Abstract
Aims: Cardiovascular disease (CVD) is a common cause of death in patients with metabolic dysfunction-associated steatotic liver disease (MASLD). Therefore, CVD surveillance is important, but it is not well established. We evaluated the association between liver fibrosis, carotid artery atherosclerosis, and coronary artery stenosis in patients with MASLD.
Methods: Overall, 153 patients with MASLD who underwent carotid artery ultrasound were enrolled. Maximum intima–media thickness including plaques (Max-IMT) was measured by ultrasound. To predict liver fibrosis, liver stiffness was measured by vibration-controlled transient elastography and the fibrosis 4 (FIB-4) index was calculated. Coronary computed tomography angiography was performed to detect coronary artery stenosis based on a Max-IMT of ≥ 1.1 mm.
Results: The median Max-IMT was 1.3 mm, and 63 patients (41.2%) had a Max-IMT of ≥ 1.5 mm. FIB-4 index and liver stiffness was significantly correlated with Max-IMT, respectively (ρ=0.356, p＜0.001, ρ=0.25, p=0.002). Liver stiffness was significantly associated with a Max-IMT of ≥1.5 mm, independent of age. Individuals with higher FIB-4 index had moderate or severe coronary artery stenosis more frequently. Individuals with higher LSM level also had moderate or severe coronary artery stenosis more frequently, especially severe stenosis.
Conclusions: Liver fibrosis parameters were associated with carotid artery atherosclerosis and coronary artery stenosis. Evaluation of liver fibrosis may be useful to identify significant atherosclerosis and coronary artery stenosis in patients with MASLD.
Abbreviations: MASLD, metabolic dysfunction-associated steatotic liver disease; CVD, cardiovascular disease; BMI, body mass index; coronary AS, coronary artery stenosis; CT, computed tomography; CTA, coronary computed tomography angiography; MACEs, major adverse cardiovascular events; AST, aspartate aminotransferase; ALT, alanine aminotransferase; GGT, γ-glutamyl transferase; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; HbA1c, hemoglobin A1c; FIB-4, fibrosis-4; IMT, intima–media thickness; LSM, liver stiffness measurement; CAP, controlled attenuation parameter; ROC, receiver operating characteristic; ASE, American Society of Echocardiography.
Introduction
Metabolic dysfunction-associated steatotic liver disease (MASLD)1), also known as non-alcoholic fatty liver disease, is a hepatic manifestation of metabolic dysfunction, and its prevalence has increased worldwide in recent years2). MASLD has a similar background to atherosclerosis, including obesity and abnormalities in glucose and lipid metabolism, and liver steatosis is also a risk factor for atherosclerosis3, 4). Recent accumulating evidence has suggested that cardiovascular disease (CVD) is a leading cause of death in patients with MASLD, together with extrahepatic malignancy and liver-related death, including death from hepatocellular carcinoma and hepatic decompensation events5-7). It has also been reported that MASLD is a risk factor for CVD, independent of other known risk factors, such as age, sex, body mass index (BMI), smoking, diabetes mellitus, alcohol consumption, and dyslipidemia5). Recent studies have indicated that MASLD is a risk factor for ischemic heart disease, heart failure, atrial fibrillation, and brain stroke8-10). Ischemic heart disease based on coronary atherosclerosis is the leading cause of cardiovascular death globally11). Therefore, atherosclerosis and underlying subclinical coronary artery stenosis (coronary AS) are reasonable targets for CVD surveillance in patients with MASLD12-14). Another study revealed that the severity of liver pathology findings is associated with the risk of CVD events15). Accumulating evidence has indicated that the fibrosis-4 (FIB-4) index and liver stiffness measured by transient elastography are reliable noninvasive methods for predicting liver fibrosis without a liver biopsy16, 17), suggesting that these parameters may be useful predictors of atherosclerosis and coronary AS.
Aim
In the present study, we aimed to clarify the associations between liver fibrosis-related parameters in MASLD and carotid atherosclerosis or coronary AS.
Methods
Patients
We retrospectively enrolled 153 patients with MASLD who underwent carotid artery ultrasound and FibroScan™ examination at our institution from January 2012 to December 2019. No patients had chest pain or electrocardiographic abnormalities related to acute ischemic heart disease, such as ST-segment elevation and high T waves. No patients had overt chronic ischemic heart disease. Six patients had a history of coronary heart disease and underwent surveillance with carotid artery ultrasound, and these patients were excluded from the coronary computed tomography angiography (CTA) analysis (Supplementary Fig.1). No patients had any other possible etiologies of liver disease, including habitual alcohol consumption (daily ethanol consumption ≥ 30 g in males and ≥ 20 g in females), hepatitis B surface antigen positivity, hepatitis C virus RNA positivity, and abnormal thyroid function. Furthermore, no patients had autoimmune liver diseases, drug-induced hepatotoxicity, hemochromatosis, or Wilson’s disease.
The study protocol was approved by the Clinical Research Ethics Review Committee of our institution, and the study was performed in accordance with the principles of the 1975 Declaration of Helsinki, as revised in 2013. The opt-out procedure was used for patients to withdraw consent in response to inclusion in the study.
Definitions of Steatosis and MASLD
All patients underwent abdominal ultrasound to assess steatosis, which was diagnosed in accordance with the following ultrasound findings18). The presence of steatosis was recognized as an increase in hepatic echogenicity, poor penetration of the posterior segment of the right lobe of the liver, and poor or no visualization of the hepatic vessels and diaphragm. All patients met at least one of the cardiometabolic criteria (overweight [BMI ≥ 23 kg/m2], glucose intolerance, hypertension, hypertriglyceridemia, low high-density lipoprotein cholesterolemia (low HDL-C), as required for the diagnosis of MASLD1).
Physical Examination and Serum Biochemical Measurements
Systolic blood pressure, body weight, and height were measured, and BMI was calculated as body mass (in kg) divided by the square of height (in m2). Venous blood samples were obtained after overnight fasting, and aspartate aminotransferase (AST), alanine aminotransferase (ALT), γ-glutamyl transferase (GGT), total cholesterol, triglycerides, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), platelet count, albumin, and hemoglobin A1c (HbA1c) were measured using conventional laboratory techniques. FIB-4 index was calculated as age×AST÷[platelet count×(ALT)1/2], and low (1.3) and high (2.67) cutoff values of the index were used to negate and suspect severe liver fibrosis (fibrosis stage 3 or cirrhosis), respectively16).
Intima–Media Thickness Measurement
Carotid artery intima–media thickness (IMT) was measured using ultrasound (LOGIQ E10; GE Healthcare, Tokyo, Japan). Carotid ultrasound was performed by an experienced operator using a high-frequency linear probe with a 3–5-cm field of view in B-mode. A center frequency of 9 MHz was used to achieve IMT measurement accuracy. IMT was defined as the intima–media complex thickness of the far wall. To assess the severity of carotid artery atherosclerosis, the maximum IMT value (Max-IMT) at the measurable site was used, including plaques in the left and right common carotid arteries, carotid sinus, and entire internal carotid artery. A Max-IMT of ≥ 1.5 mm was defined as significant atherosclerosis19).
Measurement of Liver Stiffness and Controlled Attenuation Parameter
Liver stiffness measurement (LSM) for evaluation of liver fibrosis and controlled attenuation parameter (CAP) measurement for evaluation of liver steatosis were performed within 6 months before and after the carotid ultrasound examination using vibration controlled transient elastography (FibroScan 502, Echosens, Paris, France). After overnight fasting, LSM was performed in the right hepatic lobe by an operator who had experienced at least 500 examinations. M probes were used for patients with a skin–liver surface distance of ≤ 25 mm, and XL probes were used for patients with a skin–liver surface distance of ＞25 mm. After determining the optimal site without blood vessels and space-occupying lesions using B-mode ultrasound, LSMs and CAP measurements were performed until 10 valid measurements had been obtained for each patient, and the median value was used to quantify liver fibrosis and adiposity. The units for LSMs and CAP measurements were kPa and dB/m, respectively. Based on previous report, we defined measurement failure as examinations in which 10 valid LSMs and CAP measurements were not obtained after ≥ 10 attempts. In patients with 10 valid LSMs, an LSM of ≥ 7.1 kPa and an interquartile range-to-median ratio of ＞30% were defined as unreliable20). Unreliable CAP measurements were not defined because CAP performance for the diagnosis of steatosis is not affected by measurement variability21). Patients with measurement failure or unreliable values were not included in the study. For LSM, a cutoff value of 8.9 kPa was used to predict severe liver fibrosis (fibrosis stage 3 or cirrhosis)17).
CTA Protocol
Among the 92 patients with a Max-IMT of ≥ 1.1 mm on carotid ultrasound, CTA was performed in 41 patients. The other 51 patients did not undergo CTA because of previous allergic reaction to contrast agent, concomitant bronchial asthma, renal dysfunction, and/or patient refusal (Supplementary Fig.1). Six patients were subsequently excluded because of a previous diagnosis and treatment for coronary AS-related ischemia. The remaining 35 patients were analyzed. All CTA images were visually evaluated by a cardiologist (Y.S.). The following stenosis grading scale recommended in the Society of Cardiovascular Computed Tomography guidelines was used: none, ＜25% stenosis; mild, 25%–49% stenosis; moderate, 50%–69% stenosis; severe, 70%–99% stenosis. Severe coronary AS was defined as 70%–99% luminal stenosis22).
Statistical Analysis
Continuous variables were expressed as median (interquartile range), and differences between the two groups were compared using the Mann–Whitney U test. Categorical variables were presented as number (percentage), and Fisher’s exact test was used to compare these variables between the groups. Spearman’s rank correlation coefficient was used to evaluate the correlations between two variables. A logistic regression model was used for the multivariate analysis. Explanatory variables for the multivariate analysis were selected according to significance in the univariate analyses. The diagnostic performance of Max-IMT for the diagnosis of significant coronary AS was determined by receiver operating characteristic (ROC) curve analysis. The optimal cutoff values were chosen to maximize the sum of the sensitivity and specificity using Youden’s index23). A cutoff value with at least 80% sensitivity and 80% specificity (separately) was also chosen. Differences were considered significant at p＜0.05. All analyses were performed using JMP Pro 14® (SAS Institute Inc., Cary, NC, USA).
Results
Characteristics of the Patients
The baseline characteristics of the overall patients and comparisons between the patients with and without significant carotid artery atherosclerosis are summarized in Table 1. Patients with significant carotid artery atherosclerosis were older (p＜0.001) and had a higher prevalence of hypertension (p=0.002) than those without significant atherosclerosis. BMI (p=0.002), albumin (p=0.032), and platelet count (p=0.019) were significantly lower in patients with significant atherosclerosis. HDL-C was significantly higher in patients with significant atherosclerosis (p=0.01), and statin use was more frequent in patients with significant carotid artery atherosclerosis than in those without (p=0.005). There were no significant differences in the prevalence of diabetes mellitus, dyslipidemia, or smoking between the two groups. Regarding the hepatic parameters, ALT (p=0.048) and CAP measurement (p=0.002) were significantly lower in patients with significant atherosclerosis. FIB-4 index (p＜0.001) and LSM (p=0.002) were significantly higher in patients with significant atherosclerosis (Supplementary Fig.2).
Table 1.Characteristics of the patients and comparison of the patients’ characteristics according to carotid atherosclerosis severity
| Variable |
Total
n = 153
|
Significant carotid atherosclerosis
n = 63
|
No significant carotid atherosclerosis -
n = 90
|
p-value
|
| Age, years |
60.0 (47.0-68.5) |
66 (58.0-74.0) |
53 (40-64) |
＜0.001 |
| Male, n (%)
|
65 (42.8) |
23 (36.5) |
43 (47.8) |
0.165 |
| BMI, kg/m2
|
28.5 (25.0-32.0) |
26.7 (23.5-30.4) |
28.9 (25.4-33.7) |
0.002 |
| Current smoker, n (%)
|
48 (31.4) |
24 (38.1) |
24 (26.7) |
0.135 |
| Hypertension, n (%)
|
100 (65.4) |
43 (68.3) |
38 (42.2) |
0.002 |
| Diabetes mellitus, n (%)
|
75 (49.0) |
31 (49.2) |
44 (48.9) |
0.969 |
| Dyslipidemia, n (%)
|
118 (77.1) |
53 (84.1) |
65 (72.2) |
0.080 |
| Statin use |
62 (40.8) |
34 (54.0) |
28 (31.1) |
0.005 |
| Albumin, g/dL |
4.20 (3.90-4.40) |
4.10 (3.90-4.30) |
4.20 (3.95-4.40) |
0.032 |
| Platelet counts, ×103/μL
|
204 (161-264) |
189 (142-233) |
215 (170-282) |
0.019 |
| AST, U/L |
47.0 (30.5-69.0) |
51.0 (28.0-72.0) |
46.5 (31.0-69.0) |
0.914 |
| ALT, U/L |
51.0 (34.0-91.0) |
44.0 (28.0-86.0) |
57.0 (36.0-93.3) |
0.048 |
| GGT, U/L |
62.0 (34.5-104.5) |
61.0 (34.0-117.0) |
62.5 (34.8-98.3) |
0.559 |
| Total cholesterol, mg/dL |
188 (162-204) |
141 (108-177) |
157 (98.0-226) |
0.040 |
| Triglycerides, mg/dL |
147 (102-197) |
186 (162-201) |
189 (164-206) |
0.490 |
| LDL-C, mg/dL |
113 (95.0-134) |
108 (87.0-129) |
118 (98.0-138) |
0.133 |
| HDL-C, mg/dL |
51.0 (43.0-60.3) |
54.0 (44.0-65.0) |
49.0 (43.0-57.0) |
0.010 |
| HbA1c, % |
6.20 (5.70-7.00) |
6.20 (5.60-7.20) |
6.15 (5.73-6.98) |
0.432 |
| FIB-4 index |
1.74 (0.94-2.98) |
2.48 (1.47-4.32) |
1.45 (0.83-2.34) |
＜0.001 |
| LSM, kPa |
7.60 (5.30-12.1) |
8.00 (5.50-17.1) |
7.15 (5.08-11.1) |
0.002 |
| CAP, dB/m |
288 (251-322) |
283 (228-316) |
297 (258-326) |
0.002 |
| Max-IMT, mm |
1.3 (0.8-2.0) |
2.1 (1.7-2.5) |
0.9 (0.7-1.2) |
＜0.001 |
Continuous data are shown as the median (interquartile range). Abbreviations: BMI, body mass index; AST, aspartate aminotransferase; ALT, alanine aminotransferase; GGT, γ-glutamyl transpeptidase; LDL-C, low-density lipoprotein cholesterol; HDL-C, high-density lipoprotein cholesterol; HbA1c, hemoglobin A1c; FIB-4 index, fibrosis-4 index; LSM, liver stiffness measurement; CAP, controlled attenuation parameter; Max-IMT, maximum intima–media thickness.
The correlations between hepatic fibrosis-associated parameters and Max-IMT were evaluated (Fig.1, Supplementary Table 1). Max-IMT was significantly positively correlated with age (ρ=0.442, p＜0.001) and weakly negatively correlated with platelet count (ρ=−0.202, p＜0.012) and serum albumin (ρ=−0.176, p=0.031). FIB-4 index was positively correlated with Max-IMT(ρ=0.356, p＜0.001) (Fig.1A). A weak, but significant, positive correlation was also noted between LSM and Max-IMT (ρ=0.250, p=0.002) (Fig.1B). CAP measurement was negatively correlated with Max-IMT (ρ=−0.291, p＜0.001) (Fig.1C).
Supplementary Table 1.Correlation between Max-IMT and clinical parameters
|
ρ-value |
p-value
|
| Age |
0.442 |
＜0.001 |
| BMI |
-0.248 |
0.002 |
| Albumin |
-0.176 |
0.031 |
| Platelet counts |
-0.202 |
0.012 |
| AST |
0.053 |
0.517 |
| ALT |
-0.154 |
0.057 |
| GGT |
0.024 |
0.769 |
| Total cholesterol |
-0.086 |
0.312 |
| Triglycerides |
-0.169 |
0.039 |
| LDL-C |
-0.126 |
0.128 |
| HDL-C |
0.094 |
0.251 |
| HbA1c |
0.036 |
0.661 |
| FIB-4 index |
0.356 |
＜0.001 |
| LSM |
0.250 |
0.002 |
| CAP |
-0.291 |
＜0.001 |
Correlation was tested using Spearman‘s rank correlation coefficient. Abbreviations: Max-IMT, maximum intima-media thickness; BMI, body mass index; AST, aspartate aminotransferase; ALT, alanine aminotransferase; GGT, γ-glutamyl transpeptidase; LDL-C, low-density lipoprotein cholesterol; HDL-C, high-density lipoprotein cholesterol; HbA1c, hemoglobin A1c; FIB-4 index, fibrosis 4 index; LSM, liver stiffness measurement; CAP controlled attenuation parameter.
A multivariate analysis was performed to identify the factors associated with significant carotid artery atherosclerosis (Table 2). Among the significant variables in the univariate analyses (Table 1), BMI was negatively correlated and statin use was positively associated with significant carotid artery atherosclerosis (odds ratio [OR] 0.871, p=0.014 and OR 2.69, p=0.02, respectively). LSM (OR 1.129, p=0.001) was identified as the independent factor with the strongest positive association with significant carotid artery atherosclerosis. Platelet count was not examined in the multivariate analysis because of confounding with the FIB-4 index.
Table 2.Factors associated with significant carotid artery atherosclerosis
| Covariates |
Odds ratio |
95% CI |
p-value
|
| Age |
1.031 |
0.987-1.077 |
0.160 |
| BMI |
0.871 |
0.777-0.976 |
0.014 |
| Hypertension |
2.346 |
0.872-6.316 |
0.088 |
| Statin use |
2.690 |
1.156-6.262 |
0.020 |
| Albumin |
0.952 |
0.287-3.157 |
0.936 |
| Triglycerides |
1.000 |
0.995-1.004 |
0.894 |
| HDL-C |
1.031 |
0.992-1.072 |
0.113 |
| FIB-4 index |
0.950 |
0.644-1.401 |
0.795 |
| LSM |
1.129 |
1.040-1.225 |
0.001 |
| CAP |
0.997 |
0.987-1.007 |
0.522 |
The logistic regression model was used for the analysis. Abbreviations: CI, confidence interval; BMI, body mass index; HDL-C, high-density lipoprotein cholesterol; FIB-4 index, fibrosis-4 index; LSM, liver stiffness measurement; CAP, controlled attenuation parameter.
When ≥ 70% coronary AS was defined as severe stenosis, 14 patients had significant coronary AS (coronary AS+), while 21 patients did not (coronary AS−) (Table 3). When the characteristics of the two groups were compared, there were no differences in physical parameters, prevalences of concomitant diseases, or blood test findings. Max-IMT was greater in the coronary AS+ group (p＜0.001) (Supplementary Fig.3). No significant differences were found between the two groups for FIB-4 index, LSM, and CAP. However, when coronary AS was categorized as no stenosis (＜25%), mild to moderate stenosis (25%–69%), or severe stenosis (70%–99%), 75% of individuals with FIB-4 index ＜1.30 had moderate or severe coronary artery stenosis, while 25% of those had no coronary AS. On the other hand, 86.7% of individuals with FIB-4 index ≥ 2.67 had moderate or severe coronary artery stenosis, while 13.2% of those had no coronary AS, indicating that individuals with higher the FIB-4 index had moderate or severe coronary artery stenosis more frequently (Fig.2A). Similarly, 73.7% of individuals with LSM ＜8.9 kPa had coronary stenosis ＞25%, while 26.3% of individuals had no stenosis. Contrary, 93.8% of individuals with LSM ≥ 8.9 kPa had coronary stenosis ＞25%, while 6.3% of individuals with LSM ≥ 8.9 kPa had no stenosis, suggesting that individuals with higher LSM level also had moderate or severe coronary artery stenosis more frequently, especially severe stenosis (Fig.2B).
Table 3.Comparison of characteristics according to the presence of severe coronary artery stenosis
| Variable |
Coronary AS+n = 14
|
Coronary AS-n = 21
|
p-value
|
| Age, years |
62.5 (57.8-71.8) |
64 (55-66.5) |
0.670 |
| Male, n (%)
|
6 (42,9) |
9 (42.9) |
1.000 |
| BMI, kg/m2
|
26.6 (25.2-30.8) |
26.5 (24.9-31.3) |
0.892 |
| Current smoker, n (%)
|
7 (50.0) |
8 (38.1) |
0.486 |
| Hypertension, n (%)
|
10 (71.4) |
11 (52.4) |
0.255 |
| Diabetes mellitus, n (%)
|
7 (50.0) |
12(57.1) |
0.969 |
| Dyslipidemia, n (%)
|
11 (78.6) |
17 (81.0) |
0.863 |
| Statin use |
8 (57.1) |
8 (38.1) |
0.268 |
| Albumin, g/dL |
4.15 (3.88-4.43) |
4.10 (3.95-4.35) |
0.706 |
| Platelet counts, ×103/μL
|
189 (142-233) |
202 (156-250) |
0.708 |
| AST, U/L |
52.5 (37.8-70.3) |
50.0 (34.5-81.5) |
0.640 |
| ALT, U/L |
48.5 (39.5-67.3) |
53.0 (38.0-100) |
0.313 |
| GGT, U/L |
83.5 (49.3-132) |
60.0 (25.0-79.5) |
0.103 |
| Triglycerides, mg/dL |
131 (97.3-176) |
155 (90.0-192) |
0.355 |
| Total cholesterol, mg/dL |
192 (177-201) |
184 (157-200) |
0.606 |
| LDL-C, mg/dL |
116 (108-126) |
106 (85.0-134) |
0.353 |
| HDL-C, mg/dL |
55.0 (45.3-63.5) |
53.0 (45.5-61.0) |
0.942 |
| HbA1c, % |
6.35 (5.70-8.85) |
6.60 (5.60-7.05) |
0.162 |
| LSM, kPa |
12.2 (5.4-21.4) |
7.80 (6.0-12.9) |
0.310 |
| CAP, dB/m |
284 (215-350) |
276 (228-320) |
0.647 |
Continuous data are shown as the median (interquartile range). Abbreviations: coronary AS, coronary artery stenosis; BMI, body mass index; AST, aspartate aminotransferase; ALT, alanine aminotransferase; GGT, γ-glutamyl transpeptidase; LDL-C, low-density lipoprotein cholesterol; HDL-C, high-density lipoprotein cholesterol; HbA1c, hemoglobin A1c; LSM, liver stiffness measurement; CAP, controlled attenuation parameter.
Because Max-IMT was the only factor showing a significant difference between the patients with and without severe coronary AS, the diagnostic accuracy of Max-IMT for severe coronary AS (＞70%) was examined in a ROC curve analysis. The area under the ROC curve was 0.770, and the optimal cutoff was 1.5 mm with 100% sensitivity, 42.9% specificity, 53.8% positive predictive value, and 100% negative predictive value (Fig.3). To obtain sensitivity or specificity of ＞80%, the cutoff values of 1.7 mm (85.7% sensitivity, 57.1% specificity, 57.1% positive predictive value, 85.7% negative predictive value) and 2.2 mm (50% sensitivity, 85.7% specificity, 70% positive predictive value, 72% negative predictive value) were chosen.
The Usefulness of Hepatic Parameters to Predict Advanced Atherosclerosis
In the Japanese clinical practice guidelines for non-alcoholic fatty liver disease/non-alcoholic steatohepatitis, evaluation of subclinical CVD, such as loaded electrocardiogram or carotid artery ultrasound, is recommended if the platelet count is ＜200×103/µL and/or the FIB-4 index is ≥ 2.67 or if one or more cardiometabolic risk factor is observed24). Accordingly, we examined the associations between the number of fulfilled cardiometabolic criteria for the diagnosis of MASLD (overweight, glucose intolerance, hypertension, hypertriglyceridemia, low HDL-C)1) and carotid atherosclerosis (Supplementary Table 2). As the number of cardiometabolic criteria that were met increased, carotid Max-IMT significantly increased (p=0.026). Next, we examined the performance of platelet count, FIB-4 index, and LSM to predict significant atherosclerosis of the carotid artery (Supplementary Table 3). Based on the positive predictive value for an individual examination, approximately one-half of the patients (45.3%–63.8%) with advanced liver fibrosis associated parameters showed significant atherosclerosis of the carotid artery (Max-IMT of ≥ 1.5 mm). FIB-4 index showed the greatest positive predictive value (63.8%). Meanwhile, the false-negative rate was 38.1%–54%, suggesting that these patients had significant atherosclerosis of the carotid artery despite having a platelet count of ≥ 200×103/µL, FIB-4 index of ＜2.67, and/or LSM of ＜8.9 kPa.
Supplementary Table 2.Association between the number of positive components in MASLD criteria and carotid atherosclerosis
|
Number of positive components |
p value
|
| 1 |
2 |
3 |
4 |
5 |
| Prevalence, n (%) (n = 153 in total)
|
3 (2.0) |
15 (9.8) |
34 (22.2) |
44 (28.8) |
57 (37.3) |
- |
| Carotid Max-IMT, mm (n = 153 in total)
|
0.5
(0.5-0.6)
|
0.9
(0.7-1.6)
|
1.25
(0.9-1.75)
|
1.40
(0.9-2.3)
|
1.3
(0.8-1.85)
|
0.026 |
Continuous data are shown as the median (interquartile range). Abbreviations: Max-IMT, maximum intima-media thickness.
Supplementary Table 3.Prediction performance of liver fibrosis-related parameters to identify significant carotid atherosclerosis
|
|
Max-IMT |
Sens. (%) |
Spes. (%) |
PPV (%) |
NPV (%) |
FNR (%) |
FPR (%) |
|
≥ 1.5 mm
(n = 63)
|
＜1.5 mm
(n = 90)
|
| Platelet |
＜200×103/μL (n = 71)
|
39 |
32 |
61.9 |
64.4 |
54.9 |
70.7 |
38.1 |
35.6 |
| ≥ 200×103/μL (n = 82)
|
24 |
58 |
| FIB-4 |
≥ 2.67 (n = 47)
|
30 |
17 |
47.6 |
81.1 |
63.8 |
68.9 |
52.4 |
18.9 |
| ＜2.67 (n = 106)
|
33 |
73 |
| LSM |
≥ 8.9 kPa (n = 64)
|
29 |
35 |
46.0 |
61.1 |
45.3 |
61.8 |
54 |
38.9 |
| ＜8.9 kPa (n = 89)
|
34 |
55 |
Abbreviations: FIB-4 index, fibrosis-4 index; LSM, liver stiffness measurement; Max-IMT, maximum intima–media thickness; Sens., sensitivity; Spes., specificity; PPV, positive predict value; NPV, negative predict value; FNR, false negative rate; FPR, false positive rate.
Discussion
The present study has demonstrated that liver fibrosis is positively correlated with Max-IMT and associated with an increase in Max-IMT, independent of known risk factors, including BMI and hypertension. Among patients with MASLD and a Max-IMT of ≥ 1.1 mm, patients without coronary AS decreased in accordance with increasing severity of liver fibrosis evaluated by the FIB-4 index and LSM. Accumulating evidence has suggested that the severity of pathological liver findings is associated with the risk of CVD15, 25, 26). In the longitudinal Swedish cohort study conducted by Simon et al.15), the CVD event risk was stratified by pathological liver findings of MASLD. Cirrhosis was the most significant risk factor for CVD events, followed by steatohepatitis with fibrosis, steatohepatitis without fibrosis, and simple steatosis. These pathological findings were associated with CVD event risk, independent of age and other cardiometabolic risks. In the study conducted by Niikura et al.25), pathological steatohepatitis was associated with coronary AS, as evaluated by CTA, in patients with liver biopsy-proven MASLD and chest pain or electrocardiographic abnormalities. In the present study, liver stiffness was greater in patients with severe atherosclerosis, and it was independently associated with atherosclerosis. The risk factors for, and underlying pathogenesis of, MASLD and CVD overlap. Visceral obesity, diabetes mellitus, and dyslipidemia are well-established risk factors for the occurrence and progression of MASLD and CVD27). The overlapping features include increased insulin resistance, chronic inflammation, renin–angiotensin–aldosterone system deterioration, hepatic steatosis, and fibrosis, as well as atherosclerosis28, 29).
According to the Japanese clinical practice guidelines for non-alcoholic fatty liver disease/non-alcoholic steatohepatitis24), consultation with a cardiologist is recommended if the patient has CVD complications and/or a history of CVD and/or electrocardiogram abnormalities. For patients without these conditions, loaded electrocardiogram or carotid artery ultrasound is recommended if the patient has suspected advanced liver fibrosis based on a low platelet count (＜200×103/µL) and/or a high FIB-4 index (≥ 2.67). For patients with platelet count of ≥ 200×103/µL and FIB-4 index of ＜2.67, loaded electrocardiogram or carotid artery ultrasound is recommended if one or more cardiometabolic risk factors are observed. Accumulation of cardiometabolic risk factors, which is required for diagnosis of MASLD, is generally associated with carotid artery atherosclerosis. Indeed, we identified a positive correlation between Max-IMT and the number of cardiometabolic criteria that were fulfilled, suggesting that increased cardiovascular risk is associated with carotid artery atherosclerosis in patients with MASLD. MASLD patients with multiple cardiometabolic risk factors also have a high risk of CVD and should be placed under surveillance. Regarding liver fibrosis criteria for screening of CVD, platelet count (＜200×103/µL) and FIB-4 index (≥ 2.67) were useful tools to identify significant carotid atherosclerosis, with positive predictive values of 54.9% and 63.8%, respectively, in the present study. LSM (≥ 8.9 kPa) also showed a positive predictive value of 45.3%. These data suggest that approximately one-half of the patients who meet the liver fibrosis criteria actually have significant carotid atherosclerosis and should be prioritized for CVD screening. However, considering the inadequate sensitivities and specificities, as well as the certain false-negative rates, these examinations for evaluation of liver fibrosis cannot be employed as single predictors of atherosclerosis.
Measurement of plaque thickness and carotid artery IMT using ultrasound is useful to predict the coronary artery disease risk19). It has been reported that the maximum plaque thickness associated with coronary AS, and therefore the cutoff value, is ≥ 1.54 mm30), and that plaque thickness is associated with primary major adverse cardiovascular events (MACEs) (cutoff value=1.96 mm) and secondary MACEs (cutoff value=3.13 mm)31). A recent guideline from the American Society of Echocardiography (ASE) suggested that patients with either IMT or plaque thickness of ≥ 1.5 mm have at least an intermediate risk of CVD, and should be recommended for subsequent evaluation19). The present study used the ASE criteria, and significant atherosclerosis was defined when either IMT or maximum plaque thickness was ≥ 1.5 mm. In the present study, Max-IMT was the only factor associated with severe coronary AS, suggesting that carotid ultrasound and Max-IMT evaluation may be unique screening tools to predict subclinical coronary AS in patients with MASLD. As a result, the optimal Max-IMT cutoff value to detect severe coronary AS (≥ 70% stenosis) was 1.5 mm for rule-in and 2.2 mm for rule-out according to the ROC curve analysis.
Dyslipidemia is a robust risk factor for atherosclerosis and coronary AS. In the present study, HDL-C was paradoxically higher in patients with significant carotid artery atherosclerosis than in those without. Moreover, statin use was more frequent in patients with significant carotid artery atherosclerosis than in those without, and statin use was identified as an independent predictor for the presence of significant carotid artery atherosclerosis. It is evident that statin treatment for dyslipidemia prevents atherosclerosis32). Moreover, statins reduce the risk of MASLD in patients with dyslipidemia, and also reduce the risk of CVD in patients with MASLD and dyslipidemia33). Therefore, the paradoxical result for HDL-C and statin use in the present study is considered to be an effect of statin treatment, and patients with significant carotid artery atherosclerosis are frequent statin users. In the present study, liver steatosis, measured by CAP, also paradoxically showed a negative correlation with Max-IMT. A possible explanation is the negative correlation between CAP and age (ρ=−0.39, p＜0.001) observed in the study (data not shown). Patients with higher CAP had characteristics of younger age and less severe atherosclerosis.
The present study has several limitations that should be considered. The study was a retrospective, cross-sectional, single-center study with a small population. FibroScan examination was used to predict liver fibrosis and steatosis instead of a liver biopsy. Patients with a Max-IMT of ＜1.1 mm were not evaluated for coronary AS because CTA was not performed in these patients. To confirm the IMT cutoff value on carotid artery ultrasound and to clarify the associations among hepatic pathological findings, atherosclerosis, and coronary AS in MASLD, further multi-center prospective and longitudinal studies involving larger numbers of patients with liver biopsy-proven MASLD will be needed. However, all patients included in the present study underwent carotid artery ultrasound and FibroScan examinations, whereby the association between liver fibrosis and atherosclerosis was, at least partly, identified.
Acknowledgements
We sincerely thank Maki Miyahara and all of the medical staff and the processing personnel at the research facilities who collected the clinical data. We thank Aya Kurashige, Mayumi Maeda and Yasue Matsumoto for their carotid ultrasound examinations. We thank Emily Woodhouse, PhD, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.
Notice of Grant Support
This research was supported by the Research Program on Hepatitis from Japan Agency for Medical Research and Development (AMED) [grant number JP24fk0210149], and the Health, Labour, and Welfare Policy Research Grants from the Ministry of Health, Labour, and Welfare of Japan (Policy Research for Hepatitis Measures [grant number 23HC2002]).
Conflict of Interest Disclosure
We have nothing to declare for this study.
Ethics Approval Statement
The study protocol was approved by the Clinical Research Ethics Review Committee of Saga University Hospital. The study was performed in accordance with the principles of the 1975 Declaration of Helsinki, as revised in 2013.
Patient Consent Statement
The opt-out procedure was used for patient withdrawal of consent in response to inclusion in the study.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author on reasonable request.
Permission to Reproduce Material from Other Sources
Not applicable.
Clinical Trial Registration
Not applicable.
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