Prognostic Value of Non-alcoholic Fatty Liver Disease in Predicting Cardiovascular Events in Diabetes Mellitus Patients: A Prospective Cohort Study

Abstract Background: Risk stratification of cardiovascular events in patients with type 2 diabetes mellitus (T2DM) has not been established. coronary artery calcium score (CACS) and non-alcoholic fatty liver disease (NAFLD) are independently associated with cardiovascular events in T2DM patients. This study examined the incremental prognostic value of NAFLD assessed by non-enhanced computed tomography (CT) in addition to CACS and Framingham risk score (FRS) on cardiovascular events in T2DM patients.Methods: This prospective pilot study included 529 T2DM outpatients without history of cardiovascular disease who underwent CACS measurement due to suspected coronary artery disease. NAFLD was defined on CT images as a hepatic: spleen attenuation ratio <1.0. cardiovascular events were defined as cardiovascular death, nonfatal myocardial infarction, late coronary revascularization, nonfatal stroke, or hospitalization for heart failure.Results: Of 529 patients (61% men, mean age 65 years), NAFLD was identified in 143 (27%). During the median 4.4 years of follow-up, 44 cardiovascular events were documented. In multivariate Cox regression analysis, the presence of NAFLD, CACS and FRS were associated with cardiovascular events with hazard ratios of 5.45 (95% confidential interval [CI]: 2.84–10.45; p<0.001), 1.56 (95% CI: 1.32–1.85; p<0.001), and 1.23 (95% CI: 1.08–1.39; p=0.001), respectively. The global chi-square score for predicting cardiovascular events significantly increased from 27.0 to 49.7 by adding NAFLD to CACS and FRS (p<0.001). The addition of NAFLD to a model including CACS and FRS significantly increased the C-statistic from 0.71 to 0.80 (p=0.005). The net reclassification achieved by adding CACS and FRS was 0.551 (p<0.001). Conclusions: NAFLD assessed by CT, in addition to CACS and FRS, could be useful in assessing T2DM patients at higher risk of cardiovascular events.