Table 2.

Characteristics of noninvasive imaging techniques and scoring systems

Technique/ Scoring Name	Principle	Purpose	Advantages	Limitations	CV risk prediction
TE	uses shear waves induces by an external push to measure liver stiffness. Simultaneous measurement of steatosis due to the CAP technology which is based on the ultrasound beam attenuation.	Assessment of liver stiffness and liver fat	Fast and easy to perform Non-invasive, rapid, reproducible, and highly accurate	Limited sensitivity in mild liver fibrosis due to obesity and active phase of inflammation	Increased liver stiffness and higher CAP values are associated with a metabolic dysfunction which is a risk factor for CVD.
ARFI + FAT QUANTIFICATION	ultrasound technology measures shear wave velocity generated by tissue displacement to determine the stiffness of the liver and the ultrasound beam attenuation and or the backscattering to quantify the steatosis	Evaluation of liver stiffness and fatty liver	Mounted on conventional ultrasound equipment	Requires high operator skills	Increased liver stiffness and higher value of ultrasound beam attenuation and or backscattering are associated with a risk of CVD. At the same time the application of this technology in the carotid artery evaluation can predict ASCVD risk
MRE	Uses mechanical waves to quantitatively measure tissue elasticity	Evaluation of liver fibrosis and cirrhosis	High-resolution imaging with high accuracy	Higher cost and high equipment requirements	Early identification and surveillance of CV risk through the quantification of myocardial and vascular stiffness
MRS	Utilizes chemical shift imaging to distinguish hydrogen atoms in different molecular environments	Quantification of liver fat content	Accurate quantification of liver fat	High cost, not suitable for routine clinical use	identifies metabolic derangements and delineate lipid-rich atherosclerotic plaques in the arterial vasculature
APRI	assesses liver fibrosis risk based on the ratio of serum AST and platelets	Screening for liver fibrosis	Noninvasive, easy to perform	Accuracy influenced by liver inflammation and platelet disease	Fluctuations in AST and platelet levels may lead to increased inflammation and thrombotic risk
FIB-4	based on age, ALT, platelets and AST	Assessment of liver fibrosis risk	Simple, based on routine blood tests	May not be accurate enough in early stages of disease	Score of ≥ 2.67 was a significant predictor of MACEs A valuable predictor for AVS
NFS	combines multiple serum markers and demographic characteristics	Assessment of liver fibrosis risk	Noninvasive and multifactorial	Further validation is needed to improve accuracy	Higher NFS values are associated with an increased risk of MACEs
Forns index	utilizes serum cholesterol levels, platelet count, age, and GGT levels to estimate fibrosis stage	identifying patients with significant or advanced liver fibrosis	accurately exclude advanced fibrosis, demonstrated by high NPVs	may be less reliable in the presence of certain liver conditions that affect cholesterol metabolism	significant correlations with various CV risk scores
HFS	incorporates age, sex, AST levels, albumin, HOMA-IR, and platelet count in its algorithm, adjusting for confounding variables like diabetes status	Identifying individuals presenting with substantial or progressive hepatic fibrosis	Accurately discerning the absence of advanced fibrosis, as evidenced by elevated NPVs	requires validation in diverse populations and may be influenced by factors such as age and diabetes	Exhibiting substantial associations with a spectrum of CV risk scores
Pericoronary FAI	Measures attenuation of pericoronary fat by CT scan	Assessment of cardiovascular disease risk	Noninvasive, quantifiable	Requires CT scan, radiation exposure	Greater FAI have worse cardiovascular outcomes
CCTA	Uses X-rays and computer processing to create 3D images of the coronary arteries	Assessment of coronary artery disease	High-resolution imaging that can detect early lesions	Radiation exposure, requires the use of contrast agents	Identify ASCVD

TE: transient elastography, CAP: controlled attenuation parameter, ARFI: acoustic radiation force pulse imaging, ALT: alanine transaminase, MRE: magnetic resonance elastography, MRS: magnetic resonance spectroscopy, AST: aspartate transaminase, APRI: AST to platelet ratio index, FIB-4 index: Fibrosis-4 index, NAFLD: nonalcoholic fatty liver disease, NFS: NAFLD fibrosis score, Pericoronary, FAI: Pericoronary fat attenuation index, CV risk: cardiovascular risk, CVD: cardiovascular disease, ASCVD: atherosclerotic cardiovascular disease, MACEs: major adverse cardiovascular events, AVS: aortic valve sclerosis, HFS: hepamet fibrosis score, GGT: gamma-glutamyl transferase, HOMA-IR: homeostatic model assessment for insulin resistance, NPVs: negative predictive values, CT: computed tomography, CCTA: coronary computed tomography angiography