The prognostic role of fibrosis-4 score in heart failure with reduced ejection fraction

Heart failure with reduced ejection fraction (HFrEF) and metabolic dysfunction-associated steatotic liver disease (MASLD) are both associated with liver fibrosis. HFrEF patients may develop liver fibrosis due to hepatic congestion, MASLD, or a combination of both. The Fibrosis-4 (FIB-4) score calculated using age, aspartate aminotransferase, alanine aminotransferase, and platelet count, serves as a screening tool for advanced liver fibrosis. This study examines the association between the FIB-4 score and all-cause mortality, cardiovascular mortality, and major adverse liver outcomes (MALO) in patients with HFrEF.

This study included 4,523 HFrEF patients from the Danish Heart Failure Registry. Based on FIB-4 score, 25.5% were low-risk, 45.7% were indeterminate-risk, and 28.8% were high-risk for advanced liver fibrosis. After five years, the cumulative incidence of all-cause mortality was 43% for the high-risk group, 36% for the indeterminate-risk group, and 23% for the low-risk group. The indeterminate-risk and high-risk group had an increased hazard ratio (HR) for all-cause mortality (HR 1.33, 95% confidence interval [CI] 1.16–1.52; HR 1.51, 95% CI 1.31-1.74) compared to the low-risk group. Similarly, HRs were elevated for cardiovascular mortality (HR 1.61, 95% CI 1.27–2.05; HR 2.14, 95% CI 1.67–2.74) and MALO (HR 1.77, 95% CI 1.01–3.31; HR 2.54, 95% CI 1.43–4.52).

A high FIB-4 score in patients with HFrEF is associated with increased mortality and MALO.

Graphical abstract