Risk of cardiovascular disease development in metabolically associated fatty liver disease (MAFLD): risk stratification and current therapeutic strategies

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a prevalent chronic condition, with an estimated global prevalence of 32% and rates reaching 37–42% in the Russian Federation. The disease is recognized as an independent risk factor for cardiovascular disease (CVD), which remains the leading cause of mortality in this patient population. This review aims to systematize current evidence on the association between MASLD and CVD, risk stratification approaches, and contemporary therapeutic strategies to mitigate the risk of severe cardiovascular complications within the Russian population. A literature search was conducted in the PubMed/Medline, ScienceDirect, eLibrary, and Google Scholar databases covering the period from 2020 to 2025. A total of 67 publications meeting the inclusion criteria were incorporated into this review. The analysis highlights the pivotal roles of insulin resistance, visceral obesity, systemic inflammation, dyslipidemia, and dysregulation of the gut–liver–heart axis in shaping cardiovascular risk. Liver fibrosis, defined by a FIB-4 index ≥1.3, serves as an independent predictor of CVD, conferring a two-fold increase in risk. MASLD is associated with a 2.19-fold higher risk of coronary heart disease, a 1.88-fold higher risk of stroke, and a 20% increased risk of atrial fibrillation. A stepwise risk stratification algorithm tailored to the Russian healthcare system is proposed, incorporating initial screening (using FLI or CMI), fibrosis assessment (FIB-4), advanced diagnostic refinement, and integration with established cardiovascular risk scales (SCORE2, ACC/AHA). The efficacy of non-pharmacological interventions, including weight reduction of ≥7–10%, adherence to a Mediterranean diet, and regular physical activity, is substantiated by meta-analytic data. Among pharmacological agents, GLP-1 receptor agonists (reducing CVD risk by 17%), SGLT2 inhibitors (improving survival rates to 95%), pioglitazone, and statins (lowering hepatocellular carcinoma risk by 48%) demonstrate robust cardioprotective effects. Emerging avenues include combination therapy with novel agents (resmetirom, efruxifermin) and the application of machine learning algorithms for personalized risk prediction. Identified gaps include a paucity of domestic randomized controlled trials and the absence of a dedicated national MASLD–CVD registry. The findings underscore the necessity of integrating screening protocols into routine preventive health examinations, developing regional patient referral pathways, and enhancing the competency of primary care physicians.