MASLD raises HFpEF odds by 35%, and the absolute difference is 0.35 percentage points

Design

Systematic review and meta-analysis of observational studies (two cohorts, one cross-sectional)

Population

Three studies, 899,629 people, including 47,610 with MASLD

Primary outcome

Prevalence of clinically diagnosed heart failure with preserved ejection fraction

Effect

2.2% vs 1.85%; pooled odds ratio 1.35 (95% CI 1.26–1.45, I² 0%); absolute risk increase 0.35 percentage points

This meta-analysis set out to quantify the association between metabolic dysfunction-associated steatotic liver disease and clinically diagnosed heart failure with preserved ejection fraction. From 3,313 publications screened and 123 full texts assessed, three studies met the inclusion criteria — two cohorts and one cross-sectional study, together covering 899,629 people of whom 47,610 had MASLD.

HFpEF prevalence was 2.2% in the MASLD group and 1.85% in the non-MASLD group: pooled odds ratio 1.35 (95% CI 1.26–1.45, P < 0.0001), with no heterogeneity (I² = 0%). The authors state the absolute risk increase plainly as 0.35 percentage points and describe their own findings as hypothesis-generating.

That honesty is worth matching. A 35% relative increase reads as substantial; 2.2% against 1.85% reads as almost nothing, and both describe the same result. Three observational studies cannot establish that MASLD causes HFpEF, and the two conditions share nearly every risk factor — obesity, diabetes, hypertension, insulin resistance — so confounding is not a technicality here but the central question.

• Do not add cardiac screening for MASLD on the basis of this — the absolute difference does not support a new pathway.
• Do manage the shared risk factors properly: obesity, diabetes and hypertension drive both conditions.
• Take unexplained exertional breathlessness in a patient with MASLD seriously, as you would in anyone with that risk profile.
• Note that only three studies met inclusion criteria out of 123 assessed — the evidence base is thin, not merely imprecise.

Why it matters

A 35% relative increase in a headline and a 0.35 percentage point absolute difference are the same finding, and only one of them sounds like a reason to act.

Don't overread it

Three observational studies cannot show that MASLD causes HFpEF; the two conditions share almost every risk factor.

The statistics, in plain English

This is the clearest recent illustration of why relative and absolute risk must be reported together. An odds ratio of 1.35 sounds like a third more risk; the underlying numbers are 2.2% versus 1.85%, a difference of about one case in 300 people. I² of 0% means the three studies agree with each other, which says nothing about whether all three share the same confounding — and with conditions that share this many risk factors, they almost certainly do.

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