Cardiovascular Complications of Chronic Liver Disease

Chronic liver disease is an increasingly prevalent and heterogeneous syndrome with important consequences for cardiovascular function. As the global burdens of chronic liver disease and cirrhosis continue to rise, cardiovascular disease has emerged as a major driver of overall morbidity and mortality in affected patients. Despite the growing recognition of the intersectionality between hepatology and cardiology care clinically, cardiovascular disease risk among patients with liver disease is underrecognized. This state-of-the-art review summarizes the current understanding of the bidirectional interactions between the liver and the cardiovascular system. Shared mechanisms-including inflammation, endothelial injury, and neurohormonal overactivation-that contribute to the development of adverse myocardial remodeling, atherosclerotic cardiovascular disease, heart failure, arrhythmias, pulmonary vascular syndromes, and cirrhosis-associated cardiovascular syndromes are reviewed. A specific focus is placed on metabolic dysfunction-associated steatotic liver disease, the most common form of chronic liver disease, while highlighting the distinct cardiovascular manifestations associated with other types of chronic liver disease. These include alcohol-associated liver disease and infiltrative diseases that affect the liver and heart with cardiovascular implications across the spectrum from early stages of liver disease through cirrhosis. We discuss practical approaches to detecting liver disease, including the assessment of liver fibrosis noninvasively in individuals at risk. We discuss the approach to assessing cardiovascular risk through cardiac imaging, biomarkers, and cardiac functional testing once chronic liver disease is detected. Management considerations for commonly encountered cardiovascular conditions and a critical appraisal of the evolving evidence supporting cardiometabolic therapies in patients with chronic liver disease are discussed to underscore potential cardiovascular and liver benefits. Critical evidence gaps and future research priorities are identified, including the development and evaluation of liver-informed cardiovascular risk models, incorporation of cardiovascular end points into liver disease trials, and implementation of integrated cardiohepatometabolic care pathways. Improved recognition of chronic liver disease and related cardiovascular disease risk represents a major opportunity to facilitate earlier disease detection, enhance risk stratification, and improve outcomes across the spectrum of chronic liver disease.