Fatty liver and HFpEF: a real association, a small absolute difference

Design

Systematic review and meta-analysis of three observational studies (two cohort, one cross-sectional), PROSPERO-registered

Population

899,629 adults, including 47,610 with MASLD

Primary outcome

Clinically diagnosed heart failure with preserved ejection fraction

Effect

Prevalence 2.2% with MASLD vs 1.85% without; pooled odds ratio 1.35 (95% CI 1.26-1.45), absolute risk increase 0.35%, I squared 0%

Metabolic dysfunction-associated steatotic liver disease (MASLD) and heart failure with preserved ejection fraction (HFpEF) share most of their risk factors, and this meta-analysis asked whether the clinical diagnoses track together. Three eligible studies were found — two cohorts and one cross-sectional — covering 899,629 people, of whom 47,610 had MASLD.

HFpEF was diagnosed in 2.2% of the MASLD group against 1.85% of the rest, a pooled odds ratio of 1.35 (95% CI 1.26-1.45) with no measurable heterogeneity between studies. In relative terms that is a 35% higher odds; in absolute terms it is an extra 0.35 cases per hundred people. Both numbers are true, and the second is the one that should govern how much is done about it.

The practical reading is narrow but real: in a patient with MASLD, particularly with advanced fibrosis, breathlessness deserves a proper HFpEF assessment rather than being attributed to deconditioning or obesity. It does not support a screening programme. The authors are explicit that this is hypothesis-generating, and with three studies in the pool they are right to be.

• In MASLD with unexplained breathlessness, assess for HFpEF rather than assuming deconditioning
• Give the fibrosis stage weight — advanced fibrosis carried additional risk
• Do not start screening asymptomatic MASLD patients on this evidence
• Note that shared metabolic treatment is speculation here, not a tested strategy
• Record the liver diagnosis in the cardiology letter; it is often absent

Why it matters

It puts a number on a suspicion most cardiologists already hold, and the number is smaller than the headline suggests.

Don't overread it

These were observational data and the authors call the finding hypothesis-generating; it cannot show that MASLD causes HFpEF or that treating the liver prevents it.

The statistics, in plain English

An odds ratio of 1.35 with a tight interval and I squared of 0% looks convincing, and the consistency is real, but it is consistency across only three studies — two of which are cohorts and one cross-sectional, which cannot establish sequence. The absolute risk difference of 0.35% is the number that decides whether to act on it, and it is small: about 285 people with MASLD would have to be followed for one extra HFpEF diagnosis.

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