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Abstract

We thank Drs. Sarikaya, Turan, and Celikbilek for their interest in our work. Our recommendation against screening for nonalcoholic fatty liver disease (NAFLD) in patients with suspected or confirmed coronary artery disease was based on several key points.1 First, despite the strong association between NAFLD and coronary artery disease, most such patients died of cardiovascular complications and not hepatocellular carcinoma or cirrhosis. Second, NAFLD did not predict cardiovascular outcomes in patients with already established coronary artery disease. Third, in line with the recommendations of the American Association for the Study of Liver Diseases, we agree that the optimal screening tool is yet to be defined.2 After all, it is the severity of liver disease and not the mere presence of hepatic steatosis that counts. In that regard, the use of noninvasive tests of liver fibrosis as a screening tool deserves further evaluation.3 As for the apparently lower cardiovascular mortality in patients with NAFLD and coronary artery disease, our additional analysis suggests that aggressive treatment of this high-risk group such as the use of statins has probably altered the natural history of disease.4 Patients with NAFLD were more likely to receive statins than those without (91% versus 73%; P < 0.0001), and statin users had much lower risk of death (hazard ratio 0.30, 95% confidence interval 0.20-0.45; P < 0.0001). The importance of proper management of metabolic factors cannot be overemphasized. On the other hand, we agree with Drs. Sarikaya, Turan, and Celikbilek that coronary intervention does not improve survival in patients with stable angina and should be reserved for those with stronger indications. Vincent Wai-Sun Wong, M.D.1,2 Grace Lai-Hung Wong, M.D.1,2 Henry Lik-Yuen Chan, M.D.1,2 1Department of Medicine and Therapeutics 2State Key Laboratory of Digestive Disease The Chinese University of Hong Kong Hong Kong