Risk stratification for mortality in patients with refractory hypertension based on estimated pulse wave velocity: insights from the nhanes 1999-2020 cohort

Abstract

Refractory hypertension (RH) carries a disproportionately high risk of cardiovascular disease (CVD) and target organ damage. While arterial stiffness is a recognized driver of RH, the clinical utility of estimated pulse wave velocity (ePWV) for prognostic risk stratification in this specific population remains unclear. To evaluate the independent association between ePWV, a surrogate marker of arterial stiffness, and mortality risks, aiming to establish reliable prognostic cut-offs for patients with RH. This prospective cohort study analysed 943 adult patients with RH from the National Health and Nutrition Examination Survey (NHANES) 1999-2020. Participants were stratified into quartiles based on baseline ePWV. Multivariable Cox proportional hazards models were utilized to assess the relationship between ePWV and both all-cause and CVD mortality. The MaxStat method was applied to identify optimal prognostic cut-off values, followed by Kaplan-Meier survival analysis Among 943 patients with RH (45.07% male), significant baseline differences were observed across ePWV quartiles regarding age, race, and renal function (all P<0.05). In the fully adjusted model (Model 4), ePWV as a continuous variable was an independent risk factor for both all-cause mortality (hazard ratio [HR] 1.55, 95% CI: 1.31-1.83, P<0.001) and CVD mortality (HR 1.45, 95% CI: 1.09-1.93, P=0.011). Compared to the lowest quartile (Q1), patients in the highest quartile (Q4: 13.3-16.7 m/s) exhibited a dramatically increased risk of all-cause mortality (HR 6.41, 95% CI: 2.30-17.85, P<0.001). MaxStat identified optimal predictive cut-offs of 12.10 m/s for all-cause mortality and 13.78 m/s for CVD mortality (Figure 1). Subsequent Kaplan-Meier analysis confirmed that patients exceeding these respective ePWV thresholds experienced significantly higher cumulative mortality rates (Figure 2). Elevated ePWV is independently associated with increased all-cause and CVD mortality in patients with RH. Utilizing ePWV cut-offs of 12.10 m/s and 13.78 m/s provides a robust, non-invasive method for early mortality risk stratification, offering valuable guidance for intensive clinical management in high-risk RH patients.Figure1For image description, please refer to the figure legend and surrounding text.Figure2For image description, please refer to the figure legend and surrounding text.