Comment on ‘incidence of major cardiovascular events in patients with metabolic dysfunction-associated steatotic liver disease in the general population’

We read with great interest the article titled ‘Incidence of major cardiovascular events in patients with metabolic dysfunction-associated steatotic liver disease in the general population1’ published in European Journal of Heart Failure. Drawing on the population-based GHS cohort with five-year follow-up, the authors examine associations between metabolic dysfunction-associated steatotic liver disease (MASLD) and both three-point major adverse cardiovascular events (MACE). They also analyse an extended composite outcome including atrial fibrillation and pulmonary embolism, with further assessment on incremental value over Systematic COronary Risk Evaluation 2 (SCORE2). This work provides valuable insights into the impact of MASLD on incident MACE and overall mortality in the general population. Alongside these strengths, we would like to share several concerns and considerations that might further enhance credibility and interpretability. First, extended MACE (eMACE) is clinically meaningful yet combines heterogeneous events including primary MACE plus incident atrial fibrillation and pulmonary embolism, which differ in pathophysiology, severity, and clinical management. The pooling strategy should be justified. In addition, the loss of about one in six participants raises concern for informative censoring. Baseline comparability of drop-outs vs. completers is not shown. Clarifying the precise implementation of competing-risk methods and the assumed censoring mechanism is essential to strengthen internal validity. Further elaboration on outcome composition and bias control would therefore be valuable.