LAUSR

BACKGROUND & AIMS There is an ongoing debate on whether non-alcoholic fatty liver disease (NAFLD) is an active contributor or an innocent bystander in the pathogenesis of coronary artery disease (CAD). The aim of the present study was to assess the causal relationship between NAFLD and CAD. APPROACH & RESULTS We performed two-sample Mendelian randomization (MR) analyses using summary-level data to assess the association between genetically predicted NAFLD (i.e. chronically-elevated serum alanine aminotransferase levels [cALT], imaging-based and biopsy-confirmed NAFLD) and risk of CAD. Analyses were repeated after exclusion of NAFLD susceptibility genes that are associated with impaired VLDL secretion. Inverse-variance weighted (IVW) MR analyses showed a statistically significant association between genetically predicted cALT and risk of CAD (odds ratio [OR]:1.116, 95% confidence interval [CI]:1.039,1.199), but not for the other NAFLD-related traits (OR:1.046, 95%CI:0.764,1.433 and OR:1.014, 95%CI:0.968,1.062 for imaging-based and biopsy-confirmed NAFLD, respectively). MR Egger regression revealed a statistically significant intercept, indicative of directional pleiotropy, for all traits. Repeat analyses after exclusion of genes associated with impaired VLDL secretion, showed consistent associations between genetically predicted NAFLD and CAD for all traits, i.e. cALT (OR:1.203, 95%CI:1.113,1.300), imaging-based (OR:2.149, 95%CI:1.276,3.620) and biopsy-confirmed NAFLD (OR:1.113, 95%CI:1.041,1.189), which persisted when more stringent biopsy-confirmed NAFLD criteria were used (OR:1.154, 95%CI:1.043,1.278) or when more stringent MR methods were applied. MR Egger regression did not show a statistically significant intercept. CONCLUSION The two-sample MR analyses showed a robust association between genetically predicted NAFLD and CAD after exclusion of genetic variants that are implicated in impaired VLDL secretion.