10-YEAR RISK OF CVD IN PATIENTS WITH METABOLIC SYNDROME WITH AND WITHOUT NAFLD
DOI:
https://doi.org/10.71000/jxq5se02Keywords:
Atherosclerosis; Cardiovascular Diseases; Fatty Liver; Framingham Study; Metabolic Syndrome; Risk Assessment; Ultrasonography.Abstract
Background: Metabolic syndrome is a major cardiometabolic disorder that increases the likelihood of future cardiovascular disease through clustered abnormalities such as central obesity, hypertension, dyslipidemia, and impaired glucose regulation. Non-alcoholic fatty liver disease commonly coexists with metabolic syndrome and may further increase cardiovascular risk through inflammation, insulin resistance, and endothelial dysfunction. However, liver status is not routinely included in conventional cardiovascular risk prediction tools, which may underestimate risk in affected patients.
Objective: To compare the estimated 10-year cardiovascular disease risk among patients with metabolic syndrome with and without non-alcoholic fatty liver disease and to determine whether non-alcoholic fatty liver disease independently predicts higher cardiovascular risk.
Methods: This cross-sectional observational study included 100 patients with metabolic syndrome, divided equally into two groups: metabolic syndrome with ultrasound-confirmed non-alcoholic fatty liver disease and metabolic syndrome without fatty liver on ultrasound. Demographic, clinical, and biochemical variables were recorded, including age, sex, waist circumference, blood pressure, triglycerides, high-density lipoprotein cholesterol, and fasting glucose. The 10-year cardiovascular disease risk was estimated using the Framingham Risk Score and ASCVD Risk Estimator. Group comparisons, correlation analysis, and multivariable regression analysis were performed.
Results: The mean Framingham Risk Score was significantly higher in patients with non-alcoholic fatty liver disease than in those without it (22.4 ± 8.2% versus 16.3 ± 7.6%, p = 0.03). Similarly, the mean ASCVD risk was higher in the non-alcoholic fatty liver disease group (24.1 ± 9.1% versus 18.9 ± 7.5%, p = 0.04). High cardiovascular risk was observed in 60% of patients with non-alcoholic fatty liver disease compared with 36% without it (p = 0.01). Fatty liver grade showed a positive correlation with Framingham Risk Score (r = 0.45, p = 0.01) and ASCVD risk (r = 0.42, p = 0.02). Multivariable regression showed that non-alcoholic fatty liver disease independently predicted higher Framingham Risk Score (β = 0.32, p = 0.02) and ASCVD risk (β = 0.29, p = 0.03).
Conclusion: Non-alcoholic fatty liver disease was associated with higher estimated 10-year cardiovascular disease risk among patients with metabolic syndrome. Routine liver assessment may improve cardiovascular risk stratification and help identify patients who may benefit from earlier preventive intervention.
Keywords: Atherosclerosis; Cardiovascular Diseases; Fatty Liver; Framingham Study; Metabolic Syndrome; Risk Assessment; Ultrasonography.
References
Powell EE, Wong VW, Rinella M. Non-alcoholic fatty liver disease. Lancet. 2021;397(10290):2212–2224.
Stahl EP, Dhindsa DS, Lee SK, et al. Nonalcoholic fatty liver disease and the heart. J Am Coll Cardiol. 2019;73(8):948–963.
Sinn DH, Kang D, Cho SJ, et al. NAFLD and risk of myocardial infarction. J Hepatol. 2020;73(3):533–541.
Hagström H, Nasr P, Ekstedt M, et al. Cardiovascular risk in NAFLD. Gut. 2019;68(6):1135–1142.
Wen W, Fan H, Zhang S, Hu S, Chen C, Tang J, et al. Associations between metabolic dysfunction-associated fatty liver disease and atherosclerotic cardiovascular disease. Am J Med Sci. 2024;368(6):557-68.
Rix I, Steen Pedersen J, Storgaard H, Gluud LL. Cardiometabolic effects of antidiabetic drugs in non-alcoholic fatty liver disease. Clin Physiol Funct Imaging. 2019;39(2):122-7.
Tana C, Ballestri S, Ricci F, Di Vincenzo A, Ticinesi A, Gallina S, et al. Cardiovascular Risk in Non-Alcoholic Fatty Liver Disease: Mechanisms and Therapeutic Implications. Int J Environ Res Public Health. 2019;16(17).
Weir MR. Cardiovascular risk reduction in type 2 diabetes: What the non-specialist needs to know about current guidelines. Diabetes Obes Metab. 2024;26 Suppl 5:14-24.
Fujishima Y, Kita S, Nishizawa H, Maeda N, Shimomura I. Cardiovascular significance of adipose-derived adiponectin and liver-derived xanthine oxidoreductase in metabolic syndrome. Endocr J. 2023;70(7):663-75.
Santos RD, Valenti L, Romeo S. Does nonalcoholic fatty liver disease cause cardiovascular disease? Current knowledge and gaps. Atherosclerosis. 2019;282:110-20.
Handelsman Y, Butler J, Bakris GL, DeFronzo RA, Fonarow GC, Green JB, et al. Early intervention and intensive management of patients with diabetes, cardiorenal, and metabolic diseases. J Diabetes Complications. 2023;37(2):108389.
Lewis GF, Hegele RA. Effective, disease-modifying, clinical approaches to patients with mild-to-moderate hypertriglyceridaemia. Lancet Diabetes Endocrinol. 2022;10(2):142-8.
Bashir B, Adam S, Ho JH, Linn Z, Durrington PN, Soran H. Established and potential cardiovascular risk factors in metabolic syndrome: Effect of bariatric surgery. Curr Opin Lipidol. 2023;34(5):221-33.
Masarone M, Motta BM, Torre P, Aquino M, Belladonna F, Lombardi M, et al. Evaluating cardiovascular risk in metabolic steatosis with precision medicine non-invasive approaches: insights from a cohort study. Intern Emerg Med. 2024;19(8):2293-307.
Dogru T, Kirik A, Gurel H, Rizvi AA, Rizzo M, Sonmez A. The Evolving Role of Fetuin-A in Nonalcoholic Fatty Liver Disease: An Overview from Liver to the Heart. Int J Mol Sci. 2021;22(12).
Lake JE, Taron J, Ribaudo HJ, Leon-Cruz J, Utay NS, Swaminathan S, et al. Hepatic steatosis and nonalcoholic fatty liver disease are common and associated with cardiometabolic risk in a primary prevention cohort of people with HIV. Aids. 2023;37(14):2149-59.
Nolan CJ, Prentki M. Insulin resistance and insulin hypersecretion in the metabolic syndrome and type 2 diabetes: Time for a conceptual framework shift. Diab Vasc Dis Res. 2019;16(2):118-27.
Izzy M, Fortune BE, Serper M, Bhave N, deLemos A, Gallegos-Orozco JF, et al. Management of cardiac diseases in liver transplant recipients: Comprehensive review and multidisciplinary practice-based recommendations. Am J Transplant. 2022;22(12):2740-58.
Linero PL, Castilla-Guerra L. Management of Cardiovascular Risk in the Non-alcoholic Fatty Liver Disease Setting. Eur Cardiol. 2024;19:e02.
Martin A, Lang S, Goeser T, Demir M, Steffen HM, Kasper P. Management of Dyslipidemia in Patients with Non-Alcoholic Fatty Liver Disease. Curr Atheroscler Rep. 2022;24(7):533-46.
Schmidt K, Spann A, Khan MQ, Izzy M, Watt KD. Minimizing Metabolic and Cardiac Risk Factors to Maximize Outcomes After Liver Transplantation. Transplantation. 2024;108(8):1689-99.
Stols-Gonçalves D, Hovingh GK, Nieuwdorp M, Holleboom AG. NAFLD and Atherosclerosis: Two Sides of the Same Dysmetabolic Coin? Trends Endocrinol Metab. 2019;30(12):891-902.
Kasper P, Martin A, Lang S, Kütting F, Goeser T, Demir M, et al. NAFLD and cardiovascular diseases: a clinical review. Clin Res Cardiol. 2021;110(7):921-37.
Lee HH, Cho Y, Choi YJ, Huh BW, Lee BW, Kang ES, et al. Non-alcoholic steatohepatitis and progression of carotid atherosclerosis in patients with type 2 diabetes: a Korean cohort study. Cardiovasc Diabetol. 2020;19(1):81.
Duell PB, Welty FK, Miller M, Chait A, Hammond G, Ahmad Z, et al. Nonalcoholic Fatty Liver Disease and Cardiovascular Risk: A Scientific Statement From the American Heart Association. Arterioscler Thromb Vasc Biol. 2022;42(6):e168-e85.
Romero-Pérez D, Belinchón-Romero I, Bellot P, Francés R, Marco F, Ramos-Rincón JM. Nonalcoholic fatty liver disease puts patients with psoriasis at greater cardiovascular risk. Australas J Dermatol. 2019;60(4):e304-e10.
Li M, Cui M, Li G, Liu Y, Xu Y, Eftekhar SP, et al. The Pathophysiological Associations Between Obesity, NAFLD, and Atherosclerotic Cardiovascular Diseases. Horm Metab Res. 2024;56(10):683-96.
Chun HS, Lee M, Lee HA, Lee S, Kim S, Jung YJ, et al. Risk Stratification for Sarcopenic Obesity in Subjects With Nonalcoholic Fatty Liver Disease. Clin Gastroenterol Hepatol. 2023;21(9):2298-307.e18.
Huang JF, Tsai PC, Yeh ML, Huang CF, Huang CI, Hsieh MH, et al. Risk stratification of non-alcoholic fatty liver disease across body mass index in a community basis. J Formos Med Assoc. 2020;119(1 Pt 1):89-96.
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Copyright (c) 2025 Dr Muhammad Hassan, Dr Zeeshan Ali Junejo, Dr Shayan Rehmani, Dr Ghulam Qadir Memon, Dr Sameeullah (Author)
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