Among 2,175 adults with metabolic dysfunction-associated steatotic liver disease (MASLD), aspirin use paradoxically increased all-cause mortality risk by nearly 10-fold (HR 9.82) in patients over 65 without prior cardiovascular disease. Higher Mediterranean diet scores partially mitigated this deadly association, while Mediterranean diet adherence independently reduced mortality by 39% in patients with existing cardiovascular disease. This counterintuitive finding challenges conventional wisdom about aspirin's protective effects and reveals a critical vulnerability in MASLD patients. The liver's compromised metabolic state may alter aspirin's risk-benefit profile, potentially through impaired drug metabolism, increased bleeding risk, or disrupted inflammatory pathways. This population-based analysis from NHANES 2011-2018 represents the largest examination of aspirin-mortality relationships in MASLD to date. The findings demand immediate clinical attention, as aspirin is widely prescribed for primary prevention in this exact demographic. The protective Mediterranean diet effect likely stems from its anti-inflammatory properties, which may counteract aspirin's harmful mechanisms in metabolically compromised livers. These results should fundamentally reshape prescribing patterns and highlight diet as a safer intervention for cardiovascular risk reduction in MASLD patients.