Steatotic liver disease phenotypes and cardiac autonomic dysfunction: a community-based study in China

Steatotic liver disease (SLD) is increasingly recognized as a systemic disorder linked to cardiometabolic risk. Cardiac autonomic dysfunction may represent an early mechanistic pathway connecting hepatic steatosis with adverse cardiovascular outcomes. We investigated the associations between contemporary SLD phenotypes and cardiac autonomic function, assessed by heart rate variability (HRV).

A total of 2792 participants from the Pinggu Metabolic Disease Study were included. Hepatic steatosis was defined by computed tomography (liver-spleen ratio ≤1.1). Metabolic dysfunction-associated SLD (MASLD), MASLD with moderate alcohol intake (MetALD), and alcohol-associated liver disease (ALD) were classified according to the 2024 EASL-EASD-EASO criteria. HRV indices (MeanNN, SDNN, RMSSD) were derived from digitized electrocardiograms. Sex-stratified multivariable ordinal logistic regression models were used. The prevalence of MASLD, MetALD, and ALD was 17.8%, 2.1%, and 2.5%, respectively. SLD phenotypes were generally associated with adverse HRV profiles. After adjustment, SLD phenotypes remained associated with lower MeanNN. In men, MASLD and the combined MetALD/ALD group were associated with lower SDNN quartiles, with a stronger association for MetALD/ALD (OR 2.19, 95% CI 1.55-3.09), which was also associated with lower RMSSD quartiles (OR 2.08, 95% CI 1.47-2.94). In women, MASLD was associated with lower RMSSD quartiles (OR 1.57, 95% CI 1.23-2.02). Sensitivity analyses showed generally consistent findings.

SLD phenotypes were associated with higher heart rate. In men, MASLD, MetALD, and ALD were associated with impaired overall cardiac autonomic function, whereas in women, MASLD was associated with impaired cardiac parasympathetic function.