Abstract
PURPOSE: Non-alcoholic fatty liver disease and its fibrotic sequelae have been implicated in the development of cardiovascular complications. This study investigated the association between the steatosis-associated fibrosis estimator (SAFE) and prevalent heart failure (HF), as well as evaluated whether SAFE could improve HF detection in the general population. METHODS: A total of 33,566 participants from the 2003-2018 National Health and Nutrition Examination Survey were included. HF was identified based on self-reported medical history. RESULTS: The estimated HF prevalence was 3.00%. After adjusting for demographic, anthropometric, laboratory, and medical history factors, each one-standard-deviation increase in SAFE correlated with a 58.0% rise in HF risk. Individuals in the highest quartile of SAFE had a 2.777-fold risk of HF compared to those in the lowest quartile. Smooth-curve modeling revealed an almost linear association between SAFE and HF, and subgroup analyses supported this relationship across diverse populations. Incorporating SAFE into standard cardiovascular risk factors slightly improved HF discrimination (AUC: 0.873 vs. 0.876, p < 0.001). Reclassification metrics provided additional evidence for SAFE's incremental value. CONCLUSION: This study identified a nearly linear and robust relationship between SAFE and prevalent HF, suggesting that SAFE may serve as a useful indicator for enhancing HF detection in the general population.