Liver Fibrosis Scoring Systems as Novel Tools for Predicting Recurrent Cardiovascular Events in Patients with a Prior Cardiovascular Event

Objective: Regarding the secondary prevention of cardiovascular disease (CVD), there is great interest in preventing recurrent cardiovascular events (RCVEs). The prognostic importance of liver fibrosis scores (LFSs) has previously been reported in various CVDs. We hypothesized that LFSs might also be useful predictors for RCVEs in patients with prior cardiovascular events (CVEs). Herein, we aimed to evaluate the associations of LFSs with RCVEs in a large, real-world cohort of coronary artery disease (CAD) patients with a prior CVE. Methods: In this multicenter prospective study, 6527 consecutive patients with angiography-diagnosed CAD who had experienced a prior CVE (acute coronary syndrome, stroke, percutaneous coronary intervention, or coronary artery bypass grafting) were enrolled. LFSs were computed according to the published formulas: non-alcoholic fatty liver disease fibrosis score (NFS) includes age, body mass index (BMI), impaired fasting glycemia or diabetes mellitus (DM), aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio, platelets, and albumin; fibrosis-4 (FIB-4) includes age, AST, ALT, and platelets; Forns score includes age, gamma-glutamyltransferase (GGT), and platelets; BARD includes BMI, AST/ALT ratio, and DM; GGT/platelet ratio includes GGT and platelets; AST/ALT ratio includes AST and ALT; and AST/platelet ratio index includes AST and platelets. The originally reported cutoffs were used for the categorization of low-, intermediate-, and high-score subgroups. All patients were followed up for the occurrence of RCVEs (comprising cardiovascular death, non-fatal myocardial infarction, and stroke). Cox and Poisson regression analyses were used to assess the relationship of baseline LFSs with the risk of RCVE. Results: During a mean follow-up of (54.67 ± 18.80) months, 532 (8.2%) RCVEs were recorded. Intermediate and high NFS, FIB-4, Forns, and BARD scores were independently associated with an increased risk of RCVE (hazard ratios ranging from 1.42 to 1.75 for intermediate scores and 1.35 to 2.52 for high scores). In the subgroup analyses of sex, age, BMI, DM, and hypertension status, the increased risk of RCVEs with high LFSs (NFS, FIB-4, Forns, and BARD) was maintained across the different subgroups (all P < 0.05). Conclusion: This study showed that LFSs are indeed independently associated with RCVEs, suggesting that LFSs may be used as novel tools for risk stratification in CAD patients with a prior CVE.