De Ritis ratio and cardiovascular disease: evidence and underlying mechanisms

Aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio (De Ritis ratio) has been used as a marker of alcohol-related liver disease, liver fibrosis and muscle disease. This article reviewed the literature on the association of De Ritis ratio with cardiovascular disease (CVD). Recent studies support an association between elevated De Ritis ratio and prognosis of patients with diabetes mellitus, cancers, diseases characterized by multiorgan failure, CVD, stroke and corona virus disease (COVID)-19. Elevated De Ritis ratio may indicate increased cardiometabolic risk associated with overt or occult hepatic and extrahepatic diseases and may be a metabolic trait indicating abnormalities at the level of basic metabolism that foresees the development of future metabolic diseases. De Ritis ratio correlates positively with age, female sex, C-reactive protein and impaired renal function and inversely with diabetes mellitus, obesity and metabolic syndrome. Epidemiological studies suggest an association of elevated De Ritis ratio with CVD and strongly support an association between elevated De Ritis ratio and increased risk for all-cause and CVDrelated mortality. The strength and direction of the association between De Ritis ratio and cardiovascular risk factors cannot explain the association between De Ritis ratio and CVD or CVD mortality. Elevated De Ritis ratio may represent cardiometabolic risk that is not mediated (or poorly mediated) by traditional risk factors and may be seen as an emerging nonstandard marker of cardiometabolic risk. De Ritis ratio requires standardization in terms of reference range and interpretation. Future epidemiological, clinical and laboratory (biochemical) studies are required to further investigate De Ritis ratio as a marker of cardiometabolic risk and CVD.