*Purpose: The aim of this study is to evaluate the evolution of MACE and pre-LT cardiac risk factors in LTRs over time.

*Methods: This is a retrospective cohort of 1739 adult LTRs at a single, large U.S. academic transplant center (2003-2020) using the electronic health record. NASH was defined using primary or secondary listing diagnosis for NASH or cryptogenic cirrhosis plus one metabolic risk factor. MACE was defined as death or hospitalization for myocardial infarction (MI), revascularization, stroke, or heart failure (HF). Logistic regression analysis was used to assess factors a priori that are associated with 1-year MACE among LTRs.

*Results: Figure 1 shows trends in pre-LT cardiac comorbid conditions. Between 2003 and 2020, there was a significant increase in pre-LT obesity, atherosclerotic (ASCVD), older age (≥65 years old), and NASH (p_trend<0.05 for all). There was no significant change in proportion of LTRs with diabetes, chronic kidney disease (CKD), or HF. The mean 1-year MACE rate was 18.7%. Higher 1-year MACE was observed in LTRs transplanted for NASH compared to other etiologies (26.4% vs 16.5%, p<0.0001) (Figure 2). There was an interval decrease in MACE over the study period (-0.17% per year, p_trend=0.29). In multivariable modeling, age, ASCVD, diabetes, HF, and CKD were significantly associated with MACE within 1 year of LT.

*Conclusions: There has been an overall increase in cardiac risk factor burden among LTRs between 2003 and 2020 that are also significantly associated with MACE within 1 year of LT. Unexpectedly, overall MACE decreased slightly over time in our cohort. This may reflect advancement in the identification and management of cardiovascular risk factors in LTRs. With projected continued increase in cardiac risk burden and the proportion of patients transplanted for NASH, it is critical for LT programs to develop and implement quality improvement efforts to improve cardiovascular care in LTRs.

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