Cardiovascular outcomes and subclinical atherosclerosis in metabolic-associated steatotic liver disease: long-term follow-up from a specialized outpatient cohort

BACKGROUND AND AIMS: Cardiovascular disease is the main cause of mortality in metabolic-associated steatotic liver disease (MASLD). This study evaluated both observed and predicted cardiovascular outcomes using the Framingham risk score in a MASLD cohort and assessed subclinical atherosclerosis via carotid and femoral Doppler, along with its correlates at follow-up. METHODS: Retrospective cohort included MASLD individuals under long-term optimized clinical management. Baseline Framingham scores were calculated, and observed major adverse cardiovascular events incidence was compared with predicted rates. Carotid and femoral Doppler assessed intima-media thickness and plaques. Machine learning identified factors associated with subclinical atherosclerosis. RESULTS: Between October 2023 and February 2025, 147 patients were included [median follow-up 8 (4-12) years; age 62 (55-67) years; 78% women]. The baseline Framingham score was 15.9% (7.3-24.8). At follow-up, cardiovascular events (nonfatal stroke, myocardial infarction, and heart failure) occurred in 5.3% of patients, below predicted rates, with an incidence of 6.8 per 1000 person-years. Subclinical atherosclerosis, defined by carotid or femoral plaques, was found in 77% of patients. Arterial hypertension was a reliable risk factor for plaque formation across all vascular territories. In cases with single-territory involvement, platelet count, and alanine aminotransferase levels were also associated. For patients with plaques in both carotid and femoral regions, age and insulin use emerged as additional predictors (all P < 0.05). CONCLUSION: In MASLD patients under optimized clinical treatment, the incidence of cardiovascular events was lower than predicted by the Framingham score, although subclinical atherosclerosis remained highly prevalent at the end of follow-up.