Cardiovascular risk in metabolic dysfunction associated steatotic liver disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) has emerged as the leading cause of chronic liver disease worldwide and is now recognized as a systemic cardiovascular determinant. Beyond hepatic progression toward advanced fibrosis or hepatocellular carcinoma, cardiovascular disease represents the principal driver of morbidity and mortality in these patients. Multiple cohorts and meta-analyses have consistently demonstrated that MASLD independently increases the risk of myocardial infarction, stroke, atrial fibrillation, heart failure with preserved ejection fraction, and microvascular injury. The risk gradient is magnified by the presence of fibrosis, even among young individuals and women, underscoring the need for systematic vascular risk assessment in hepatology practice. The mechanistic underpinnings of this association encompass insulin resistance, lipotoxicity, systemic inflammation, endothelial dysfunction, coagulation abnormalities, cardiac remodeling, and emerging axes such as the gut microbiota. Classical cardiovascular risk prediction algorithms, however, perform suboptimally in MASLD, supporting the integration of hepatic biomarkers, vascular imaging modalities, and combined risk models. Management should rely on intensive lifestyle modification, including a 7-10% weight reduction, adoption of Mediterranean or DASH dietary patterns, structured aerobic and resistance exercise, and complete avoidance of alcohol and tobacco. Pharmacotherapy is anchored in statins and lipid-lowering agents, complemented by GLP-1 receptor agonists, SGLT2 inhibitors, and novel compounds such as resmetirom, within a comprehensive cardio-hepato-metabolic framework. Longitudinal follow-up mandates a multidisciplinary and dynamic approach, integrating vascular prevention, hepatic protection, and renal care as inseparable pillars of contemporary MASLD management.