Metabolic dysfunction-associated steatotic liver disease and incident coronary events with revascularization: A nationwide cohort study

Abstract

Background and aims: Metabolic dysfunction-associated steatotic liver disease (MASLD), a new diagnostic category replacing non-alcoholic fatty liver disease (NAFLD), is strongly linked to cardiovascular diseases. Most previous studies defined cardiovascular outcomes broadly and relied only on diagnostic codes, limiting clinical specificity. We aimed to investigate whether MASLD, defined using the fatty liver index (FLI), is associated with an increased risk of acute coronary syndrome (ACS) and myocardial infarction (MI) with revascularization in the Korean general population. Methods: We analyzed 211,881 adults from the Korean NHIS-HEALS cohort who underwent health screening in 2009-2010. MASLD was defined using the fatty liver index (FLI >= 30) in combination with at least one metabolic risk factor, while excluding heavy alcohol intake and viral hepatitis. The primary outcomes were ACS and MI with revascularization, identified using both diagnostic and procedure codes. Cox proportional hazards models were applied, adjusting for cardiovascular, lifestyle, and socioeconomic factors. Results: Individuals with MASLD had a higher cumulative incidence of ACS and MI compared with non-MASLD. Compared to those without MASLD, fully adjusted HRs (95% CIs) for ACS with revascularization were 1.34 (1.16-1.55) and 1.35 (1.08-1.68) in men with intermediate-risk and high-risk MASLD, and 1.44 (1.16-1.79) and 1.16 (0.76-1.77) in women. A comparable association was found for MI with revascularization. Conclusions: MASLD was significantly associated with an increased risk of ACS and MI with revascularization. These findings support MASLD as an early marker and potential preventive target for atherosclerotic cardiovascular disease.