This meta-analysis investigated the prognostic value of the Fibrosis-4 index (FIB-4) index for adverse outcomes of coronary artery disease (CAD). The study aimed to systematically summarize and quantify the available evidence on the association between FIB-4 and adverse outcomes in CAD.

Four online databases (PubMed, Embase, Cochrane, and Web of Science) were searched to collect studies published up to May 21, 2025 exploring the association of the FIB-4 index with adverse outcomes in patients with CAD. The quality of the studies was assessed using the Newcastle-Ottawa Scale (NOS). A random-effects model was applied to pool hazard ratios (HRs) with 95% confidence intervals (CIs).

We retrieved 5,809 publications in total. Twelve studies (31,817 CAD patients) were included after screening. All included studies scored ≥ 7 on the NOS, suggesting acceptable methodological quality. As a continuous variable, the FIB-4 index showed a significant positive association with adverse outcomes of CAD: all-cause mortality (ACM) (HR = 1.10, p for effect < 0.001) and cardiovascular death (HR = 1.13, p for effect < 0.001). As a categorical variable, the FIB-4 index exhibited a consistent positive association with adverse outcomes of CAD, although the results should be interpreted cautiously due to significant between-study heterogeneity: ACM (HR = 2.32, p for effect < 0.001), cardiovascular death (HR = 1.55, p for effect = 0.005), and major adverse cardiovascular events (MACEs, HR = 1.77, p for effect < 0.001). When the FIB-4 index was examined as a continuous variable, variability across disease populations was a source of heterogeneity.

This meta-analysis revealed a consistent positive association of the FIB-4 index with adverse outcomes of CAD. Further validation is required to establish its clinical utility.