Association of metabolic dysfunction-associated steatotic liver disease markers and atherosclerotic disease burden

Abstract Introduction Metabolic dysfunction-associated steatotic liver disease (MASLD) is increasingly recognized as a multisystem disorder closely linked to cardiovascular morbidity. While its association with coronary artery disease (CAD) is well established, evidence regarding its relationship with systemic atherosclerosis remains limited. This study aimed to investigate the association between non-invasive MASLD markers and atherosclerotic burden across multiple vascular territories. Methods We conducted a retrospective single-center study including 56 patients who underwent coronary angiography, vascular ultrasonography (carotid arteries, lower limb arteries, abdominal aorta), and transient liver elastography (FibroScan ® ) between 2023 and 2025. Liver parameters included liver stiffness measurement (LSM), controlled attenuation parameter (CAP), and non-invasive scores: FibroScan-AST (FAST), Fibrosis-4 Index (FIB-4), and advanced generative liver evaluation 3 + (AGILE 3 +). Atherosclerotic disease burden was classified as disease-free (0 vascular sites affected), focal (1 site), intermediate (2–3 sites), or generalized (4–6 sites) based on the evaluation of six vascular territories and was further quantified using SYNTAX I and Gensini scores (CAD), NASCET method (carotid artery stenosis, CAS), Bollinger score (peripheral artery disease, PAD), and Kronzon score (aortic sclerosis, AS). Results Liver parameters and scores correlated significantly with greater atherosclerotic burden. Patients with atherosclerotic cardiovascular disease (ASCVD) ( n = 45) demonstrated significantly higher liver stiffness (LSM: 5.8 [4.2–7.5] vs. 4.5 [3.0–5.1] kPa; p = 0.0472) and steatosis (CAP: 253 [220.5–290.5] vs. 210 [184–251.0] dB/m; p = 0.0097) compared to those without ASCVD. Non-invasive liver scores were significantly elevated in ASCVD patients and variably associated with vascular burden and severity scores after adjustment for sex and age: AGILE 3 + correlated with SYNTAX I ( β = 0.008446, p = 0.0045), Gensini ( β = 0.0024, p = 0.049), and Kronzon score ( β = 0.06413, p = 0.0274). FAST correlated with the Kronzon score ( β = 0.04011, p = 0.0064). Hepatic steatosis (CAP ≥ 248 dB/m) or fibrosis (LSM ≥ 6.5 kPa) was present in 73.3% of ASCVD patients vs. 36.4% of No ASCVD ( p = 0.0325). Conclusion Non-invasive hepatic markers—particularly the AGILE 3 + score—demonstrated significant associations with the presence and extent of systemic atherosclerosis. These findings support a “liver–vascular axis” and highlight the potential utility of liver-derived scores as surrogate markers of cardiovascular risk in patients with MASLD.