This retrospective observational study evaluates the relationship between non-invasive liver fibrosis and metabolic markers and estimated cardiovascular risk in adults with metabolic dysfunction-associated steatotic liver disease (MASLD). The primary objective is to assess the association between the Fibrosis-4 index (FIB-4) and 10-year cardiovascular disease risk estimated using the American Heart Association PREVENT equations, with particular attention to the effect of age on this association. Secondary analyses evaluate the Fibrosis-3 index (FIB-3), triglyceride-glucose index (TyG), and liver stiffness measurement (LSM) in relation to PREVENT-estimated risks of cardiovascular disease, atherosclerotic cardiovascular disease, and heart failure.
This is a retrospective, single-center, observational study of adults with metabolic dysfunction-associated steatotic liver disease (MASLD) evaluated between January 1, 2024 and April 30, 2026. MASLD was defined by hepatic steatosis on ultrasonography together with at least one cardiometabolic risk factor, after exclusion of alternative causes of chronic liver disease. Clinical and laboratory data were obtained from electronic medical records. Non-invasive indices included the Fibrosis-4 index (FIB-4), Fibrosis-3 index (FIB-3), triglyceride-glucose index (TyG), and liver stiffness measurement (LSM) by transient elastography when available. Cardiovascular risk was estimated using the American Heart Association Predicting Risk of Cardiovascular Disease EVENTs (PREVENT) base equations. Ten-year estimates were calculated for total cardiovascular disease (PREVENT-CVD), atherosclerotic cardiovascular disease (PREVENT-ASCVD), and heart failure (PREVENT-HF). The primary analysis examines the association between FIB-4 and PREVENT-CVD risk. FIB-3 and TyG are evaluated as secondary markers, while analyses involving PREVENT-ASCVD, PREVENT-HF, and LSM are supportive. Because age is incorporated into FIB-4 and is also a major determinant of cardiovascular risk, crude associations are compared with age-adjusted partial Spearman correlations. A sensitivity analysis is also performed in participants without diabetes. Participants with prior cardiovascular disease were excluded from the primary prevention cohort. Analyses are based on complete cases, without imputation of missing data.
Study Type
OBSERVATIONAL
Enrollment
271
Göztepe Prof. Dr. Süleyman Yalçın City Hospital
Istanbul, Turkey (Türkiye)
Correlation between FIB-4 score and 10-year PREVENT-CVD risk
FIB-4 score (unitless) was calculated as (age × AST)/(platelet count × √ALT). Ten-year PREVENT-CVD risk was expressed as a percentage (%) and calculated using the published sex-specific American Heart Association PREVENT base equation. Correlation was quantified using Spearman's rank correlation coefficient (rho; unitless, range -1 to +1). An age-adjusted partial Spearman correlation was also calculated.
Time frame: At the index clinical evaluation during the retrospective study period (January 1, 2024 to April 30, 2026)
Correlation between FIB-3 score and 10-year PREVENT-CVD risk
FIB-3 score (unitless) was calculated as 5 × ln(AST) - 2 × ln(ALT) - 0.18 × (platelet count/10) - 5. Ten-year PREVENT-CVD risk was expressed as a percentage (%) and calculated using the published sex-specific American Heart Association PREVENT base equation. Correlation was quantified using Spearman's rank correlation coefficient (rho; unitless, range -1 to +1). An age-adjusted partial Spearman correlation was also calculated.
Time frame: At the index clinical evaluation during the retrospective study period (January 1, 2024 to April 30, 2026)
Correlation between TyG index and 10-year PREVENT-CVD risk
The triglyceride-glucose (TyG) index (unitless) was calculated as ln\[(fasting triglycerides × fasting glucose)/2\], with triglycerides and glucose expressed in mg/dL. Ten-year PREVENT-CVD risk was expressed as a percentage (%) and calculated using the published sex-specific American Heart Association PREVENT base equation. Correlation was quantified using Spearman's rank correlation coefficient (rho; unitless, range -1 to +1). An age-adjusted partial Spearman correlation was also calculated.
Time frame: At the index clinical evaluation during the retrospective study period (January 1, 2024 to April 30, 2026)
Correlation between liver stiffness measurement and 10-year PREVENT-CVD risk
Liver stiffness measurement (LSM) was expressed in kilopascals (kPa) and measured by transient elastography using a FibroScan 502 Touch system (Echosens, Paris, France). Ten-year PREVENT-CVD risk was expressed as a percentage (%) and calculated using the published sex-specific American Heart Association PREVENT base equation. Correlation was quantified using Spearman's rank correlation coefficient (rho; unitless, range -1 to +1). An age-adjusted partial Spearman correlation was also calculated.
Time frame: At the index clinical evaluation during the retrospective study period (January 1, 2024 to April 30, 2026)
Correlation between FIB-4 score and 10-year PREVENT-ASCVD risk
FIB-4 score (unitless) was calculated as (age × AST)/(platelet count × √ALT). Ten-year PREVENT-ASCVD risk was expressed as a percentage (%) and calculated using the published sex-specific American Heart Association PREVENT base equation. Correlation was quantified using Spearman's rank correlation coefficient (rho; unitless, range -1 to +1). An age-adjusted partial Spearman correlation was also calculated.
Time frame: At the index clinical evaluation during the retrospective study period (January 1, 2024 to April 30, 2026)
Correlation between FIB-3 score and 10-year PREVENT-ASCVD risk
FIB-3 score (unitless) was calculated as 5 × ln(AST) - 2 × ln(ALT) - 0.18 × (platelet count/10) - 5. Ten-year PREVENT-ASCVD risk was expressed as a percentage (%) and calculated using the published sex-specific American Heart Association PREVENT base equation. Correlation was quantified using Spearman's rank correlation coefficient (rho; unitless, range -1 to +1). An age-adjusted partial Spearman correlation was also calculated.
Time frame: At the index clinical evaluation during the retrospective study period (January 1, 2024 to April 30, 2026)
Correlation between TyG index and 10-year PREVENT-ASCVD risk
The triglyceride-glucose (TyG) index (unitless) was calculated as ln\[(fasting triglycerides × fasting glucose)/2\], with triglycerides and glucose expressed in mg/dL. Ten-year PREVENT-ASCVD risk was expressed as a percentage (%) and calculated using the published sex-specific American Heart Association PREVENT base equation. Correlation was quantified using Spearman's rank correlation coefficient (rho; unitless, range -1 to +1). An age-adjusted partial Spearman correlation was also calculated.
Time frame: At the index clinical evaluation during the retrospective study period (January 1, 2024 to April 30, 2026)
Correlation between liver stiffness measurement and 10-year PREVENT-ASCVD risk
Liver stiffness measurement (LSM) was expressed in kilopascals (kPa) and measured by transient elastography using a FibroScan 502 Touch system (Echosens, Paris, France). Ten-year PREVENT-ASCVD risk was expressed as a percentage (%) and calculated using the published sex-specific American Heart Association PREVENT base equation. Correlation was quantified using Spearman's rank correlation coefficient (rho; unitless, range -1 to +1). An age-adjusted partial Spearman correlation was also calculated.
Time frame: At the index clinical evaluation during the retrospective study period (January 1, 2024 to April 30, 2026)
Correlation between FIB-4 score and 10-year PREVENT-HF risk
FIB-4 score (unitless) was calculated as (age × AST)/(platelet count × √ALT). Ten-year PREVENT-HF risk was expressed as a percentage (%) and calculated using the published sex-specific American Heart Association PREVENT base equation. Correlation was quantified using Spearman's rank correlation coefficient (rho; unitless, range -1 to +1). An age-adjusted partial Spearman correlation was also calculated.
Time frame: At the index clinical evaluation during the retrospective study period (January 1, 2024 to April 30, 2026)
Correlation between FIB-3 score and 10-year PREVENT-HF risk
FIB-3 score (unitless) was calculated as 5 × ln(AST) - 2 × ln(ALT) - 0.18 × (platelet count/10) - 5. Ten-year PREVENT-HF risk was expressed as a percentage (%) and calculated using the published sex-specific American Heart Association PREVENT base equation. Correlation was quantified using Spearman's rank correlation coefficient (rho; unitless, range -1 to +1). An age-adjusted partial Spearman correlation was also calculated.
Time frame: At the index clinical evaluation during the retrospective study period (January 1, 2024 to April 30, 2026)
Correlation between TyG index and 10-year PREVENT-HF risk
The triglyceride-glucose (TyG) index (unitless) was calculated as ln\[(fasting triglycerides × fasting glucose)/2\], with triglycerides and glucose expressed in mg/dL. Ten-year PREVENT-HF risk was expressed as a percentage (%) and calculated using the published sex-specific American Heart Association PREVENT base equation. Correlation was quantified using Spearman's rank correlation coefficient (rho; unitless, range -1 to +1). An age-adjusted partial Spearman correlation was also calculated.
Time frame: At the index clinical evaluation during the retrospective study period (January 1, 2024 to April 30, 2026)
Correlation between liver stiffness measurement and 10-year PREVENT-HF risk
Liver stiffness measurement (LSM) was expressed in kilopascals (kPa) and measured by transient elastography using a FibroScan 502 Touch system (Echosens, Paris, France). Ten-year PREVENT-HF risk was expressed as a percentage (%) and calculated using the published sex-specific American Heart Association PREVENT base equation. Correlation was quantified using Spearman's rank correlation coefficient (rho; unitless, range -1 to +1). An age-adjusted partial Spearman correlation was also calculated.
Time frame: At the index clinical evaluation during the retrospective study period (January 1, 2024 to April 30, 2026)
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