Integrating the Care of Metabolic Dysfunction-associated Steatotic Liver Disease Into Cardiac Rehabilitation: A Multisystem Approach.

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent chronic liver disease worldwide, affecting 1 in 3 adults and driven by the rising incidence of obesity and type 2 diabetes. MASLD is also a significant contributor to cardiovascular morbidity and mortality. Cardiovascular disease remains the leading cause of death in people with MASLD, often preceding liver complications. In this review, we outline the epidemiology and shared pathophysiologic mechanisms of MASLD with cardiovascular disease. Furthermore, we present a compelling case for integrating cardiac rehabilitation (CR) into MASLD care to address the shared metabolic and inflammatory drivers of both conditions. Evidence from recent clinical trials and guidelines supports the need for holistic, multidisciplinary strategies, including exercise, diet, and pharmacotherapy. CR is no longer solely a post-cardiac event intervention, but an opportunity for proactive cardiometabolic risk reduction in MASLD patients, especially those with fibrosis or type 2 diabetes. Incorporating MASLD into CR programs can facilitate early identification of high-risk individuals and deliver integrated care targeting both liver and cardiovascular outcomes. Cardiologists, hepatologists, and primary care providers must recognize MASLD as a cardiometabolic risk enhancer and consider CR referral, even before overt cardiovascular events occur. CR may be a critical yet underutilized opportunity to modify cardiovascular- and liver-related outcomes in people with MASLD.