Antihypertensive medication use, particularly ACEIs and ARBs, was associated with lower fibrosis prevalence and all-cause mortality in MASLD compared with calcium channel blockers.
Key Findings
Results
ACEIs were associated with significantly lower all-cause mortality compared with calcium channel blockers in adults with MASLD receiving antihypertensive monotherapy.
Analysis restricted to monotherapy users among participants with MASLD (n=458; 86 deaths total; CCB reference group n=47; 15 deaths)
Adjusted hazard ratio for ACEIs vs. CCBs: aHR 0.30 (95% CI, 0.11–0.82)
Inverse probability of treatment weighting and survey weights were applied in Cox models
Data drawn from NHANES 1999–2018 linked to mortality through 2019
Results
ARBs were associated with significantly lower all-cause mortality compared with calcium channel blockers in adults with MASLD receiving antihypertensive monotherapy.
Adjusted hazard ratio for ARBs vs. CCBs: aHR 0.25 (95% CI, 0.07–0.94)
Calcium channel blockers served as the reference group
Analysis used a prevalent-user design with antihypertensive exposure defined at baseline based on self-reported medication use
Findings were broadly consistent across sensitivity analyses including alternative model specifications and expanded covariate adjustment
Results
Antihypertensive medication use overall was associated with lower odds of liver fibrosis as defined by FIB-4 in US-FLI-defined MASLD populations.
Adjusted odds ratio for FIB-4-defined fibrosis in MASLD: aOR 0.51 (95% CI, 0.29–0.91)
Cross-sectional analysis using logistic regression with inverse probability of treatment weighting and survey weights
Fibrosis assessed using FIB-4 and APRI within a model-based framework derived from vibration-controlled transient elastography
Steatosis (MASLD) was defined by the US Fatty Liver Index (US-FLI)
Results
Antihypertensive medication use overall was associated with lower odds of liver fibrosis as defined by APRI in US-FLI-defined MASLD populations.
Adjusted odds ratio for APRI-defined fibrosis in MASLD: aOR 0.49 (95% CI, 0.28–0.89)
Results were consistent with FIB-4-based fibrosis findings, supporting robustness of the cross-sectional association
Findings were broadly consistent across sensitivity analyses
Methods
The study used a prevalent-user design with NHANES data spanning 1999–2018, linked to mortality through 2019, to examine antihypertensive drug class effects in MASLD.
Total monotherapy sample: n=458 participants with MASLD
Antihypertensive exposure was defined at baseline based on self-reported medication use, consistent with a prevalent-user design
Comparative analyses were restricted to monotherapy users to allow class-level comparisons
Survey weights were incorporated to account for the complex NHANES sampling design
What This Means
This research suggests that among adults with metabolic dysfunction-associated steatotic liver disease (MASLD, commonly known as fatty liver disease) who also have high blood pressure, the type of blood pressure medication used may matter for health outcomes. Specifically, people taking ACE inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) had roughly 70–75% lower risk of dying from any cause during the follow-up period compared to people taking calcium channel blockers, when looking only at those on a single blood pressure medication. Additionally, taking antihypertensive medications in general was associated with about half the odds of having significant liver scarring (fibrosis) compared to not taking them.
The study used data from a large, nationally representative US survey (NHANES) collected between 1999 and 2018, with deaths tracked through 2019. Liver disease severity was estimated using blood-based scoring tools (FIB-4 and APRI) validated against specialized liver stiffness measurements, and statistical techniques were used to try to account for differences between groups of patients taking different medications.
The authors emphasize that these findings are 'hypothesis-generating' and not proof of cause and effect, because the study design cannot rule out that patients who were prescribed ACEIs or ARBs were healthier in ways that weren't fully measured. Prospective studies — ones that follow patients forward in time with careful controls — are needed to confirm whether choosing ACEIs or ARBs over other blood pressure drugs actually improves liver outcomes or survival in people with fatty liver disease.
Wu Y, Fang F. (2026). Associations of antihypertensive medication class with liver fibrosis and mortality in US adults with MASLD.. Clinical and experimental hypertension (New York, N.Y. : 1993). https://doi.org/10.1080/10641963.2026.2725928