Metabolic Dysfunction-Associated Steatotic Liver Disease and Atherosclerotic Cardiovascular Disease: Shared Pathophysiology, Biomarkers, and Emerging Therapeutic Strategies

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common chronic liver disease worldwide and is increasingly recognized as an important cardiovascular risk modifier. Cardiovascular disease is the leading cause of mortality among individuals with MASLD, reflecting shared pathophysiologic mechanisms with atherosclerotic cardiovascular disease. These include insulin resistance, lipotoxicity, oxidative stress, chronic inflammation, endothelial dysfunction, and progressive fibrogenesis, which contribute to both hepatic disease progression and atherosclerotic plaque development. Noninvasive biomarkers and imaging modalities provide complementary tools for integrated risk assessment. Serum measures of insulin resistance, atherogenic dyslipidemia, inflammation, and composite fibrosis scores are associated with both liver disease severity and cardiovascular risk. Vibration-controlled transient elastography enables noninvasive assessment of hepatic fibrosis and steatosis, while coronary artery calcium scoring is a robust predictor of subclinical atherosclerosis and cardiovascular events. Increasing evidence demonstrates a positive association between hepatic fibrosis severity and coronary artery calcium burden, supporting combined hepatic and cardiovascular evaluation in patients with MASLD. Therapeutic strategies targeting shared cardiometabolic pathways offer a potential dual benefit. Lifestyle modification remains foundational for improving hepatic disease activity and reducing cardiovascular risk. Statins are safe in MASLD and provide established cardiovascular protection. Glucagon-like peptide-1 receptor agonists and other emerging metabolic therapies demonstrate promise in improving liver disease activity while favorably modifying cardiometabolic risk factors. Recognition of MASLD as a systemic cardiometabolic disorder has important implications for cardiovascular risk stratification and multidisciplinary care.