FIB-4 Serves as a Referral Index for Coronary Artery Calcification in Patients With MASLD

The association between metabolic dysfunction-associated steatotic liver disease (MASLD), liver fibrosis, and coronary artery calcification (CAC) remains uncertain. We investigated their relationships and the predictive role of the Fibrosis-4 (FIB-4) index.

The study included 6058 subjects undergoing health check-ups and coronary computed tomography. Steatotic liver disease (SLD) was identified via ultrasonography or hepatic steatosis index > 36. MASLD was defined as SLD with at least one of the five cardiometabolic risk factors. Liver fibrosis severity was assessed using the FIB-4 index to assess its association with CAC and predictive performance at different CAC thresholds.

MASLD was present in 39.8% of participants, with a higher CAC prevalence than non-MASLD individuals (51.1% vs. 42.5%, p < 0.001). Factors associated with the presence of CAC included age (odds ratio [OR]/95% confidence intervals [CI]: 1.117/1.106-1.128, p < 0.001), male gender (OR/95% CI: 4.448/3.660-5.406, p < 0.001), MASLD (OR/95% CI: 1.570/1.342-1.837, p < 0.001), and FIB-4 (OR/95% CI: 1.217/1.034-1.433, p = 0.018). Among MASLD subjects, the prevalence of CAC increased with FIB-4 value and cardiometabolic burdens. FIB-4 values increased progressively in patients with higher coronary artery calcium scores (p-trend < 0.001). A FIB-4 cut-off of ≥ 2.67 provided the highest positive predictive value (89.7%) for the presence of CAC, while a cut-off of 1.26 offered the best negative predictive value (95.1%) for severe CAC.

MASLD patients with elevated FIB-4 are at increased risk of coronary atherosclerosis. Incorporating FIB-4 into routine assessment may help identify high-risk individuals who could benefit from early cardiology referral and preventive cardiovascular care.