Impact of steatotic liver diseases on diabetes mellitus risk in patients with atrial fibrillation: a nationwide population study

Hyunho Ryu; So-Ryoung Lee; Eue‐Keun Choi; Y. Go; Kyung-Yeon Lee; JungMin Choi; Seokmoon Han; Jae-Hyun Kim; Hyo‐Jeong Ahn; Soonil Kwon; Bong-Seoung Kim; Kyungdo Han; Sang‐Hyun Oh; Gregory Y H Lip

doi:10.1186/s12933-025-02795-5

June 7, 2025Cardiovascular DiabetologyOpen Access

Impact of steatotic liver diseases on diabetes mellitus risk in patients with atrial fibrillation: a nationwide population study

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Why the study?

AF and DM frequently coexist with worse prognosis, and while steatotic liver disease may predispose to DM, its impact among patients with AF is unclear.

Does steatotic liver disease increase the risk of incident diabetes mellitus in non-diabetic patients with atrial fibrillation?

Structured PICO

Does steatotic liver disease increase the risk of incident diabetes mellitus in non-diabetic patients with atrial fibrillation?

P

Population

195,195 non-diabetic individuals who developed atrial fibrillation (AF) between 2010 and 2018 from the Korean National Health Insurance Service database, mean age 64.4 ± 13.0 years, 57.5% male.

I

Intervention

Steatotic liver disease (SLD) categorized as metabolic dysfunction-associated SLD (MASLD), MASLD with increased alcohol intake (MetALD), or alcohol-related liver disease (ALD) based on fatty liver index (FLI) ≥ 30 and daily alcohol intake.

C

Comparator

Non-SLD (FLI < 30).

O

Outcome

Incident diabetes mellitus (DM).

Steatotic liver disease significantly increases the risk of new-onset diabetes mellitus in patients with atrial fibrillation, particularly among younger adults.

Implication

SLD subtypes were associated with higher incident DM in AF; leaves open whether screening alters outcomes in this population.

Abstract

BACKGROUND: Atrial fibrillation (AF) frequently coexists with diabetes mellitus (DM), leading to a worse prognosis if both are present. Steatotic liver disease (SLD) may also predispose to DM, but its impact among AF patients is unclear. We aimed to determine whether metabolic dysfunction-associated SLD (MASLD), MASLD with increased alcohol intake (MetALD), or alcohol-related liver disease (ALD) elevates DM risk in AF. METHODS: Non-diabetic individuals who developed AF between 2010 and 2018 from the Korean National Health Insurance Service database were included. Patients with a fatty liver index (FLI) < 30 were classified as non-SLD, whereas those with FLI ≥ 30 and at least one cardiometabolic risk factors were categorized as MASLD, MetALD, or ALD based on daily alcohol intake. Incident DM hazard ratios (HRs) were estimated with Cox regression models. RESULTS: Among 195,195 patients (mean age 64.4 ± 13.0 years, 57.5% male); 108,918 (55.8%) in non-SLD, 71,795 (36.8%) in MASLD, 7644 (3.9%) in MetALD, and 6838 (3.5%) in ALD, respectively. Over a mean follow-up of 6.0 ± 2.9 years, 25,632 (13.0%) developed DM. Compared with non-SLD, the adjusted HRs with 95% confidence intervals (CIs) for incident DM were 1.930 (1.879-1.983), 1.789 (1.682-1.904), and 1.932 (1.817-2.054) for MASLD, MetALD, and ALD, respectively. In the age 20-39 years group, adjusted HRs with 95% CIs were 5.844 (4.501-7.587), 5.354 (3.681-7.787), and 7.033 (4.660-10.615), respectively. CONCLUSION: SLD confers an increased risk of new-onset DM in AF patients, especially in younger adults. Implementing management strategies to prevent DM in AF patients with SLD might mitigate the risk of DM and its potential impact on AF-related outcomes.