Fatty liver (MASLD) and the heart: joint care

Summary: Fatty liver disease (MASLD) affects 30 to 35% of adults and raises the risk of cardiovascular disease, the most common cause of death in those affected. Yet it is often overlooked in cardiology, and in liver medicine the heart risk is often underestimated. An international expert team therefore recommends treating MASLD as a cardiometabolic disease: with shared early detection, risk assessment and treatment.

State of the evidence: The recommendation appeared in 2026 in Nature Reviews Gastroenterology & Hepatology. It includes studies and approvals up to 2025. No systematic literature search is described. This article was written on 17 October 2026; newer studies are not included.

What is it about?

MASLD (metabolic dysfunction-associated steatotic liver disease, formerly NAFLD) means fat in the liver plus at least one metabolic risk factor. It ranges from simple fat build-up through inflammation (MASH) and scarring (fibrosis) to cirrhosis and liver cancer. Because liver and heart share the same metabolic problems – insulin resistance, inflammation, unfavourable blood fats – they influence each other. The authors propose joining the two fields.

How was it studied?

This is an expert recommendation by 16 specialists from Asia, Europe, the USA and Australia, not a new patient study. It summarises studies and guidelines and sets out eleven recommendations, separately for cardiology and hepatology.

What does the recommendation show?

• Heart risk rises: In a large meta-analysis, MASLD was linked to a 45% higher risk of fatal and non-fatal cardiovascular events, and 150% higher with advanced fibrosis. Heart failure (50% higher) and atrial fibrillation (20% higher) are also more common.
• Not only the liver: Per 1,000 person-years in one analysis, 5.54 people with MASLD died of cardiovascular disease, 4.21 of cancer outside the liver and 1.75 of liver disease.
• Fibrosis counts more than fat: It is not the fat but the scarring of the liver that best predicts heart risk. People with advanced fibrosis have up to 2.5 times more major cardiovascular events than people with little scarring.
• Simple tests are often not enough: Up to 80% of those affected have normal liver enzymes. Ultrasound detects fat only when 20 to 30% of the liver is affected.
• Two-step search: First the FIB-4 index from age, liver enzymes and platelets (below 1.3, or below 2.0 from age 65: low risk); otherwise a liver stiffness measurement (VCTE). From 8 kPa fibrosis counts as significant, from 12 to 14 kPa as advanced, followed by referral to hepatology.
• Heart risk in the liver clinic: Everyone with MASLD should have blood pressure, blood sugar, blood fats, weight and smoking checked. Nearly 70% of those affected have poorly controlled high blood pressure. With high risk, heart tests or referral to cardiology follow.
• Treatable: Resmetirom (March 2024) and semaglutide (August 2025) are provisionally approved in the US for MASH with moderate to advanced fibrosis. In an interim analysis, MASH resolved in 63% on semaglutide versus 34% on placebo.
• Double benefit: GLP-1 drugs are first choice for obesity or type 2 diabetes; SGLT2 inhibitors suit heart failure or kidney disease. Statins are safe with heart risk and should not be withheld out of concern for the liver.
• Alcohol: Even about 20 g a day or less is linked to more fibrosis; a heart-protective effect of moderate drinking is considered unlikely.
• Joining trials: Heart trials should record liver measures, liver trials heart events. The authors call for joint guidelines from both fields.

Where are the limits?

• These are expert opinions; no formal grading of the strength of evidence is described.
• For resmetirom, long-term data on cardiovascular events beyond one year are missing, and cost-effectiveness is limited. The semaglutide data come from an interim analysis.
• The approvals apply to the US; how therapy is reimbursed elsewhere is not covered.
• Genetic testing is not recommended for routine use on current evidence.
• The proposed pathway is a concept; its use in daily practice is not yet tested.

What does this mean for me?

The recommendation describes groups and says nothing about your personal risk. It does show that with fatty liver, heart and liver should be considered together. If you have type 2 diabetes, obesity or high blood pressure, you can ask your family doctor to assess your fibrosis risk and heart risk. Discuss with your doctor which tests and treatments make sense for you.

This article does not replace medical advice.

Source and notes

• Citation: Zhou XD, Jeong S, Chen QF, et al. Heart–liver co-management in MASLD: expert perspectives and recommendations from a multidisciplinary cardiometabolic framework. Nat Rev Gastroenterol Hepatol 2026. DOI: 10.1038/s41575-026-01255-z.
• Study type: Expert recommendation.
• Funding: Not stated in the text.
• Conflicts of interest: Many authors report fees, consulting or research grants from pharmaceutical and medical technology companies, including Novo Nordisk, Boehringer Ingelheim, Eli Lilly, AstraZeneca and Gilead; several report stock holdings. Some authors report no competing interests.