Non-alcoholic Fatty Liver Disease/Metabolic Dysfunction-Associated Steatotic Liver Disease and the Risk of Incident Atrial Fibrillation: An Updated Systematic Review and Meta-Analysis of Cohort Studies

Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly non-alcoholic fatty liver disease (NAFLD), has been inconsistently linked to incident atrial fibrillation (AF) across observational cohorts.We performed an updated systematic review and meta-analysis of cohort studies, following the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines, searching PubMed/MEDLINE, Embase, Scopus, and Web of Science through July 25, 2026, for studies comparing incident AF risk in adults with versus without NAFLD/MASLD.Adjusted effect estimates were pooled using a random-effects model, with heterogeneity assessed via the I² statistic and explored through subgroup and univariable meta-regression analyses.Eighteen cohort studies comprising over 15 million participants from Asia, Europe, and North America met inclusion criteria.Pooling all studies demonstrated a significantly increased risk of incident AF among individuals with NAFLD/MASLD compared with those without (pooled risk ratio (RR) 1.23, 95% confidence interval (CI) 1.12-1.34,p < 0.001), with substantial statistical heterogeneity (I² = 99.4%).In an exploratory analysis of three studies, advanced disease with hepatic fibrosis was also associated with increased AF risk (RR 1.19, 95% CI 1.11-1.28).In the present meta-analysis, NAFLD/MASLD was associated with a modestly higher risk of incident AF after adjustment for conventional cardiometabolic risk factors, although heterogeneity was very high.These findings support attention to AF risk in this population and the use of standardized diagnostic approaches in future research.