Lower MACE but higher mortality in chronic hepatitis B infection: A competing risk explanation?

Lower MACE but higher mortality in chronic hepatitis B infection: A competing risk explanation?To the Editor,We read with interest the recent study by Chen et al. [1].Examining the association between chronic hepatitis B virus (HBV) infection and cardiovascular outcomes.The authors report a lower incidence of major adverse cardiovascular events (MACE) among HBV-infected individuals despite higher all-cause mortality.While these findings are noteworthy, their interpretation may warrant further clarification.First, the study indicates that HBV infection was associated with a higher prevalence of hyperlipidemia.Given that dyslipidemia is a wellestablished risk factor for atherosclerotic cardiovascular disease, the simultaneous observation of increased lipid abnormalities and reduced MACE appears difficult to reconcile from a biological perspective.This discrepancy raises the possibility that residual confounding or other unaccounted factors may have influenced the observed associations.Second, the coexistence of lower cardiovascular event rates and higher overall mortality complicates the interpretation of a potential cardioprotective effect.A reduction in observed cardiovascular events in the setting of increased mortality may reflect competing risks related to chronic liver disease, including cirrhosis or hepatocellular carcinoma, rather than a true reduction in cardiovascular disease progression.Finally, the authors report that antiviral therapy was associated with reduced risks of myocardial infarction, stroke, and cardiovascular mortality, whereas no significant associations were observed for heart failure or peripheral arterial disease.This heterogeneity across cardiovascular outcomes suggests that the decline in composite MACE may be driven primarily by selected atherosclerotic endpoints rather than a uniform reduction in cardiovascular risk.Further analyses incorporating competing risk models and stratification by liver disease severity may help clarify the interpretation of these findings.