Nonalcoholic Fatty Liver Disease Increases Risk for HF With Preserved Ejection Fraction

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Using a cohort of Medicare beneficiaries, researchers sought to determine the association between nonalcoholic fatty liver disease and heart failure.

Risk for incident heart failure (HF) with an etiology of HF with preserved ejection fraction (HFpEF) was increased among patients with nonalcoholic fatty liver disease (NAFLD). These findings, from a retrospective cohort study, were published in the Journal of the American Heart Association.

Investigators from the University of Texas Southwestern Medical Center sourced data from the fee-for-service Medicare beneficiaries Part A and B claims database. Patients (N=870,535) with no prior history of HF and 2 years or more of records prior to 2015 were assessed for HF outcomes between 2015 and 2016 on the basis of NAFLD status.

Patients had a mean age of 74.5± 7.1 years, 56.9% were women, 87% were White individuals, 81.2% had hypertension, 51.8% had diabetes, and 25.6% had obesity. Patients with baseline NAFLD differed from controls for all baseline characteristics, in which the NAFLD cohort was younger, had more women, and included more comorbidities (all P <.001).

During the follow-up period, 5% of patients received a diagnosis of HF. The HF etiologies included HFpEF (37%), HF with reduced ejection fraction (HFrEF; 25%), or etiology data were missing.

HF was diagnosed more among the NAFLD cohort (6.4% vs 5.0%; adjusted hazard ratio [aHR], 1.23; 95% CI, 1.18-1.29; P <.001). Stratified by subtype, NAFLD was associated with increased risk for HFpEF (aHR, 1.24; 95% CI, 1.14-1.34; P <.001) but not HFrEF (aHR, 1.09; 95% CI, 0.98-1.2; P =.12).

In a subgroup analysis, no significant interaction effects were observed on the basis of gender, ethnicity, or obesity status (all P >.01). Similarly, stratifying patients on the basis of inpatient or outpatient billing codes did not alter the general trends observed.

This study was limited by the large proportion of patients who had missing data about their HF subtype.

“Our findings suggest an epidemiological link between NAFLD and HF beyond shared risk factors,” the study authors said. “Thus, the current epidemic of NAFLD could significantly drive the changing landscape of HF epidemiological features, where HFpEF is set to become the predominant HF subtype in the upcoming 2 decades.”

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Fudim M, Zhong L, Patel KV, et al. Nonalcoholic fatty liver disease and risk of heart failure among medicare beneficiaries. J Am Heart Assoc. 2021;10(22):e021654. doi:10.1161/JAHA.121.021654