LAUSR

With great interest, we have read the recent article by Simon et al, reporting a significant association between nonalcoholic fatty liver disease (NAFLD) and incident major adverse cardiovascular events. The authors found that patients with biopsyproven NAFLD had a significantly higher incidence of ischaemic heart disease, stroke, congestive heart failure and death due to cardiovascular disease (CVD), when compared with matched controls. An excess in CVD morbidity and mortality was evident across all stages of NAFLD and increased with worsening disease severity. The authors are to be congratulated for conducting such a large populationbased retrospective cohort study including data of more than 10 000 patients with histologically confirmed NAFLD free of preexisting CVD at baseline followed over a very long observation period of 13.6 years. The findings are in line with several recently published studies and provide further evidence that NAFLD might be an independent risk factor for CVD morbidity and mortality. The cardiovascular mortality in the studied Epidemiology Strengthened by Histopathology Reports in Sweden (ESPRESSO) cohort was approximately 28% during the followup period and the prevalence of major cardiometabolic risk factors (including diabetes, hypertension, dyslipidaemia) was markedly higher in NAFLD patients than in the matched control group. Unfortunately, there is only incomplete information available on the control or treatment rate of these cardiovascular comorbidities in the analysed historical cohort (study period: 1966–2016). Information, for example, on the frequency of lipidlowering therapy with statins, has only been available since 2006. Interestingly, comparing the current study with studies of similar NAFLD cohorts clearly shows, that with the increase in the proportion of treated cardiometabolic comorbidities, the rate of adverse CVD events as well as the CVD mortality dramatically decrease (table 1 and figure 1). This observation clearly underlines that (1) optimal management of cardiovascular comorbidities is imperative in this highrisk population and (2) cardiovascular prevention must be a main pillar of any intervention strategy. In addition to the identification of patients with advanced stages of liver fibrosis, particular attention must be paid to the detection and adequate treatment control of type 2 diabetes, hypertension and atherogenic dyslipidaemia, which are interrelated with NAFLD severity and key determinants of cardiovascular risk. Letter