FIB‐4 Serves as a Referral Index for Coronary Artery Calcification in Patients With MASLD

Background/Aims The association between metabolic dysfunction‐associated steatotic liver disease (MASLD), liver fibrosis, and coronary artery calcification (CAC) remains uncertain. We investigated their relationships and the predictive role of the Fibrosis‐4 (FIB‐4) index. Methods The study included 6058 subjects undergoing health check‐ups and coronary computed tomography. Steatotic liver disease (SLD) was identified via ultrasonography or hepatic steatosis index > 36. MASLD was defined as SLD with at least one of the five cardiometabolic risk factors. Liver fibrosis severity was assessed using the FIB‐4 index to assess its association with CAC and predictive performance at different CAC thresholds. Results MASLD was present in 39.8% of participants, with a higher CAC prevalence than non‐MASLD individuals (51.1% vs. 42.5%, p < 0.001). Factors associated with the presence of CAC included age (odds ratio [OR]/95% confidence intervals [CI]: 1.117/1.106–1.128, p < 0.001), male gender (OR/95% CI: 4.448/3.660–5.406, p < 0.001), MASLD (OR/95% CI: 1.570/1.342–1.837, p < 0.001), and FIB‐4 (OR/95% CI: 1.217/1.034–1.433, p = 0.018). Among MASLD subjects, the prevalence of CAC increased with FIB‐4 value and cardiometabolic burdens. FIB‐4 values increased progressively in patients with higher coronary artery calcium scores ( p ‐trend < 0.001). A FIB‐4 cut‐off of ≥ 2.67 provided the highest positive predictive value (89.7%) for the presence of CAC, while a cut‐off of 1.26 offered the best negative predictive value (95.1%) for severe CAC. Conclusion MASLD patients with elevated FIB‐4 are at increased risk of coronary atherosclerosis. Incorporating FIB‐4 into routine assessment may help identify high‐risk individuals who could benefit from early cardiology referral and preventive cardiovascular care.