Impact of Liver Fibrosis Score on Prognosis in Patients With Previous Myocardial Infarction

A Prospective Cohort Study

Ye-Xuan Cao; Meng Zhang; Hui-Wen Zhang; Jing-Lu Jin; Hui-Hui Liu; Yan Zhang; Yuan-Lin Guo; Na-Qiong Wu; Cheng-Gang Zhu; Rui-Xia Xu; Ying Gao; Qian Dong; Jing Sun; Jian-Jun Li


Liver International. 2021;41(6):1294-1304. 

In This Article

Abstract and Introduction


Background & Aims: Liver fibrosis score (LFS) has been used for predicting the cardiovascular outcomes (CVOs) in diverse populations. However, the association of LFS with CVOs in patients with previous myocardial infarction (MI) remains undetermined. We aimed to examine the prognostic value of LFS in patients with prior MI in a prospective cohort.

Methods: A total of 3718 patients with previous MI were consecutively enrolled from March 2009 to January 2019. Five LFSs including the fibrosis-4 (FIB-4) score, non-alcohol fatty liver disease fibrosis score (NFS), Forns score, HUI score and BARD score were used. The CVOs covered major adverse cardiac event (MACEs), cardiovascular mortality and all-cause mortality. Cox proportional hazards model was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs).

Results: During a mean follow-up of 47.4 ± 24.8 months, 431 (11.6%) MACEs occurred. Kaplan-Meier analysis demonstrated that higher LFSs resulted in a significantly higher probability of CVOs. Compared to the lowest score group, multivariable-adjusted HRs (95% CIs) of the highest group of FIB-4, NFS, Forns score, HUI score and BARD score were 1.75 (1.32–2.33), 2.37 (1.70–3.33), 2.44 (1.61–3.73), 1.58 (1.16–2.14) and 1.27 (1.03–1.57) respectively. These LFSs were also independent predictors of cardiovascular mortality and all-cause mortality. Similar results were observed across subgroups analysis. The addition of LFSs to a prediction model significantly increased the C-statistic for CVOs.

Conclusions: The present study firstly demonstrated that LFS could be used as a risk stratification tool for predicting CVOs in patients with previous MI, which should be evaluated further.


Non-alcoholic fatty liver disease (NAFLD), also called metabolic dysfunction-associated fatty liver disease (MAFLD), is the most common cause of chronic liver disease worldwide and represents a wide spectrum of hepatic disorders, in which patients with increased liver fibrosis (LF) were reported to have a worse prognosis.[1–4] Liver biopsy is considered the gold standard for the assessment of fibrosis severity but it cannot be performed on the general population due to several inevitable limitations.[5] Therefore, noninvasive liver fibrosis scores (LFSs) composed of routinely clinical and laboratory variables were specifically constructed with the advantages of high applicability, widespread availability and low cost.[6] Fibrosis-4 score (FIB-4),[7] NAFLD fibrosis score (NFS),[8] Forns score,[9] BARD score[10] and HUI score[11] are the most commonly used LFSs. These LFSs were originally developed in patients with chronic hepatitis B virus or other liver diseases, and have been extensively validated for their accuracy in distinguishing histological fibrosis with reasonable accuracy.[6] These LFSs have also suggested to be useful in excluding advanced fibrosis and can also be used in patients with normal transaminases in routine clinical practice.[12,13]

There is emerging evidence that LFS can serve as a valuable tool for risk prediction in a broader population beyond NAFLD, since the components of the LFS reflect systemic insulin resistance, obesity and the metabolic syndrome.[14,15] Recent data have shown an independent role of LFS in the development and progression of atherosclerosis, such as coronary artery calcification.[16,17] Furthermore, there is testimony indicating that LFS could be used to identify patients who are at a higher risk for future all-cause and cardiovascular mortality in the general population and patients with NAFLD.[18–20] For example, LFS was recently found to be associated with mortality in patients with heart failure or with CAD.[21,22]

Myocardial infarction (MI) is one of the leading causes of morbidity and mortality in patients with CAD.[23] Although several risk factors, like age, hypertension and LDL-C, have been found to be associated with cardiovascular outcomes (CVOs) in patients with MI, the contributions of metabolic factors to CVO risk might be underestimated.[24] Till now, no prospective data are currently available concerning the prognostic implications of LFSs in patients with MI. Besides, the previous studies have evaluated the relationship between LFSs and mortality, but whether the LFSs are independent predictors for major adverse cardiac event (MACE) remains undetermined currently. To expand the clinical utility of the LFSs, the aim of this study was to examine the prognostic value of FIB-4, NFS, Forns score, HUI score and BARD score for CVOs and their abilities to reclassify risk among patients with previous MI in a prospective large Chinese cohort.