Risk factors

A causal link between NAFLD and CVD remains unproven

Wednesday, 10 Apr 2019

Nonalcoholic fatty acid disease (NAFLD), often described as ‘the liver disease of the metabolic syndrome’, shares many common risk factors with cardiovascular disease, but to date there is no evidence of a causal link to risk of cardiovascular events, an expert says. 

Gastroenterologist Marno Ryan from St Vincent’s Hospital in Melbourne told delegates attending Amgen One in Melbourne that people with NAFLD appeared to have an increased risk of cardiovascular disease (CVD) compared with the population, but this was more likely to be a “para-phenomenon occurring in the setting of insulin resistance and low grade inflammation” rather than a causal link between the two conditions.

Dr Ryan advised cardiologists to consider the presence of NAFLD in their patients and refer for management if there is elevated ALT/GGT or steatosis on ultrasound.

Conversely, she said, hepatologists needed to manage cardiovascular risk factors in their patients with NAFLD, with aggressive lipid lowering forming a key component of management.

Are statins harmful in patients with liver disease, including NASH?

Nonalcoholic steatohepatitis (NASH) represents around 25-30% of patients with NAFLD,1 and is defined as hepatic stenosis and inflammation with hepatocyte injury (ballooning) with or without fibrosis. It can progress to cirrhosis, liver failure and cancer.

Dr Ryan told delegates that the inappropriate cessation of statins in patients with NASH occurred far too often and was a ‘big problem’.

More education was required to assure referring physicians that statins were rarely harmful in these patients. “There’s now a general consensus that there are no concerns with statins in fatty liver,” she told the conference.

As a result, Dr Ryan told delegates that she routinely writes back to physicians who have ceased a statin to explain that there is no reason for the patient to discontinue therapy.

The American Association for the Study of Liver Diseases backs up this view in their guidance on cardiovascular risk in patients with NASH, where they recommend aggressive modification of CVD risk factors in all patients with NAFLD: “Patients with NAFLD/NASH are not at higher risk for serious liver injury from statins. Thus, statins can be used to treat dyslipidemia in patients with NAFLD and NASH,”2 the guidelines state.


This article was sponsored by Amgen, which has no control over editorial content. The content is entirely independent and based on published studies and experts’ opinions, the views expressed are not necessarily those of Amgen.



  1. Rinella M. Nonalcoholic fatty liver disease: a systematic review. JAMA2015;313(22):2263-2273. https://www.ncbi.nlm.nih.gov/pubmed/26057287
  2. Chalasani N. et al. The diagnosis and management of non-alcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases. Hepatology 2018;67:328-357. https://www.ncbi.nlm.nih.gov/pubmed/28714183

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