FIB-4 showed an independent statistical association with CAD severity in MASLD patients (OR=1.445, P=0.016), with a within-subgroup significant association observed among hypertensive patients, but weak standalone discriminatory ability (AUC=0.569) and no confirmed effect heterogeneity across subgroups.
Key Findings
Results
FIB-4 index showed an independent correlation with CAD severity in MASLD patients after adjustment for major cardiovascular confounders.
OR = 1.445, P = 0.016 in multivariable ordinal logistic regression
Confounders adjusted for included age, hypertension, and diabetes history
Study population: 423 patients presenting with chest pain with MASLD who underwent coronary angiography
CAD severity was graded into 4 ordinal groups by Gensini score to quantify degree of coronary stenosis
Cross-sectional study design
Results
Among hypertensive patients, a statistically significant association between FIB-4 and CAD severity was observed in stratified fully adjusted models.
OR = 1.507, P = 0.022 in the hypertensive subgroup
No meaningful association was found in normotensive patients
Formal interaction testing did not confirm statistically significant effect modification (P for interaction > 0.05)
The authors note that 'these subgroup differences may reflect chance variation rather than true effect heterogeneity'
Caution is warranted when interpreting this subgroup finding given the lack of confirmed effect heterogeneity
Results
FIB-4 had modest standalone discriminatory ability for moderate-to-severe CAD.
AUC for moderate-to-severe CAD was 0.569
Described as 'modest standalone discriminatory ability of FIB-4 alone'
ROC curve analysis was performed alongside Bootstrap validation
Authors concluded FIB-4 'cannot be used as an independent screening tool for all MASLD patients in primary and cardiology clinical practice'
Results
Non-significant positive trends in FIB-4 association with CAD severity were observed in men and patients under 60 years, but no meaningful association was found in women or patients aged 60 years or older.
Stratified analyses were performed by sex, age, hypertension, and diabetes
Non-significant positive trends observed in men and those < 60 years
No meaningful association found in women or patients ≥ 60 years
All P for interaction > 0.05 across all subgroups, indicating no confirmed effect modification
No meaningful association was found in diabetic patients either
Conclusions
FIB-4 index can serve only as an auxiliary indicator to supplement cardiovascular risk stratification alongside conventional risk factors in MASLD patients.
Described as 'a simple, low-cost marker' that 'can only serve as an auxiliary indicator to supplement cardiovascular risk stratification alongside conventional risk factors'
FIB-4 is characterized as 'an inexpensive, routine laboratory-based non-invasive marker for staging hepatic fibrosis'
Authors state it has 'weak standalone discriminative power'
MASLD and CAD are linked via the 'liver-heart axis' through 'shared inflammatory and metabolic mechanisms'
Coronary angiography was used as 'the diagnostic gold standard for coronary artery disease'
What This Means
This research studied whether a simple blood test score called the FIB-4 index — which is normally used to assess liver scarring (fibrosis) — could help predict how severe coronary artery disease (CAD) is in patients who also have metabolic fatty liver disease (MASLD). The study included 423 patients who had chest pain and fatty liver disease and underwent coronary angiography (a procedure that directly visualizes blockages in the heart's arteries). The researchers found that higher FIB-4 scores were statistically linked to more severe coronary artery disease overall, and this link was particularly apparent among patients who also had high blood pressure. However, the FIB-4 index on its own was only weakly able to distinguish patients with more severe CAD from those with less severe disease (AUC of 0.569, where 1.0 would be perfect and 0.5 would be no better than chance).
Importantly, the study found no statistically confirmed difference in how strongly FIB-4 related to CAD across different patient groups (men vs. women, younger vs. older, hypertensive vs. normotensive, diabetic vs. non-diabetic), meaning the apparent stronger effect in hypertensive patients could be due to chance rather than a true biological difference. No meaningful association was found in women, patients aged 60 or older, patients without high blood pressure, or diabetic patients.
This research suggests that the FIB-4 index — a cheap and easy-to-calculate score derived from routine blood tests — may provide some additional information about coronary artery disease severity in MASLD patients when used alongside other established risk factors, but it is not strong enough to be used on its own as a screening tool. Clinicians should treat it as one supplementary piece of information rather than a standalone indicator of heart disease risk in this patient population.
Zhang Z, Ma J, Huang J. (2026). Correlative association between FIB-4 index and graded coronary artery disease severity among MASLD patients: A hypertension-stratified analysis.. Diabetes research and clinical practice. https://doi.org/10.1016/j.diabres.2026.113508