Coronary plaque phenotypes, inflammation and cardiovascular prognosis in metabolic dysfunction-associated steatotic liver disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) correlates with cardiovascular events. We sought to assess the association of coronary computed tomographic angiography (CCTA)-detected high-risk plaque characteristics (HRPC) and coronary inflammation with MASLD and their prognostic implications. This retrospective study comprised two independent cohorts: the internal cohort enrolled eligible participants undergoing both CCTA and abdominal CT within 3 months. Low-attenuation plaque burden (LAPB) and fat attenuation index (FAI) were assessed via CCTA. MASLD was defined by hepatic steatosis plus ≥ 1 cardiometabolic risk factor. This cohort analyzed MASLD associations with plaque characteristics and clinical outcomes, while the external cohort validated the results. Major adverse cardiovascular events (MACE) included cardiovascular death, nonfatal myocardial infarction, stroke, and unstable angina hospitalization. The internal cohort comprised 1,966 patients, with 640 (32.6%) diagnosed with MASLD. Over median 7-year follow-up, MASLD patients had significantly higher MACE rates versus non-MASLD (26.1% vs. 9.1%; P < 0.001), partially associated with LAPB (mediation effect 53.8%) and FAI (mediation effect 44.4%). MASLD patients with LAPB > 4% (35.8%; P < 0.001) or elevated FAI (41.9%; P < 0.001) manifested significantly elevated MACE risk post-adjustment for traditional risk factors. In the 373-patient external cohort with MASLD, FAI and LAPB retained robust prognostic performance; their integration with clinical factors yielded superior risk stratification (C-index 0.76 vs. 0.63; net reclassification index = 0.74, P < 0.001). MASLD patients exhibited poorer cardiovascular outcomes, which is statistically linked in part to greater coronary inflammation and vulnerable plaques. Integrating these markers enhanced prognostic value for risk stratification.