C-reactive protein-triglyceride glucose index as a predictor of heart failure risk in adults with MASLD: a prospective cohort study.

Heart failure (HF) is a major complication of metabolic dysfunction-associated steatotic liver disease (MASLD). The C-reactive protein-triglyceride glucose index (CTI), which reflects systemic inflammation and insulin resistance, is linked to cardiovascular outcomes, but its predictive value for HF in MASLD patients remains unclear. We aimed to evaluate the baseline and cumulative CTI (CumCTI) in relation to incident HF and explore blood pressure as a potential mediator. We included 26,499 participants with MASLD from the Kailuan Study. The baseline and CumCTI values were calculated and examined for associations with HF via Cox regression. Restricted cubic splines were used to assess dose‒response patterns. Predictive performance was evaluated using C-index, reclassification metrics, time-dependent ROC curves, and calibration analyses. During a median follow-up of 16.0 years, 1,158 HF events occurred. A higher CTI was independently associated with increased HF risk (HR for Q4 vs. Q1: 1.78; 95% CI: 1.48-2.11; P < 0.001), with each 1-SD increase corresponding to a 27% greater risk (HR 1.27; 95% CI: 1.19-1.35). CumCTI showed stronger associations with HF and modestly improved model discrimination and reclassification compared with conventional risk factors. Time-dependent ROC analyses showed slight increases in AUC at 5 and 10 years after adding CumCTI (0.782 to 0.783 and 0.763 to 0.767, respectively), with good calibration between predicted and observed risks. Mediation analysis indicated that systolic and diastolic blood pressure explained only a small proportion of the CTI-HF association. Associations were stronger for CumCTI in participants aged < 60 years. These findings suggest that a higher CTI, especially cumulative exposure, is independently associated with HF risk in MASLD and may provide complementary information for cardiovascular risk assessment.