Observational Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Jul 27, 2020; 12(7): 378-388
Published online Jul 27, 2020. doi: 10.4254/wjh.v12.i7.378
Non-alcoholic steatohepatitis and the risk of myocardial infarction: A population-based national study
Sara Ghoneim, Aneesh Dhorepatil, Aun Raza Shah, Ganesh Ram, Subhan Ahmad, Chang Kim, Imad Asaad
Sara Ghoneim, Aneesh Dhorepatil, Aun Raza Shah, Subhan Ahmad, Chang Kim, Department of Internal Medicine, Case Western Reserve University at MetroHealth Medical Center, Cleveland, OH 44109, United States
Ganesh Ram, Department of Pain Management, The Schulich School of Medicine and Dentistry, London, Ontario N6A 5C1, Canada
Imad Asaad, Division of Gastroenterology, Case Western Reserve University at MetroHealth Medical Center, Cleveland, OH 44109, United States
Author contributions: Ghoneim S, Dhorepatil A, Shah AR, Ram G, and Asaad I designed the research; Ghoneim S, Dhorepatil A, Shah AR, Ram G, Ahmad S and Kim C performed the research; Kim C analyzed the data; Ghoneim S, Dhorepatil A, Shah AR, Ram G, Asaad A wrote the paper; All authors provide approval for the final version to be published.
Institutional review board statement: This study is exempt from Case Western Reserve/Metrohealth Medical Center IRB approval as the dataset used by Explorys database is de-identified.
Informed consent statement: Informed consent was not required for this study, as it is exempt from IRB approval because the data set used in the database is de-identified.
Conflict-of-interest statement: All authors have no conflict of interest and nothing to disclose.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Sara Ghoneim, MD, Doctor, Department of Internal Medicine, Case Western Reserve University at MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, United States. saragho@gmail.com
Received: January 11, 2020
Peer-review started: January 11, 2020
First decision: April 18, 2020
Revised: May 25, 2020
Accepted: June 10, 2020
Article in press: June 10, 2020
Published online: July 27, 2020
Abstract
BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a systemic disease with bidirectional relationships with cardiovascular disease (CVD). Non-alcoholic steatohepatitis (NASH) is a more severe subtype of NAFLD. Patients with NASH exhibit more intra and extrahepatic inflammation, procoagulant imbalances and proatherogenic lipid profiles. Whether NASH increases the risk of ischemic heart disease is currently unclear.

AIM

To investigate the relationship between acute myocardial infarction (MI) and NASH in a large cohort of subjects in the United States.

METHODS

We reviewed data from a large commercial database (Explorys IBM) that aggregates electronic health records from 26 large nationwide healthcare systems. Using systemized nomenclature of clinical medical terms (SNOMED CT), we identified adult with the diagnosis of NASH from 1999-2019. We included patients with the diagnosis of acute MI from 2018-2019. Comorbidities known to be associated with NASH and MI such as obesity, diabetes mellitus, hyperlipidemia, smoking, male gender, and hypertension were collected. Univariable and multivariable analyses were performed to investigate whether NASH is independently associated with the risk of MI.

RESULTS

Out of 55099280 patients, 43170 were diagnosed with NASH (0.08%) and 107000 (0.194%) had a MI within 2018-2019. After adjusting for traditional risk factors, NASH conferred greater odds of MI odds ratio (OR) 1.5 [95% confidence interval (CI): 1.40-1.62]. Hyperlipidemia had the strongest association with MI OR 8.39 (95%CI: 8.21-8.58) followed by hypertension OR 3.11 (95%CI: 3.05-3.17) and smoking OR 2.83 (95%CI: 2.79-2.87). NASH had a similar association with MI as the following traditional risk factors like age above 65 years OR 1.47 (95%CI: 1.45-1.49), male gender OR 1.53 (95%CI: 1.51-1.55) diabetes mellitus OR 1.89 (95%CI: 1.86-1.91).

CONCLUSION

MI appears to be a prevalent disease in NASH. Patients with NASH may need early identification and aggressive cardiovascular risk modification.

Keywords: Non-alcoholic steatohepatitis, Myocardial infarction, Non-alcoholic fatty liver disease, Ischemic cardiovascular disease, United States population, Atherosclerosis

Core tip: Non-alcoholic steatohepatitis (NASH) is a severe subtype of nonalcoholic fatty liver disease. The progression of non-alcoholic fatty liver disease is mirrored by activation of hepatic and systemic inflammatory cascades that maybe implicated in the pathogenesis of cardiovascular disease. Using a large electronic medical record database, we performed a national-based population study to investigate the association between NASH and myocardial infarction (MI). In this large cohort study, NASH was associated with increased risk of MI independent of traditional risk factors. Close follow up and aggressive risk modification maybe indicated to prevent major cardiovascular events in patients with NASH.