Association between the liver fat score (LFS) and cardiovascular diseases in the national health and nutrition examination survey 1999-2016

Ann Med. 2021 Dec;53(1):1065-1073. doi: 10.1080/07853890.2021.1943514.


Background: The liver fat score (LFS) has been proposed to be a simple non-invasive marker of non-alcoholic fatty liver disease (NAFLD), which is highly prevalent in the general population. We tested its association with cardiovascular diseases (CVDs) and prognosis.

Methods: 17,244 adult participants from the National Health and Nutrition Examination Survey 1999-2016 were included. LFS is calculated from variables including serum aspartate transaminase/alanine transaminase (AST/ALT) ratio, fasting serum aspartate transaminase (AST) level, fasting serum insulin level, presence of metabolic syndrome and diabetes mellitus. In cross-sectional analysis, logistic regression was used to examine the association of the LFS with coronary heart disease (CHD), myocardial infarction (MI), congestive heart failure (CHF), stroke and angina pectoris. Mortality during follow-up was analysed using Cox proportional hazard regression.

Results: LFS was associated with CHD (adjusted odds ratio [OR]: 1.09 per standard deviation [SD], 95% confidence interval [95% CI]: 1.03-1.15) (p = .003), CHF (1.11, 1.04-1.18) (p = .003) and angina pectoris (1.08, 1.02-1.13) (p = .005). LFS was not associated with MI or stroke, but was associated with increased all-cause and cardiovascular mortality with hazard ratios (HRs) of 1.10 (95% CI: 1.07-1.13) (p < .001) and 1.12 (95% CI: 1.06-1.17) (p < .001), respectively.

Conclusions: NAFLD is usually asymptomatic, but this large study of a large general population shows that LFS is associated with CHD, CHF, angina pectoris, cardiovascular and all-cause mortality. Determining the LFS is worthwhile, as it identifies people with NAFLD, who may also be at increased cardiovascular risk.Key MessagesLiver fat score (LFS), a non-invasive marker of non-alcoholic fatty liver disease (NAFLD), is associated with coronary heart disease (CHD), congestive heart failure (CHF) and angina.LFS is also associated with increased cardiovascular and all-cause mortality.Determining the LFS is worthwhile as it identifies people with NAFLD as well as increased cardiovascular risk.

Keywords: Cardiovascular disease prevention; liver fat score; metabolic syndrome; non-alcoholic fatty liver disease score.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Angina Pectoris
  • Aspartate Aminotransferases
  • Cardiovascular Diseases* / epidemiology
  • Coronary Disease*
  • Cross-Sectional Studies
  • Heart Failure* / epidemiology
  • Humans
  • Non-alcoholic Fatty Liver Disease* / diagnosis
  • Non-alcoholic Fatty Liver Disease* / epidemiology
  • Nutrition Surveys
  • Risk Factors
  • Stroke*


  • Aspartate Aminotransferases

Grants and funding

This work was supported by an Undergraduate Research Internship from the Li Ka Shing Faculty of Medicine, University of Hong Kong, awarded to Chun-On Lee.