Sonographic Grading of Non-alcoholic Fatty Liver Disease and Its Association With Serum Biomarkers, Echocardiography, and Electrocardiogram.

INTRODUCTION

Non-alcoholic fatty liver disease (NAFLD) is the hepatic manifestation of metabolic syndrome and is increasingly recognized as a systemic disorder associated with cardiovascular morbidity. Sonographic grading of NAFLD may reflect progressive metabolic and cardiovascular involvement; however, evidence evaluating the association between ultrasonographic severity and serum biomarkers, echocardiographic parameters, and electrocardiographic findings remains limited. This study aimed to evaluate the association between sonographic grading of NAFLD and serum biomarkers, echocardiographic parameters, and electrocardiographic findings.

MATERIALS AND

METHODS

This prospective observational study included 96 adults with sonographically diagnosed NAFLD attending a tertiary care center between March 2024 and October 2025. Participants were categorized into Grade 1, Grade 2, and Grade 3 NAFLD based on ultrasonographic findings. Serum lipid profile and liver enzymes were evaluated, followed by transthoracic echocardiography and 12-lead electrocardiography. Continuous variables were compared using one-way analysis of variance with Tukey's post-hoc test, while categorical variables were analyzed using the chi-squared test or Fisher's exact test, as appropriate. A p-value of <0.05 was considered statistically significant.

RESULTS

Increasing sonographic grade of NAFLD was associated with progressive elevations in total cholesterol, triglyceride, low-density lipoprotein (LDL), very-low-density lipoprotein (VLDL), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) levels, together with a significant reduction in high-density lipoprotein (HDL) levels (all p<0.001). Echocardiographic evaluation demonstrated significant increases in interventricular septal thickness, left ventricular mass, left ventricular mass index, left ventricular dimensions, and progressive reductions in ejection fraction and early-to-late ventricular filling velocity ratio (E/A ratio) (all p<0.001). The prevalence of left ventricular diastolic dysfunction increased from 10 (22.7%) in Grade 1 to 18 (52.9%) in Grade 2 and 14 (77.8%) in Grade 3 (p<0.001). QTc prolongation similarly increased from 6 (13.6%) to 11 (32.4%) and 12 (66.7%) across Grades 1-3 (p<0.001). Although P-wave and T-wave abnormalities were more frequent in advanced disease, these associations were not statistically significant.

CONCLUSIONS

Increasing sonographic severity of NAFLD is associated with worsening biochemical abnormalities, adverse cardiac remodelling, left ventricular diastolic dysfunction, and QTc prolongation. Ultrasonographic grading, combined with routine biochemical, echocardiographic, and electrocardiographic evaluation, may facilitate the early cardiovascular risk stratification and comprehensive management of patients with NAFLD.