Metabolic dysfunction-associated steatotic liver disease (MASLD) and cardiac arrhythmias: current evidence and future...

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent chronic liver disease worldwide and is increasingly recognized as a multisystem cardiometabolic disorder. Beyond its association with cardiovascular morbidity and mortality, growing evidence suggests that MASLD may contribute to cardiac arrhythmias.

This narrative review summarizes current evidence from observational studies, systematic reviews, and meta-analyses investigating the association between MASLD and cardiac arrhythmias. Evidence indicates that MASLD is associated with an increased risk of cardiac arrhythmias, independently of traditional cardiometabolic risk factors. In this sense, MASLD has been consistently linked to a higher prevalence and incidence of AF, increased risk of AF recurrence after catheter ablation, QTc interval prolongation, ventricular arrhythmias, and conduction defects. Importantly, arrhythmic susceptibility appears to parallel liver disease severity, with advanced fibrosis emerging as a potential determinant of increased risk. Proposed mechanisms include insulin resistance, chronic low-grade inflammation, oxidative stress, endothelial dysfunction, autonomic imbalance, adipose tissue dysfunction, and systemic profibrotic pathways leading to myocardial structural and electrical remodeling.

MASLD should be considered a cardiometabolic risk enhancer extending beyond hepatic complications. Although current evidence is mainly observational and does not establish causality, the consistent association between MASLD and cardiac arrhythmias supports greater awareness of arrhythmic risk, particularly among individuals with obesity, type 2 diabetes, or advanced fibrosis. Prospective studies are required to define optimal risk stratification strategies and determine whether effective MASLD treatment can reduce arrhythmia burden and improve cardiovascular outcomes.