When the sum isn’t the whole - The vascular status score and its components in hypertension identification: The African PREDICT study

The vascular status score (VSS) is an emerging composite index, developed to investigate early vascular changes by integrating pulse wave velocity (PWV), augmentation index (AIx), and carotid intima-media thickness (cIMT). Although prior studies have linked the VSS to inflammatory and metabolic dysfunction, its association with hypertension remains unexplored. This study compared the ability of the VSS and its individual components in identifying hypertension, regardless of phenotype, among young South African adults. We included 1,019 participants aged 20 - 30 years from a community-based cohort. Office and ambulatory blood pressures were measured, and hypertension phenotypes were defined according to the 2024 ESC guidelines. Carotid-femoral PWV, Aix, and cIMT were assessed and combined to calculate the composite VSS. Receiver operating characteristic (ROC) analyses determined optimal cut points for VSS and its components relative to normotensive and hypertensive classifications, and odds ratios were adjusted for relevant covariates. Among the indices examined, only PWV demonstrated consistent sensitivity and specificity across hypertension phenotypes. While a VSS above 4 modestly increased the odds of masked, sustained, and white-coat hypertension (odds ratios ranging from 1.74 to 2.35, all P < 0.05), only PWV accurately identified masked and sustained hypertension (odds ratios 2.25-2.70, all P < 0.01). Neither AIx nor cIMT achieved comparable diagnostic utility. Despite the promise of a composite vascular index, PWV independently outperformed the VSS and its other components in detecting hypertension in young adults. These findings suggest that PWV may be the most reliable individual biomarker for early hypertension identification in young adults.