Association of hepatic steatosis and fibrosis with 10-year estimated cardiovascular disease risk in hypertensive patients and the mediating role of triglyceride-glucose index

Background Nonalcoholic fatty liver disease (NAFLD)/metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent chronic liver disease worldwide and has been significantly associated with both hypertension and cardiovascular disease (CVD). However, whether NAFLD/MASLD constitutes an independent risk factor for CVD remains inconclusive, and evidence from hypertensive populations is limited. Moreover, the underlying mechanisms of this complex association have not yet been fully elucidated. Methods A total of 1,083 participants from the NHANES database were included in this study. Eligible individuals were aged 30–79 years, had hypertension, and were free of cardiovascular disease (CVD) at baseline. Hepatic steatosis and significant liver fibrosis were assessed noninvasively using the United States Fatty Liver Index (USFLI) and the Fibrosis-4 (FIB-4) index, respectively. Hepatic steatosis was defined as a USFLI score ≥ 30, and significant fibrosis was defined as a FIB-4 index ≥ 1.3. Insulin resistance (IR) was estimated using the triglyceride-glucose (TyG) index. The 10-year risk of a first fatal or nonfatal CVD event was calculated using the PREVENT risk equation. Results Compared with individuals with simple steatosis (n = 483) or without hepatic steatosis (n = 313), those with both hepatic steatosis and significant fibrosis (n = 287) had a significantly higher estimated 10-year CVD risk (20.5% vs. 14.7% vs. 39.4%, p < 0.001). After adjusting for sex, education, race/ethnicity, physical activity, poverty-income ratio (PIR), and chronic kidney disease (CKD), individuals with both hepatic steatosis and significant fibrosis had a markedly increased risk of experiencing a first fatal or nonfatal CVD event over 10 years compared to those without steatosis (adjusted odds ratio: 15.2, 95% CI: 5.42–63.49). Sensitivity analyses confirmed the robustness of these findings. Furthermore, the TyG index significantly mediated 16.85% of the association between steatosis with significant fibrosis and the 10-year risk of CVD events. Conclusions Among individuals with hypertension but without a prior history of cardiovascular disease, those with both hepatic steatosis and significant fibrosis had a markedly higher estimated 10-year CVD risk compared to those with steatosis alone or without steatosis. Moreover, this association was significantly mediated by the TyG index.