Prevalence of heart failure with preserved ejection fraction (HFpEF) and symptoms in patients with metabolic dysfunction-associated steatotic liver disease (MASLD)
M Ramadan, F S Davidovski, C Espersen, M Dons, P Nabilou, S Wiese, A Jensen, M Sengeloev, A Al-Rubai, M Werge, E Badu, M Thing, M Pareek, L L Gluud, T B Biering-SoerensenAbstract
Background
Metabolic dysfunction-associated steatotic liver disease (MASLD) is associated with an increased risk of heart failure, particularly heart failure with preserved ejection fraction (HFpEF). The prevalence of HFpEF and related patient-reported functional limitations in MASLD patients with preserved left ventricular ejection fraction (LVEF) is has not been well characterised.
Purpose
To determine the prevalence of HFpEF and associated clinical, hepatic, echocardiographic, and patient-reported features in MASLD patients with preserved LVEF.
Methods
This cross-sectional study included adults with MASLD confirmed by vibration-controlled transient elastography (VCTE), defined as controlled attenuation parameter (CAP) ≥250 dB/m, who underwent comprehensive echocardiography. Patients with LVEF ≥50% were included in this analysis. HFpEF was defined according to the 2021 European Society of Cardiology (ESC) criteria requiring symptoms/signs and objective echocardiographic evidence of elevated filling pressures. Natriuretic peptides were unavailable. Symptoms, functional limitations, and physical activity were assessed by structured questionnaire. Associations between HFpEF, clinical and echocardiographic measures were examined using regression models adjusted for age, sex, and body-mass-index (BMI).
Results
Among 475 MASLD patients with preserved LVEF, 166 (35%) fulfilled ESC-defined HFpEF criteria. Compared with non-HFpEF (n=309), HFpEF patients reported a higher burden of HF-related symptoms, including dyspnoea, fatigue, peripheral oedema, and NYHA class ≥II, and had more activity limitations across multiple domains (all p≤0.049) (Figure 1). HFpEF patients were older (62 [55–68] vs 60 [52–65] years, p=0.004), had higher BMI (30.3 [27.8–34.0] vs 29.4 [26.3–33.3] kg/m², p=0.025), greater waist circumference (103 [95–113] vs 100 [91–109] cm, p=0.005), and higher systolic blood pressure (143 [133–154] vs 136 [125–149] mmHg, p<0.001). Hypertension was more prevalent (58% vs 48%, p=0.048) and hsCRP levels were higher (3.4 [1.7–6.6] vs 2.6 [1.4–5.0] mg/L, p=0.033). Structurally, LV hypertrophy was more common (7.2% vs 1.3%, p=0.002), and diastolic dysfunction was more frequent (18% vs 11%, p=0.030) in HFpEF patients. Liver stiffness, CAP, and FIB-4 index did not differ between groups. In multivariable models, systolic blood pressure remained independently associated with HFpEF (OR 1.18 per 10 mmHg, 95% CI 1.05–1.33) (Figure 2).
Conclusion
In MASLD patients with preserved LVEF, 35% fulfilled ESC-defined HFpEF criteria. HFpEF was associated with higher cardiometabolic burden, more pronounced patient-reported symptoms and functional limitations, and higher systolic blood pressure, while VCTE-based liver disease severity measures were similar between groups. Notably, HF-related symptom burden was substantial across the cohort, including among patients not fulfilling ESC-defined HFpEF criteria.Figure 1Figure 2