Background: Clinical practice guidelines recommend early identification of cognitive impairment in individuals with hypertension with the help of risk prediction tools based on risk factors.

Objective: The aim of this study was to develop a superior machine learning model based on easily collected variables to predict the risk of early cognitive impairment in hypertensive individuals, which could be used to optimize early cognitive impairment risk assessment strategies.

Methods: For this cross-sectional study, 733 patients with hypertension (aged 30-85, 48.98% male) enrolled in multi-center hospitals in China were divided into a training group (70%) and a validation group (30%). After least absolute shrinkage and selection operator (LASSO) regression analysis with 5-fold cross-validation determined the modeling variables, three machine learning classifiers, logistic regression (LR), XGBoost (XGB), and gaussian naive bayes (GNB), were developed. The area under the ROC curve (AUC), accuracy, sensitivity, specificity, and F1 score were used to evaluate the model performance. Shape Additive explanation (SHAP) analysis was performed to rank feature importance. Further decision curve analysis (DCA) assessed the clinical performance of the established model and visualized it by nomogram.

Results: Hip circumference, age, education levels, and physical activity were considered significant predictors of early cognitive impairment in hypertension. The AUC (0.88), F1 score (0.59), accuracy (0.81), sensitivity (0.84), and specificity (0.80) of the XGB model were superior to LR and GNB classifiers.

Conclusion: The XGB model based on hip circumference, age, educational level, and physical activity has superior predictive performance and it shows promise in predicting the risk of cognitive impairment in hypertensive clinical settings.