Silent Liver and Silent Arteries: Graded Association between Fatty Liver Severity and Carotid Intima-media Thickness

Introduction: Non-alcoholic fatty liver disease (NAFLD) is increasingly recognized as an independent risk factor for cardiovascular disease. Carotid intima-media thickness (CIMT), measured by high-resolution ultrasonography, is a validated, non-invasive marker of early atherosclerosis. This study evaluated the association between ultrasonographic grades of fatty liver and CIMT in asymptomatic individuals. Methods: This prospective observational study conducted over 18 months included 303 asymptomatic individuals with fatty liver detected on routine abdominal ultrasonography. Patients with significant alcohol intake, chronic liver disease, or established cardiovascular disease were excluded. Fatty liver was graded (Grades I–III) using standard ultrasonographic criteria. Bilateral CIMT was measured using high-resolution Doppler ultrasonography at the common carotid artery. Mean CIMT values were compared across fatty liver grades, and statistical analysis was performed to evaluate the association between hepatic steatosis severity and CIMT. Results: Among the 303 participants, 211 (69.6%) had Grade I fatty liver, 81 (26.7%) had Grade II, and 11 (3.6%) had Grade III disease. A significant progressive increase in CIMT was observed with advancing fatty liver grade ( P < 0.001). Mean CIMT increased from 0.49 mm (right) and 0.51 mm (left) in Grade I to 0.63 mm and 0.66 mm in Grade II, reaching 0.76 mm and 0.88 mm, respectively, in Grade III. Patients with moderate-to-severe fatty liver (Grades II and III) had significantly higher CIMT than those with Grade I disease, indicating a greater burden of subclinical atherosclerosis. Conclusion: Higher grades of NAFLD are significantly associated with increased CIMT, suggesting a strong positive relationship between hepatic steatosis severity and early atherosclerotic changes. While Grade I fatty liver generally demonstrates normal CIMT, Grades II and III are associated with clinically relevant increases. Carotid ultrasonography is a simple, non-invasive tool that may aid cardiovascular risk stratification and early preventive intervention in patients with NAFLD.