Features of treatment of heart failure in patients with metabolic dysfunction-associated steatotic liver disease. Literature review

Common pathophysiologic pathways and increasing global prevalence of morbidity and mortality rates of metabolic dysfunction‑associated steatotic liver disease (MASLD) and heart failure (HF) express the need for optimized multidisciplinary management strategies. In patients with concomitant MASLD and HF, drug classes such as angiotensin‑converting enzyme inhibitors, angiotensin receptor blockers, angiotensin and neprilysin receptor inhibitors, beta‑blockers, mineralocorticoid receptor antagonists, and sodium‑dependent glucose cotransporter‑2 inhibitors demonstrate benefits, while loop diuretics may worsen MASLD. The features of patients with concurrent MASLD and HF remain insufficiently explored. Very few randomized controlled trials have examined the therapeutic benefits of evidence‑based therapies in HF patients with MASLD. Loop diuretics and mineralocorticoid receptor antagonists are commonly used medications in heart failure patients, but their safety profile and pathophysiologic effectiveness have yet to be understood in patients with MASLD. Existing literature suggests a hastening of hepatic lipid deposition in MASLD, but larger randomized studies are needed to corroborate these findings. The effects of beta‑blockers and digoxin in MASLD should also be explored. Emerging data suggest that glucagon‑like peptide‑1 receptor agonists may be beneficial in patients with heart failure, particularly in those with metabolic syndrome or with preserved left ventricular ejection fraction and obesity. Further studies are needed to identify the optimal medical treatment for heart failure with moderately reduced left ventricular ejection fraction, regardless of MASLD presence, as existing recommendations have been extrapolated from randomized controlled trials involving patients with heart failure with reduced or preserved left ventricular ejection fraction. Collaborations between cardiologists and hepatologists in the prevention and co‑management of comorbid disease in this patient population are vital to mitigate the global threats of metabolic syndrome, MASLD, and heart failure.