Non-alcoholic fatty liver disease (NAFLD), metabolic syndrome and cardiovascular events in atrial fibrillation. A prospective multicenter cohort study

Clinical Guidelines of the Russian Society for the Study of the Liver, Russian Gastroenterological Association, Russian Society for the Prevention of Non-Communicable Diseases, Russian Association of Endocrinologists, Russian Scientific Medical Society of Therapists, National Society of Preventive Cardiology, Russian Association of Gerontologists and Geriatricians on Non-Alcoholic Fatty Liver Disease

Aim. The clinical guidelines are intended to provide information support for making decisions by gastroenterologists, general practitioners and internists that will improve the quality of medical care for patients with non-alcoholic fatty liver disease, taking into account the latest clinical data and principles of evidence-based medicine. Key points. Clinical guidelines contain information about current views on etiology, risk factors and pathogenesis of nonalcoholic fatty liver disease, peculiarities of its clinical course. Also given recommendations provide information on current methods of laboratory and instrumental diagnostics, invasive and non-invasive tools for nonalcoholic fatty liver disease and its clinical phenotypes assessment, approaches to its treatment, considering the presence of comorbidities, features of dispensary monitoring and prophylaxis. The information is illustrated with algorithms of differential diagnosis and physician's actions. In addition, there is information for the patient and criteria for assessing the quality of medical care. Conclusion. Awareness of specialists in the issues of diagnosis, treatment and follow-up of patients with nonalcoholic fatty liver disease contributes to the timely diagnosis and initiation of treatment, which in the long term will significantly affect their prognosis and quality of life.

The association of fatty liver index and metabolic syndrome with cardiovascular outcomes, liver-related mortality, and all-cause mortality: a nationwide cohort study

We investigated the risk of cardiovascular events, all-cause mortality, and liver-related mortality according to the presence of metabolic syndrome (MetS) and fatty liver index (FLI). In this retrospective longitudinal population-based cohort study, we used Korean National Health Insurance Service data from 2009 to 2012. Nonalcoholic fatty liver disease (NAFLD) was defined as FLI ≥ 60. Risk of all-cause mortality, liver-related mortality, and major adverse cardiovascular events (MACE) including myocardial infarction (MI), stroke, heart failure (HF), and cardiovascular disease (CVD)-related mortality was assessed according to the presence of MetS and FLI among adults (aged 40 to 80 years) who underwent health examinations (n = 769,422). During a median 8.59 years of follow up, 44,356 (5.8%) cases of MACE, 24,429 (3.2%) cases of all-cause mortality, and 1114 (0.1%) cases of liver-related mortality were detected in the entire cohort. When the FLI < 30 without MetS group was set as a reference, the FLI ≥ 60 with MetS group had the highest risk of MACE (adjusted hazard ratio [aHR] 2.05, 95% confidence interval [CI] 1.98-2.13) and all-cause mortality (aHR 1.96, 95% CI 1.86-2.07). The risk of liver-related mortality (aHR 10.71, 95% CI 8.05-14.25) was highest in the FLI ≥ 60 without MetS group. The FLI ≥ 60 with MetS group had a higher risk of MACE (aHR 1.39, 95%CI 1.28-1.51), a lower risk of liver-related mortality (aHR 0.44, 95%CI 0.33-0.59), and no significant difference in all-cause mortality compared with the FLI ≥ 60 without MetS group. The FLI ≥ 60 with MetS group was associated with the highest risk of MACE and the FLI ≥ 60 without MetS group had the highest risk liver-related mortality, but there was no significant difference in all-cause mortality between two groups. In conclusion, as FLI levels increase, the risk of MACE increases, and the risk increases additively in the presence of MetS. The risk of liver-related mortality increases with higher FLI levels, the effect of high FLI on increased risk is more significant in groups without MetS compared to those with MetS.

Risk of Adverse Events in Anticoagulated Patients With Atrial Fibrillation and Nonalcoholic Fatty Liver Disease

BACKGROUND

The clinical impact of nonalcoholic fatty liver disease (NAFLD) in patients with atrial fibrillation (AF) is still controversial.

AIM

To evaluate the 1-year risk of all-cause death, thromboembolic events, and bleeding in patients with AF-NAFLD.

METHODS

Retrospective study with a health research network (TriNetX). Patients with AF on oral anticoagulation (OAC) were categorized according to the presence of NAFLD into 2 groups. The primary outcomes were the 1-year risks of (1) a composite cardiovascular outcome (all-cause death, myocardial infarction, stroke, cardiac arrest, and pulmonary embolism) and (2) a composite hemorrhagic outcome (intracranial hemorrhage and gastrointestinal bleeding). Cox regression analysis before and after propensity score matching was used to estimate hazard ratio (HR) and 95% 95% CI,. Sensitivity analyses investigated the risk associated with cirrhosis, thrombocytopenia, and type of OAC (warfarin vs non-vitamin K antagonist oral anticoagulants (NOACs).

RESULTS

We identified 22 636 patients with AF-NAFLD (69 ± 12 years, 46.7% females) and 391 014 patients with AF and without liver disease (72 ± 12 years, 42.7% females). NAFLD was associated with a higher risk of composite cardiovascular (HR, 1.54; 95% CI, 1.47-1.61) and hemorrhagic (HR, 1.56; 95% CI, 1.42-1.72) outcomes. This was consistent also for all the single outcomes. Cirrhotic and thrombocytopenic patients with AF-NAFLD showed the highest risks. Compared to patients with AF-NAFLD on NOACs, those on warfarin were associated with a higher risk of cardiovascular and hemorrhagic outcomes.

CONCLUSION

In patients with AF, NAFLD is associated with a higher 1-year risk of adverse events, with the risk of adverse events progressively increasing from noncirrhotic to cirrhotic and from nonthrombocytopenic to thrombocytopenic patients. NOACs were associated with a better effectiveness and safety profile compared to warfarin.

Patients with atrial fibrillation and common exclusion criteria from clinical trials are at high risk of clinical events: the Murcia AF Project II (MAFP-II) cohort study

BACKGROUND

Some clinical characteristics and comorbidities in atrial fibrillation (AF) patients are exclusion criteria in randomized clinical trials (RCTs) investigating oral anticoagulants (OAC). However, these conditions are present also in everyday clinical practice patients. We compared the risk of adverse clinical outcomes between patients with and without RCT exclusion criteria.

METHODS

The Murcia AF Project II was an observational cohort study including AF outpatients starting vitamin K antagonists (VKAs) from July 2016 to June 2018. For the selection of the exclusion criteria, the four pivotal RCTs of direct-acting OAC (DOACs) were used as reference. During 2 years, all ischemic strokes/transient ischemic attacks, major adverse cardiovascular events (MACEs), major bleeds, and all-cause deaths were recorded.

RESULTS

1050 patients (51.5% female, median age 77 years) were included, of whom 368 (35%) met at least one exclusion criterion for RCTs. During follow-up, the incidence rate ratios for major bleeding, MACE and all-cause mortality were higher among patients with exclusion criteria (all p < 0.001). Patients fulfilling at least one exclusion criterion had increased risks of major bleeding (aHR 1.48; 95% CI 1.22-1.81; p < 0.001), MACE (aHR 1.51, 95% CI 1.10-2.09, p = 0.012), and mortality (aHR 3.22, 95% CI 2.32-4.48, p < 0.001), as well as a lower event-free survival (all log-rank p < 0.001).

CONCLUSIONS

In this AF cohort taking VKAs, more than one-third had at least one RCT exclusion criteria, which translates into higher risk of major bleeding, MACE, and death. These observations should be considered when translating RCTs results to AF patients for a proper and a more patient-centered management.

Patients with atrial fibrillation and diabetes mellitus affected by nonalcoholic fatty liver disease have a greater risk of mortality and worse clinical outcomes

Background

Nonalcoholic fatty liver disease (NAFLD) is associated with several adverse clinical outcomes. In this study, we assessed the association between NAFLD and several clinical outcome measures in patients with diabetes mellitus (DM) and atrial fibrillation (AF).

Methods

We queried the National Inpatient Sample (NIS) between 2016 and 2019 for adult patients who were hospitalized with DM and AF. NAFLD was the independent variable. The primary outcome was inpatient mortality. The secondary outcomes were cardiogenic shock, cardiac arrest, gastrointestinal bleeding (GIB), invasive mechanical ventilation, length of stay, and total hospital charges. A multivariable logistic regression model was used to estimate odds ratios with a 95% confidence interval (CI) and a P value of less than 0.05 was considered significant.

Results

There were 6 723 293 hospitalizations with AF and DM and 253 639 (3.7%) had NAFLD. NAFLD and non-NAFLD cohorts had a mean age of 70.4 vs. 73.8 years, respectively. Overall, 55.6% were male and 73.8% were White. NAFLD was found to be significantly associated with in-hospital mortality [adjusted odds ratio (AOR), 4.2; 95% CI, 4.08-4.32], cardiogenic shock (AOR, 4.78; 95% CI, 4.59-4.98), cardiac arrest (AOR, 3.43; 95% CI, 3.27-3.59), GIB (AOR, 1.92; 95% CI, 1.86-1.98), length of stay, and total hospital charges.

Conclusion

In patients with AF and DM patients, the presence of NAFLD was associated with significantly worse clinical outcomes and higher resource utilization. Adverse cardiovascular events were common as well as GIB. Screening and prevention strategies modifying the risk and disease severity of NAFLD are needed.

Metabolic Syndrome and Atrial Fibrillation: Different Entities or Combined Disorders

Obesity, hypertension, insulin resistance, and dyslipidemia are all clusters of an entity called "Metabolic Syndrome". The global trends of this syndrome's incidence/prevalence continue to increase reciprocally, converting it into a massive epidemic problem in the medical community. Observing the risk factors of atrial fibrillation, a medical condition that is also converted to a scourge, almost all parts of the metabolic syndrome are encountered. In addition, several studies demonstrated a robust correlation between metabolic syndrome and the occurrence of atrial fibrillation. For atrial fibrillation to develop, a combination of the appropriate substrate and a trigger point is necessary. The metabolic syndrome affects the left atrium in a multifactorial way, leading to atrial remodeling, thus providing both the substrate and provoking the trigger needed, which possibly plays a substantial role in the progression of atrial fibrillation. Due to the remodeling, treatment of atrial fibrillation may culminate in pernicious sequelae, such as repeated catheter ablation procedures. A holistic approach of the patient, with simultaneous treatment of both entities, is suggested in order to ensure better outcomes for the patients.

Cardiovascular Morbidity and Mortality Related to Non-alcoholic Fatty Liver Disease: A Systematic Review and Meta-analysis

Whether non-alcoholic fatty liver disease (NAFLD) is a cardiovascular (CV) risk factor is debated. We performed a systematic review and meta-analysis to assess the CV morbidity and mortality related to NAFLD in the general population, and to determine whether CV risk is comparable between lean and non-lean NAFLD phenotypes. We searched multiple databases, including PubMed, Embase, and the Cochrane Library, for observational studies published through 2022 that reported the risk of CV events and mortality. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) for all-cause mortality, CV mortality, myocardial infarction (MI), stroke, atrial fibrillation (AF), and major adverse cardiovascular and cerebrovascular events (MACCE) were assessed through random-effect meta-analysis. We identified 33 studies and a total study population of 10,592,851 individuals (mean age 53±8; male sex 50%; NAFLD 2, 9%). Mean follow-up was 10±6 years. Pooled ORs for all-cause and CV mortality were respectively 1.14 (95% CI, 0.78-1.67) and 1.13 (95% CI, 0.57-2.23), indicating no significant association between NAFLD and mortality. NAFLD was associated with increased risk of MI (OR 1.6; 95% CI, 1.5-1.7), stroke (OR: 1.6; 95% CI, 1.2-2.1), atrial fibrillation (OR: 1.7; 95% CI, 1.2-2.3), and MACCE (OR: 2.3; 95% CI, 1.3-4.2). Compared with non-lean NAFLD, lean NAFLD was associated with increased CV mortality (OR: 1.50; 95% CI, 1.1-2.0), but similar all-cause mortality and risk of MACCE. While NAFLD may not be a risk factor for total and CV mortality, it is associated with excess risk of non-fatal CV events. Lean and non-lean NAFLD phenotypes exhibit distinct prognostic profiles and should receive equitable clinical care.

Mediterranean Diet: A Tool to Break the Relationship of Atrial Fibrillation with the Metabolic Syndrome and Non-Alcoholic Fatty Liver Disease

Atrial fibrillation (AF) is the most common supraventricular arrhythmia associated with increased cardiovascular and non-cardiovascular morbidity and mortality. As multiple factors may predispose the onset of AF, the prevention of the occurrence, recurrence and complications of this arrhythmia is still challenging. In particular, a high prevalence of cardio-metabolic comorbidities such as the metabolic syndrome (MetS) and in its hepatic manifestation, the non-alcoholic fatty liver disease (NAFLD), have been described in the AF population. A common pathogenetic mechanism linking AF, MetS and NAFLD is represented by oxidative stress. For this reason, in the past decades, numerous studies have investigated the effect of different foods/nutrients with antioxidant properties for the prevention of, and their therapeutic role is still unclear. In this narrative comprehensive review, we will summarize current evidence on (1) the association between AF, MetS and NAFLD (2) the antioxidant role of Mediterranean Diet and its components for the prevention of AF and (3) the effects of Mediterranean Diet on MetS components and NAFLD.

Statin liver safety in non-alcoholic fatty liver disease: A systematic review and metanalysis

AIMS

Statin liver safety in non-alcoholic fatty liver disease (NAFLD) patients is not well defined. We analysed differences in liver function tests, including alanine transaminase aminotransferase (ALT), aspartate transaminase (AST) and gamma-glutamyl transpeptidase (GGT) in NAFLD patients treated or not treated with statins.

METHODS

We performed a systematic review of MEDLINE via PubMed and EMBASE databases and metanalysis of clinical studies investigating levels of ALT, AST and GGT in NAFLD according to statin treatment. Mean difference (MD) and percentage MD were calculated between the two groups.

RESULTS

We included 22 studies with 2345 NAFLD patients. Overall, 16 were before-after interventional, five were cross-sectional and one was combined cross-sectional/interventional study. In all interventional studies, except one, patients had raised ALT, AST and GGT at baseline. Interventional studies showed reduced ALT values with an MD reduction of -27.2 U/L (95% CI -35.25/-19.15) and a percentage MD reduction of -35.41% (95% CI -44.78/-26.04). Also, AST values were reduced after statin treatment in interventional studies with an MD of -18.82 U/L (95% CI -25.63/-12.02) (percentage -31.78%, 95% CI -41.45/-22.11). Similarly, GGT levels were reduced after statin treatment with an MD of -19.93 U/L (95% CI -27.10/-12.77) (percentage -25.57%, 95% CI -35.18/-15.97). Cross-sectional studies showed no difference in AST and GGT values between patients treated with and without statins.

CONCLUSION

In interventional studies, ALT, AST and GGT were reduced after statin treatment with a percentage mean difference of -35.41%, -31.78% and -25.57%, respectively, while observational studies showed a null effect, suggesting liver safety of statins in NAFLD patients.

Redefining non-alcoholic fatty liver disease to metabolic associated fatty liver disease: Is this plausible?

Recently, a single letter change has taken the world by storm. A group of experts have developed a consensus to upgrade the term non-alcoholic fatty liver disease (NAFLD) to metabolic associated fatty liver disease (MAFLD), suggesting that MAFLD would more accurately reflect not only the disease pathogenesis but would also help in patient stratification for management with NAFLD. However, the difference of opinion exists, which has made the NAFLD vs MAFLD debate the current talk of the town. This review will focus on the plausibility and implications of redefining NAFLD as MAFLD.