Association between severity of liver and cardiovascular damage in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) according to cardiovascular risk categories

Background In 2023, the nomenclature of non-alcoholic fatty liver disease (NAFLD) was replaced by the more inclusive terminology of metabolic dysfunction-associated steatotic liver disease (MASLD), characterized by hepatic steatosis with at least one cardiometabolic risk factor. MASLD encompasses different disease severities ranging from steatosis, steatohepatitis (MASH), fibrosis, cirrhosis, and hepatocellular carcinoma. In 2021, the European Society of Cardiology (ESC) redefine CV risk and identified three risk categories (low, high, and very high). Aim To evaluate, in a cohort of MASLD patients without a history of previous CV events, the severity of liver damage and metabolic comorbidities according to the ESC 2021 CV risk. Methods 287 MASLD patients, fully characterized for metabolic, liver, and CV features, were divided into 3 groups according to the degree of CV risk. Liver fibrosis was assessed by liver stiffness measurement (LSM) and confirmed by histology in 30. CV damage was defined by the presence of carotid plaques or carotid intima-media thickness (cIMT) ≥ 0.9 mm by ultrasound. Epicardial fat thickness (EFT) was evaluated by echocardiography. Results with rising CV risk a significant increase in BMI (29±4.8 vs 31±4.4 kg/m2, p<0.001), obesity (33% vs 58%, p<0.001), liver fibrosis (4.7± 2.0 vs 5.2± 2.2 kPa, p=0.02), EFT (7.3±2.8 vs 8.3±3.0 mm, p=0.04), diabetes (7 vs 23%, p=0.004) and hypertension (39 vs 63%, p=0.003) was observed, as expected, carotid plaques and cIMT progressively increased from low to high-very high CV risk (p<0.001, and p=0.0003, respectively). At multivariate analysis, adjusted for age, sex, and all metabolic parameters, LSM was independently associated with the highest CV risk (OR 1.2, 95% C.I. 1.01-1.31). Conclusion The association between cardiometabolic factors and liver fibrosis severity exposes patients with MASLD to increased CV risk and should be well evaluated in all patients, thus making integrated management mandatory to reduce CV and liver disease progression.