Cardiovascular outcomes and subclinical atherosclerosis in metabolic-associated steatotic liver disease: long-term follow-up from a specialized outpatient cohort.

BACKGROUND AND AIMS: Cardiovascular disease is the main cause of mortality in metabolic-associated steatotic liver disease (MASLD). This study evaluated both observed and predicted cardiovascular outcomes using the Framingham risk score in a MASLD cohort and assessed subclinical atherosclerosis via carotid and femoral Doppler, along with its correlates at follow-up.

METHODS

Retrospective cohort included MASLD individuals under long-term optimized clinical management. Baseline Framingham scores were calculated, and observed major adverse cardiovascular events incidence was compared with predicted rates. Carotid and femoral Doppler assessed intima-media thickness and plaques. Machine learning identified factors associated with subclinical atherosclerosis.

RESULTS

Between October 2023 and February 2025, 147 patients were included [median follow-up 8 (4-12) years; age 62 (55-67) years; 78% women]. The baseline Framingham score was 15.9% (7.3-24.8). At follow-up, cardiovascular events (nonfatal stroke, myocardial infarction, and heart failure) occurred in 5.3% of patients, below predicted rates, with an incidence of 6.8 per 1000 person-years. Subclinical atherosclerosis, defined by carotid or femoral plaques, was found in 77% of patients. Arterial hypertension was a reliable risk factor for plaque formation across all vascular territories. In cases with single-territory involvement, platelet count, and alanine aminotransferase levels were also associated. For patients with plaques in both carotid and femoral regions, age and insulin use emerged as additional predictors (all P  < 0.05).

CONCLUSION

In MASLD patients under optimized clinical treatment, the incidence of cardiovascular events was lower than predicted by the Framingham score, although subclinical atherosclerosis remained highly prevalent at the end of follow-up.