Fibrosis-4 (FIB-4) score is associated with early diastolic dysfunction in metabolic dysfunction-associated steatotic liver disease (MASLD)
S K Ryu, S H Shin, C W GohAbstract
Background
Metabolic dysfunction-associated steatotic liver disease (MASLD) shares key pathophysiological mechanisms with cardiovascular disease. The Fibrosis-4 (FIB-4) score is a well-established tool for assessing liver fibrosis in MASLD. The FIB-4 score is known to be useful for predicting the risk of heart failure as well as advanced liver disease. We evaluated the relationship between FIB-4 and early diastolic dysfunction in MASLD patients free of structural heart disease, systolic dysfunction, and cardiac symptoms.
Methods
We analyzed consecutive middle-aged adults (aged 30–60 years) who underwent both echocardiography and liver ultrasonography at our Hospital between April 2020 and February 2026. After excluding those with significant echocardiographic abnormalities, a total of 4,056 participants were finally included in the analysis. All analyzed participants maintained a left ventricular ejection fraction (LVEF) greater than 50% and were free of significant valvular disease. MASLD was diagnosed according to the Korean Association for the Study of the Liver (KASL) guidelines, which define overweight as a BMI ≥ 23 kg/m2 and waist circumference thresholds of ≥ 90 cm for men and ≥ 80 cm for women. FIB-4 scores were stratified into low-risk (< 1.3), intermediate-risk (1.3–2.67), and high-risk (> 2.67) groups.
Results
Among the study population, 61.0% (n=2,476) presented with fatty liver, of which 94.9% (n=2,349) met the diagnostic criteria for MASLD. In the MASLD cohort, the mean age was 45.4 ± 8.3 years and 17.4% were female. Metabolic abnormalities were highly prevalent, with 87.6% being overweight or having increased waist circumference, 67.4% having glucose metabolism dysfunction, and 45.5% having elevated blood pressure. The mean FIB-4 score was 1.69 ± 0.80, with 42.9% in the low-risk group and 57.1% in the combined intermediate-to-high-risk groups. Correlation analysis revealed that the FIB-4 score significantly correlated with age (R=0.046,p<0.05), LA volume index:LAVi (R=0.090,p<0.001), e' velocity (R=-0.053,p<0.05), LV mass index (R=0.131,p<0.001), E/e’ ratio (R=0.046,p<0.05), and deceleration time (R=0.090,p<0.001). Compared to the low-risk group, the intermediate-to-high-risk groups exhibited significantly higher LAVi (22.6 vs. 21.3 p<0.001), TRjet peak velocity (2.00 vs. 1.98 p<0.05) and lower e'(8.60 vs. 8.84 p<0.01). Furthermore, the FIB-4 index remained a significant independent predictor of the E/e’ ratio even after adjusting for age, sex, and the number of metabolic syndrome components.
Conclusion
The FIB-4 score is significantly associated with early-stage cardiac dysfunction in asymptomatic individuals with MASLD. Since the FIB-4 score can be easily calculated from routine blood tests, it may serve as a clinically valuable marker for the early detection of subclinical cardiac dysfunction in this population.Multiple Linear Regression analysis