Abstract
PURPOSE: Given the high and rising prevalence of metabolic dysfunction-associated fatty liver disease (MAFLD) among the aging population and its established link to cardiovascular risk, this study aimed to evaluate the predictive value of dynamic metabolic trajectories for ECG-defined cardiovascular risk in elderly patients with MAFLD. PATIENTS AND METHODS: This three-year longitudinal study enrolled 1086 elderly patients with MAFLD from Weifang City, Shandong Province, China. Group-based trajectory modeling (GBTM) was applied to identify dynamic changes in 12 metabolic indicators. The predictive performance of the metabolic trajectory model was compared with that of the cross-sectional model using 5-fold cross-validation. Multivariable logistic regression was employed to evaluate the independent associations between specific metabolic trajectories and ECG-defined cardiovascular risk. RESULTS: During follow-up, 877 participants (80.76%) developed new ECG abnormalities. The trajectory model demonstrated a modest but statistically significant improvement in discrimination over the cross-sectional model (ΔAUC = 0.054). Specific progressively worsening metabolic trajectories were strongly associated with increased risk: the "Obesity-Increasing" BMI, "Moderate Hypertension-Increasing" SBP, and "High Level-Increasing" TC trajectories. Notably, a "legacy effect" of liver injury was evident: patients whose elevated AST later declined ("High-Decreasing" trajectory) still faced substantially elevated cardiovascular risk (aOR = 4.15; aRR = 1.20). Conversely, the "Moderate Diabetes-Decreasing" FPG trajectory (aOR = 0.49; aRR = 0.82) and adherence to a predominantly vegetarian diet (aOR = 0.22; aRR = 0.61) were associated with significantly lower risk. Advanced age remained a strong independent risk factor. CONCLUSION: Dynamic metabolic trajectories offer incremental predictive value over static measures in predicting ECG-defined cardiovascular risk in elderly MAFLD patients. Clinical management should shift from state-based to trend-based intervention, focusing on early control of adverse trends, long-term vigilance for patients with a history of liver injury, and active improvement of reversible risk factors. Tailored dietary interventions are also recommended. These findings provide an evidence-based foundation for developing precise and proactive risk prevention strategies in this high-risk population.