Link Between Non-Alcoholic Fatty Liver Disease and Atrial Fibrillation: A Systematic Review and Meta-Analysis

A systematic review and meta-analysis of cohort studies on the potential association between NAFLD/MAFLD and risk of incident atrial fibrillation

Background and objective

The association between atrial fibrillation (AF) and non-alcoholic fatty liver disease (NAFLD) or metabolic-associated fatty liver disease (MAFLD) has been explored in recent cohort studies, however, the results have been controversial and inconclusive. This meta-analysis aimed to explore this potential association.

Methods

We systematically searched PubMed, Embase, and Web of Science databases to identify all relevant cohort studies investigating the association between NAFLD/MAFLD and AF published from database inception to October 30, 2022. Random-effects models were utilized to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) for summary purposes. Additionally, subgroup and sensitivity analyses were performed.

Results

A total of 13 cohort studies with 14 272 735 participants were included. Among these, 12 cohort studies with 14 213 289 participants (median follow-up of 7.8 years) showed a significant association between NAFLD and an increased risk of incident AF (HR = 1.18, 95% CI: 1.12-1.23, P < 0.00001). Our subgroup analyses mostly yielded similar results, and the results of sensitivity analyses remained unchanged. However, meta-analysis of data from 2 cohort studies with 59 896 participants (median follow-up of 2.15 years) showed that MAFLD was not linked to incident AF (HR = 1.36, 95% CI: 0.63-2.92, P = 0.44).

Conclusion

Current evidence shows that NAFLD may be linked to a slightly higher risk of developing AF, particularly among Asian populations and those diagnosed with NAFLD using FLI criteria. Nevertheless, there is not enough evidence to support the proposed association between MAFLD and an increased risk of AF. To better understand this relationship, future studies should consider factors such as specific population, the severity of NAFLD/MAFLD, diagnostic methods of NAFLD and AF, and cardiometabolic risk factors.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero, identifier CRD42022371503.

Non-Alcoholic Fatty Liver Disease and Risk of Macro- and Microvascular Complications in Patients with Type 2 Diabetes

Non-alcoholic fatty liver disease (NAFLD) is considered the hepatic manifestation of metabolic syndrome. To date, NAFLD is the most frequent chronic liver disease seen day by day in clinical practice across most high-income countries, affecting nearly 25–30% of adults in the general population and up to 70% of patients with T2DM. Over the last few decades, it clearly emerged that NAFLD is a “multisystemic disease” and that the leading cause of death among patients with NAFLD is cardiovascular disease (CVD). Indeed, several observational studies and some meta-analyses have documented that NAFLD, especially its advanced forms, is strongly associated with fatal and non-fatal cardiovascular events, as well as with specific cardiac complications, including sub-clinical myocardial alteration and dysfunction, heart valve diseases and cardiac arrhythmias. Importantly, across various studies, these associations remained significant after adjustment for established cardiovascular risk factors and other confounders. Additionally, several observational studies and some meta-analyses have also reported that NAFLD is independently associated with specific microvascular conditions, such as chronic kidney disease and distal or autonomic neuropathy. Conversely, data regarding a potential association between NAFLD and retinopathy are scarce and often conflicting. This narrative review will describe the current evidence about the association between NAFLD and the risk of macro- and microvascular manifestations of CVD, especially in patients with T2DM. We will also briefly discuss the biological mechanisms underpinning the association between NAFLD and its advanced forms and macro- and microvascular CVD.

Warfarin Dosing and Outcomes in Chronic Kidney Disease: A Closer Look at Warfarin Disposition

BACKGROUND

Chronic Kidney Disease (CKD) is a prevalent worldwide health problem. Patients with CKD are more prone to developing cardiovascular complications such as atrial fibrillation and stroke. This warrants the use of oral anticoagulants, such as warfarin, in this population. While the efficacy and safety of warfarin in this setting remain controversial, a growing body of evidence emphasizes that warfarin use in CKD can be problematic. This review discusses 1) warfarin use, dosing and outcomes in CKD patients; and 2) possible pharmacokinetic mechanisms for altered warfarin dosing and response in CKD.

METHODS

Structured search and review of literature articles evaluating warfarin dosing and outcomes in CKD. Data and information about warfarin metabolism, transport, and pharmacokinetics in CKD were also analyzed and summarized.

RESULTS

The literature data suggest that changes in warfarin pharmacokinetics such as protein binding, nonrenal clearance, the disposition of warfarin metabolites may partially contribute to altered warfarin dosing and response in CKD.

CONCLUSION

Although the evidence to support warfarin use in advanced CKD is still unclear, this synthesis of previous findings may help in improving optimized warfarin therapy in CKD settings.

Nonalcoholic Fatty Liver Disease Is Associated with Increased Atrial Fibrillation Risk in an Elderly Chinese Population: A Cross-Sectional Study

Background

Atrial fibrillation and nonalcoholic fatty liver disease are two pathological conditions that are highly prevalent worldwide and share multiple CVD risk factors. There are rare researches performed among elderly adults.

Aims

We conducted this cross-sectional analysis of elderly adults (≥65 years) to investigate the association between atrial fibrillation and nonalcoholic fatty liver disease.

Methods

We analyzed clinical data of the elderly adults (≥ 65 years) who had health examination in Zhenhai Lianhua Hospital, Ningbo, China, in 2014.

Results

522 of the 1688 participants were diagnosed with nonalcoholic fatty liver disease, and 39 participants were diagnosed as having atrial fibrillation. Nonalcoholic fatty liver disease was associated with risk factors for AF in the elderly Chinese population (OR 1.95, 95% CI 1.03-3.69). Adjustments for age, gender, systolic blood pressure, fasting plasma glucose, γ-glutamyl transpeptidase, high-density lipoprotein, triglycerides, total cholesterol and albumin, nonalcoholic fatty liver disease, and prevalent atrial fibrillation remained statistically significant (OR 2.76, 95% CI 1.32-5.77).

Conclusions

Our results show that nonalcoholic fatty liver disease is associated with an increased risk of atrial fibrillation in an elderly Chinese population.

Nonalcoholic fatty liver disease as a predictor of atrial fibrillation: a systematic review and meta-analysis

INTRODUCTION

Numerous epidemiologic studies have investigated the link between nonalcoholic fatty liver disease (NAFLD) and long-term atrial fibrillation (AF) risk, but the results are surprisingly conflicting.

AIM

Therefore, we systematically reviewed all published studies assessing the risk of AF in patients with NAFLD and conducted a meta-analysis.

MATERIAL AND METHODS

We performed a literature search using PubMed, EMBASE and Cochrane Library databases in February 2017 with no restrictions. Two cohort studies and two cross-sectional studies were identified, involving a total of 5150 subjects (NAFLD: 1655; controls: 3495) in this meta-analysis. Data from selected studies were extracted and a meta-analysis was performed using a random effects model.

RESULTS

Nonalcoholic fatty liver disease patients had a significantly higher risk of AF compared to controls (relative risk (RR): 2.61; 95% confidence interval (CI): 1.34-5.06, p = 0.00; I² = 52.5%, p = 0.097). In a further analysis stratified by presence of type 2 diabetes, the increased risk was present predominantly in patients with type 2 diabetes (RR = 5.10; 95% CI: 2.43-10.7, p < 0.001; I² = 0, p = 0.958). However, subjects without type 2 diabetes were at slightly increased risk of AF but the relative risk did not reach statistical significance (RR = 1.68; 95% CI: 0.99-2.82, p = 0.05; I² = 0, p = 0.461).

CONCLUSIONS

Our meta-analysis suggested that ultrasound-diagnosed NAFLD patients have a significantly higher risk for AF after adjustment for numerous important clinical risk factors for AF. These results need to be confirmed in large prospective studies.

Linking atrial fibrillation with non-alcoholic fatty liver disease: potential common therapeutic targets

Non-alcoholic fatty liver disease (NAFLD) and atrial fibrillation (AF) are common chronic non-infectious diseases with rising incidences. NAFLD is an independent risk factor for the onset of AF, after adjusting potentially related factors. The pathogenesis of these diseases share several mechanisms including reduced adiponectin level, insulin resistance, and renin angiotensin aldosterone system (RAAS) activation, in addition to activation of common disease pathways that promote inflammation, oxidative stress, and fibrosis. Furthermore, statins and RAAS blockers exert therapeutic effects concurrently on NAFLD and AF. The common pathogenesis of NAFLD and AF may serve as a potential therapeutic target in the future.