Abstract
INTRODUCTION: A complex bidirectional association between type 2 diabetes (T2D) and non-alcoholic fatty liver disease (NAFLD) has been linked to unfavourable metabolic profile and an increasing risk of cardiovascular disease (CVD). This study aimed to investigate long-term CVD outcomes in patients with NAFLD according to glycaemic status using a nationwide cohort of Korean adults. METHODS: This longitudinal study included 1 057 775 patients with NAFLD, who had participated in the national health screening in 2009 from baseline to the date of diagnosis of myocardial infarction (MI), stroke and cardiovascular (CV) death or up to 2020 during a follow-up period of 11.3 years. The baseline glycaemic status was divided into three categories (normal fasting glucose (NFG), impaired fasting glucose (IFG) and T2D). RESULTS: A total of 26 491 cases of MI, 55 791 cases of stroke and 11 147 cases of CV death were identified. After adjusting for possible covariates, participants with T2D had a higher risk of CVD, with HRs of 1.39 (95% CI 1.35 to 1.44) for MI, 1.39 (95% CI 1.36 to 1.42) for stroke and 1.46 (95% CI 1.39 to 1.52) for CV death, compared with those with NFG. The IFG group did not exhibit a significant increase in the risk of MI, stroke and CV death compared with the NFG group. The increased risk of CVD attributable to T2D was more profound among individuals with fewer conventional risk factors, including younger age, not obese and the absence of hypertension. CONCLUSION: T2D is associated with an increased risk of CVD and CV mortality in patients with NAFLD. These results suggest that the identification of T2D in individuals with NAFLD may help in the early prediction of future progression of CVD.