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


One-thousand nine-hundred nineteen subjects who underwent CCTA during annual physical check-ups at Taipei Veteran General Hospital between 2015 and 2018 were surveyed. After exclusion of subjects who consumed significant amounts of alcohol, history of Hepatitis B and C viruses and history of coronary artery disease, 1502 subjects (mean age 58.32 ± 9.87 years; 1085 males and 417 females) were included. The study flow chart is shown in Figure 2. Three-hundred eleven (20.7%) subjects were classified as having moderate to severe liver steatosis based on abdominal sonography, 609 (40.5%) were non, and 582 (38.7%) were considered mild steatosis. Two independent experienced gastroenterologists who were blinded to clinical presentation and laboratory findings were invited to review all sonography again, and the kappa value was 0.856, which showed satisfactory agreement of fatty liver quantification in our current study. The baseline characteristics of the study subjects are shown in Table 1. Compared with non-steatosis, fatty liver subjects had significantly higher blood pressure, BMI, waist circumference (WC), unfavourable lipid profiles, including higher LDL-C and triglycerides and lower values of HDL-C. Furthermore, fatty liver subjects consisted of more males than females. Males had higher blood pressures, higher blood sugars, higher HbA1C, lower AST to ALT ratio, higher AST to platelet ratio index (APRI), higher smoking, alcohol consumption, and higher incidences of hypertension and diabetes in addition to metabolic syndrome. The severity of liver steatosis on sonography is in accordance to APRI in our study population.

Figure 2.

The flowchart of inclusion of study subjects

Table 2 shows the atherosclerotic plaque patterns and severity in the coronary arteries. Coronary atherosclerotic plaques were found in more than half the subjects, and the presence of coronary plaques correlated with the severity of liver steatosis (non-steatosis: 53%, mild steatosis: 64.1%, and moderate to severe steatosis: 66.9%; P < .001). All of the CAC scores, ABOS, SIS and SSS scores were higher in the moderate to severe NAFLD group, suggesting the severity of liver steatosis correlated with coronary atherosclerosis severity. For various coronary artery plaque characteristics, there was a significant association between mixed type plaques and increasing severity of liver steatosis (23.6% vs 32% vs 38.9%; p for trend < 0.05). The association between atherosclerosis severity and plaque patterns was also analysed by APRI (Supplement Table S1). The total calcium score, overall plaque, calcified plaque and mixed plaque are all associated with severity of APRI and positive trend except non-calcified plaque. After adjusting for age, gender, diabetes, hypertension, smoking, waist circumference and LDL-C, the severity of liver steatosis correlated with the risk for the presence of mixed type coronary plaques (p for trend 0.043), and the association existed, especially for the mixed plaque and moderate to severe NAFLD (hazard ratio [HR]:1.44, 95% confidence interval [CI]: 1.01–2.05) as shown in Figure 3, and Table 3.

Figure 3.

Association of coronary artery plaque pattern and severity of fatty liver

Subgroup analysis of the risk of presence of overall coronary plaques and mixed plaques showed a significant trending association with increasing severity of liver steatosis and overall plaque, especially among those who were <65 years old, male, without metabolic syndrome, non-smoker, low BMI and lower LDL-c levels (Figure 4). For the presence of mixed type, the severity of liver steatosis correlated with the risk of the presence of vulnerable plaques among each subgroup.

Figure 4.

Sensitivity analysis in the presence of risk factors for overall and mixed coronary plaque