Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) is a growing cause of morbidity and mortality, with cardiovascular disease as the leading cause of death. Hypertension is a common comorbidity, yet the impact of antihypertensive medications on MASLD outcomes remains unclear. This study examines the associations between antihypertensive medication use, liver fibrosis, and mortality in MASLD patients. Methods: We analyzed pooled data from NHANES (1999-2018) linked to National Death Index records. MASLD was defined using validated non-invasive indices (US-FLI, FLI, HSI), and liver fibrosis was assessed using FIB-4, APRI, NFS, and BARD scores. Cox proportional hazards models with inverse probability of treatment weighting (IPTW) were used to evaluate the associations between antihypertensive medications (ACEIs, ARBs,β-blockers, CCBs, and diuretics) and clinical outcomes, with multiple sensitivity analyses conducted to assess the robustness of the findings. Results: Among 19,603 participants (mean age 49.5 years, 52.5% female), antihypertensive use was associated with a significantly lower risk of liver fibrosis (FIB-4-defined) in MASLD (aHR, 0.17; 95% CI, 0.04-0.78). ACEIs (aHR, 0.25; 95% CI, 0.08-0.74) and ARBs (aHR, 0.23; 95% CI, 0.06-0.86) were associated with lower all-cause mortality compared to CCBs. Conclusion: ACEIs and ARBs were associated with reduced liver fibrosis and all-cause mortality in MASLD patients. These findings support further investigation into the potential role of renin-angiotensin system inhibition as a therapeutic strategy in MASLD. Key words: Steatotic liver disease; Metabolic dysfunction-associated steatotic liver disease; Liver fibrosis; Antihypertensive medications; Mortality.

The authors have declared no competing interest.

This study did not receive any funding

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