The present study was conducted to evaluate the external validity of various cardiovascular disease (CVD) risk assessment tools in predicting CVD events among individuals with metabolic dysfunction associated steatotic liver disease (MASLD).

The Amol prospective cohort study spanned a follow-up period of seven years, from 2009 to 2010 to 2016–2017..A total of 1,431 individuals aged 40–75 years were included. The 10-year cardiovascular risk was estimated for each participant using four risk assessment tools: the Pooled Cohort Equations of the American College of Cardiology/American Heart Association (ACC/AHA), the Systematic Coronary Risk Evaluation (SCORE) equations, the Framingham General Cardiovascular Risk Profile, and the SCORE2 equations. Receiver Operating Characteristic (ROC) curves were used to assess the discrimination ability of these tools.

The ACC/AHA tool demonstrated the highest predictive ability for both fatal CVD events (AUC: 0.92, 95% CI: 0.88–0.97 for men; AUC: 0.87, 95% CI: 0.79–0.96 for women) and composite CVD events (AUC: 0.68, 95% CI: 0.62–0.75 for men; AUC: 0.79, 95% CI: 0.72–0.85 for women).

Based on these findings, cardiovascular risk assessment tools, particularly the ACC/AHA tool, can be applied in clinical settings to evaluate the future risk of CVD events in women with MASLD. However, the SCORE equations also exhibited excellent predictive ability for fatal cardiac events, requiring fewer variables.