariate adjustment. CONCLUSIONS: Antihypertensive medication use, particularly ACEIs and ARBs, was associated with lower fibrosis prevalence and all-cause mortality in MASLD. These findings are hypothesis-generating and require confirmation in prospective studies.