Cardiovascular risk assessment tools are insufficient for patients with metabolic dysfunction associated steatotic liver disease.

Introduction: Risk for cardiovascular (CV) events is estimated by the Framingham Risk Score (FRS), Pooled Cohort Equation (PCE) and the American Heart Association Predicting Risk of CVD EVENTs (PREVENT) equation. The applicability of these risk tools in patients with MASLD is uncertain. This study sought to determine the accuracy of the FRS, PCE, and PREVENT in a real-world cohort of patients with MASLD.

Methods: This analysis included US adults ≥ age 30 with MASLD in the TARGET-NASH study. Five to ten-year CV risk was estimated using original and recalibrated versions of the FRS and PCE, and original PREVENT equation. Discrimination among prediction models was assessed using Harrell's concordance statistic and calibration was evaluated using a modified Hosmer Lemeshow test comparing observed and predicted CV events. Logistic regression was used to assess the contribution of liver disease to observed CV events.

Results: Overall, 1,090 patients were included. There was an increase in observed CV events from MASL to cirrhosis. FRS demonstrated a weak ability to identify patients who went on to experience a CV event (C-statistic 0.58, 95% CI 0.52-0.63) as did the AHA PREVENT model (C-statistic 0.60, 95% CI 0.54-0.65). Both the FRS and PCE demonstrated a significant lack of calibration (p<0.01), with overestimation in the highest deciles and underestimation in the lowest deciles of predicted risk.

Conclusions: Commonly used tools to identify CV risk performed poorly in a cohort of patients with MASLD. As CV related death is the greatest source of mortality among patients with MASLD, better risk assessment tools are required.