Table 2.
Cardiovascular disease risk factors and treatment targets in patients with metabolic dysfunction-associated steatotic liver disease40,43-50
| Risk factor | Optimal target | Preferred pharmacotherapeutic agent | Comments |
|---|---|---|---|
| LDL cholesterol | Moderate or intermediate risk* (diabetes alone): < 100 mg/dL (< 2.6 mmol/L) Higher risk (diabetes+multiple other ASCVD risk factors): < 70 mg/dL (< 1.8 mmol/L) High risk (established ASCVD): < 55 mg/dL (< 1.4 mmol/L)† |
1st line: Statin at an appropriate dose/intensity for risk category Moderate intensity: ≥ 30% decrease from baseline e.g., simvastatin 20–40 mg,43,44 atorvastatin 10–20 mg, rosuvastatin 5–10 mg, pravastatin 40–80 mg, lovastatin 40 mg, pitavastatin 2–4 mg High intensity: ≥ 50% decrease from baseline, e.g., rosuvastatin 20–40 mg, atorvastatin 40–80 mg 2nd line: Ezetimibe or PCSK9i can be added if the target is not achieved on maximal tolerated statin dose. |
Safe and may be used if serum aminotransferase level is < 3 × upper limit of normal. All patients at moderate or high risk must start statin regardless of baseline LDL cholesterol level. |
| Triglycerides44 | < 150 mg/dL (< 1.7 mmol/L) | Intensify lifestyle modification and optimize glycemic control | Fibrates do not improve cardiovascular outcomes. |
| BP | Treat if BP ≥ 140/90 mmHg in all patients Treat if BP ≥ 130/80 mmHg in diabetes or ASCVD risk ≥ 10% Aim for BP 120–129/70–79 mmHg |
RAS blockade preferred if albuminuria present or patient has IHD or heart failure. | For elderly patients ( ≥ 65 years) who are nursing home residents with high burden of comorbidity and limited life expectancy, treatment decision should be based on patient preference and team-based assessment of risk vs. benefit. |
| BMI and waist circumference | Ethnicity- and gender-specific targets BMI: < 23 kg/m2 for Asians and < 25 kg/m2 for Caucasians Waist circumference: Asian, < 80 cm (< 85 cm in Korea)48 for female, < 90 cm for male; Caucasian, < 80 cm for female, < 94 cm for male Weight loss ≥ 5% |
Lifestyle modification. Adjunctive GLP1 RA with proven cardiovascular benefit if BMI ≥ 27 kg/m2 with comorbidities or BMI ≥ 30 kg/m2 without comorbidities |
Weight loss ≥ 5% can lower HbA1c and BP and improve lipid profile. Use of GLP1 RA has cardiorenal benefits in patients with diabetes. Bariatric surgery results in sustained weight loss, improves liver histology, and reduces cardiovascular events. |
| HbA1c | < 6.5%‡50 | SGLT2 inhibitor preferred in patients with CVD/heart failure/CKD. GLP1 RA preferred in patients with CVD/albuminuria. |
Pioglitazone improves liver histology in MASLD, lowers glucose, and improves cardiovascular outcomes, but demonstrates safety concerns e.g., heart failure and side effects such as weight gain/edema. SGLT2 inhibitor improves liver fat content and may improve histology in MASLD. GLP1 RA improves liver fat content and histology in MASLD. |
*CVD risk calculated using the American College of Cardiology/American Heart Association ASCVD risk calculator (Risk Estimator Plus), a tool to estimate 10-year risk of a first ASCVD event based on the Pooled Cohort Equations (available online at tools.acc.org/ASCVD-Risk-Estimator-Plus): < 5%, low risk; 5% to < 7.5%, borderline risk; 7.5% to < 20%, moderate/ intermediate risk; and ≥ 20%, high risk; †American Diabetes Association (ADA) 2023 guidelines recommend a target LDL < 55 mg/dL (< 1.4 mmol/L) in patients with diabetes and established ASCVD; however, the American Heart Association 2018 guidelines recommend a target LDL < 70 mg/dL (< 1.8 mmol/L) in this group of patients; ‡HbA1c target should be individualized as recommended by the ADA.
LDL, low-density lipoprotein; ASCVD, atherosclerotic cardiovascular disease; PCSK9i, proprotein convertase subtilisin/kexin type 9 inhibitor; BP, blood pressure; RAS, renin-angiotensin system; IHD, ischemic heart disease; BMI, body mass index; GLP1 RA, glucagon-like peptide-1 receptor agonist; HbA1c, glycosylated hemoglobin; SGLT2, sodium glucose cotransporter-2; CVD, cardiovascular disease; CKD, chronic kidney disease; MASLD, metabolic dysfunction-associated steatotic liver disease.