Prevalence and clinical correlates of metabolic dysfunction-associated steatotic liver disease in heart failure

Background The nomenclature change from non-alcoholic fatty liver disease to metabolic dysfunction-associated steatotic liver disease (MASLD) better encapsulates the associated metabolic milieu. While MASLD is associated with increased heart failure (HF) risk, characteristics and outcomes of MASLD in patients with HF remain unclear.This paper aims to examine the prevalence and clinical correlates of MASLD in patients with HF from the Asian Sudden Cardiac Death in Heart Failure (ASIAN-HF) Registry.Methods MASLD was defined as evidence of hepatic steatosis, with at least one of five metabolic criteria (among body mass index, glucose, blood pressure, triglycerides and high-density lipoprotein thresholds). Findings were externally validated in Clinical Data Analysis and Reporting System (CDARS), a Hong Kong HF cohort and BIOlogy Study to TAilored Treatment in Chronic Heart Failure (BIOSTAT-CHF), a HF cohort across 11 European countries.Results Of 2698 patients with HF in ASIAN-HF, 927 (34.4%) had MASLD. They were younger, more often women and more likely to have HF with preserved ejection fraction (HFpEF) compared with those without MASLD. All-cause mortality was lower in MASLD versus non-MASLD (7.1% vs 11.7%, p=0.001), even after multivariable adjustment (adjusted HR (aHR) 0.58, 95% CI 0.39 to 0.86, p=0.007). All-cause mortality was also lower in MASLD versus non-MASLD in CDARS and BIOSTAT-CHF; however, after multivariable adjustment, the association remained significant only in CDARS (aHR 0.82, 95% CI 0.80 to 0.84, p<0.001) and was attenuated in BIOSTAT-CHF (aHR 1.08, 95% CI 0.67 to 1.73, p=0.750). Using waist-to-height ratio instead of body mass index in the MASLD definition reclassified <3% of patients.Conclusions In patients with HF, MASLD is highly prevalent, especially in younger women with HFpEF and is associated with better 1-year survival than in those without MASLD.