New research reveals a strong link between a common liver disease affecting nearly 90 million Americans and heart failure, with nearly half of patients showing early signs of heart damage.
Researchers from Duke University examined the health data of 570 patients at the university’s hospital system who had metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as non-alcoholic fatty liver disease (NAFLD), which, according to the most recent data, affects more than 86 million Americans.
They tracked the patients’ medical histories for 11 years from the time they were diagnosed with MASLD, a condition where excess fat builds up in the liver and can lead to inflammation and scarring over time.
Almost a fifth of patients developed heart failure over that period, while nearly half showed signs of heart failure despite never being formally diagnosed with a cardiac condition.
The burden of MASLD in the US is significant, affecting more than one in three US adults on average. The disease stems from the body’s difficulty processing fats and sugars and often progresses without causing noticeable symptoms until it reaches a severe, sometimes irreversible, stage.
A person in the early stages of disease can have a significant amount of liver fat and some scarring without feeling sick, allowing the disease to progress undetected for years or even decades.
The latest research found that as MASLD slowly and silently scars the liver until it can no longer filter toxins from the blood, the heart becomes progressively weaker and prone to failure. Yet only five percent of patients in the study had ever been diagnosed with heart failure.
Dr Marat Fudim, a researcher at Duke Clinical Research Institute and co-author of the report, said in a statement: ‘The findings highlight a critical gap in the recognition and diagnosis of heart failure in this high-risk group.’
Nearly 100 million Americans have a chronic liver disease that results when too much fat builds up and causes scarring (stock)
The researchers specifically selected 570 patients with MASLD that was confirmed by a liver biopsy – ‘the gold standard for diagnosis,’ Dr Fudim said, because it provides the most accurate diagnosis.
The patients had been diagnosed with MASLD between 2007 and 2013 and were followed until they died or until January 2023.
The average age of the study population was about 50 years. Less than two percent had been diagnosed with heart failure before the liver biopsy.
Nearly 40 percent had diabetes, 59 percent had high blood pressure and almost 60 percent had high levels of fat in the blood.
Seventy-one patients (12.5 percent) died during the study’s follow-up period. Of these, nine were liver-related, three were due to cardiovascular causes, 23 were due to other known causes, and the cause of death could not be ascertained on manual chart review in 36 patients.
Over that period, researchers found that 100 patients in the study met the criteria for heart failure despite not having been formally diagnosed.
Of those with stage 4-level liver scarring, indicating the most advanced form of the disease, 33 percent who had not been diagnosed before the study were deemed to have heart failure by the researchers when the study was completed.
The biggest risk factors were being older and female, potentially due to decreasing levels of estrogen, which protects against liver dysfunction, as women age. Other conditions, such as diabetes and high blood pressure, also increased the risk.
The graph comes from an unrelated study that projected the number of US adults with MASLD will rise from 86 million (33.7 percent) in 2020 to 122 million (41.4 percent) by 2050
The lack of symptoms of MASLD in the early stages leads to patients being diagnosed at a point where damage to the liver may be extensive
The researchers also looked for early warning signs of heart failure, such as shortness of breath, swelling in the legs, ankles, and feet, irregular or rapid heartbeat, and dizziness.
Researchers also considered how many times people had been hospitalized for heart trouble, blood tests showing key markers of heart strain, and scans showing the heart was stiff and had trouble filling with blood.
They discovered that many more people had clues pointing to heart problems than those who actually developed diagnosable heart failure.
Nearly half of all the patients showed these early warning signs during the study,
Around 6.7 million Americans are living with heart failure, and it is the direct cause of approximately 8.5 percent of all deaths from heart disease.
Duke gastroenterologist and lead author Dr Kara Wegermann said: ‘Our findings point to the under diagnosis of HF and lack of recognition of diastolic dysfunction in patients with MASLD.
‘There is a real opportunity to develop better screening strategies so we can identify these patients earlier or even prevent symptomatic heart failure.’
Based on their findings, the study authors strongly recommend implementing targeted heart screening for MASLD patients who are at the highest risk.
They specifically suggested that individuals who also have diabetes, high cholesterol, or are female should receive regular and proactive heart check-ups, which would allow doctors to detect heart failure much earlier in these vulnerable groups, leading to timelier intervention and better outcomes.
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