Abstract Introduction An elevated aspartate aminotransferase to alanine aminotransferase (AST/ALT) ratio has been reported to be associated with an increased risk of cardiovascular disease (CVD) in primary care patients and those with a history of CVD. However, its association to future CVD events in high-risk diabetic patients with diabetic complication(s) but no history of CVD remains unclear. Purpose This study aimed to investigate whether the AST/ALT ratio is associated with future CVD events in high-risk diabetic patients without a history of CVD. Methods A post-hoc analysis was conducted using data from the EMPATHY study, which compared intensive and standard statin therapy in patients with type 2 diabetes mellitus, diabetic retinopathy, and hypercholesterolaemia, all without a history of CVD. Patients were categorized into two groups based on previous studies and the median AST/ALT ratio in this study (cut-off: 1.0). The association between the AST/ALT ratio and CVD events was analysed. Results A total of 4,871 patients were divided into the high ( 1.0, n = 2,414) and the low (≤ 1.0, n = 2,457) AST/ALT ratio groups. During a median follow-up of 36.7 months, 261 CVD events occurred. The CVD incidence was significantly higher in the high AST/ALT ratio group than in the low AST/ALT ratio group (P = 0.008, log-rank test; Fig. 1). Multivariate Cox regression analysis showed that the high AST/ALT ratio was significantly associated with an increased risk of CVD compared to the low AST/ALT ratio (HR, 1.36 95% CI, 1.04–1.79, P = 0.002). This association remained significant when analysing the AST/ALT ratio as a continuous variable. Cubic spline curves indicated no linear relationship between either AST or ALT levels and CVD events, whereas the AST/ALT ratio exhibited a linear association (Fig. 2). The association was consistent across subgroups stratified by sex, age, body mass index, and hemoglobin A1c, and remained robust even after excluding patients with alcoholic liver disease and metabolic dysfunction-associated steatotic liver disease. Conclusions An elevated AST/ALT ratio was significantly associated with an increased risk of CVD in diabetic patients with, diabetic retinopathy, and hypercholesterolaemia without a history of CVD. The AST/ALT ratio may serve as a simple and cost-effective biomarker for identifying diabetic patients at higher risk of future CVD events. Monitoring this ratio could facilitate early detection and management of cardiovascular risk in this population.Fig.1 Fig.2
Ono et al. (Sat,) studied this question.