Prognostic value of non-alcoholic fatty liver disease for predicting cardiovascular events in patients with diabetes mellitus with suspected coronary artery disease: a prospective cohort study

Abstract

Background Risk stratification of cardiovascular events in patients with type 2 diabetes mellitus (T2DM) has not been established. Coronary artery calcium score (CACS) and non-alcoholic fatty liver disease (NAFLD) are independently associated with cardiovascular events in T2DM patients. This study examined the incremental prognostic value of NAFLD assessed by non-enhanced computed tomography (CT) in addition to CACS and Framingham risk score (FRS) for cardiovascular events in T2DM patients. Methods This prospective pilot study included 529 T2DM outpatients with no history of cardiovascular disease who underwent CACS measurement because of suspected coronary artery disease. NAFLD was defined on CT images as a liver:spleen attenuation ratio < 1.0. Cardiovascular events were defined as cardiovascular death, nonfatal myocardial infarction, late coronary revascularization, nonfatal stroke, or hospitalization for heart failure. Results Among 529 patients (61% men, mean age 65 years), NAFLD was identified in 143 (27%). Forty-four cardiovascular events were documented during a median follow-up of 4.4 years. In multivariate Cox regression analysis, NAFLD, CACS, and FRS were associated with cardiovascular events (hazard ratios and 95% confidence intervals 5.43, 2.82–10.44, p < 0.001; 1.56, 1.32–1.86, p < 0.001; 1.23, 1.08–1.39, p = 0.001, respectively). The global χ2 score for predicting cardiovascular events increased significantly from 27.0 to 49.7 by adding NAFLD to CACS and FRS (p < 0.001). The addition of NAFLD to a model including CACS and FRS significantly increased the C-statistic from 0.71 to 0.80 (p = 0.005). The net reclassification achieved by adding CACS and FRS was 0.551 (p < 0.001). Conclusions NAFLD assessed by CT, in addition to CACS and FRS, could be useful for identifying T2DM patients at higher risk of cardiovascular events.

Prognostic impact of liver fibrosis and steatosis by transient elastography for cardiovascular and mortality outcomes in individuals with nonalcoholic fatty liver disease and type 2 diabetes: the Rio de Janeiro Cohort Study

“…A prospective investigation in NAFLD patients followed-up for a median of 27 months demonstrated that LSM was a predictor of all-cause mortality [ 19 ]. One previous study with 529 patients with type 2 diabetes [ 29 ] suggested that the presence of NAFLD, defined by CT imaging (liver/spleen attenuation rate, which detects liver steatosis, not fibrosis) was predictive of cardiovascular events occurrence over a median follow-up of 4.4 years. Another study with 1120 type 2 diabetic patients [ 30 ] reported that only the subgroup with liver fibrosis, defined by the FIB-4, a non-invasive laboratorial score, had progressive carotid intima-media thickening over a median follow-up of 6–8 years.…”

High pericoronary adipose tissue attenuation on computed tomography angiography predicts cardiovascular events in patients with type 2 diabetes mellitus: post-hoc analysis from a prospective cohort study

“…The CACS was calculated using the Agatston method, which involved multiplying the area of each calcified plaque by a density factor determined using the peak pixel intensity within the plaque. The plaque-specific scores for all slices were added together [ 17 ]. The density factor was 1, 2, 3, and 4 for plaques with peak intensities of 130–199, 200–299, 300–399, and ≥ 400 Hounsfield units (HU), respectively.…”

Association between higher pericoronary adipose tissue attenuation measured by coronary computed tomography angiography and nonalcoholic fatty liver disease

“…An abdominal non-contrast CT scan was performed just before the cardiac scan on the same day, as previously described. [ 2 , 11 ] Hepatic and splenic Hounsfield attenuations were measured in the largest possible regions. The regions of interest included 2 areas that were aligned to the anterior-posterior dimension of the right liver lobe and one that was aligned to the spleen.…”