Synopsis
Recognise clustered cardiometabolic risk without diagnostic shorthand, identify metabolic steatotic liver and advanced fibrosis, and treat each modifiable vascular and hepatic driver.
- Metabolic syndrome describes central adiposity, dysglycaemia, raised blood pressure and atherogenic lipids clustering through insulin resistance; treat the components rather than relying on the label.
- NICE now uses metabolic dysfunction-associated steatotic liver disease terminology in NG49, while local records and evidence may still say NAFLD; document what diagnostic criteria were used.
- MASLD ranges from steatosis through inflammatory injury and fibrosis to cirrhosis and liver cancer; fibrosis stage, not transaminase height, drives liver prognosis.
Key red flags
Ascites, jaundice, variceal bleeding, encephalopathy, sarcopenia or hepatorenal dysfunction indicates advanced disease and requires urgent or expedited hepatology depending on physiological stability.
Investigation priorities
Document central adiposity and a major treatable vascular component.
Refine fibrosis, portal-hypertension and cirrhosis risk after an abnormal first-line test.
Management branches
Central adiposity or dysglycaemia suggests clustered cardiometabolic risk.
- Measure pressure, HbA1c, lipids, adiposity, smoking, sleep and liver context, and ask about cardiovascular symptoms, medicines, alcohol and family history.
- Use separate NICE thresholds to treat hypertension, diabetes, lipids and obesity, agreeing practical nutrition, activity, sleep and smoking goals without depending on a syndrome label.
Key medicines
Atorvastatin for cardiovascular prevention in MASLDUse the NICE indication-based oral dose, commonly 20 mg once daily for eligible primary prevention or 80 mg once daily for secondary prevention, adjusted for interactions and tolerability.
Pioglitazone in specialist-selected advanced fibrosisUse only an endocrinology or hepatology-selected once-daily regimen within the current NICE and diabetes context after discussing uncertain liver benefit and patient-specific risks.