​News Release

Strong Association Between Non-alcoholic Fatty Liver Disease and Coronary Artery Disease Among Healthy Individuals

Singapore, 22 March 2022
– Two studies by a team of researchers from the National Heart Centre Singapore (NHCS) established that non-alcoholic fatty liver disease (NAFLD) has strong association with coronary atherosclerosis, even in healthy individuals.

NAFLD refers to a range of liver conditions caused by a build-up of fats in the liver that affects individuals who do not drink or drink little alcohol. It is a well-established and significant independent risk factor for cardiovascular diseases (CVD)1,2. In a systematic review conducted on over 60 publications on NAFLD3, NHCS researchers affirmed a significant positive association between NAFLD and subclinical coronary atherosclerosis, as defined by increased Carotid Intima-Media Thickness (CIMT) and Coronary Artery Calcium (CAC) scores. This latest meta-analysis demonstrated that individuals with NAFLD are at increased risk of coronary atherosclerosis. Besides a cross-sectional association, the team also observed that NAFLD was associated with the development and/or progression of coronary atherosclerosis. These was seen not only in Western populations but also in Asian populations.

“The results from this meta-analysis provided us with additional insights in the relationship between NAFLD and coronary atherosclerosis, reinforcing the importance of screening and management of CVD risk factors in patients with NAFLD. It would also help in the development of strategies to identify those susceptible among the NAFLD population,” shared Associate Professor Jonathan Yap, Consultant, Department of Cardiology, NHCS, who is one of the key investigators of the research studies.

Recognising that NAFLD has a significant association with CAD in patients and to further analyse its impact on the Asian population, the team embarked on a separate in-depth study1 to evaluate this in a group of healthy individuals. Over 660 healthy individuals aged between 21 and 69 years old were recruited as part of the SingHEART study cohort from October 2015 to July 2020. These individuals have no prior cardiovascular diseases (such as ischaemic heart disease, stroke and peripheral vascular disease) or diabetes. The SingHEART4 study is an ongoing contemporary multi-ethnic population-based study of healthy Asian adults living in Singapore.

Basic investigations including coronary calcium scan was performed on these healthy participants. CAC measures the amount of calcium in the walls of the heart’s arteries, which could indicate plaque build-up and coronary atherosclerosis. Even though these healthy participants had no prior CVD, with a low prevalence of diabetes, obesity and hypertension, the team discovered a proportion of these patients had NAFLD and/or coronary atherosclerosis, with a significant association between NAFLD and coronary atherosclerosis. Also, the participants with NAFLD had significantly higher burden of metabolic risk factors, including higher blood pressure and Body Mass Index (BMI).

“The findings from both studies present important clinical implications – suggesting the need for prompt and optimal preventive strategies so as to minimise future cardiovascular risk in those with NAFLD. Through this sharing, we hope to highlight this association to the primary doctors and healthcare providers so that early detection and intervention can be performed,” said Associate Professor Yeo Khung Keong, Deputy Medical Director and Senior Consultant, Department of Cardiology, NHCS.”

1. Mark YZ Wong, Jonathan JL Yap et al. Non-alcoholic fatty liver disease is associated with subclinical coronary artery disease in otherwise healthy individuals. Academy of Medicine, Singapore, 2021, 50:500-2 https://doi.org/10.47102/annals-acadmedsg.2020639
2. Stahl EP, Dhindsa DS, Lee SK, et al. Nonalcoholic fatty liver disease and the Heart: JACC state-of-the-art review. J Am Coll Cardiol 2019;73:948–63.
3. Wong MYZ, Yap JJL, Sultana R, et al. Association between non-alcoholic fatty liver disease and subclinical atherosclerosis in Western and Asian cohorts: an updated meta-analysis. Open Heart 2021;8:e001850. doi:10.1136/openhrt-2021-001850
4. Yap J, Lim WK, Sahlén A, et al. Harnessing technology and molecular analysis to understand the development of cardiovascular diseases in Asia: a prospective cohort study (SingHEART). BMC Cardiovasc Disord 2019;19:259