Editorial: Beyond Viral Eradication—Cardiometabolic Risk and Cardiovascular Outcomes After SVR in Chronic Hepatitis C

The advent of direct-acting antivirals (DAAs) has dramatically altered the natural history of chronic hepatitis C, shifting the clinical focus from viral eradication to the long-term management of residual intrahepatic and extrahepatic risks including cardiovascular disease after achieving a sustained virologic response (SVR) 1-3. Steatotic liver disease (SLD) is an increasingly prevalent chronic liver disease and is recognized as a risk factor not only for liver-related events but also for cardiovascular events and extrahepatic malignancies 4. Although SLD frequently coexists with chronic hepatitis C and has been positioned as a risk factor for hepatocellular carcinoma, its impact on extrahepatic outcomes, particularly cardiovascular disease, has not been fully clarified 5, 6. From this background, the study by Tsai et al. provides important insights into how SLD and cardiometabolic risk burden shape major adverse cardiovascular events (MACE) in patients with chronic hepatitis C after complete viral eradication 7. Using two large nationwide cohorts from Taiwan, the authors demonstrated that the incidence of MACE after successful hepatitis C treatment was significantly higher in patients with concomitant SLD than in those without SLD, with particularly elevated risk observed among patients with metabolic dysfunction–associated steatotic liver disease (MASLD). Importantly, a clear dose–response relationship was identified between the number of cardiometabolic risk factors and MACE, with hypertension showing the strongest contribution as a single factor. Similar patterns have been reported in broader MASLD populations, suggesting that patients with chronic hepatitis C who achieve complete viral eradication but have concomitant SLD should be followed with the same level of attention to MACE as patients with MASLD itself 8. This suggests that post-SVR care should focus on MACE as well as liver related events. One of the notable findings of this study is that the impact of cardiometabolic risk burden on MACE was most pronounced in patients without advanced liver fibrosis or chronic kidney disease. This paradoxical finding suggests that cardiometabolic risk is most relevant in earlier disease stages, while its impact may be masked by competing risks in advanced disease. Accordingly, cardiovascular risk assessment remains important even in patients with preserved hepatic and renal function after SVR. However, there are several limitations in this study. Cardiometabolic risk factors were assessed at baseline rather than longitudinal follow-up. Viral eradication of chronic hepatitis C has been suggested to alter lipid profiles and potentially influence atherosclerotic risk, and how cardiometabolic risk factors evolve after SVR and subsequently affect long-term outcomes remains an important area for future investigation 9, 10. Nevertheless, the large sample size, rigorous competing risk analyses, and consistent dose-dependent associations observed in this study support the robustness of the findings. In summary, Tsai et al. demonstrate that cardiometabolic risk, together with SLD, plays a central role in cardiovascular outcomes in patients with chronic hepatitis C after viral eradication. This study shifts the focus of post-SVR care from virologic success alone toward long-term metabolic risk management, highlighting MASLD as a critical therapeutic target. Future studies tracking metabolic changes and testing targeted interventions will be essential to translate these insights into meaningful improvements in patient outcomes. Shun-Ichi Wakabayashi: writing – original draft, writing – review and editing. Takefumi Kimura: writing – original draft, writing – review and editing. Naoki Tanaka: writing – review and editing, writing – original draft. This research was supported by AMED under grant number JP24fk0210125, JP256f0137007j0001 and by JSPS KAKENHI grant number JP25K20541. The authors declare no conflicts of interest. This article is linked to Tsai et al. papers. To view these articles, visit https://doi.org/10.1111/apt.70500 and https://doi.org/10.1111/apt.70567. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.