World Liver Day 2021: Understanding The Link Between Non-Alcoholic Fatty Liver Disease And Heart Health
World Liver Day is observed on 19 April each year to spread awareness about this liver diseases. Read here as expert explains the link between non-alcoholic fatty liver disease and cardiovascular disease.
World Liver Day 2021: Maintaining a healthy body weight can help keep your liver healthy
- World Liver Day is observed on 19 April each year
- Non-alcoholic fatty liver disease is a common pathological condition
- NAFLDs are linked with your heart health in several ways
Non-alcoholic fatty liver disease (NAFLD) is a common pathological condition worldwide and refers to accumulation of fat in the Liver. NAFLD represents a spectrum of progressive liver disease occurring in the absence of excessive alcohol consumption that ranges from isolated intrahepatic triglyceride accumulation (simple steatosis), through intrahepatic triglyceride accumulation plus inflammation and hepatocyte injury (non-alcoholic steatohepatitis, NASH), and ultimately progresses to End stage Liver Disease / Liver Cirrhosis and potentially Liver cancer. Although a significant proportion of the population has NAFLD, only a minority progresses to advanced liver disease or liver-related death. It is odd but is true that NAFLD patients die of cardiovascular diseases, which is incidentally the most common cause of death rather than due to liver cirrhosis. This is unsurprising as there are close associations between NAFLD and the established CVD. Risk factors encapsulated by the metabolic syndrome, including abdominal obesity, hypertension, bad fats and insulin resistance. There are strong associations of NAFLD with early changes in left ventricular morphology and/or diastolic dysfunction, impaired myocardial energy metabolism and reduced coronary artery flow.
The many ways your heart health is linked with liver condition
NAFLD and arterial hypertension:
Arterial hypertension is the most common modifiable risk factor for CVD. World Health Organisation (WHO) estimates, approximately 54% of all strokes and 47% of all cases of ischemic heart disease are a direct consequence of high blood pressure. Hypertension also increases the risk for the development and progression of heart failure, peripheral arterial occlusive disease and cardiac arrhythmias, especially atrial fibrillation. Among NAFLD patients, the prevalence of arterial hypertension varies from 40-70% and emerging evidence has shown that NAFLD is strongly associated with an increased risk of incident early-hypertension (i.e. systolic blood pressure: 120-139 mmHg, diastolic blood pressure: 80-89 mmHg). Few studies from France and Germany show 2-3 fold increase in the incidence of arterial hypertension over observation periods of 9 and 5 years, respectively.
NAFLD and coronary artery disease:
NAFLD patients are also at higher risk of clinically manifesting atherosclerosis. In a meta-analysis of 25,837 patients, it was reported that NAFLD patients had a 2.26 times higher risk of clinical coronary artery disease when compared to individuals without NAFLD. In a study of 360 patients with myocardial infarction it was observed higher in-hospital and 3-year mortality rates in NAFLD patients than in controls.
NAFLD and cardiac arrhythmias:
There is strong evidence to suggest, that NAFLD is associated with an increased risk of cardiac arrhythmias such as atrial fibrillation and ventricular arrhythmias. This is true as NAFLD is characterized by low-grade inflammation with increased production of pro-inflammatory mediators. In addition, insulin resistance, the core feature of the metabolic syndrome, may lead to decreased potassium, affecting the prolongation of ventricular repolarisation. Several reports have suggested that NAFLD is associated with the presence of aortic-valve sclerosis and mitral annulus calcification. There are no specific approved pharmacological therapies for NAFLD, an optimal management of metabolic risk factors is essential to reduce cardiovascular risk.
Body weight loss:
In particular, weight loss is of great importance in overweight or obese NAFLD patients and can be achieved by caloric restriction or intensive exercise. While a bodyweight loss of about 5% is already associated with a substantial reduction in liver fat content of about 30% and an improvement of metabolic abnormalities, a weight loss of at least 7-10% might be needed to substantially reduce hepatocyte inflammation, and a total weight loss of at least 10% is necessary for prognostically relevant fibrosis regression.
Weight loss alone is insufficient to reduce the cardiovascular risk of NAFLD patients and must always be accompanied by further lifestyle modifications, including dietary and exercise interventions targeting changes in fat distribution of both adipose tissue depots (e.g. abdominal, pericardial, and renal sinus) and ectopic fat deposits (e.g. hepatic, intermuscular, and pancreatic). Current European clinical practice guidelines for NAFLD recommend 150-200 min/week of moderate intensity aerobic physical activities, such as brisk walking or stationery cycling for NAFLD patients. Reduction in weight loss and NASH inflammation also reduces Cardio-vascular morbidity and mortality.
The diagnosis of NAFLD deserves a thoughtful cardiovascular risk assessment and evaluation for subclinical atherosclerosis. This has the potential to enable improved identification of high-risk patients who are candidates for therapeutic interventions in order to address the unacceptable global disease burden attributable to the intertwined pandemic of metabolic and cardiovascular diseases. While there is currently few approved specific drug treatment for the liver, concomitant cardiovascular risk factors should be targeted through the use of statins, antihypertensive drugs, preferably ACE inhibitors and angiotensin-receptor blockers, aspirin and insulin-sensitizing drugs.
(Dr. Kunal Das, Consultant and HOD, Dept. of Gastroenterology and Hepatology, Manipal Hospitals, Dwarka)
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