BACKGROUND: Metabolic dysfunction-associated steatotic liver disease (MASLD) is strongly associated with coronary heart disease (CHD), but convenient and effective biomarkers for identifying CHD risk in patients with MASLD remain limited. The C-reactive protein-triglyceride-glucose index (CTI) reflects both systemic inflammation and insulin resistance, and may add value to cardiovascular risk stratification. This study examined the association of CTI with the presence and severity of CHD in patients with MASLD and developed a nomogram for individualized CHD assessment. METHODS: This study included 611 patients with MASLD who underwent coronary angiography. Participants were classified according to coronary angiography findings. Logistic regression was first performed to assess the association between CTI and CHD, followed by subgroup and restricted cubic spline (RCS) analyses. Among patients with CHD, the association between CTI and coronary lesion severity was assessed. Receiver operating characteristic (ROC) analysis and DeLong's test were applied to compare the discriminative performance of CTI with other simple insulin resistance-related indices. Independent predictors of CHD were identified using the least absolute shrinkage and selection operator (LASSO) regression and multivariable logistic regression, and a nomogram model was subsequently established and internally validated. RESULTS: Among the 611 patients with MASLD, 387 (63.3%) had CHD. CTI was independently associated with odds of CHD (OR 2.48, 95% CI 1.69-3.63, P < 0.001) and higher CTI levels corresponded to greater coronary stenosis severity. The association between CTI and CHD was generally stable across common subgroups, but it was stronger in patients aged ≥55 years. CTI showed significantly better discriminative ability for CHD than other simple indices of insulin resistance. Smoking status, age, neutrophils (NEUT), non-high-density lipoprotein cholesterol (non-HDL-C), serum albumin (ALB), CTI, and subclinical carotid atherosclerosis (SCAS) were included in the final nomogram. The AUC was 0.845 (95% CI 0.815-0.876), indicating good discrimination for CHD. CONCLUSIONS: Higher CTI was associated with CHD presence and greater coronary lesion burden among MASLD patients. The nomogram may help identify patients who warrant further cardiovascular evaluation.