The impact of modifiable risk factors on the long‐term outcomes of non‐alcoholic fatty liver disease. Issue 2 (29th November 2019) - Paik, James M.
Summary: Background: Cardiovascular (CV) disease is the leading cause of mortality in patients with non‐alcoholic fatty liver disease (NAFLD). The American Heart Association (AHA) developed 7 CV health metrics (poor, intermediate and ideal health) to improve CV health. Aim: To assess population‐attributable fractions (PAFs) of CV health metrics to all‐cause and CV mortality among NAFLD patients Methods: We included adult participants from National Health and Nutrition Examination Survey (NHANES 1988‐1994) with clinical and mortality data. NAFLD was defined as the presence of hepatic steatosis on ultrasonography in the absence of other chronic liver diseases and excessive alcohol use. Results: A total of 4040 adults with NAFLD and 7515 without were included. NAFLD had fewer ideal health metrics than non‐NAFLD (age‐standardised prevalence: 20% vs 10% for ≤1 ideal health metric; 5.1% vs 8.7% for ≥6, all P < .001). Following median follow‐up of 19.2 years (IQR: 17.5‐21.0 years), 1, 136 NAFLD subjects (327 CV deaths) and 1600 non‐NAFLD subjects (447 CV deaths) died. Increased number of ideal health metrics (all trend P < .0001) correlated with lower risk for all‐cause and CV mortality. If all NAFLD subjects achieved 7 ideal health metrics, 66% of all‐cause deaths and 83% of CV deaths were preventable. Among NAFLD subjects, lack of glycaemic control (adjusted PAF = 28.3% all‐cause; 38.1% CV) and hypertension (adjusted PAF of 23% all‐cause; 52.8% CV) were the largest mortality contributors. Ideal physical activity level obtainment provided an adjusted PAF = 13.9% all‐cause and 13.8% CV mortality. Conclusions: Attainment of ideal CV health metrics provides protection against all‐cause and CV deaths in NAFLD.