The Association of the Steatosis Severity in Fatty Liver Disease With Coronary Plaque Pattern in General Population

Pai-Feng Hsu; Ying-Wen Wang; Chung-Chi Lin; Yuan-Jen Wang; Yaw-Zon Ding; Teh-Ling Liou; Shao-Sung Huang; Tse-Min Lu; Wan-Leong Chan; Shing-Jong Lin; Hsin-Bang Leu


Liver International. 2021;41(1):81-90. 

In This Article

Abstract and Introduction


Background and Aims: Nonalcoholic fatty liver disease (NAFLD) is commonly observed in patients with cardiovascular disease (CVD). However, whether the steatosis severity of NAFLD is independently associated with coronary artery atherosclerosis is still controversial.

Methods: Consecutive Taiwanese individuals (1502) who received coronary computed tomography angiography (CCTA) and abdominal sonography as part of a general routine health evaluation were enrolled. The association between steatosis severity, coronary atherosclerosis involvement and various plaque patterns were analysed.

Results: Compared with non-steatosis, NAFLD subjects had more cardiovascular risk factors that correlated with the severity of steatosis (P for the trend <.05). The presence of atherosclerotic plaques correlated with the severity of steatosis (none: 53%, mild: 64.1%, and moderate to severe: 66.9%; P for the trend <.001). Parameters of coronary atherosclerosis, including atheroma burden obstructive score (ABOS), segment involvement score (SIS) and segment stenosis score (SSS), were higher in the moderate to severe steatosis group. After adjusting for major confounding factors, the severity of steatosis still correlated with the mixed plaque pattern (P = .043). Subgroup analysis of the risk of the presence of overall coronary and mixed plaques showed a significant association with increasing severity of steatosis, especially among these who were <65 years old, male, without metabolic syndrome, and with lower low-density lipoprotein choleseterol values.

Conclusion: In this general population, steatosis severity of NAFLD is associated with coronary artery atherosclerosis burden. Furthermore, steatosis severity correlated with the risk of the presence of coronary plaques, especially high-risk plaques, and was independent of traditional risk factors.


Non-alcoholic fatty liver disease (NAFLD) is a disorder in which fat infiltrates the liver. NAFLD constitutes a wide spectrum of problems ranging from simple steatosis to more severe manifestations, such as non-alcoholic steatohepatitis, which may lead to cirrhosis and hepatic failure.[1,2] The prevalence of NAFLD has been estimated at 10% to 39% in various populations,[2–4] and the incidence of this disease is increasing worldwide. Subjects with NAFLD usually present multiple cardiovascular risk factors, such as hypertension,[5] diabetes, obesity,[6] and metabolic syndrome,[7] suggesting a close link with atherosclerosis. NAFLD may share the same pathogenesis with cardiovascular diseases (CVD). Furthermore, clinical observations indicate that NAFLD patients have a higher risk of cardiovascular mortality and morbidity independent of traditional risk factors, suggesting that NAFLD is possibly an independent risk factor for CVD,[8,9] and a decrease in liver steatosis may provide benefits with respect to CVD prevention.

Systemic inflammation, endothelial dysfunction, hepatic insulin resistance, an increase in oxidative stress, and altered lipid metabolism have been reported be key factors in the mechanisms connecting NAFLD and CVD risk.[10] However, there are limited data evaluating the association between the severity of NAFLD steatosis and subclinical atherosclerosis markers. Sinn et al reported higher annual coronary calcium score progression in subjects with NAFLD than in those without NAFLD (22% vs 17%), independent of cardiovascular and metabolic risk factors.[11] Recently, Lee et al further analysed coronary plaque characteristics, showing the NAFLD was associated with the presence of non-calcified (soft) plaque in coronary arteries.[12] However, only an association between the presence of soft plaques and NAFLD has been reported, and there are few studies associating various coronary atheroma plaque patterns with NAFLD steatosis severity. The relationship among coronary atheroma burden, various plaque patterns, and NAFLD steatosis severity can be questioned. Our current study is a cross-sectional observational study designed to evaluate the association between coronary atherosclerosis and NAFLD steatosis severity in the general population.