Liver Fibrosis Scores May Hint at Heart Failure Risk

Noninvasive liver fibrosis scores, commonly used to assess liver disease severity, are now being linked to a higher prevalence of heart failure in the general US population.¹

A recent study published in the Journal of the American Heart Association analyzed data from nearly 20,000 individuals and found that scores like Fibrosis-4 (FIB-4), nonalcoholic fatty liver disease fibrosis score (NFS), and the aspartate aminotransferase to platelet ratio index (APRI) are significantly associated with heart failure risk.

To come to this finding, researchers used data from the National Health and Nutrition Examination Survey spanning 2011 to 2018. Advanced liver fibrosis risk was identified using FIB-4, NFS, and APRI scores, which measured a national prevalence of 4.20%, 8.06%, and 0.35%, respectively. According to the researchers, this suggests a prevalence between 0.32% and 5.96% of advanced liver fibrosis risk in the US.

Higher scores were tied to an increased likelihood of heart failure. Specifically, a 1-unit increase in these scores was linked to a:

• 15% increase in heart failure risk based on FIB-4 (OR, 1.15; 95% CI, 1.07-1.23)
• 42% increase based on NFS (OR, 1.42; 95% CI, 1.23-1.64)
• 44% increase based on APRI (OR, 1.44; 95% CI, 1.15-1.81)

These associations remained clear when scores were treated as categorical variables. Individuals with FIB-4 scores of 2.67 or higher had more than twice the risk of heart failure compared with those with scores below 1.3 (OR, 2.18; 95% CI, 1.47-3.24). Similarly, participants with NFS scores above 0.675 were more than 2.5 times more likely to have heart failure than those with scores under –1.455 (OR, 2.53; 95% CI, 1.37-4.68).

The association between APRI scores and heart failure was particularly pronounced in women. This sex-specific relationship indicates that women might face a higher risk, though the exact reasons remain unclear.

Noninvasive liver fibrosis scores were positively associated with the likelihood of heart failure. | Image credit: filins – stock.adobe.com

“This modifying effect was not observed in NFS scores, leaving it unclear whether sex directly impacts the occurrence of heart failure in individuals with liver fibrosis,” the researchers noted. “Future prospective studies are needed to provide further insights into this intriguing topic.

While advanced nonalcoholic fatty liver disease (NAFLD) has been previously tied to heart failure risk, this study is one of the first to look at the connection between specific scores and the risk of heart failure in the general population. Previous research had primarily focused on patients with preexisting liver conditions or those diagnosed with NAFLD. By extending the analysis to a broader demographic, the findings suggest that noninvasive liver fibrosis scores could serve as a simple, affordable tool for identifying individuals at risk of heart failure.

One previous study from the American Heart Association identified more than 3.8 million adults with NAFLD, including approximately 400,000 who also had heart failure.² Older adults, males, and individuals with diabetes or coronary heart disease were at especially high risk for heart failure. Even after accounting for factors like age, race, and gender, the study found that adults with NAFLD were 3.5 times more likely to have heart failure compared with those without NAFLD.

The implications for clinical practice are significant. Aside from imaging, liver biopsies are the gold standard for diagnosing liver fibrosis, but they are invasive and costly.³ In contrast, noninvasive scores like FIB-4, NFS, and APRI can be calculated using routine blood tests, making them accessible for widespread use.¹

“The incorporation of noninvasive liver fibrosis scoring into clinical practice equips health care professionals with a valuable tool for identifying individuals at higher risk for heart failure, all without resorting to invasive procedures such as liver biopsy,” the researchers emphasized. “This advancement in risk assessment can greatly enhance patient care and ultimately lead to better outcomes in the prevention and management of heart failure.”

The researchers acknowledged potential biases related to the cross-sectional design and the reliance on self-reported data, which may affect the generalizability of the findings. Additionally, while the associations between liver fibrosis scores and heart failure are strong, causality cannot be established, and further longitudinal studies are necessary to confirm these links.

As the prevalence of metabolic diseases like NAFLD continues to grow, leveraging noninvasive liver fibrosis scores could become a key strategy in the early identification of heart failure risk, ultimately leading to better patient outcomes and more targeted preventive measures.

References

1. Liu X, Zhang HJ, Fang CC, et al. Association between noninvasive liver fibrosis scores and heart failure in a general population. J Am Heart Assoc. Published online November 7, 2024. doi:10.1161/JAHA.123.035371
2. Christensen T. Fatty liver disease may increase heart failure risk. American Heart Association. November 16, 2022. Accessed November 12, 2024. https://www.heart.org/en/news/2022/11/16/fatty-liver-disease-may-increase-heart-failure-risk
3. Tsai E, Lee TP. Diagnosis and evaluation of nonalcoholic fatty liver disease/nonalcoholic steatohepatitis, including noninvasive biomarkers and transient elastography. Clin Liver Dis. 2018;22(1):73-92. doi:10.1016/j.cld.2017.08.004