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

Abstract Background 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. Method and Results 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). Conclusion A high FIB-4 score in patients with HFrEF is associated with increased mortality and MALO.Graphical abstract