Incremental prognostic value of non-alcoholic fatty liver disease over coronary computed tomography angiography findings in patients with suspected coronary artery disease

Association study of NAFLD with pericoronary adipose tissue and pericardial adipose tissue: Diagnosis of stable CAD patients with NAFLD based on radiomic features

BACKGROUND AND AIM

Nonalcoholic fatty liver disease (NAFLD) is prone to complicated cardiovascular disease, and we aimed to identify patients with NAFLD who are prone to developing stable coronary artery disease (CAD).

METHODS AND RESULTS

We retrospectively recruited adults who underwent coronary computed tomography angiography (CTA). A total of 127 NAFLD patients and 127 non-NAFLD patients were included in this study. Clinical features and imaging parameters were analysed, mainly including pericardial adipose tissue (PAT), pericoronary adipose tissue (PCAT), and radiomic features of 6792 PCATs. The inflammatory associations of NAFLD patients with PAT and PCAT were analysed. Clinical features (model 1), CTA parameters (model 2), the radscore (model 3), and a composite model (model 4) were constructed to identify patients with NAFLD with stable CAD. The presence of NAFLD resulted in a greater inflammatory involvement in all three coronary arteries (all P < 0.01) and was associated with increased PAT volume (r = 0.178**, P < 0.05). In the presence of NAFLD, the mean CT value of the PAT was significantly correlated with the fat attenuation index (FAI) in all three vessels and had the strongest correlation with the RCA FAI (r = 0.55, p < 0.001). A total of 9 radiomic features were screened by LASSO regression to calculate radiomic scores. In the model comparison, model 4 had the best performance of all models (AUC 0.914 [0.863-0.965]) and the highest overall diagnostic value of the model (sensitivity: 0.814, specificity: 0.941).

CONCLUSIONS

NAFLD correlates with PAT volume and PCAT inflammation. Furthermore, combining clinical features, CTA parameters, and radiomic scores can improve the efficiency of early diagnosis of stable CAD in patients with NAFLD.

Managing chronic coronary syndrome: how do we achieve optimal patient outcomes?

INTRODUCTION

Chronic coronary syndrome (CCS) remains the leading cause of death worldwide with high admission/re-admission rates. Medical databases were searched on CCS & its management.

AREAS COVERED

This review discusses phenotypes per stress-echocardiography, noninvasive/invasive testing (coronary computed-tomography angiography-CCTA; coronary artery calcium - CAC score; echocardiography assessing wall-motion, LV function, valvular disease; biomarkers), multidisciplinary management (risk factors/anti-inflammatory/anti-ischemic/antithrombotic therapies and revascularization), newer treatments (colchicine/ivabradine/ranolazine/melatonin), cardiac rehabilitation/exercise improving physical activity and quality-of-life, use of the implantable-defibrillator, and treatment with extracorporeal shockwave-revascularization for refractory symptoms.

EXPERT OPINION

CCS is age-dependent, leading cause of death worldwide with high hospitalization rates. Stress-echocardiography defines phenotypes and guides prophylaxis and management. CAC is a surrogate for atherosclerosis burden, best for patients of intermediate/borderline risk. Higher CAC-scores indicate more severe coronary abnormalities. CCTA is preferred for noninvasive detection of CAC and atherosclerosis burden, determining stenosis' functional significance, and guiding management. Combining CAC score with CCTA improves diagnostic yield and assists prognosis. Echocardiography assesses LV wall-motion and function and valvular disease. Biomarkers guide diagnosis/prognosis. CCS management is multidisciplinary: risk-factor management, anti-inflammatory/anti-ischemic/antithrombotic therapies, and revascularization. Newer therapies comprise colchicine, ivabradine, ranolazine, melatonin, glucagon-like peptide-1-receptor antagonists. Cardiac rehabilitation/exercise improves physical activity and quality-of-life. An ICD protects from sudden death. Extracorporeal shockwave-revascularization treats refractory symptoms.

Association between severity of nonalcoholic fatty liver disease and major adverse cardiovascular events in patients assessed by coronary computed tomography angiography

BACKGROUND

The effect of nonalcoholic fatty liver disease (NAFLD) on major adverse cardiovascular events (MACEs) can be influenced by the degree of coronary artery stenosis. However, the association between the severity of NAFLD and MACEs in patients who underwent coronary computed tomography angiography (CCTA) is unclear.

METHODS

A total of 341 NAFLD patients who underwent CCTA were enrolled. The severity of NAFLD was divided into mild NAFLD and moderate-severe NAFLD by abdominal CT results. The degree of coronary artery stenosis was evaluated by using Coronary Artery Disease Reporting and Data System (CAD-RADS) category. Cox regression analysis and Kaplan-Meier analysis were used to assess poor prognosis.

RESULTS

During the follow-up period, 45 of 341 NAFLD patients (13.20%) who underwent CCTA occurred MACEs. The severity of NAFLD (hazard ratio [HR] = 2.95[1.54-5.66]; p = 0.001) and CAD-RADS categories 3-5 (HR = 16.31[6.34-41.92]; p < 0.001) were independent risk factors for MACEs. The Kaplan-Meier analysis showed that moderate to severe NAFLD patients had a worsen prognosis than mild NAFLD patients (log-rank p < 0.001). Moreover, the combined receiver operating characteristic curve of the severity of NAFLD and CAD-RADS category showed a good predicting performance for the risk of MACEs, with an area under the curve of 0.849 (95% CI = 0.786-0.911).

CONCLUSION

The severity of NAFLD was independent risk factor for MACEs in patients with obstructive CAD, having CAD-RADS 3-5 categories on CCTA.

Prognostic value of metabolic dysfunction-associated steatotic liver disease over coronary computed tomography angiography findings: comparison with no-alcoholic fatty liver disease

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the proposed name change for non-alcoholic fatty liver disease (NAFLD). This study aimed to investigate the association of cardiovascular disease risk with MASLD and NAFLD in patients who underwent clinically indicated coronary computed tomography angiography (CCTA).

METHODS

This retrospective study included 2289 patients (60% men; mean age: 68 years) with no history of coronary artery disease who underwent CCTA. The steatotic liver was defined as a hepatic-to-spleen attenuation ratio of < 1.0 on CT just before CCTA. MASLD is defined as the presence of hepatic steatosis along with at least one of the five cardiometabolic risk factors. Adverse CCTA findings were defined as obstructive and/or high-risk plaques. Major adverse cardiac events (MACE) encompassed composite coronary events, including cardiovascular death, acute coronary syndrome, and late coronary revascularization.

RESULTS

MASLD and NAFLD were identified in 415 (18%) and 368 (16%) patients, respectively. Adverse CCTA findings were observed in 40% and 38% of the patients with MASLD and with NAFLD, respectively. Adverse CCTA findings were significantly associated with MASLD (p = 0.007) but not NAFLD (p = 0.253). During a median follow-up of 4.4 years, 102 (4.4%) MACE were observed. MASLD was significantly associated with MACE (hazard ratio 1.82, 95% CI 1.18-2.83, p = 0.007), while its association with NAFLD was not significant (p = 0.070). By incorporating MASLD into a prediction model of MACE, including the risk score and adverse CCTA findings, global chi-squared values significantly increased from 87.0 to 94.1 (p = 0.008).

CONCLUSIONS

Patients with MASLD are likely to have a higher risk of cardiovascular disease than those with NAFLD. Concurrent assessment of MASLD during CCTA improves the identification of patients at a higher risk of cardiovascular disease among those with clinically indicated CCTA.

Prognostic value of coronary artery calcium score for the prediction of atherosclerotic cardiovascular disease in participants with suspected nonalcoholic hepatic steatosis: Results from the multi-ethnic study of atherosclerosis

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD) events; thus, a diagnostic approach to help identify NAFLD patients at high risk is needed. In this study, we hypothesized that coronary artery calcium (CAC) screening could help stratify the risk of ASCVD events in participants with suspected nonalcoholic hepatic steatosis.

METHODS

A total of 713 participants with suspected nonalcoholic hepatic steatosis without previous cardiovascular events from the Multi-Ethnic Study of Atherosclerosis (MESA) were followed for the occurrence of incident ASCVD. Nonalcoholic hepatic steatosis was defined using nonenhanced computed tomography and liver/spleen attenuation ratio <1. Cox proportional hazards regression models were used to estimate hazard ratios (HR). C-statistics and areas under the time-dependent receiver operating characteristic curves (tAUC) were used to compare incremental contributions of CAC score when added to the clinical risk factors.

RESULTS

In multivariable analyses, CAC score was found to be independently associated with incident ASCVD (HR = 1.33, 95% CI = 1.22-1.44, P < .001). The addition of CAC score to clinical risk factors increased the C-statistic from 0.677 to 0.739 (P < .001) and tAUC at 10 years from 0.668 to 0.771, respectively. In subgroup analyses, the incremental prognostic value of CAC score was more significant in participants with low/borderline- (<7.5%) and intermediate- (7.5%-20%) 10-year ASCVD risk scores.

CONCLUSIONS

The inclusion of CAC score in global risk assessment was found to significantly improve the classification of incident ASCVD events in participants with suspected nonalcoholic hepatic steatosis, indicating a potential role for CAC screening in risk assessment.

Hepatic steatosis evidenced by computed tomography in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) and acute myocardial infarction (AMI) have common pathological links. This study investigates the prognostic impact of NAFLD assessed as hepatic steatosis (HS) by computed tomography (CT) in AMI patients and explores the mechanistic role of NAFLD in cardiovascular (CV) events using coronary angioscopy (CAS).

METHODS

We retrospectively examined 342 AMI patients who underwent CT followed by primary percutaneous coronary intervention (PCI) between January 2014 and December 2019. HS was defined as a hepatic to spleen attenuation ratio of <1.0 on CT scans. Major cardiac events (MCE) included cardiac death, non-fatal myocardial infarction, target-vessel revascularization, and target-lesion revascularization.

RESULTS

HS was identified in 88 patients (26 %). Patients with HS were significantly younger, had a higher body mass index, and higher hemoglobin A1c, triglyceride, and malondialdehyde low-density lipoprotein levels (all p < 0.05). MCE occurred more frequently [27 (30.7 %) vs. 39 (15.4 %), p = 0.001] in the HS group than in the non-HS group. In the multivariate analysis, the presence of HS was an independent predictor of MCE after adjusting for metabolic risk factor and liver function markers. Among the 74 patients who underwent CAS for a median of 15 days after primary PCI, 51 (69 %) had intrastent thrombus, which was strongly associated with the presence of HS [18 (35 %) vs. 1 (4 %), p = 0.005].

CONCLUSIONS

AMI patients with NAFLD detected by CT often had CAS-derived intrastent thrombi and were at a high risk for CV events. Therefore, these patients should be carefully monitored.

Impacts of Non-alcoholic Fatty Liver Disease on Acute Coronary Syndrome: Evidence and Controversies

PURPOSE OF REVIEW

Acute coronary syndrome (ACS) and non-alcoholic fatty liver disease (NAFLD) are two clinically common disease entities that share numerous risk factors. This review aimed to discuss the impacts of NAFLD on ACS.

RECENT FINDINGS

In an era of improved control of traditional risk factors, the substantial burden of cardiometabolic abnormalities has caused widespread concern. NAFLD is considered the hepatic component of metabolic syndrome, which can exert an impact on human health beyond the liver. Accumulating studies have demonstrated that NAFLD is closely related to cardiovascular disease, especially coronary artery disease. Interestingly, although recent data have suggested an association between NAFLD and the incidence and outcomes of ACS, the results are not consistent. In this review, we comprehensively summarized evidence and controversies regarding whether NAFLD is a contributor to either the development of ACS or worse outcomes in patients with ACS. The potential pathophysiological and molecular mechanisms involved in the impacts of NAFLD on ACS were also elucidated.

A clinical study of the correlation between metabolic-associated fatty liver disease and coronary plaque pattern

Nonalcoholic fatty liver disease (NAFLD) is the hepatic manifestation of metabolic syndrome (MetS) and has been correlated with coronary atherosclerosis (CAS). Since NAFLD was renamed metabolic-associated fatty liver disease(MAFLD) in 2020, no studies have evaluated the correlation between MAFLD and CAS. The aim of this study was to evaluate the relationship between MAFLD and CAS. A total of 1330 patients underwent continuous coronary computed tomography angiography (CCTA) and abdominal ultrasound as part of a routine physical examination. Ultrasonography was used to assess fatty liver, and CCTA was used to assess coronary artery plaques, degree of stenosis, and diseased blood vessels. Univariate and multivariate logistic regression analyses were performed with plaque type and degree of stenosis as dependent variables and MAFLD and traditional cardiovascular risk factors as independent variables to analyze the correlation between MAFLD and CAS. Among the 1164 patients, 680 (58.4%) were diagnosed with MAFLD through a combination of ultrasound and auxiliary examinations. Compared with the non-MAFLD group, the MAFLD group had more cardiovascular risk factors,and the MAFLD group had more likely to have coronary atherosclerosis, coronary stenosis and multiple coronary artery stenosis.In the univariate logistic regression, MAFLD was significantly correlated with overall plaque, calcified plaques, noncalcified plaques, mixed plaques,and significant stenosis in the coronary arteries.(p < 0.05). After adjusting for cardiovascular risk factors , MAFLD was correlated with noncalcified plaques (1.67; 95% confidence interval (CI) 1.15-2.43; p = 0.007) and mixed plaques (1.54; 95% CI 1.10-2.16; p = 0.011). In this study, MAFLD group had more cardiovascular risk factors, MAFLD was correlated with coronary atherosclerosis,and significant stenosis.Further study found independent associations between MAFLD and noncalcified plaques and mixed plaques, which suggest a clinically relevant link between MAFLD and coronary atherosclerosis.

Decreased liver-to-spleen ratio in low-dose computed tomography as a biomarker of fatty liver disease reflects risk for myocardial ischaemia

Aims

A strong association between fatty liver disease (FLD) and coronary artery disease is consistently reported. Our aim was to evaluate whether FLD diagnosed using low-dose non-contrast computed tomography (LDCT), as a by-product of myocardial perfusion imaging (MPI), is associated with myocardial ischaemia or left ventricular function parameters.

Methods and results

We analysed 742 patients who had undergone MPI using single photon emission computed tomography (SPECT) and LDCT. A liver-to-spleen ratio (in Hounsfield units) of <1 was defined as FLD. Myocardial ischaemia was defined as a summed difference score (SDS) ≥3. Left ventricular size and systolic function were assessed from the electrocardiogram-gated SPECT. FLD patients were younger (63 vs. 68 years) and had a higher body mass index (34.6 vs. 29.0 kg/m2) and a higher SDS (2.65 vs. 1.63), P < 0.001 for all. Independently of several possible confounding factors including traditional risk factors, patients with FLD had a 1.70-fold risk of ischaemia (95% confidence interval 1.11-2.58, P = 0.014). Left ventricular end-diastolic volume (109 vs. 109 mL) and ejection fraction (61 vs. 61%) were comparable in those with and without FLD (non-significant for both).

Conclusions

With the help of LDCT, it is possible to identify FLD, which is associated with an increased risk of myocardial ischaemia. Therefore, evaluation of FLD from LDCT is recommended along with MPI.

Association between High Pericoronary Adipose Tissue Computed Tomography Attenuation and Impaired Flow-Mediated Dilation of the Brachial Artery

AIMS

Pericoronary adipose tissue (PCAT) attenuation on coronary computed tomography angiography (CTA) is a noninvasive biomarker for pericoronary inflammation and is associated with cardiac mortality. We aimed to investigate the association between PCAT attenuation and endothelial dysfunction assessed using flow-mediated dilation (FMD).

METHODS

A total of 119 outpatients who underwent both coronary CTA and FMD measurements were examined. PCAT attenuation values were assessed at the proximal 40-mm segments of all three major coronary arteries on coronary CTA. Endothelial function was assessed using FMD. Patients were then classified into two groups: those with endothelial dysfunction (FMD ＜4%, n=44) and those without endothelial dysfunction (FMD ≥ 4%, n=75).

RESULTS

In all three coronary arteries, PCAT attenuation was significantly higher in patients with endothelial dysfunction than in those without endothelial dysfunction. Multivariate logistic regression analysis revealed that PCAT attenuation in the right coronary artery (odds ratio [OR]=1.543; 95% confidence interval [CI]=1.004-2.369, p=0.048) and left anterior descending artery (OR=1.525, 95% CI=1.004-2.369, p=0.049) was an independent predictor of endothelial dysfunction. Subgroup analysis of patients with adverse CTA findings (significant stenosis and/or high-risk plaque) and those with coronary artery calcium score ＞100 showed that high PCAT attenuation in all three coronary arteries was a significant predictor of endothelial dysfunction.

CONCLUSION

High PCAT attenuation was significantly associated with FMD-assessed endothelial dysfunction in patients with suspected coronary artery disease. Our results suggest that endothelial dysfunction is one of the pathophysiological mechanisms linking pericoronary inflammation to cardiac mortality.

Hepatic fat as a novel marker for high-risk coronary atherosclerotic plaque features in familial hypercholesterolaemia

BACKGROUND & AIMS

Hepatic steatosis has been associated with increased risk of coronary artery disease. Individuals with familial hypercholesterolaemia have accelerated but variable progression of coronary artery disease. We investigated whether hepatic steatosis is associated with novel coronary atherosclerosis biomarkers in adults with heterozygous familial hypercholesterolaemia, using comprehensive coronary computed tomographic angiography.

METHODS

We conducted a cross-sectional study of 213 asymptomatic patients with familial hypercholesterolaemia (median age 54.0 years, 59 % female) who underwent coronary computed tomographic angiography for cardiovascular risk assessment in an outpatient clinic. High-risk plaque features, plaque volume and pericoronary adipose tissue attenuation were assessed. From concurrently captured upper abdominal images, severity of hepatic steatosis was computed, as liver minus spleen computed tomography attenuation and stratified into quartiles.

RESULTS

Of 213 familial hypercholesterolaemia patients, 59 % had coronary artery calcium, 36 % obstructive coronary artery disease (≥50 % stenosis) and 77 % high-risk plaque features. Increasing hepatic steatosis was associated with higher calcium scores, more high-risk plaque features and presence of obstructive coronary artery disease. Hepatic steatosis was associated with the presence of high-risk plaque features (OR: 1.48; 95 % CI: 1.09-2.00; p = 0.01), particularly in the proximal coronary segments (OR: 1.52; 95 % CI: 1.18-1.96; p = 0.001). Associations persisted on multivariable logistic regression analysis adjusting for cardiometabolic factors, obstructive coronary artery disease and calcium score. Hepatic steatosis was associated with higher plaque volumes (Q4: 499 mm³ vs Q1: 414 mm³, p = 0.02), involving mainly low attenuation and noncalcified plaques (both p = 0.03). No differences in pericoronary adipose tissue attenuation were observed.

CONCLUSIONS

Hepatic steatosis is associated with multiple indices of advanced coronary atherosclerosis in familial hypercholesterolaemia patients, particularly high-risk plaque features, independent of conventional cardiovascular risk factors and markers. This may involve specific mechanisms related to hepatic steatosis.

CLINICAL TRIAL NUMBER

N/A.

Association between Cardiovascular Disease and Liver Disease, from a Clinically Pragmatic Perspective as a Cardiologist

Cardiovascular diseases and liver diseases are closely related. Non-alcoholic fatty liver disease has the same risk factors as those for atherosclerotic cardiovascular disease and may also be a risk factor for atherosclerotic cardiovascular disease on its own. Heart failure causes liver fibrosis, and liver fibrosis results in worsened cardiac preload and congestion. Although some previous reports regard the association between cardiovascular diseases and liver disease, the management strategy for liver disease in patients with cardiovascular diseases is not still established. This review summarized the association between cardiovascular diseases and liver disease. In patients with non-alcoholic fatty liver disease, the degree of liver fibrosis progresses with worsening cardiovascular prognosis. In patients with heart failure, liver fibrosis could be a prognostic marker. Liver stiffness assessed with shear wave elastography, the fibrosis-4 index, and non-alcoholic fatty liver disease fibrosis score is associated with both liver fibrosis in patients with liver diseases and worse prognosis in patients with heart failure. With the current population ageing, the importance of management for cardiovascular diseases and liver disease has been increasing. However, whether management and interventions for liver disease improve the prognosis of cardiovascular diseases has not been fully understood. Future investigations are needed.

Prognostic Value of Nonalcoholic Fatty Liver Disease in Patients With Severe Aortic Stenosis Who Underwent Transcatheter Aortic Valve Implantation

Nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of cardiovascular events. Although the association between NAFLD and aortic valve sclerosis has been described, the prevalence and prognostic implications of NAFLD among patients with severe aortic stenosis (AS) have not been described. In addition, the effect of the presence of severe tricuspid regurgitation (TR) on the prevalence of NAFLD remains unexplored. Accordingly, we investigated the prognostic implications of NAFLD among patients with severe AS with and without concomitant significant TR. A total of 538 patients (aged 80 ± 7 y, 49.6% men) who underwent noncontrast computed tomography before transcatheter aortic valve implantation (TAVI) between 2007 and 2019 were included. NAFLD was defined as a liver-to-spleen attenuation ratio <1.0 on noncontrast computed tomography. NAFLD was present in 118 patients (21.9%). There were no significant differences in pulmonary arterial pressure, right atrial pressure, or the prevalence of significant TR between patients with and without NAFLD. During a median follow-up of 47 months (interquartile range 20 to 70 months), 224 patients (41.6%) died. Univariate Cox regression analysis demonstrated that NAFLD was not significantly associated with all-cause death among patients treated with TAVI (hazard ratio 1.32, 95% confidential interval 0.97 to 1.79, p = 0.07). In conclusion, among patients with severe AS who underwent TAVI, the prevalence of significant TR and the clinical outcomes were similar in patients with and without NAFLD.

The Fibrosis-4 Index Predicts Cardiovascular Prognosis in Patients With Severe Isolated Tricuspid Regurgitation

BACKGROUND

The fibrosis-4 (FIB-4) index is used to evaluate liver disease patients. It can also be used to evaluate the prognosis for heart disease patients; however, its ability to determine the prognosis of severe isolated tricuspid regurgitation (TR) patients is unclear. This study aimed to clarify the association between FIB-4 index scores and the cardiovascular prognosis for severe isolated TR patients.

METHODS AND RESULTS

This was a dual-center, retrospective study. From 2011 to 2019, 111 consecutive outpatients with severe isolated TR (mean age, 68.6 years; 53.2% male) were evaluated. Major adverse cardiovascular events (MACEs) were defined as the composite of cardiovascular death, hospitalization for heart failure, myocardial infarction, and stroke. The association between FIB-4 index scores and echocardiography was also evaluated. During a median follow up of 3.0 years, 24 patients were lost to follow up and 40 MACEs occurred. Baseline FIB-4 index scores for patients with MACEs were significantly higher than those for patients without MACEs. A multivariate analysis revealed that FIB-4 index scores are significantly associated with MACEs (hazard ratio, 1.89; 95% confidence interval, 1.01-3.54; P=0.046). A linear regression analysis indicated that FIB-4 index scores were correlated with echocardiographic parameters, including the left atrial volume index and left ventricular end-diastolic diameter.

CONCLUSIONS

The FIB-4 index score may be a useful predictor of MACEs for patients with severe isolated TR.

The Association of Triglyceride to High-Density Lipoprotein Cholesterol Ratio with High-Risk Coronary Plaque Characteristics Determined by CT Angiography and Its Risk of Coronary Heart Disease

The triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratio is an independent risk index for cardiovascular events. This study aimed to evaluate the association between TG/HDL-C ratio and coronary plaque characteristics as seen on coronary computed tomography angiography (CCTA) and the corresponding increase in the likelihood of cardiovascular events. A total of 935 patients who underwent CCTA for suspected coronary artery disease (CAD) were included. High-risk plaques (HRP) were defined based on three characteristics: positive remodeling, low-density plaques, and spotty calcification. Significant stenosis was defined as luminal narrowing of >70%. Patients with a higher TG/HDL-C ratio showed significantly greater prevalence of HRP and significant stenosis than patients with low TG/HDL-C ratios (p < 0.01). Multivariate logistic analysis demonstrated that the TG/HDL-C ratio was significantly associated with the presence of HRP (p < 0.01) but not with significant coronary stenosis (p = 0.24). During the median follow-up period of 4.1 years, 26 cardiovascular events including cardiovascular death and acute coronary syndrome occurred. The highest TG/HDL-C tertile was associated with cardiovascular events, with the lowest TG/HDL-C tertile as the reference (hazard ratio, 3.75; 95% confidence interval, 1.04−13.50). A high TG/HDL-C ratio is associated with the presence of CCTA-verified HRP, which can lead to cardiovascular events in patients with suspected CAD.

New Insights into Non-Alcoholic Fatty Liver Disease and Coronary Artery Disease: The Liver-Heart Axis

Non-alcoholic fatty liver disease (NAFLD) represents the hepatic expression of the metabolic syndrome and is the most prevalent liver disease. NAFLD is associated with liver-related and extrahepatic morbi-mortality. Among extrahepatic complications, cardiovascular disease (CVD) is the primary cause of mortality in patients with NAFLD. The most frequent clinical expression of CVD is the coronary artery disease (CAD). Epidemiological data support a link between CAD and NAFLD, underlain by pathogenic factors, such as the exacerbation of insulin resistance, genetic phenotype, oxidative stress, atherogenic dyslipidemia, pro-inflammatory mediators, and gut microbiota. A thorough assessment of cardiovascular risk and identification of all forms of CVD, especially CAD, are needed in all patients with NAFLD regardless of their metabolic status. Therefore, this narrative review aims to examine the available data on CAD seen in patients with NAFLD, to outline the main directions undertaken by the CVD risk assessment and the multiple putative underlying mechanisms implicated in the relationship between CAD and NAFLD, and to raise awareness about this underestimated association between two major, frequent and severe diseases.

Association of Oxidized Low-Density Lipoprotein in Nonalcoholic Fatty Liver Disease with High-Risk Plaque on Coronary Computed Tomography Angiography: A Matched Case-Control Study

Nonalcoholic fatty liver disease (NAFLD) is a risk factor for the development of atherosclerotic cardiovascular diseases (CVDs), and oxidative stress has been proposed as a shared pathophysiological condition. This study examined whether oxidized low-density lipoprotein (LDL) is involved in the underlying mechanism that links coronary atherosclerosis and NAFLD. This study included 631 patients who underwent coronary computed tomography angiography (CTA) for suspected coronary artery disease. NAFLD was defined on CT images as a liver-to-spleen attenuation ratio of <1.0. Serum-malondialdehyde-modified LDL (MDA-LDL) and coronary CTA findings were analyzed in a propensity-score-matched cohort of patients with NAFLD (n = 150) and those without NAFLD (n = 150). This study analyzed 300 patients (median age, 65 years; 64% men). Patients with NAFLD had higher MDA-LDL levels and a greater presence of CTA-verified high-risk plaques than those without NAFLD. In the multivariate linear regression analysis, MDA-LDL was independently associated with NAFLD (β = 11.337, p = 0.005) and high-risk plaques (β = 12.487, p = 0.007). Increased MDA-LDL may be a mediator between NAFLD and high-risk coronary plaque on coronary CTA. Increased oxidative stress in NAFLD, as assessed using MDA-LDL, may be involved in the development of CVDs.

High pericoronary adipose tissue attenuation on computed tomography angiography predicts cardiovascular events in patients with type 2 diabetes mellitus: post-hoc analysis from a prospective cohort study

Background

Pericoronary adipose tissue (PCAT) attenuation on coronary computed tomography angiography (CTA) is a non-invasive biomarker for pericoronary inflammation. We aimed to investigate the prognostic value of PCAT attenuation in patients with type 2 diabetes mellitus (T2DM).

Methods

We included 333 T2DM patients (mean age, 66 years; male patients, 211; mean body mass index, 25 kg/m²) who underwent clinically indicated coronary CTA and examined their CT findings, coronary artery calcium score, pericardial fat volume, stenosis (> 50% luminal narrowing), high-risk plaque features of low-attenuation plaque and/or positive remodelling and/or spotty calcification, and PCAT attenuation. We assessed PCAT attenuation in Hounsfield units (HU) of proximal 40-mm segments of the left anterior descending artery (LAD) and right coronary artery (RCA). Cardiovascular events were defined as cardiac death, hospitalisation for acute coronary syndrome, late coronary revascularisation, and hospitalisation for heart failure.

Results

During a median follow-up of 4.0 years, we observed 31 cardiovascular events. LAD-PCAT attenuation was significantly higher in patients with cardiovascular events than in those without (− 68.5 ± 6.5 HU vs − 70.8 ± 6.1 HU, p = 0.045), whereas RCA-PCAT attenuation was not (p = 0.089). High LAD-PCAT attenuation (> − 70.7 HU; median value) was significantly associated with cardiovascular events in a model that included adverse CTA findings, such as significant stenosis and/or high-risk plaque (hazard ratio; 2.69, 95% confidence interval; 1.17–0.20, p = 0.020). After adding LAD-PCAT attenuation to the adverse CTA findings, the C-statistic and global chi-square values increased significantly from 0.65 to 0.70 (p = 0.037) and 10.9–15.0 (p = 0.043), respectively.

Conclusions

In T2DM patients undergoing clinically indicated coronary CTA, high LAD-PCAT attenuation could significantly predict cardiovascular events. This suggests that assessing LAD-PCAT attenuation can help physicians identify high-risk T2DM patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01478-9.

Risk of cardiovascular events in patients with non-alcoholic fatty liver disease: a systematic review and meta-analysis

AIMS 

Non-alcoholic fatty liver disease (NAFLD) is a highly prevalent disease and has been repeatedly associated with an increased risk of cardiovascular disease. However, the extent of such association is unclear. We conducted a systematic review and meta-analysis of the literature to evaluate the risk of myocardial infarction (MI), ischaemic stroke (IS), atrial fibrillation (AF), and heart failure (HF) in NAFLD patients.

METHODS AND RESULTS 

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically searched PubMed and EMBASE, from inception to 6 March 2021, and included all studies reporting the incidence of MI, IS, AF, and HF in patients with and without NAFLD. Random-effect fmodels were used to estimate pooled odds ratio (OR), 95% confidence intervals (CI), and 95% prediction intervals (PI); subgroup analyses, meta-regressions, and sensitivity analyses were additionally performed. Among 3254 records retrieved from literature, 20 studies were included. Non-alcoholic fatty liver disease was associated with an increased risk of MI (OR: 1.66, 95% CI: 1.39-1.99, 95% PI: 0.84-3.30), IS (OR: 1.41, 95% CI: 1.29-1.55, 95% PI 1.03-1.93), AF (OR: 1.27, 95% CI: 1.18-1.37, 95% PI: 1.07-1.52), and HF (OR: 1.62, 95% CI: 1.43-1.84, 95% CI: 1.04-2.51). We identified significant subgroup differences according to geographical location, study design, NAFLD definition, and risk of bias; meta-regressions identified mean age, male sex, and study-level characteristics as potential moderators of the risk of MI and IS.

CONCLUSIONS 

Non-alcoholic fatty liver disease was associated with increased risk of MI, IS, AF, and HF. Age, sex, and study characteristics may moderate the strength of this association. Further studies are required to evaluate specific cardiovascular prevention strategies in patients with NAFLD.