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CME / ABIM MOC / CE

Is Nonalcoholic Fatty Liver Disease Associated With Atherosclerotic Cardiovascular Disease?

  • Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 5/27/2022
  • Valid for credit through: 5/27/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for cardiologists, gastroenterologists, diabetologists/endocrinologists, internists, nurses, physician assistants, and other members of the health care team who treat and manage patients with nonalcoholic fatty liver disease who may be at risk for atherosclerotic cardiovascular disease.

The goal of this activity is that learners will be better able to describe risk factors and pathophysiology underlying nonalcoholic fatty liver disease, its associations with atherosclerotic cardiovascular disease, diagnostic and screening strategies, and potential interventions, based on the first-ever American Heart Association scientific statement on nonalcoholic fatty liver disease and its association with heart disease.

Upon completion of this activity, participants will:

  • Assess nonalcoholic fatty liver disease diagnostic and screening strategies, course, and association with atherosclerotic cardiovascular disease, based on an American Heart Association scientific statement
  • Evaluate potential interventions for nonalcoholic fatty liver disease, based on an American Heart Association scientific statement
  • Outline implications for the healthcare team


Disclosures

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All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Medscape policies. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Megan Brooks

    Freelance writer, Medscape

    Disclosures

    Disclosure: Megan Brooks has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed the following relevant financial relationships:
    Stocks, stock options, or bonds: AbbVie (former)

Editor/Nurse Planner

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Yaisanet Oyola, MD, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has disclosed no relevant financial relationships.


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CME / ABIM MOC / CE

Is Nonalcoholic Fatty Liver Disease Associated With Atherosclerotic Cardiovascular Disease?

Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 5/27/2022

Valid for credit through: 5/27/2023

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Clinical Context

Nonalcoholic fatty liver disease (NAFLD) is increasingly prevalent, now affecting more than 25% of adults worldwide. Without specific testing for NAFLD, the condition is typically silent until advanced, potentially irreversible liver impairment develops.

Rates of NAFLD are rising in association with rising rates of obesity and metabolic syndrome, with 25% of adults worldwide believed to be affected.

NAFLD is an increasingly common, underdiagnosed, and underappreciated independent risk factor for atherosclerotic cardiovascular disease (ASCVD), the American Heart Association (AHA) says in the first-ever scientific statement on NAFLD and its association with heart disease.

Study Synopsis and Perspective

NAFLD is often "hidden or missed in routine medical care," P. Barton Duell, MD, chair of the statement writing group, says in a news release.

"It is important to know about the condition and treat it early because it is a risk factor for chronic liver damage and cardiovascular disease," says Dr Duell, from the Knight Cardiovascular Institute, Oregon Health & Science University, Portland.

Indeed, ASCVD is the principal cause of death in patients with NAFLD, the authors note.

The statement was published online April 14 in Arteriosclerosis, Thrombosis, and Vascular Biology.

It provides an overview of the underlying risk factors and pathology of NAFLD, links to ASCVD, diagnostic and screening strategies, and potential interventions. It also emphasizes the need for greater awareness and monitoring for NAFLD and access to improved screening tools and treatment and highlights the lifestyle changes to help prevent and treat the disorder.

Hidden CVD Risk Factor

Unless specific testing is performed, NAFLD typically remains silent until advanced and potentially irreversible liver damage sets in, the writing group says.

They caution that measuring alanine aminotransferase (ALT) and aspartate aminotransferase (AST) might not be helpful for diagnosing NAFLD and nonalcoholic steatohepatitis (NASH) because of poor sensitivity and specificity. AST and ALT levels can be in the normal range in patients with NAFLD, even patients with NASH, although levels can approach the upper limit of normal.

"Liver biopsy is the gold standard for diagnosis of NAFLD and NASH, but the procedure is expensive and has increased risk of complications," the group points out.

Improved diagnostic strategies for identifying NAFLD and NASH are needed, but existing modalities, such as ultrasound-based vibration-controlled transient elastography, are useful for disease staging and longitudinal monitoring, although underused, the writing group says.

They note that most patients with hepatic steatosis do not progress to NASH, cirrhosis, or hepatocellular carcinoma, but a subgroup will.

Because it is difficult to identify which patients will have disease progression, imaging studies, possibly in combination with liver biopsy, are "essential" for monitoring disease severity and progression.

Routine liver ultrasound is useful if it shows hepatic steatosis, but it cannot quantify the extent of steatosis or rule out hepatic steatosis, the group states.

Lifestyle Intervention

The group notes that NAFLD occurs in association with insulin resistance (with or without diabetes), obesity (especially visceral adiposity), metabolic syndrome, and dyslipidemia. Genetic factors (monogenic or polygenic) modulate the risk for development of NAFLD and progression to NASH.

Many risk factors for NAFLD are also risk factors for ASCVD, and when assessing ASCVD risk, NAFLD can be considered a "risk enhancer," the group advises.

They say that lifestyle intervention is the "key therapeutic intervention" for patients with NAFLD. This includes dietary modification, increased physical activity, weight loss, and alcohol avoidance.

In many patients, the loss of 5% to 10% of body weight can reverse hepatic steatosis and stabilize or diminish NASH. However, this goal is often difficult to achieve. Additional treatment goals include improved insulin sensitivity, reduced hyperglycemia, and triglyceride lowering.

"Part of the good news about managing NAFLD is that healthy eating, regular exercise, and weight loss or avoiding weight gain are all valuable interventions to improve health in most of us, regardless of whether we have NAFLD," Dr Duell says in the release.

Drug therapies include glucagon-like peptide 1 receptor agonists, which can "modestly" improve NAFLD in association with improved glycemia, weight loss, and reduced risk for major adverse cardiovascular events, the writing group says.

Novel experimental drug therapies that target various steps in the pathogenesis of NAFLD are currently in development, but most have modest efficacy, and toxicity is a limiting factor for some agents, the group says.

"It is hoped that with increased awareness of NAFLD, better access to reliable imaging tools for screening and monitoring for NAFLD and proven tools for the treatment of NAFLD, the rising tide of NASH and more advanced hepatic disease can be reversed and adverse ASCVD outcomes prevented," they write.

This scientific statement was prepared by the volunteer writing group on behalf of the AHA's Council on Atherosclerosis, Thrombosis and Vascular Biology; the Council on Hypertension; the Council on the Kidney in Cardiovascular Disease; the Council on Lifestyle and Cardiometabolic Health; and the Council on Peripheral Vascular Disease.

This research had no commercial funding. A complete list of author disclosures is available with the publication.

Arterioscler Thromb Vasc Biol. Published online April 14, 2022.[1]

Study Highlights

  • NAFLD is common, with global prevalence higher than 25% and increasing everywhere, in tandem with rising rates of obesity and metabolic syndrome.
  • Hepatic complications of NAFLD include NASH, hepatic cirrhosis, and hepatocellular carcinoma.
  • Most patients with NAFLD are undiagnosed and are unaware of having it, as without specific testing, NAFLD is typically silent until advanced, potentially irreversible liver impairment develops.
  • NAFLD and NASH are increasingly prevalent but underdiagnosed and underappreciated as risk factors for ASCVD morbidity and mortality.
  • AST and ALT are not useful for diagnosing NAFLD and NASH because of poor sensitivity and specificity--they can be normal, even in patients with NASH.
  • Liver biopsy is the gold standard for diagnosing NAFLD and NASH, but it is expensive and may cause complications.
  • Existing modalities, including ultrasound-based vibration-controlled transient elastography assessment of hepatic elasticity and steatosis are useful for disease staging and longitudinal monitoring, but are underused.
  • Most patients with hepatic steatosis do not progress to develop NASH, cirrhosis, or hepatocellular carcinoma, but some will.
  • Genetic factors (monogenic or polygenic) modulate the risk for development of NAFLD and progression to NASH, which is an increasingly common cause of end-stage liver disease.
  • As identifying which patients will have disease progression is difficult, imaging studies, possibly combined with liver biopsy, are essential to monitor disease severity and progression.
  • Routine hepatic ultrasonography is useful if it detects hepatic steatosis, but it is too insensitive to quantify the extent of steatosis or to exclude hepatic steatosis.
  • Improved diagnostic strategies to identify NAFLD and NASH are therefore needed.
  • NAFLD is associated with insulin resistance, with or without diabetes; obesity (especially visceral adiposity), metabolic syndrome, and dyslipidemia (hypertriglyceridemia, increased free fatty acids, low high-density lipoprotein, and small dense low-density lipoprotein).
  • NAFLD is therefore a contributor to and marker for increased risk for ASCVD, which is the leading cause of death in patients with NAFLD.
  • The presence of NAFLD is associated with increased ASCVD risk compared with individuals with the same ASCVD risk factors but without NAFLD.
  • NAFLD can be considered a risk enhancer when ASCVD risk is assessed in patients.
  • There is a major gap in NAFLD and NASH treatment.
  • A key intervention is lifestyle modification, including weight loss, increased physical activity, dietary modification, and alcohol avoidance.
  • Although 5% to 10% body weight loss can reverse hepatic steatosis and stabilize or reduce NASH in many patients, this goal is often difficult to achieve.
  • Additional treatment goals are improved insulin sensitivity, reduced hyperglycemia, and triglyceride lowering.
  • Glucagon-like peptide 1 receptor agonists may modestly improve NAFLD in association with improved glycemia, weight loss, and reduced risk for major adverse cardiovascular events.
  • Although many experimental drugs with targeted mechanisms of action are being developed, toxicity is a limiting issue for some, and most have modest efficacy.
  • Further studies are needed to identify optimal treatment interventions to prevent hepatic and cardiovascular complications from NAFLD.
  • An informational handout about NAFLD is available for patient education.
  • Increased awareness of NAFLD, better access to reliable imaging tools for screening and monitoring, and proven treatments are needed to reverse the rising tide of NASH and more advanced hepatic disease and to prevent adverse ASCVD outcomes.

Clinical Implications

  • NAFLD and NASH are increasingly prevalent but underdiagnosed and underappreciated as risk factors for ASCVD morbidity and mortality.
  • Further studies are needed to identify optimal treatment interventions to prevent hepatic and cardiovascular complications from NAFLD.
  • Implications for the Health Care Team: Members of the healthcare team should reinforce the importance of lifestyle modification, including weight loss, increased physical activity, dietary modification, and alcohol avoidance for patients at risk for NAFLD and NASH.

 

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