Association of steatotic liver disease with all-cause and cardiovascular mortality among prehypertensive or hypertensive patients

Background: Prehypertension and hypertension often coexist with non-alcoholic fatty liver disease (NAFLD) during the progression of cardiovascular disease (CVD). International academic liver societies have recently reached a consensus to replace NAFLD with the new term 'steatotic liver disease' (SLD). In this study, we aimed to evaluate the impact of different SLD subtypes on all-cause and CVD mortality in individuals with prehypertension or hypertension. Methods: We included 6074 adults from the National Health and Nutrition Examination Survey (2003-18). The US fatty liver index was used as the diagnostic criterion for SLD, and participants were classified into no SLD, metabolic dysfunction-associated steatotic liver disease (MASLD), metabolic dysfunction-associated and alcohol-related liver disease (MetALD), and alcohol-related liver disease (ALD). For cases of MASLD, MetALD, and ALD, we further assessed advanced fibrosis using the fibrosis-4 (FIB-4) index. Additionally, we calculated hazard ratios (HRs) and 95% confidence intervals (CIs) using Cox proportional hazards regression models to assess the associations of SLD subtypes and advanced fibrosis with all-cause and CVD mortality. Results: There were 3505 (57.7%) participants with no SLD, 1284 (21.1%) with MASLD, 777 (12.8%) with MetALD, and 508 (8.4%) with ALD. During a median follow-up period of 8.2 years, the risk of all-cause and CVD mortality progressively increased in participants with MASLD (HR = 1.28; 95% CI = 1.01-1.63 and HR = 1.55; 95% CI = 1.04-2.33, respectively), MetALD (HR = 1.41; 95% CI = 1.05-1.88 and HR = 1.78; 95% CI = 1.10-2.87, respectively), and ALD (HR = 1.83; 95% CI = 1.32-2.53 and HR = 1.80; 95% CI = 1.01-3.19, respectively). Among the individuals with MASLD, MetALD, and ALD, advanced fibrosis was also associated with an increased risk of all-cause and CVD mortality. Conclusions: Individuals with MASLD, MetALD, and ALD had a higher risk of all-cause and CVD mortality than those without SLD. Therefore, early intervention strategies targeting SLD prevention and management may help individuals with prehypertension and hypertension to improve their long-term health.