Cardio-hepatic axis in metabolic dysfunction-associated steatotic liver disease: Mechanisms, clinical implications and therapeutic opportunities

Figure 2 Integrated cardio-hepatic risk stratification workflow for metabolic dysfunction-associated steatotic liver disease. All patients receive annual screening for type 2 diabetes mellitus, hypertension and dyslipidaemia plus baseline atherosclerotic cardiovascular disease risk assessment via the PREVENT equation. Step 1: Fibrosis-4 (FIB-4) index initial fibrosis screening (low: FIB-4 < 1.3; grey zone: 1.3 ≤ FIB-4 ≤ 2.67; high: FIB-4 > 2.67). Grey zone patients proceed to vibration-controlled transient elastography liver stiffness measurement (LSM) measurement (exclude advanced fibrosis: LSM < 8 kPa; grey zone: 8 kPa ≤ LSM < 12 kPa; advanced fibrosis: LSM ≥ 12 kPa); enhanced liver fibrosis score (cutoff ≥ 9.8) serves as a vibration-controlled transient elastography substitute. Three management tiers are defined: (1) Routine biennial follow-up for low-risk patients; (2) Annual monitoring with coronary artery calcium recalibration for intermediate-risk individuals; and (3) Urgent multidisciplinary specialist referral for high-risk patients. All patients with type 2 diabetes mellitus or established cardiovascular disease require yearly fibrosis reassessment. XL probe is suggested for obese patients to measure controlled attenuation parameter steatosis grade simultaneously. MASLD: Metabolic dysfunction-associated steatotic liver disease; T2DM: Type 2 diabetes mellitus; FIB-4: Fibrosis-4; ELF: Enhanced liver fibrosis; LSM: Liver stiffness measurement; CVD: Cardiovascular disease; CAC: Coronary artery calcium; VCTE: Vibration-controlled transient elastography.