High-risk coronary plaque at coronary CT angiography is associated with nonalcoholic fatty liver disease, independent of coronary plaque and stenosis burden: results from the ROMICAT II trial

Microbes: Drivers of Chenpi manufacturing, biotransformation, and physiological effects

Chenpi holds a rich history of both edible and medicinal applications worldwide, garnering increased attention from researchers in recent years due to its diverse physiological effects. While current research predominantly exploresed its chemical composition and physiological effects, there remains a notable gap in knowledge concerning its manufacturing, characteristic chemical substances, and the underlying mechanisms driving its physiological effects. In this review, the impacts of microbes on the manufacturing, biotransformation, and physiological effects of Chenpi were summarized, as well as the present status of product development. Furthermore, this review engaged in an in-depth discussion highlighting the challenges and shortcomings in recent research, while proposing potential directions and prospects. Additionally, the claim that "The longer the aging, the better the quality" of Chenpi was scientifically evaluated for the first time, providing a solid theoretical foundation for advancing the Chenpi industry.

Non-Alcoholic Fatty Liver Disease and Coronary Artery Disease: A Bidirectional Association Based on Endothelial Dysfunction

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease and is regarded as a liver manifestation of metabolic syndrome. It is linked to insulin resistance, obesity, and diabetes mellitus, all of which increase the risk of cardiovascular complications. Endothelial dysfunction (EnD) constitutes the main driver in the progression of atherosclerosis and coronary artery disease (CAD). Several pathophysiological alterations and molecular mechanisms are involved in the development of EnD in patients with NAFLD. Our aim is to examine the association of NAFLD and CAD with the parallel assessment of EnD, discussing the pathophysiological mechanisms and the genetic background that underpin this relationship. This review delves into the management of the condition, exploring potential clinical implications and available medical treatment options to facilitate the deployment of optimal treatment strategies for these patients.

Association of liver multi-parameter quantitative metrics determined by dual-layer spectral detector computed tomography (SDCT) with coronary plaque scores

Background

Hepatic steatosis is closely related to the occurrence and development of coronary plaques. Spectral detector computed tomography (SDCT) can provide more precise multiparameter quantitative parameters for hepatic steatosis. Hence, the purpose of this cross-sectional study was to explore the effect of quantitative liver metrics measured using SDCT on the extent and severity of coronary plaques.

Methods

In patients who underwent upper abdomen unenhanced SDCT and coronary computed tomography angiography, plaque extent and severity were assessed using segmental involvement score (SIS) and segmental stenosis score (SSS). Liver fat quantification was evaluated by polychromatic and virtual mono-energetic images at 40 and 70 kev, spectral attenuation curve slope, and effective atomic number (CT40 keV, CT70 kev, λHU, and Zeff, respectively). A logistic regression model evaluated the factors influencing high SIS and SSS.

Results

Enrolled patients (n=644) were divided into groups: low SIS (<5) (n=451), high SIS (≥5) (n=193), low SSS (<5) (n=461), and high SSS (≥5) (n=183). Zeff was more closely correlated with SIS (standard partial regression coefficient =-0.422, P<0.001) and SSS (standard partial regression coefficient =-0.346, P<0.001). Zeff was divided into four groups using interquartile intervals. Compared with the patients in the lowest quartile, those in the second [odds ratio (OR) =2.116, 95% confidence interval (CI): 1.134-3.949, P=0.018], third (OR =2.832, 95% CI: 1.461-5.491, P=0.002), and fourth (OR =3.584, 95% CI: 1.857-6.918, P<0.001) quartiles showed higher risk for high SIS. And correspondingly, the second (OR =1.933, 95% CI: 1.040-3.592, P=0.037), third (OR =2.900, 95% CI: 1.499-5.609, P=0.002), and fourth (OR =3.368, 95% CI: 1.743-6.510, P<0.001) quartiles showed higher risk for high SSS, especially in those who were <60 years old, male and had visceral adipose tissue/subcutaneous adipose tissue <1.18.

Conclusions

The SDCT-Zeff was an independent factor associated with high SIS and SSS. The quantification of liver fat may be useful for evaluating the risk and prognosis of coronary atherosclerosis.

Increased prevalence of high-risk coronary plaques in metabolic dysfunction associated steatotic liver disease patients: A meta-analysis

BACKGROUND

Metabolic dysfunction associated steatotic liver disease (MASLD) is associated with an increased risk of coronary artery disease. Computed Tomography Coronary Angiography (CTCA) can assess both the extent and the features of coronary plaques. We aimed to gather evidence about the prevalence and features of coronary plaques among MASLD patients.

METHODS

PubMed, Scopus, and Google Scholar databases were searched for randomized controlled trials and adjusted observational studies assessing the prevalence and features of coronary plaques by means of CTCA in MASLD patients as compared with a control group. The prevalence of coronary stenosis (defined as >30% and >50% diameter of stenosis), of increasing coronary artery calcium (CAC) score and of high-risk features (namely low-attenuation plaques, napkin ring sign, spotty calcification and positive remodelling) in MASLD patients were the endpoints of interest.

RESULTS

Twenty-four observational studies were included. MASLD was associated with an increased prevalence of critical coronary stenosis compared with controls (odds ratio [OR] 1.54, 95%CI 1.23-1.93). Increased values of CAC score were observed in MASLD patients (OR 1.35, 95%CI 1.02-1.78 and OR 2.26, 95%CI 1.57-3.23 for CAC score 0-100 and >100, respectively). An increased risk of 'high-risk' coronary plaques was observed in MASLD patients (OR 2.13, 95%CI 1.42-3.19). As high-risk features plaques, a higher prevalence of positive remodelling and spotty calcification characterize MASLD patients (OR 2.92, 95%CI 1.79-4.77 and OR 2.96, 95%CI 1.22-7.20).

CONCLUSIONS

Patients with MASLD are at increased risk of developing critical coronary stenosis and coronary plaques characterized by high-risk features as detected by CTCA.

Application and research progress of magnetic resonance proton density fat fraction in metabolic dysfunction-associated steatotic liver disease: a comprehensive review

Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD), formerly known as Non-Alcoholic Fatty Liver Disease (NAFLD), is a chronic liver disorder associated with disturbances in lipid metabolism. The disease is prevalent worldwide, particularly closely linked with metabolic syndromes such as obesity and diabetes. Magnetic Resonance Proton Density Fat Fraction (MRI-PDFF), serving as a non-invasive and highly quantitative imaging assessment tool, holds promising applications in the diagnosis and research of MASLD. This paper aims to comprehensively review and summarize the applications and research progress of MRI-PDFF technology in MASLD, analyze its strengths and challenges, and anticipate its future developments in clinical practice.

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.

Lipoprotein subclasses are associated with Hepatic steatosis: insights from the prospective multicenter imaging study for the evaluation of chest pain (PROMISE) clinical trial

Objectives

To determine the relationship between lipoprotein particle size/number with hepatic steatosis (HS), given its association with traditional lipoproteins and coronary atherosclerosis.

Methods

Individuals with available CT data and blood samples enrolled in the PROMISE trial were studied. HS was defined based on CT attenuation. Lipoprotein particle size/number were measured by nuclear magnetic resonance spectroscopy. Principal components analysis (PCA) was used for dimensionality reduction. The association of PCA factors and individual lipoprotein particle size/number with HS were assessed in multivariable regression models. Associations were validated in an independent cohort of 59 individuals with histopathology defined HS.

Results

Individuals with HS (n=410/1,509) vs those without (n=1,099/1,509), were younger (59±8 vs 61±8 years) and less often females (47.6 % vs 55.9 %). All PCA factors were associated with HS: factor 1 (OR:1.36, 95 %CI:1.21-1.53), factor 3 (OR:1.75, 95 %CI:1.53-2.02) and factor 4 (OR:1.49; 95 %CI:1.32-1.68) were weighted heavily with small low density lipoprotein (LDL) and triglyceride-rich (TRL) particles, while factor 2 (OR:0.86, 95 %CI:0.77-0.97) and factor 5 (OR:0.74, 95 %CI:0.65-0.84) were heavily loaded with high density lipoprotein (HDL) and larger LDL particles. These observations were confirmed with the analysis of individual lipoprotein particles in PROMISE. In the validation cohort, association between HS and large TRL (OR: 8.16, 95 %CI:1.82-61.98), and mean sizes of TRL- (OR: 2.82, 95 %CI:1.14-9.29) and HDL (OR:0.35, 95 %CI:0.13-0.72) were confirmed.

Conclusions

Large TRL, mean sizes of TRL-, and HDL were associated with radiographic and histopathologic HS. The use of lipoprotein particle size/number could improve cardiovascular risk assessment in HS.

Prognostic Value of Non-alcoholic Fatty Liver Disease and RCA Pericoronary Adipose Tissue CT Attenuation in Patients with Acute Chest Pain

RATIONALE AND OBJECTIVES

Pericoronary adipose tissue (PCAT) CT attenuation of right coronary artery (RCA) and non-alcoholic fatty liver disease (NAFLD) have prognostic value for major adverse cardiovascular events (MACE) in patients with coronary artery disease. However, the superior prognostic value between RCA PCAT CT attenuation and NAFLD remains unclear in patients with acute chest pain. This study is to evaluate the prognostic value of NAFLD for MACE, and further assess the incremental prognostic value of NAFLD over PCAT CT attenuation.

MATERIALS AND METHODS

Between January 2011 and December 2021, all consecutive emergency patients with acute chest pain referred for coronary CT angiography (CCTA) were retrospectively enrolled. MACE included unstable angina requiring hospitalization, coronary revascularization, non-fatal myocardial infarction, and all-cause death. Patients' baseline and CCTA characteristics, RCA PCAT CT attenuation, and the presence of NAFLD were used to evaluate risk factors of MACE using multivariable Cox regression analysis. The prognostic value of NAFLD compared to RCA PCAT CT attenuation was analyzed.

RESULTS

A total of 514 patients were enrolled (mean age, 58.36 ± 13.05 years; 310 men). During a median follow-up of 31 months, 60 patients (11.67%) experienced MACE. NAFLD (HR = 2.599, 95% CI: 1.207, 5.598, P = 0.015) and RCA PCAT CT attenuation (HR = 1.026, 95% CI: 1.001, 1.051, P = 0.038) were independent predictors of MACE. The global Chi-square analysis showed that NAFLD improved the risk of MACE more than that using clinical risk factors and CCTA metrics (59.51 vs 54.44, P = 0.024) or combined with RCA PCAT CT attenuation (63.75 vs 59.51, P = 0.040).

CONCLUSION

NAFLD and RCA PCAT CT attenuation were predictors of MACE. NAFLD had an incremental prognostic value beyond RCA PCAT CT attenuation for MACE in patients with acute chest pain. Adding CT-FFR into the risk prediction of patients with acute chest pain is worth considering.

Management of cardiovascular risk in patients with metabolic dysfunction-associated steatotic liver disease

The novel term Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) is proposed to replace non-alcoholic fatty liver disease (NAFLD) to highlight the close association with the metabolic syndrome. MASLD encompasses patients with liver steatosis and at least one of five cardiometabolic risk factors which implies that these patients are at increased risk of cardiovascular disease (CVD). Indeed, the prevalence of CVD in MASLD patients is increased and CVD is recognized as the most common cause of death in MASLD patients. We here present an update on the pathophysiology of CVD in MASLD, discuss the risk factors, and suggest screening for CVD in patients with MASLD. Currently, there is no FDA-approved pharmacological treatment for MASLD, and no specific treatment recommended for CVD in patients with MASLD. Thus, the treatment strategy is based on weight loss and a reduction and treatment of CVD risk factors. We recommend screening of MASLD patients for CVD using the SCORE2 system with guidance to specific treatment algorithms. In all patients with CVD risk factors, lifestyle intervention to induce weight loss through diet and exercise is recommended. Especially a Mediterranean diet may improve hyperlipidemia and if further treatment is needed, statins should be used as first-line treatment. Further, anti-hypertensive drugs should be used to treat hypertension. With the epidemic of obesity and type 2 diabetes mellitus (T2DM) the risk of MASLD and CVD is expected to increase, and preventive measures, screening, and effective treatments are highly needed to reduce morbidity and mortality in MASLD patients.

The differences between patients with nonalcoholic fatty liver disease (NAFLD) and those without NAFLD, as well as predictors of functional coronary artery ischemia in patients with NAFLD

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a chronic liver disease associated with metabolic syndrome. It is the most common cause of cryptogenic cirrhosis. The disease is also involved in the occurrence and development of type 2 diabetes and atherosclerosis and can directly affect the outcome of patients with coronary heart disease. Therefore, the focus of treatment of nonalcoholic fatty liver disease has also begun to focus on the treatment of risk factors for atherosclerotic heart disease. In this study, we investigated the difference between patients with coronary artery stenosis combined with NAFLD and those without NAFLD and evaluated the predictive factors and value of functional coronary artery ischemia in patients with NAFLD.

HYPOTHESIS

Many clinical factors (such as age, BMI, hyperglycemia) and imaging parameters (such as CACS grade) in the NAFLD group were different from those in the non-NAFLD group. The predictive model combined with multiple influencing factors has a good value in predicting coronary artery ischemia in patients with NAFLD.

METHODS

We collected the clinical and imaging data of patients who underwent coronary computed tomography angiography and coronary artery calcification score (CACS) scans between January and June 2023. A total of 392 patients were included and divided into the NAFLD group and the non-NAFLD group. Based on CT fractional flow reserve (CT-FFR), patients with NAFLD were divided into CT-FFR ≤ 0.08 group and CT-FFR > 0.08 group.

RESULTS

Significant differences were observed between the non-NAFLD and NAFLD groups in terms of age, body mass index, hyperglycemia, hyperlipidemia, triglyceride, high-density lipoprotein, coronary artery disease-reporting and data system (CAD-RADS) classification, CACS classification, number of diseased coronary arteries, and CT-FFR ≤ 0.80 ratio (p < .05). The CAD-RADS and CACS classifications can independently predict functional coronary artery ischemia in NAFLD patients. The combined use of CAD-RADS and CACS classifications resulted in an area under the curve of 0.819 (95% confidence interval: 0.761-0.876) for predicting coronary artery ischemia in NAFLD patients, which was higher than the individual classification methods (CAD-RADS: 0.762, CACS: 0.742) (p = .000).

CONCLUSIONS

There are differences between patients with coronary artery stenosis and NAFLD and those without NAFLD. The CAD-RADS classification and CACS classification can economically and efficiently predict functional coronary artery ischemia in patients with NAFLD, which has crucial value in clinical diagnosis and treatment.

Nonalcoholic Fatty Liver Disease (NAFLD) and Cardiovascular Risk: Is Imaging Helpful?

Nonalcoholic Fatty Liver Disease (NAFLD) is proving to be a globally prevalent condition. Moreover, NAFLD may be an independent risk factor associated with higher cardiovascular (CVD) morbidity and mortality. Further studies are needed to assess whether NAFLD needs to be included in the atherosclerotic risk score algorithms or whether patients with NAFLD need to be screened early on to assess their CVD risk especially since imaging such as positron emission tomography can be used to assess both NAFLD and CV disease at the same time. Therefore employing cardiovascular imaging modalities to investigate the incidence, extent, and nature of atherosclerotic lesions in NAFLD may be beneficial. Additionally, whether treating NAFLD halts the progression of CVD on imaging remains to be seen. Further research to delineate NAFLD and CVD associations, deciphering screening imaging modalities, and investigating targeted interventions could improve CVD morbidity and mortality in NAFLD.

Association between non-alcoholic fatty liver disease and coronary artery disease outcomes: A systematic review and meta-analysis

OBJECTIVES

To evaluate the association between non-alcoholic fatty liver disease (NAFLD) and cardiovascular outcomes, including angina, coronary artery disease (CAD), coronary artery calcification (CAC), myocardial infarction (MI), and calcified coronary plaques.

METHODS

A comprehensive search of databases, including PubMed, EMBASE, and Cochrane Library, was conducted up to January 2023. Studies were included investigating the relationship between NAFLD and cardiovascular outcomes in adult populations. Exclusion criteria were studies on animals, pediatric populations, and those not published in English. Two reviewers assessed the risk of bias in the included studies using the Newcastle-Ottawa Scale. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using random-effects models.

RESULTS

The meta-analysis included 32 studies with a total of 5,610,990 participants. NAFLD demonstrated significant associations with increased risks of angina (Relative Risk (RR): 1.45, 95% CI: 1.17, 1.79), CAD (RR: 1.21, 95% CI: 1.07, 1.38), CAC >0 (RR: 1.39, 95% CI: 1.15, 1.69), and calcified coronary plaques (RR: 1.55, 95% CI: 1.05, 2.27). However, no significant association was found between NAFLD and CAC >100 (RR: 1.16, 95% CI: 0.97, 1.38) or MI (RR: 1.70, 95% CI: 0.16, 18.32).

CONCLUSION

The meta-analysis demonstrated a significant association between NAFLD and cardiovascular outcomes independent of conventional cardiovascular disease (CVD) risk factors. These findings emphasize the importance of prevention, early detection, and proper management of NAFLD.

Early-stage non-alcoholic fatty liver disease in relation to atherosclerosis and inflammation

BACKGROUND AND AIMS

Non-alcoholic fatty liver disease (NAFLD) is a multisystem disease closely linked to cardiovascular disease (CVD). This study aims to investigate the connection between early-stage NAFLD and atherosclerosis, as well as the correlation between liver fibrosis and coronary heart disease while exploring underlying inflammatory mechanisms.

METHODS

In this retrospective study, the authors analyzed data from 607 patients who underwent both coronary computed tomography angiography (CCTA) and abdominal ultrasonography (US). Logistic regression was utilized to examine the association between NAFLD and atherosclerosis, while mediation analysis was conducted to explore whether inflammatory markers mediate the link between liver fibrosis and coronary artery disease.

RESULTS

Among the 607 patients included, 237 (39.0 %) were diagnosed with NAFLD through ultrasonography. After adjusting for traditional cardiovascular risk factors, ALT, and AST, NAFLD demonstrated a significant correlation with carotid intimal thickening (1.58, 95 % CI 1.04‒2.40; p = 0.034) and non-calcified plaque (1.56, 95 % CI 1.03‒2.37; p = 0.038). Additionally, fibrosis predictive markers, including FIB-4 > 1.3 (1.06, 95 % CI 2.30‒5.00; p = 0.035) and APRI (6.26, 95 % CI 1.03‒37.05; p = 0.046), independently correlated with coronary heart disease after adjusting for cardiovascular risk factors. Conversely, among systemic inflammatory markers, only the neutrophil-to-lymphocyte ratio (NLR) and systemic inflammatory response index (SIRI) are independently associated with coronary heart disease. ROC curve analysis indicated that combining predictive fibrosis markers or inflammatory markers with traditional cardiovascular risk factors enhanced the predictive accuracy for coronary heart disease. Mediation analysis revealed that NLR fully mediated the effect of liver fibrosis on coronary heart disease.

CONCLUSION

NAFLD is associated with carotid intimal thickening and non-calcified plaque, suggesting an increased cardiovascular risk. Furthermore, liver fibrosis independently increases the risk of coronary heart disease in the early-stage NAFLD population, and inflammation may play a fully mediating role in the effect of liver fibrosis on coronary heart disease. Early intervention is crucial for NAFLD patients to mitigate future major adverse cardiovascular events.

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.

Non-alcoholic fatty liver disease and compromised endothelial function in people with type 2 diabetes

INTRODUCTION

Nonalcoholic fatty liver disease (NAFLD) frequently coexists with type 2 diabetes mellitus (T2DM) and synergistically contributes to the development of atherosclerosis. Flow-mediated dilation (FMD) is a commonly used noninvasive test for assessing endothelial function. The main objective of this study was to explore FMD in patients with T2DM with and without NAFLD.

METHODS

In this cross-sectional study, conducted on people with T2DM, NAFLD was defined as controlled attenuation parameter (CAP) score > 302 dB/m. Endothelial dysfunction was detected when arterial FMD of brachial artery was equal or less than 0.7%. Regression analyses were applied to assess factors associated with impaired FMD.

RESULT

A total of 147 patients (72 with NAFLD and 75 without NAFLD) were included in the final analysis. Patients with NAFLD were more likely to develop FMD ≤ 7% (77.8% vs. 58.7%, P = 0.01). In multivariate analysis, NAFLD (OR = 2.581, 95% CI (1.18-5.62), P = 0.017) and hypertension (HTN) (OR = 3.114, 95% CI (1.31-7.35), P = 0.010) were associated with an increased risk of impaired FMD. However, female sex was associated with a decreased risk of impaired FMD (OR = 0.371, 95% CI (0.15-0.87), P = 0.024).

CONCLUSION

NAFLD is associated with endothelial dysfunction in people with T2DM. This risk is comparable with the risk imposed by HTN, highlighting the importance of screening and management of NAFLD in these patients.

New Insights into the Pathogenesis of Metabolic-Associated Fatty Liver Disease (MAFLD): Gut-Liver-Heart Crosstalk

Metabolism-associated fatty liver disease (MAFLD) is a multifaceted disease that involves complex interactions between various organs, including the gut and heart. It is defined by hepatic lipid accumulation and is related to metabolic dysfunction, obesity, and diabetes. Understanding the intricate interplay of the gut-liver-heart crosstalk is crucial for unraveling the complexities of MAFLD and developing effective treatment and prevention strategies. The gut-liver crosstalk participates in the regulation of the metabolic and inflammatory processes through host-microbiome interactions. Gut microbiota have been associated with the development and progression of MAFLD, and its dysbiosis contributes to insulin resistance, inflammation, and oxidative stress. Metabolites derived from the gut microbiota enter the systemic circulation and influence both the liver and heart, resulting in the gut-liver-heart axis playing an important role in MAFLD. Furthermore, growing evidence suggests that insulin resistance, endothelial dysfunction, and systemic inflammation in MAFLD may contribute to an increased risk of cardiovascular disease (CVD). Additionally, the dysregulation of lipid metabolism in MAFLD may also lead to cardiac dysfunction and heart failure. Overall, the crosstalk between the liver and heart involves a complex interplay of molecular pathways that contribute to the development of CVD in patients with MAFLD. This review emphasizes the current understanding of the gut-liver-heart crosstalk as a foundation for optimizing patient outcomes with MAFLD.

Liver Fibrosis Scores and Coronary Artery Disease: Novel Findings in Patients with Metabolic Dysfunction-Associated Fatty Liver Disease

Background

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a recently proposed term as a more appropriate definition for nonalcoholic fatty liver disease (NAFLD). Previous studies have shown an association between liver fibrosis scores and cardiovascular disease (CVD) in patients with NAFLD. In this study, we aimed to investigate the relationship between liver fibrosis scores and coronary artery disease (CAD) severity in patients with MAFLD.

Methods

This study was conducted on 1346 patients with MAFLD at the Second Hospital of Dalian Medical University between January 2018 and December 2021. We calculated the liver fibrosis scores, including the fibrosis 4 (FIB-4) score, nonalcoholic fatty liver disease fibrosis score (NFS), and aspartate aminotransferase-to-platelet ratio index (APRI). We divided the participants into three groups based on the degree of coronary artery stenosis assessed using coronary computed tomography angiography (CCTA): CAD (≥50%), non-obstructive (1-49%), and normal (no stenosis).

Results

An increased FIB-4 score and NFS were significantly associated with CAD severity in patients with MAFLD. The percentage of patients with a high FIB-4 score was higher in the CAD group than in the other two groups (5.80%, 4.31%, and 2.24%, respectively; p<0.001), as was the percentage of patients with NFS (11.12%, 5.19%, and 0.93%, respectively; p<0.001). Carotid atherosclerosis, creatinine levels, and CAC scores were significant predictors of CAD. The FIB-4 score and NFS were independently associated with CAD even after adjusting for sex and well-known cardiovascular risk factors. The APRI was not a significant factor for CAD in any model. In the bivariate correlation analysis, the FIB-4 score and NFS were directly correlated with CAC scores.

Conclusion

Non-invasive liver fibrosis scores (FIB-4 and NFS) were significantly associated with the CAD severity and CAC scores in patients with MAFLD. Screening for CAD may be beneficial for subjects with high liver fibrosis risk MAFLD.

Advanced Cardiac Imaging and Women's Chest Pain: A Question of Gender

Awareness of gender differences in cardiovascular disease (CVD) has increased: both the different impact of traditional cardiovascular risk factors on women and the existence of sex-specific risk factors have been demonstrated. Therefore, it is essential to recognize typical aspects of ischemic heart disease (IHD) in women, who usually show a lower prevalence of obstructive coronary artery disease (CAD) as a cause of acute coronary syndrome (ACS). It is also important to know how to recognize pathologies that can cause acute chest pain with a higher incidence in women, such as spontaneous coronary artery dissection (SCAD) and myocardial infarction with non-obstructive coronary arteries (MINOCA). Coronary computed tomography angiography (CCTA) and cardiac magnetic resonance imaging (CMR) gained a pivotal role in the context of cardiac emergencies. Thus, the aim of our review is to investigate the most frequent scenarios in women with acute chest pain and how advanced cardiac imaging can help in the management and diagnosis of ACS.

Imaging modalities for measuring body composition in patients with cancer: opportunities and challenges

Body composition assessment (ie, the measurement of muscle and adiposity) impacts several cancer-related outcomes including treatment-related toxicities, treatment responses, complications, and prognosis. Traditional modalities for body composition measurement include body mass index, body circumference, skinfold thickness, and bioelectrical impedance analysis; advanced imaging modalities include dual energy x-ray absorptiometry, computerized tomography, magnetic resonance imaging, and positron emission tomography. Each modality has its advantages and disadvantages, thus requiring an individualized approach in identifying the most appropriate measure for specific clinical or research situations. Advancements in imaging approaches have led to an abundance of available data, however, the lack of standardized thresholds for classification of abnormal muscle mass or adiposity has been a barrier to adopting these measurements widely in research and clinical care. In this review, we discuss the different modalities in detail and provide guidance on their unique opportunities and challenges.

Liver fat quantification in photon counting CT in head to head comparison with clinical MRI - First experience

PURPOSE

To compare liver fat quantification between MRI and photon-counting CT (PCCT).

METHOD

A cylindrical phantom with inserts containing six concentrations of oil (0, 10, 20, 30, 50 and 100%) and oil-iodine mixtures (0, 10, 20, 30 and 50% fat +3 mg/mL iodine) was imaged with a PCCT (NAEOTOM Alpha) and a 1.5 T MRI system (MR 450w, IDEAL-IQ sequence), using clinical parameters. An IRB-approved prospective clinical evaluation included 12 obese adult patients with known fatty liver disease (seven women, mean age: 61.5 ± 13 years, mean BMI: 30.3 ± 4.7 kg/m²). Patients underwent a same-day clinical MRI and PCCT of the abdomen. Liver fat fractions were calculated for four segments (I, II, IVa and VII) using in- and opposed-phase on MRI ((Mean_in - Mean_opp)/2*Mean_in) and iodine-fat, tissue decomposition analysis in PCCT (Syngo.Via VB60A). CT and MRI Fat fractions were compared using two-sample t-tests with equal variance. Statistical analysis was performed using RStudio (Version1.4.1717).

RESULTS

Phantom results showed no significant differences between the known fat fractions (P = 0.32) or iodine (P = 0.6) in comparison to PCCT-measured concentrations, and no statistically significant difference between known and MRI-measured fat fractions (P = 0.363). In patients, the mean fat signal fraction measured on MRI and PCCT was 13.1 ± 9.9% and 12.0 ± 9.0%, respectively, with an average difference of 1.1 ± 1.9% between the modalities (P = 0.138).

CONCLUSION

First experience shows promising accuracy of liver fat fraction quantification for PCCT in obese patients. This method may improve opportunistic screening for CT in the future.

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.

Two-dimensional Convolutional Neural Network Using Quantitative US for Noninvasive Assessment of Hepatic Steatosis in NAFLD

Background Quantitative US (QUS) using radiofrequency data analysis has been recently introduced for noninvasive evaluation of hepatic steatosis. Deep learning algorithms may improve the diagnostic performance of QUS for hepatic steatosis. Purpose To evaluate a two-dimensional (2D) convolutional neural network (CNN) algorithm using QUS parametric maps and B-mode images for diagnosis of hepatic steatosis, with the MRI-derived proton density fat fraction (PDFF) as the reference standard, in patients with nonalcoholic fatty liver disease (NAFLD). Materials and Methods: Consecutive adult participants with suspected NAFLD were prospectively enrolled at a single academic medical center from July 2020 to June 2021. Using radiofrequency data analysis, two QUS parameters (tissue attenuation imaging [TAI] and tissue scatter-distribution imaging [TSI]) were measured. On B-mode images, hepatic steatosis was graded using visual scoring (none, mild, moderate, or severe). Using B-mode images and two QUS parametric maps (TAI and TSI) as input data, the algorithm estimated the US fat fraction (USFF) as a percentage. The correlation between the USFF and MRI PDFF was evaluated using the Pearson correlation coefficient. The diagnostic performance of the USFF for hepatic steatosis (MRI PDFF ≥5%) was evaluated using receiver operating characteristic curve analysis and compared with that of TAI, TSI, and visual scoring. Results Overall, 173 participants (mean age, 51 years ± 14 [SD]; 96 men) were included, with 126 (73%) having hepatic steatosis (MRI PDFF ≥5%). USFF correlated strongly with MRI PDFF (Pearson r = 0.86, 95% CI: 0.82, 0.90; P < .001). For diagnosing hepatic steatosis (MRI PDFF ≥5%), the USFF yielded an area under the receiver operating characteristic curve of 0.97 (95% CI: 0.93, 0.99), higher than those of TAI, TSI, and visual scoring (P = .015, .006, and < .001, respectively), with a sensitivity of 90% (95% CI: 84, 95 [114 of 126]) and a specificity of 91% (95% CI: 80, 98 [43 of 47]) at a cutoff value of 5.7%. Conclusion A deep learning algorithm using quantitative US parametric maps and B-mode images accurately estimated the hepatic fat fraction and diagnosed hepatic steatosis in participants with nonalcoholic fatty liver disease. ClinicalTrials.gov registration nos. NCT04462562, NCT04180631 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Sidhu and Fang in this issue.

Nonalcoholic fatty liver disease is associated with myocardial ischemia by CT myocardial perfusion imaging, independent of clinical and coronary CT angiography characteristics

OBJECTIVE

The aim of this study was to evaluate whether patients with nonalcoholic fatty liver disease (NAFLD) have more myocardial malperfusion on CT myocardial perfusion imaging (CT-MPI), as well as to further assess if NAFLD is a predictor of myocardial ischemia independently.

METHODS

A total of 310 consecutive patients were included for analysis. All patients were divided into two groups according to the presence or absence of NAFLD, which was diagnosed by noncontrast cardiac CT partially covered liver and spleen. Clinical characteristics as well as imaging features including coronary artery calcium score, CCTA, and CT-MPI findings were analyzed. Univariable and multivariable logistic regression analyses were used to find out the relationship between NAFLD and myocardial ischemia.

RESULTS

NAFLD (unadjusted hazard ratio [HR]: 2.4, 95% confidence interval [CI]: 1.2 to 4.4, p = 0.008), male (HR: 2.6, 95% CI: 1.5 to 4.5, p = 0.001), obstructive CAD (HR: 2.3, 95% CI: 1.3 to 4.2, p = 0.004), and FAI ≥ -70.1 HU (HR: 3.1, 95% CI: 1.8 to 5.5, p < 0.001) were associated with myocardial ischemia in univariable analysis. After adjusting for traditional CAD risk factors and CT characteristics in the multivariable regression analysis, NAFLD (HR: 2.3, 95% CI: 1.2 to 4.4, p = 0.016) was an independent predictor of myocardial ischemia.

CONCLUSION

Our data suggest that myocardial ischemia was more prevalent in patients with NAFLD, and NAFLD is a predictor of myocardial ischemia independent of traditional cardiovascular risk factors and CCTA characteristics.

KEY POINTS

• NAFLD patients had higher calcium score, incidence of obstructive coronary artery disease, grade of CAD-RADS, quantitative plaque characteristics, and incidence of fat attenuation index ≥ -70.1 HU. • NAFLD patients had a higher incidence of myocardial ischemia, myocardial hypoperfusion, and hypoperfusion myocardial segments ratio. • NAFLD was a predictor of myocardial ischemia, independent of traditional cardiovascular risk factors, and CCTA characteristics.

Comprehensive Review of Cardiovascular Disease Risk in Nonalcoholic Fatty Liver Disease

Nonalcoholic Fatty Liver Disease (NAFLD) is a growing global phenomenon, and its damaging effects in terms of cardiovascular disease (CVD) risk are becoming more apparent. NAFLD is estimated to affect around one quarter of the world population and is often comorbid with other metabolic disorders including diabetes mellitus, hypertension, coronary artery disease, and metabolic syndrome. In this review, we examine the current evidence describing the many ways that NAFLD itself increases CVD risk. We also discuss the emerging and complex biochemical relationship between NAFLD and its common comorbid conditions, and how they coalesce to increase CVD risk. With NAFLD's rising prevalence and deleterious effects on the cardiovascular system, a complete understanding of the disease must be undertaken, as well as effective strategies to prevent and treat its common comorbid conditions.

A Meta-Analysis on the Global Prevalence, Risk factors and Screening of Coronary Heart Disease in Nonalcoholic Fatty Liver Disease

BACKGROUND & AIMS

Cardiovascular disease remains the leading cause of death in patients with nonalcoholic fatty liver disease (NAFLD). Studies examining the association of coronary heart disease (CHD) and NAFLD are cofounded by various cardiometabolic factors, particularly diabetes and body mass index. Hence, we seek to explore such association by investigating the global prevalence, independent risk factors, and influence of steatosis grade on manifestation of CHD among patients with NAFLD.

METHODS

Two databases, Embase and Medline, were utilized to search for articles relating to NAFLD and CHD. Data including, but not limited to, continent, diagnostic methods, baseline characteristics, prevalence of CHD, CHD severity, NAFLD severity, and risk factors were extracted.

RESULTS

Of the 38 articles included, 14 reported prevalence of clinical coronary artery disease (CAD) and 24 subclinical CAD. The pooled prevalence of CHD was 44.6% (95% confidence interval [CI], 36.0%-53.6%) among 67,070 patients with NAFLD with an odds ratio of 1.33 (95% CI, 1.21%-1.45%; P &lt; .0001). The prevalence of CHD was higher in patients with moderate to severe steatosis (37.5%; 95% CI, 15.0%-67.2%) than those with mild steatosis (29.6%; 95% CI, 13.1%-54.0%). The pooled prevalence of subclinical and clinical CAD was 38.7% (95% CI, 29.8%-48.5%) and 55.4% (95% CI, 39.6%-70.1%), respectively.

CONCLUSION

Steatosis was found to be related with CHD involvement, with moderate to severe steatosis related to clinical CAD. Early screening and prompt intervention for CHD in NAFLD are warranted for holistic care in NAFLD.

Shared Mechanisms between Cardiovascular Disease and NAFLD

The burden of nonalcoholic fatty liver disease (NAFLD) is rising globally. Cardiovascular disease is the leading cause of death in patients with NAFLD. Nearly half of individuals with NAFLD have coronary heart disease, and more than a third have carotid artery atherosclerosis. Individuals with NAFLD are at a substantially higher risk of fatal and nonfatal cardiovascular events. NAFLD and cardiovascular disease share multiple common disease mechanisms, such as systemic inflammation, insulin resistance, genetic risk variants, and gut microbial dysbiosis. In this review, we discuss the epidemiology of cardiovascular disease in NAFLD, and highlight common risk factors. In addition, we examine recent advances evaluating the shared disease mechanisms between NAFLD and cardiovascular disease. In conclusion, multidisciplinary collaborations are required to further our understanding of the complex relationship between NAFLD and cardiovascular disease and potentially identify therapeutic targets.

Coronary Computed Tomography Angiography for the Assessment of Sirolimus-Eluting Resorbable Magnesium Scaffold

Background: Little evidence to date has described the feasibility and diagnostic accuracy of coronary computed tomography angiography (CCTA) with noninvasive fractional flow reserve (CT-FFR) in coronary vessels with resorbable magnesium scaffold (RMS). Methods: The SHERPA-MAGIC is a prospective study enrolling patients receiving RMS. The present analysis considered patients undergoing CCTA 18 months after the index procedure. CCTA images were employed to investigate reabsorption status, luminal measurements, and noninvasive FFR. Three-year follow-up was available for all patients. Results: Overall, 26 patients with a total of 29 coronary arteries treated with 35 RMS were considered. The most frequently involved vessel was left anterior descendent (LAD). Median stent length was 25 (20–25) mm, with a median diameter of 3 (3–3.5) mm. At 18-month CCTA, all scaffolded segments were patent. Complete RMS reabsorption was observed in 27 (93%, 95% CI 77–99%) cases. Median minimal lumen diameter (MLD) and area (MLA) of the scaffolded segments were 2.5 [2.1–2.8] mm and 6.4 [4.4–8.4] mm², respectively. Median CT-FFR was 0.88 [0.81–0.91]. Only one (3.5%) vessel showed a flow-limiting CT-FFR value ≤0.80. During the 3-year follow-up, only one (4%) adverse event was observed. Conclusions: In patients undergoing RMS implantation, CCTA including noninvasive CT-FFR evaluation is feasible and allows investigation of long-term RMS performance.

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 between Coronary Artery Plaque Progression and Liver Fibrosis Biomarkers in Population with Low Calcium Scores

Background: The severity of nonalcoholic fatty liver disease (NAFLD) has been found to be associated with atherosclerosis burden. However, whether liver fibrosis scores can be used to predict atherosclerosis progression, especially for patients with low calcium scores, remains undetermined. Methods: A total of 165 subjects who underwent repeated coronary computed tomography angiography (CCTA) and had low calcium scores (<100) were enrolled. The segment stenosis score (SSS) from the CCTA was measured, and the association between SSS progression and biochemical parameters was analyzed in addition to liver fibrosis scores, including nonalcoholic fatty liver disease fibrosis score (NFS), fibrosis-4 index (FIB-4), aspartate aminotransferase (AST) to platelet ratio index (APRI), and Forns score. Results: When compared with those without plaque at baseline (SSS = 0), subjects with plaque had higher blood pressure, higher coronary artery calcium (CAC) scores, and higher liver fibrosis scores, including Forns score, Fib-4, and NFS. During the medium follow-up interval of 24.7 months, 60 (39.4%) patients displayed SSS progression, while the remaining 105 (63.6%) patients showed no CAD progression. In a multivariate analysis, being male having a high diastolic blood pressure (DBP), and having a high NFS liver fibrosis score were independently associated with the odds ratio for SSS progression. Conclusions: Higher baseline blood pressure and liver fibrosis markers are associated with the presence of coronary artery disease (CAD) plaques in subjects in early CAD stages. For disease progression, the male gender, DBP, and NFS appear to be independently associated with coronary atherosclerosis plaque progression in subjects with low calcium scores.

Plaque progression at coronary CT angiography links non-alcoholic fatty liver disease and cardiovascular events: a prospective single-center study

OBJECTIVES

The presence of non-alcoholic fatty liver disease (NAFLD) has been associated with major adverse cardiovascular events (MACEs); however, the mechanisms that initiate the risk for MACEs in patients with NAFLD remain unknown. We sought to investigate whether plaque progression (PP), determined by coronary CT angiography (CCTA), moderate the relationship between NAFLD and MACEs.

METHODS

A total of 1683 asymptomatic participants (mean age, 63.3 ± 9.4 [range, 38-85] years; 1117 men) who underwent baseline and follow-up CCTA examination were prospectively included in our study. All of the participants were divided into the NAFLD and non-NAFLD groups. PP was determined by follow-up CCTA. The primary endpoint was MACEs, defined as the composite of all-cause death, nonfatal myocardial infarction, and unplanned hospitalization for acute coronary syndrome leading to revascularization.

RESULTS

At follow-up CCTA, participants with NAFLD showed higher incidence of PP than those without [33.0% (248/752) vs. 16.6% (155/931), p < 0.001]. Compared with non-NAFLD participants, participants with NAFLD had a lower 9.7-year event-free survival rate (80.9 vs. 66.4%, log-rank p < 0.001). Cox regression analysis revealed NAFLD was significantly associated with MACEs (HR = 1.63, 95% CI: 1.28 to 2.06, p < 0.001) after adjusting for covariables. However, this association was no longer significant after adjustment for PP (HR = 1.10, 95% CI: 0.84 to 1.45, p = 0.496). The mediation analysis revealed that PP had a significant indirect effect (β = 0.0587, 95% CI: 0.0424 to 0.08, p < 0.001) and mediated 99.8% (p = 0.002) for the relationship between NAFLD and MACEs.

CONCLUSIONS

Plaque progression, identified by follow-up CCTA, mediates the relationship between NAFLD and MACEs.

KEY POINTS

The incidence of CCTA-identified PP was higher for participants with NAFLD than those without NAFLD (248/752 [33.0%] vs. 155/931 [16.6%], p < 0.001). Participants with NAFLD had a lower 9.7-year event-free survival rate than those without NAFLD (66.4% vs. 80.9%, log-rank p < 0.001). The mediation analysis revealed that PP had a significant indirect effect (β = 0.0587, 95% CI: 0.0424 to 0.08, p < 0.001) and mediated 99.8% (p = 0.002) for the relationship between NAFLD and MACEs.

Metabolic Syndrome Severity Predicts Mortality in Nonalcoholic Fatty Liver Disease

Background and Aims

Previous studies have examined the effects of metabolic syndrome (MetS) presence rather than the severity on mortality risk in nonalcoholic fatty liver disease (NAFLD). We used the MetS severity score, a validated gender- and race-specific measure, to assess the relationship between MetS severity and mortality risk in NAFLD.

Methods

The study included 10,638 adults aged between 20 and 74 years who participated in the Third National Health and Nutrition Examination Survey. NAFLD was defined as mild, moderate, or severe hepatic steatosis on ultrasound without excessive alcohol intake and other liver diseases. Adjusted Cox proportional models were used to test the association between the MetS severity score and mortality risk related to all-cause, heart disease, diabetes, and hypertension.

Results

The median MetS severity score was significantly higher in NAFLD (0.49 [69th] vs -0.23 [41st]). An increase in the MetS severity corresponded to a linear rise in biomarkers for cardiovascular disease, insulin resistance, lipid abnormalities, and liver and kidney problems. The MetS severity score was a significant predictor for all-cause and cause-specific adjusted mortalities. A quartile increase in MetS severity score was associated with higher mortality risks from all-causes adjusted hazard ratio (aHR) 1.36 (95% confidence interval [CI]: 1.17-1.57), heart disease aHR 1.70 (95% CI: 1.17-2.47), diabetes aHR 3.64 (95% CI: 2.27-5.83), and hypertension aHR 1.87 (95% CI: 1.14-3.04). A higher MetS severity score was also associated with nonlinear increased risks of mortality in all adjusted models.

Conclusion

The MetS severity score is a clinically accessible tool that can be used to identify and monitor NAFLD patients at the highest risk of mortality.

Hepatosteatosis and Atherosclerotic Plaque at Coronary CT Angiography

Purpose

To assess the association between nonalcoholic fatty liver disease (NAFLD) and quantitative atherosclerotic plaque at CT.

Materials and Methods

In this post hoc analysis of the prospective Scottish Computed Tomography of the HEART trial (November 2010 to September 2014), hepatosteatosis and coronary artery calcium score were measured at noncontrast CT. Presence of stenoses, visually assessed high-risk plaque, and quantitative plaque burden were assessed at coronary CT angiography. Multivariable models were constructed to assess the impact of hepatosteatosis and cardiovascular risk factors on coronary artery disease.

Results

Images from 1726 participants (mean age, 58 years ± 9 [SD]; 974 men) were included. Participants with hepatosteatosis (155 of 1726, 9%) had a higher body mass index, more hypertension and diabetes mellitus, and higher cardiovascular risk scores (P < .001 for all) compared with those without hepatosteatosis. They had increased coronary artery calcium scores (median, 43 Agatston units [AU] [interquartile range, 0-273] vs 19 AU [0-225], P = .046), more nonobstructive disease (48% vs 37%, P = .02), and higher low-attenuation plaque burden (5.11% [0-7.16] vs 4.07% [0-6.84], P = .04). However, these associations were not independent of cardiovascular risk factors. Over a median of 4.7 years, there was no evidence of a difference in myocardial infarction between those with and without hepatosteatosis (1.9% vs 2.4%, P = .92).

Conclusion

Hepatosteatosis at CT was associated with an increased prevalence of coronary artery disease at CT, but this was not independent of the presence of cardiovascular risk factors.Keywords: CT, Cardiac, Nonalcoholic Fatty Liver Disease, Coronary Artery Disease, Hepatosteatosis, Plaque QuantificationClinical trial registration no. NCT01149590 Supplemental material is available for this article. © RSNA, 2022See also commentary by Abohashem and Blankstein in this issue.

Gender-Based Association of Coronary Artery Calcification and Framingham Risk Score With Non-alcoholic Fatty Liver Disease and Abdominal Obesity in Taiwanese Adults, a Cross-Sectional Study

Background

It is not certain whether non-alcoholic fatty liver disease (NAFLD) or abdominal obesity (AO) has stronger associations with atherosclerosis and coronary artery disease (CAD) risk across different genders. The purpose of this study was to determine the gender-based association of NAFLD and AO with subclinical atherosclerosis represented by coronary artery calcification (CAC) and CAD risk by Framingham risk score (FRS).

Methods

A total of 1,655 participants in a health-screening program (mean age: 49.44 years; males: 70.33%) were enrolled for analysis. Fatty liver and coronary artery calcium score (CACS) were measured via ultrasonography (US) and multi-detector computed tomography (MDCT). The presence of CAC was defined as having a CACS > 0, intermediate to high CAD risk was defined as FRS ≥ 10%, while the presence of AO was defined as having a waist circumference (WC) of ≥90 cm for men and ≥80 cm for women. Participants were categorized into four groups depending on the presence or absence of NAFLD and/or AO.

Results

The percentage of subjects with CACS > 0 was highest in the AO-only group (overall: 42.6%; men: 48.4%; women: 35.8%); and FRS ≥ 10% was highest in the group with both abnormalities (overall: 50.3%%; men: 57.3%; women: 32.4%). After adjustment factors, the odds ratio (OR) for CAC and FRS was the highest in the group with both abnormalities [men: 1.61 (1.13–2.30) for CACS > 0 and 5.86 (3.37–10.20) for FRS ≥ 10%; women: 2.17 (1.13–4.16) for CACS > 0 and 6.31 (2.08–19.10) for FRS ≥ 10%]. In men, the OR of NAFLD was higher than that of AO [1.37 (1.03–1.83) vs. 1.35 (1.02–1.79) for CACS > 0, 3.26 (2.13–4.98) vs. 2.97 (1.91–4.62) for FRS ≥ 10%]. However, women with AO consistently showed increased OR for CACS > 0 [1.87 (1.11–3.16)] and FRS ≥ 10% [4.77 (2.01–11.34)].

Conclusion

The degree of association of NAFLD and AO with CAC and FRS depends on the gender. NAFLD is more closely associated with CACS > 0 and FRS ≥ 10% in men and AO in women, respectively. NAFLD and AO could be considered independent determinants of CAC and FRS by gender.

The evolving role of coronary computed tomography in understanding sex differences in coronary atherosclerosis

Our understanding of sex differences in subclinical atherosclerosis and plaque composition and characteristics have greatly improved with the use of coronary computed tomography (CCTA) over the past years. CCTA has emerged as an important frontline diagnostic test for women, especially as we continue to understand the impact of non-obstructive atherosclerosis as well as diffuse, high risk plaque as precursors of acute cardiac events in women. Based on its ability to identify complex plaque morphology such as low attenuation plaque, high risk non calcified plaque, positive remodeling, fibrous cap, CCTA can be used to assess plaque characteristics. CCTA can avoid false positive of other imaging studies, if included earlier in assessment of ischemic symptoms. In the contemporary clinical setting, CCTA will prove useful in further understanding and managing cardiovascular disease in women and those without traditional obstructive coronary disease.

The Association of Alanine Aminotransferase Levels With Myocardial Perfusion Imaging and Cardiovascular Morbidity

INTRODUCTION

Studies suggest that non-alcoholic fatty liver disease (NAFLD) is associated with an independent risk of cardiovascular disease (CVD). We utilized a large cohort of patients undergoing myocardial perfusion imaging (MPI) with single photon emission computed tomography (SPECT) to determine the association between alanine aminotransferase (ALT) as a surrogate marker for presumed NAFLD, and the presence of myocardial ischemia and mortality.

METHODS

We retrospectively assessed SPECT-MPI results and medical records of individuals evaluated between 1997 and 2008. We excluded patients with known non-NAFLD liver diseases, ALT values <17 or >340 U/L and absent liver tests. Elevated ALT cases were classified as presumed NAFLD. The primary endpoint was abnormal SPECT-MPI. Secondary endpoints included cardiac death, acute myocardial infarction and all-cause mortality.

RESULTS

Of 26,034 patients who underwent SPECT-MPI, 11,324 met inclusion criteria. 1635 (14.4%) patients had elevated ALT. SPECT-MPI results did not differ significantly between subjects with elevated ALT and controls. Elevated ALT was associated with increased risk for the composite endpoint of cardiac death or acute myocardial infarction at 5-year follow-up (hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.01-1.67) and in all-cause mortality (HR 1.27, CI 1.02-1.58) but only in patients with normal SPECT-MPI.

CONCLUSIONS

The long-term mortality of patients with abnormal SPECT-MPI is not modulated by ALT, likely reflecting an already high risk and established CVD. However, patients with normal SPECT-MPI are at increased risk for a future cardiac event if they have an elevated ALT level, suggesting an important role for NAFLD in earlier stages of CVD.

Development, validation, qualification, and dissemination of quantitative MR methods: Overview and recommendations by the ISMRM quantitative MR study group

On behalf of the International Society for Magnetic Resonance in Medicine (ISMRM) Quantitative MR Study Group, this article provides an overview of considerations for the development, validation, qualification, and dissemination of quantitative MR (qMR) methods. This process is framed in terms of two central technical performance properties, i.e., bias and precision. Although qMR is confounded by undesired effects, methods with low bias and high precision can be iteratively developed and validated. For illustration, two distinct qMR methods are discussed throughout the manuscript: quantification of liver proton-density fat fraction, and cardiac T₁ . These examples demonstrate the expansion of qMR methods from research centers toward widespread clinical dissemination. The overall goal of this article is to provide trainees, researchers, and clinicians with essential guidelines for the development and validation of qMR methods, as well as an understanding of necessary steps and potential pitfalls for the dissemination of quantitative MR in research and in the clinic.

Quantification of Liver Fat Content with CT and MRI: State of the Art

Hepatic steatosis is defined as pathologically elevated liver fat content and has many underlying causes. Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide, with an increasing prevalence among adults and children. Abnormal liver fat accumulation has serious consequences, including cirrhosis, liver failure, and hepatocellular carcinoma. In addition, hepatic steatosis is increasingly recognized as an independent risk factor for the metabolic syndrome, type 2 diabetes, and, most important, cardiovascular mortality. During the past 2 decades, noninvasive imaging-based methods for the evaluation of hepatic steatosis have been developed and disseminated. Chemical shift-encoded MRI is now established as the most accurate and precise method for liver fat quantification. CT is important for the detection and quantification of incidental steatosis and may play an increasingly prominent role in risk stratification, particularly with the emergence of CT-based screening and artificial intelligence. Quantitative imaging methods are increasingly used for diagnostic work-up and management of steatosis, including treatment monitoring. The purpose of this state-of-the-art review is to provide an overview of recent progress and current state of the art for liver fat quantification using CT and MRI, as well as important practical considerations related to clinical implementation.

The associations between coronary artery disease, and non-alcoholic fatty liver disease by computed tomography

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is increasing in recognition as a hepatic condition that is unrelated to significant alcoholic consumption, but has rather, been suggested to constitute cardiovascular risk (irrespective of traditional risk factors and high-risk plaque features). Both coronary artery disease and NAFLD share the same pathophysiology and metabolic profile. NAFLD can theoretically be a source/initiator for coronary artery disease (CAD). We aimed to study the association between NAFLD, CAD, the presence of high-risk plaque features, and the severity of stenosis.

RESULTS

We recruited 800 patients with suspected obstructive CAD and planned for coronary computed tomography angiography (CCTA), Exclusion criteria: heavy alcohol consumption; contraindications to contrast media; unevaluated coronary-artery segments; other known liver disease; and use of oral corticosteroids and/or amiodarone. Non-enhanced Computed Tomography abdomen was performed before the CCTA to detect NAFLD. To study the association between NAFLD and the presence of CAD, patients were classified as to either have, or not have CAD. The CAD group were then further studied for the presence of high-risk plaque features: napkin ring sign, Positive remodelling, Low Hounsfield unit (HU), and Spotty calcium; and their association with NAFLD. Thirty-two per cent of patients had NAFLD and 45% had CAD. A significant association between NAFLD and CAD was found (OR 4.21, 95% CI (confidence interval) (2.83-6.25), p = 0.000). In CAD patients, significant associations were present between NAFLD and high-risk plaque features: Napkin ring sign, Positive remodelling, Low HU, and Spotty calcium (OR 7.88, 95% CI (4.39-14.12), p < 0.001, OR 5.84, 95% (3.85-8.85), p < 0.001, OR 7.25, 95% CI (3.31-15.90), p < 0.001 and OR 6.66, 95% CI (3.75-11.82), p < 0.001), respectively. NAFLD was present in 39.30%, 50.00%, 20.00%, 54.50% and 100.00% of patients with CAD; and 1-24%; 25-49%; 50-69%; 7 = 0-99%, LMD (Left Main Disease) > 50% stenosis or 3V disease, and Total occlusion, respectively, p < 0.001.

CONCLUSIONS

NAFLD is strongly associated with CAD, high-risk plaque features and higher grade of stenosis.

Early Cardiac Dysfunction in Biopsy-proven Nonalcoholic Fatty Liver Disease

Backgrounds/Aims

Nonalcoholic fatty liver disease (NAFLD) encompasses a range of diseases from nonalcoholic fatty liver (NAFL) to nonalcoholic steatohepatitis (NASH) and has been linked to cardiovascular disease and sub-clinical cardiac remodeling. This paper presents a retrospective study of biopsy-proven NAFL and NASH to examine the differences in subclinical cardiac remodeling.

Methods

Patients were recruited from an institutional repository of patients with liver-biopsy-confirmed NAFLD. Patients with a transthoracic echocardiogram (TTE) within 12 months of the liver biopsy were included. The parameters of the diastolic dysfunction were reviewed for the differences between NAFL and NASH as well as between the stages and grades of NASH.

Results

Thirty-three patients were included in the study, 17 with NAFL and 16 with NASH. The NASH patients were more likely to have lower platelets, higher AST, higher ALT, and higher rates of type 2 diabetes mellitus, coronary artery disease, and hypertension than the NAFL patients. The E/e' ratio on transthoracic echocardiogram was significantly higher in NASH compared to NAFL, advanced-stage NASH compared to early stage, and high-grade NASH compared to low-grade. The E/e' ratio was also significantly higher in NASH than NAFL in patients without diabetes mellitus. The presence of diastolic dysfunction trended toward significance. The other markers of diastolic dysfunction were similar. Logistic regression revealed a statistical association with E/e' and NASH.

Conclusions

NASH patients had evidence of a higher E/e' ratio than NAFL, and there was a trend towards a significant diastolic dysfunction. Patients with NASH compared to NAFL should be closely monitored for signs and symptoms of cardiac dysfunction.

Multisite multivendor validation of a quantitative MRI and CT compatible fat phantom

PURPOSE

Chemical shift-encoded magnetic resonance imaging enables accurate quantification of liver fat content though estimation of proton density fat-fraction (PDFF). Computed tomography (CT) is capable of quantifying fat, based on decreased attenuation with increased fat concentration. Current quantitative fat phantoms do not accurately mimic the CT number of human liver. The purpose of this work was to develop and validate an optimized phantom that simultaneously mimics the MRI and CT signals of fatty liver.

METHODS

An agar-based phantom containing 12 vials doped with iodinated contrast, and with a granular range of fat fractions was designed and constructed within a novel CT and MR compatible spherical housing design. A four-site, three-vendor validation study was performed. MRI (1.5T and 3T) and CT images were obtained using each vendor's PDFF and CT reconstruction, respectively. An ROI centered in each vial was placed to measure MRI-PDFF (%) and CT number (HU). Mixed-effects model, linear regression, and Bland-Altman analysis were used for statistical analysis.

RESULTS

MRI-PDFF agreed closely with nominal PDFF values across both field strengths and all MRI vendors. A linear relationship (slope = -0.54 ± 0.01%/HU, intercept = 37.15 ± 0.03%) with an R² of 0.999 was observed between MRI-PDFF and CT number, replicating established in vivo signal behavior. Excellent test-retest repeatability across vendors (MRI: mean = -0.04%, 95% limits of agreement = [-0.24%, 0.16%]; CT: mean = 0.16 HU, 95% limits of agreement = [-0.15HU, 0.47HU]) and good reproducibility using GE scanners (MRI: mean = -0.21%, 95% limits of agreement = [-1.47%, 1.06%]; CT: mean = -0.18HU, 95% limits of agreement = [-1.96HU, 1.6HU]) were demonstrated.

CONCLUSIONS

The proposed fat phantom successfully mimicked quantitative liver signal for both MRI and CT. The proposed fat phantom in this study may facilitate broader application and harmonization of liver fat quantification techniques using MRI and CT across institutions, vendors and imaging platforms.

Association of Hepatic Steatosis With Major Adverse Cardiovascular Events, Independent of Coronary Artery Disease

BACKGROUND & AIMS

Hepatic steatosis has been associated with increased risk of major adverse cardiovascular events (MACE) but it is not clear whether steatosis is independently associated with risk of MACE. We investigated whether steatosis is associated with risk of MACE independently of the presence and extent of baseline coronary artery disease, assessed by comprehensive contrast-enhanced computed tomography angiography (CTA).

METHODS

We conducted a nested cohort study of 3756 subjects (mean age, 60.6 years; 48.4% men) who underwent coronary CTA at 193 sites in North America, from July 2010 through September 2013, as part of the PROMISE study, which included noninvasive cardiovascular analyses of symptomatic outpatients without coronary artery disease. Independent core laboratory readers measured hepatic and splenic attenuation, using non-contrast computed tomography images to identify steatosis, and evaluated coronary plaques and stenosis in coronary CTA images. We collected data on participants' cardiovascular risk factors, presence of metabolic syndrome, and body mass index. The primary endpoint was an adjudicated composite of MACE (death, myocardial infarction, or unstable angina) during a median follow-up time of 25 months.

RESULTS

Among the 959 subjects who had steatosis (25.5% of the cohort), 42 had MACE (4.4%), whereas among the 2797 subjects without steatosis, 73 had MACE (2.6%) (hazard ratio [HR] for MACE in subjects with steatosis, 1.69; 95% CI, 1.16-2.48; P = .006 for MACE in subjects with vs without steatosis). This association remained after adjustment for atherosclerotic cardiovascular disease risk scores, significant stenosis, and metabolic syndrome (adjusted HR, 1.72; 95% CI, 1.16-2.54; P = .007) or obesity (adjusted HR, 1.75; 95% CI, 1.19-2.59; P = .005). Steatosis remained independently associated with MACE after adjustment for all CTA measures of plaques and stenosis.

CONCLUSIONS

Hepatic steatosis is associated with MACE independently of other cardiovascular risk factors or extent of coronary artery disease. Strategies to reduce steatosis might reduce risk of MACE. ClinicalTrials.gov no: NCT01174550.