Association of the metabolic score for visceral fat (METS‑VF) with incident subclinical carotid atherosclerosis in Chinese health‑screening participants: a retrospective cohort study

Abstract Background Visceral adiposity contributes to metabolic dysfunction and atherogenesis; however, whether integrated indices of visceral fat-related metabolic burden are independently associated with incident preclinical vascular disease remains unclear. This study analyzed a large Chinese health-screening cohort to determine the relationship between metabolic score for visceral fat (METS‑VF) and incident subclinical carotid atherosclerosis (SCCA). Methods A total of 4,109 participants without baseline SCCA who underwent carotid ultrasonography at a tertiary health management center in 2022 were included. Follow-up was measured from the date of baseline ultrasonography to the onset of SCCA or the last available health check-up. METS‑VF was calculated using a validated algorithm and analyzed both as a continuous variable and by quartiles. Missing covariates were handled using multiple imputation. Cox proportional hazards regression was applied to assess time-to-event associations, restricted cubic splines were used to examine dose–response relationships, and sensitivity analyses were conducted to corroborate the findings. Results Participants were followed for a median of 35 months (IQR: 24–37 months; total: 9,315 person-years), during which 890 incident SCCA cases were identified (cumulative incidence: 21.7%). In multivariable models controlling for covariates, every single‑unit increment in METS‑VF corresponded to a 30% greater hazard for SCCA (HR = 1.30; 95% CI 1.15–1.48; P < 0.001). Relative to the lowest quartile (Q1), participants in Q3 had an adjusted HR of 1.42 (95% CI 1.13–1.79; P = 0.003), and those in Q4 had an adjusted HR of 1.46 (95% CI 1.15–1.86; P = 0.002); the trend across quartiles was significant ( P = 0.002). Restricted cubic spline modeling demonstrated a significant linear association (overall P = 0.001; P for non-linearity = 0.998). These associations remained robust across predefined subgroups and sensitivity analyses. Conclusions Among Chinese health‑screening participants, higher METS-VF was associated with an increased risk of incident SCCA after multivariable adjustment. As a simple and cost-effective integrative marker, METS‑VF may deserve further evaluation as a risk stratification tool. Trial registration Chinese Clinical Trial Registry, ChiCTR2600119965; Registered on March 6, 2026, https://www.chictr.org.cn/showprojEN.html?proj=302327 .