LETTER
Second, we believe that health care use status could also
Metabolic Dysfunction-Associated
Fatty Liver Disease, Statins, and
Atherosclerotic Cardiovascular
Disease
To the Editor:
In a recent nationwide study, Yeoh and colleagues reported
an increased risk of atherosclerotic cardiovascular disease
(ASCVD) in people with metabolic dysfunction-associated
fatty liver disease (MAFLD).1 Previous studies have sug-
gested that fatty liver disease is associated with cardiovas-
cular disease risk.2 However, information regarding the
influence of statin use in critical outcomes in MAFLD
patients has been lacking. By providing evidence evaluating
the risk of ASCVD through the analysis of datasets from the
robust NHANES database the results of the study by Yeoh
et al could provide clinicians with critical information about
cardiovascular disease development in patients with
MAFLD. Though the conclusions of the study were sound
and convincing, we would like to raise some points regard-
ing the influence of co-medications and status of health
care use, which could potentially influence the interpreta-
tion of the results.
First, underlying utilization status of medications that
could influence the risk of ASCVD and major adverse car-
diovascular events, such as the use of tramadol, corticoste-
roids, or TNF inhibitors, were not considered in the current
study.3,4 Given that the baseline characteristic of co-medi-
cations was not reported in the study, we are unable to eval-
uate the co-medication status of the MAFLD and non-
MAFLD groups. However, given the high concurrence of
MAFLD and inflammatory bowel diseases, participants
may have potential underlying need of these co-medica-
tions. In this case, we believe that the influence of these
drugs has been recommended to be taken into account and
should not be neglected,5 and we recommend that future
studies consider the potential influence of co-medications.
Funding: None.
Conflict of Interest: None.
Authorship: All authors had access to the data and a role in writing
this manuscript.
Requests for reprints should be addressed to Shuo-Yan Gau, School of
Medicine, Chung Shan Medical University, Taichung, Taiwan; No. 110,
Sec. 1, Jianguo N. Rd., South District, Taichung City 40201, Taiwan.
E-mail address: sixsamurai.shien15@gmail.com
0002-9343/$ -see front matter © 2023 Elsevier Inc. All rights reserved.
potentially influence the trend of developing future
ASCVD. In epidemiological studies, influence of medical
surveillance bias can lead to potential misinterpretation of
the results.6 Consequently, we believe that within the fol-
lowing period, the number of medical departments visited
could influence the incidence of future ASCVD. However,
in the current study design, influence of participants’ health
care use status has not been considered. In this case, we
would like to raise this issue and recommend that future
studies consider health care use status in order to more pre-
cisely evaluate the risk of ASCVD.
Hui-Chin Chang, MLSa,b,c
Shuo-Yan Gauc,d
a
Library, Chung Shan Medical Uni-
versity Hospital, Taichung, Taiwan
b
Evidence-Based Medicine Center,
Chung Shan Medical University
Hospital, Taichung, Taiwan
c
School of Medicine, Chung Shan
Medical University, Taichung,
Taiwan
d
Department of Medical Education
and Research, Kaohsiung Veterans
General Hospital, Taiwan
https://doi.org/10.1016/j.amjmed.2023.07.013
References
1. Yeoh A, Cheung R, Ahmed A, Chitnis AS, Do A, Wong RJ. Cardiovas-
cular disease risk and statin use among adults with metabolic dysfunc-
tion associated fatty liver disease. Am J Med 2023;136(7) [669-676.e1.
2. Duell PB, Welty FK, Miller M, et al. Nonalcoholic fatty liver disease
and cardiovascular risk: a scientific statement from the American Heart
Association. Arterioscler Thromb Vasc Biol 2022;42(6):e168–85.
3. Saul H, Gursul D. Even low doses of steroids increase the risk of car-
diovascular disease in people with inflammatory diseases. BMJ
2021;375:n2599.
4. Gau SY, Huang JY, Wei JC. Tramadol use increases mortality and risk
of major adverse cardiovascular events in rheumatoid arthritis patients:
evidence from a population-based cohort study. Eur J Prev Cardiol
2022;29(6):e237–8.
5. Rolski F, Blyszczuk P. Complexity of TNF-alpha signaling in heart dis-
ease. J Clin Med 2020;9(10):3267.
6. Bower JK, Patel S, Rudy JE, Felix AS. Addressing bias in electronic
health record-based surveillance of cardiovascular disease risk: finding
the signal through the noise. Curr Epidemiol Rep 2017;4(4):346–52.